Anticipatory Grief And/Or Anticipatory Growth

Death ends a life, not a relationship.

~~ Morrie Schwartz

Anticipatory grief is exactly what it says: the feeling of anxiety and sadness at loss, begun before the loss occurs.  When loss means death, the term applies to both the survivors and the person who is dying.  The lost love object may be a pet or other animal, not necessarily a human being.  Loss may refer to non-death-related events as well, such as impending divorce, planned mastectomy, or a company downsizing.

The individual’s sense of loss takes place not only in the emotional, psychosocial and cognitive spheres but also in biological, cultural, and spiritual spheres.¹

In important respects, anticipatory grief is different from the grief experienced by a survivor after the death of a loved one.  It is not just the early onset of “normal” grief.  Anticipation may draw the survivor closer to the dying person, in an effort to comfort, control the dying process, and even to stave off death itself.  Attachment is intensified.

Anticipation brings to the survivor a strong concentration on the shape of his life after the loved one’s death.  He questions the consequences to himself of the loved one’s death.  With this sharp self-focus comes somewhat lessened attention to the dying person and a degree of associated guilt for the requisite withdrawal.  Guilt is usually a springboard for anger.  Wherever directed, anger can then produce further guilt – the so-called vicious circle.

Additionally, “the threat of loss arouses anxiety and actual loss gives rise to sorrow…Each situation is likely to arouse anger.”²

Anticipatory grief gives both the survivors and the dying an opportunity to resolve unfinished business, to speak what needs to be spoken, and to say goodbye.  Noted specialist, Dr. Ira Byock, proposed that we think in terms of these five parameters or talking-tasks: I forgive you, please forgive me, thank you, I love you, and goodbye.  He called these “the five things of relationship completion.”³

Death and dying expert and emergency medicine physician, Dr. Monica Williams-Murphy, suggests that we add one more item to this list of five tasks: “it’s OK to die.”⁴

Accordingly, these six tasks would appear on the death-and-dying To-Do list:

1. I forgive you;
2. Please forgive me;
3. Thank you;
4. I love you;
5. It’s OK to die;
6. Goodbye.

These tasks could also be seen as a rehearsal of the death.  Not easy but well worth the effort.  They benefit the survivors in avoiding regrets later on, after the death.  They help the dying to reach emotional balance and peace.

For the survivors, applying the six tasks bears some resemblance to the concept of prehabilitation.  In prehab, targeted physical and psychosocial exercises plus nutrition guidance before surgery often improve post-surgical outcomes – including reduced morbidity and preventing hospital readmissions.⁵

Not every listed item might actually occur.  Also, the tasks are not expected to be accomplished in the precise order shown here.  Moreover, they may be repeated many times, especially for confirmation.

The key concept in this configuration is talking about it, having the open conversations about death…and the future.  For virtually every one of us, there exists a future…and a past.

All told, this work can lead to a greater sense of healing and peace at the end of life.  It represents strength and growth.  Psychiatrist and authority on death, Dr. Elisabeth Kubler-Ross, wrote that death is the final stage of growth.⁶   The ultimate goal of growth is the search for our own Self.  We never stop searching, even to the very end.  It is a moral mission of deepest significance and meaning.

Scientific research indicates that we are still unclear about the optimum general value of anticipatory grief in the aftermath of a loved one’s death.  Does anticipatory grief help the post-death bereavement?  Does it make grief easier to bear?  Is grief easier to manage?  Does it shorten the acute mourning period?  There is practical evidence that anticipatory grief is helpful in the time after the death.

Preparation seems frequently beneficial.  “People who had some advance warning of an impending death did better [than those without advance warning] when assessed at 13 months post-death…”⁷   Yet, everyone is unique and different, and anticipatory grief is only one variable in a mosaic of the individual survivor’s lifetime of experiences.  Empirically, the sum of these experiences form an important factor in determining the usefulness of anticipatory grief.

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The story of Dr. Morris Schwartz is a good example of anticipatory grief, both for the dying and for the surviving.  Morrie was a prominent professor of sociology.  He was also an unwilling ALS patient.  Mitch was one of his most devoted students.  During the last months of Morrie’s life, they met and talked on Tuesdays.  Morrie taught his student many profound lessons in dying – and living.  Both men were intent on anticipation of loss.  Here is one of Morrie’s numerous wise remarks:

ALS is horrible only if you see it that way.  It’s horrible to watch my body slowly wilt away to nothing.  But it’s also wonderful because of all the time I get to say goodbye.  Not everyone is so lucky.⁸

On another occasion, Morrie was interviewed by Ted Koppel, formerly with ABC-TV’s “Nightline:”

Ted, when all this started, I asked myself, “Am I going to withdraw from the world, like most people do, or am I going to live?”  I decided I’m going to live – or at least try to live – the way I want, with dignity, with courage, with humor, with composure.  There are some mornings when I cry and cry and mourn for myself.  Some mornings, I’m so angry and bitter.  But it doesn’t last too long.  Then I get up and say, “I want to live…”  So far, I’ve been able to do it.  Will I be able to continue?  I don’t know.  But I’m betting on myself that I will.”⁹

Mitch still grows from Morrie’s life lessons:

The last class of my old professor’s life took place once a week, in his home, by a window in his study where he could watch a small hibiscus plant shed its pink flowers.  The class met on Tuesdays.  [It had only one student.  I was the student.]  No books were required.  The subject was the meaning of life.  It was taught from experience.  —  The teaching goes on.¹⁰

Morrie’s story is filled with dignity, grace and hope.  The honest telling of a life story is a continuous process of self-discovery and therefore growth. Someone he loved was listening.  Really listening – with eager interest, patience, and love.  To listen is exceedingly supportive.¹¹   He could still teach; this was one of his special and treasured abilities.  He believed his story would live on.  The bonds would survive and grow because death ends a life but not a relationship.  Mitch wrote a very long paper for his last class with Morrie. He completed the writing after Morrie died.  It demonstrates the power of connection and ongoing attachment.  Its title is Tuesdays with Morrie.  This book is a sterling gift to all of us.

∞  ∞  ∞

Anticipatory grief – an end note from one little boy:

In one of the stars I shall be living.  In one of them I shall be laughing…Only you – you alone – will have stars that can laugh.  And when your sorrow is comforted…you will be content that you have known me…You will always be my friend.  You will want to laugh with me.  And you will sometimes open your window for that pleasure…And your friends will be properly astonished to see you look up at the sky!  Then you will say to them, “Yes, the stars always make me laugh!”  And they will think you are crazy.

~~ Antoine de Saint-Exupery,

The Little Prince¹²

∞  ∞  ∞

References:

1. National Cancer Institute (NCI), “About Cancer: Advanced Cancer & Caregivers: Planning for the Caregiver: Grief, Bereavement, and Coping with Loss,” https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-hp-pdq#section/_164 .

2. John Bowlby, Loss: Sadness and Depression, vol. III of the trilogy: Attachment and Loss, New York: Basic Books, Inc., 1980, p. 40.

3. Ira Byock, MD, Dying Well: Peace and Possibilities at the End of Life, New York: Riverhead Books, 1998, p.140.

Ira Byock, MD, Four Things that Matter Most: A Book about Living, New York: Free Press, 2004.

4. Monica Williams-Murphy, MD and Kristian Murphy, It’s OK to Die, USA: MKN, LLC, 2011, pp. 179-185.

5. Interview with Julie Silver, MD, Harvard Medical School, Department of Physical Medicine and Rehabilitation, “Prehabilitation Before Cancer Treatment Improves Outcomes,” http://www.medscape.com/viewarticle/808781

6. Elisabeth Kubler-Ross, MD, Death: The Final Stage of Growth, Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1975.

Elisabeth Kubler-Ross, On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and their own Families, New York: The Macmillan              Company, 1969.

7. J. William Worden, PhD, Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, New York: Springer Publishing Company, 1982, p. 92.

8. Mitch Albom, Tuesdays with Morrie: An Old Man, a Young Man, and Life’s Greatest Lesson, New York: Doubleday, 1997, p. 37.

9. Albom, ibid., pp. 21-22.

10. Albom, ibid., p. 192.

11. “The moral life, the life that transforms lives, begins in the ear, in the act of listening.”

Rabbi Lord Jonathan H. Sacks, PhD, To Heal a Fractured World: The Ethics of Responsibility, New York: Schocken Books, 2005, p. 255.

12. Antoine de Saint-Exupery, The Little Prince, New York: Harcourt Brace & Company, 1943, pp. 104-105.

13. Sacks, op. cit., p. 270.

Image credits:

Top: www.hdimagesnew.com

End: dandelion clock on leaves, http://commons.wikipedia.org/wiki/File:dandelion_clock_on_leaves.jpg

Tags: #eol  #hpm  #anxiety  #anger  #grief  #peace  #healing  #growth

Rea L. Ginsberg, LCSW-C, ACSW, BCD

May 28, 2017

Dandelion clock –

symbol of grief, healing, and hope.

The greatest achievement in life is to be,

Even for one other person, even for one moment,

An agent of hope and peace.¹³

∞  ∞  ∞

Rea Ginsberg is a retired director of social work services, hospice coordinator, and adjunct professor of clinical social work.  She can be reached on LinkedIn and on Twitter @rginsberg2.