Articles: Grief Process

Anticipatory Grief

Understanding anticipatory grief is not as straight forward as it might seem.

Traditionally, anticipatory grief, as the term suggests, has been thought of as the grief that a person might experience in anticipation of a death. For example, a person gets a life threatening diagnosis and is told they have a year to live. That year gives both family and the patient themselves the opportunity to “anticipate” or get ready for the death; deal with unfinished business; prepare psychologically and emotionally for the death; say their goodbyes, among other things. These are all things that sudden and unexpected death does not permit.

By doing such things, the general view was that the grief would somehow be LESS in both intensity and in time, because the opportunity existed to anticipate and therefore prepare for the eventuality (if not the inevitability).

In an ideal and predictable world, this theory would work well. However, death, and life threatening illness is never so predictable or programmable. Several factors come into play. Due to advances in medical technology, the time between “diagnosis” and death is lengthening. People tend not to die immediately from illness. Numerous remissions and relapses, which lengthen periods of anticipatory grief, not to mention the increased social, physical, emotional and financial pressures, long term family disruption and uncertainty: all these factors influence the way we grieve when someone could be dying. People are learning to “live with dying” so family and friends may wonder if it is “giving up hope” to actually grieve in anticipation. Indeed, nowadays many people recover from illnesses that were once considered terminal.

One of the major misconceptions is that anticipatory grief is merely “a post death grief begun pre-death”. Consider that phrase carefully. The concept is that there is a fixed volume of grief to be experienced, and if we experience that grief in anticipation of the loss, the remaining grief that is experienced after the death will be diminished. Therefore it would not be unusual to hear someone say after a death, “Oh, I did all my grieving during the illness. I don’t need to grieve now.”

This is a fallacy, however. First, there is no fixed volume of grief. If there were, the grief after an unanticipated loss would be the same in volume as an anticipated one except it would come in its entirety after the death. But in fact, we know that grief following unanticipated bereavement differs both in form and duration from anticipated grief. This is because the sudden and unexpected death overwhelms the adaptive capacities of the person that mourners are often unable to grasp the full implications of their loss, which we will see in the next section.

Also, I think there have been several misconceptions around the traditional explanations of anticipatory death. The first is the over emphasis on the ultimate loss of DEATH, without due regard to the other losses involved in a life threatening diagnosis. Anticipatory grief has to take MANY losses associated with a life threatening illness into account, of which death is only one. These might include the loss of functioning, health, abilities, body parts, hair; the loss of the future that had been planned, with the loss of hopes dreams and expectations, the loss of security, predictability and control; and the loss of relationship.

Anticipatory grief must not be thought of as solely relating to the death. In addition, the phenomenon of anticipatory grief is not composed exclusively of grief over losses that are being anticipated, but encompass grief for losses that have already befallen, or are currently being experienced.

Another misconception is that if we grieve in anticipation, this necessarily means that we have given up on the person, and “decathected” (the term “decathexis” means the opposite of “attachment”). However, in good anticipatory grief, what we are decathecting from is not the person themselves but from the idea of the person being in the future and the relinquishing of all the hopes dreams connected to a long term future with that person. The future can be grieved without relinquishing the present. Continued involvement with the dying person and making the most of what we have left is not inconsistent by the experience of anticipatory grief.

Again, this is what happens IDEALLY. But we see many examples of people who, for example, after years of old age, illness or infirmity in a nursing home, are abandoned by family, who might claim they find it “too difficult” to see their loved one in such a situation over such a long period of time, or just simply forget about them. This is known as premature decathexis, the family having decathected from the person themselves rather than from the person as healthy or in their familiar role in the family.

So, the term “anticipatory grief” is on one hand a misnomer, yet on the other, it exists. To understand this seeming contradiction, the following statement may be helpful: “A rehearsal is not the real thing.” No matter how much we get ready for and anticipate a death, we are never fully prepared. Because what we anticipate is never the same as when it happens. The feelings we have when it does happen are usually not ones we might have anticipated. But that does not mean that in anticipation we do not grieve.

It is important to note that there are two perspectives of anticipatory grief. The first is that of the dying person themselves. The other perspective is that of those who are emotionally involved in some way with the dying person, whether that be family, friends, colleagues, community, etc. It is important to understand the loss from BOTH perspectives.

 

Perhaps part of the difficulty is that the term “anticipatory” implies something that is in the future. However, there are THREE focal points towards which anticipatory grief directs itself: the past, the present AND the future. From the moment that a life threatening diagnosis is given, there are past losses that have already occurred, present losses that are occurring on an ongoing basis, and future losses that will occur, of which death is only one. 

Losses in the Past: 

Let’s consider the case of a 55 year old man, married with two children, one in high school and one in university, who is told he has cancer and has one year to live. The moment this life threatening illness is diagnosed, there are losses that have already occurred which must be mourned. Both he and his wife might grieve over the vibrant and healthy man she has ALREADY lost to cancer. They might mourn their altered relationship, lifestyle and their dreams for the future that will never be realized. 

It will not be unusual for her to remember the activities they shared when he was well; to recall how, in contrast to how he currently is, he was strong and independent; to grieve over the fact that so many limitations have been placed on their lives and interfered with their plans; and to mourn for all that has already been taken away by the illness. 

Each of these losses is a fait accompli — and this is what is meant by anticipate the grief entailing mourning over losses in the past. This past may be recent, or in the more distant past, as in the lost opportunities that are regretted in light of the limited time left in both cases, paying attention to these past losses does not mean that the wife is not still fully involved with her husband in his present state. 

In fact, because of her concern for her remaining time with him and out of her desire to protect him, the wife may not even address these losses.  She may work to keep them out of her own consciousness and push them aside to deal with after the death. Even if she does feel grief over them she might not show it.  However, despite what is done with it, the situation calls for some grief response because losses have transpired.  The issue is that even in the shadow of the ultimate loss of death, their other losses that have already occurred and that necessitate a grief process.

Exercise:    

What might be some of the losses that have ALREADY occurred for the man, for his wife, for his children, his work colleagues, friends at the moment the diagnosis is revealed, and the days that follow. 

Losses in the present.

In addition, the woman experiences conditions which stimulate grief in the present.  She witnesses the ongoing losses of progressive debilitation increasing dependence continual uncertainty, decreasing control, and so forth.  A fundamental part of her grief is grief for what is currently being lost and for the future that is being eroded.  This is different from grief about what will happen in the future.  Rather it pertains to grieve for what is slipping away from a right now for the sense of having her loved one being taken away from her and for what the increasing awareness of her husband’s impending death means at this very moment in time.

Exercise:    

What might be some of the losses that could be PRESENTLY occurring on a daily basis for the man, for his wife, for his children, his work colleagues, friends etc.

 

Losses in the future.

 

Both the patient and those involved will also grieve for future losses yet to come.  Not only is her husband’s ultimate death mourned, but also the losses that will arise before his death.  This may entail mourning for such things as the fact that she and her husband will not be able to take the annual vacation this year.  She knows that he will lose his mobility and become bedridden such grieving is not limited exclusively to losses that happened prior to the death.  It may also focus on those losses that will might issue in the future after the death as a consequence of it: the loneliness, the insecurity, the social discomfort, the uncertain identity, the economic uncertainty, the lifestyle alterations, the fact that dad will not be present to walk their daughter down the aisle on her wedding day, among many, many others.

 

Exercise:    

What might be some of the losses in the FUTURE that will or might occur for the man himself, z well as for his wife, for his children, his work colleagues, friends etc.

It is critical to recognize that a major component of anticipatory grief is the mourning of the absence of a loved one in the future.  Although the reality of this absence will not be fully realized until the death has occurred and the person is no longer there, it is possible to get a small but important indication of “what this will be like” through experiences that foreshadowed his permanent absence in the future. 

For example, during the illness, experiences such as when the wife is forced to attend a social function alone; or go to a parent-teacher interview; or where the children must accommodate themselves to their father missing their award ceremonies sports triumphs; or the family must become accustomed to a reduced income; all these things reinforce not only the current reality, but portend a small bit of what the world will be like after the death.  They do not mean that that is not continued investment in the father in the presence, only that there are starting to be pre-cursors of the ultimate loss that is drawing closer.

Can you think of other examples from perspectives of all the participants?

Ideally, any decathexis that occurs in anticipatory grief is not from the dying patient in the present, but from the image of the dying person as someone who will be present in the future.  There should be continued involvement with the patient in the here and now, despite the decreased emotional investment in those hopes, dreams and expectations of a future that formally included that person. Emotional energy gradually must be withdrawn (decathected) from the concept of the person as someone in the future beyond this terminal illness.

It might be helpful to recognize that in anticipatory grief, the primary loss is not the death but the illness. Or are the losses that arise because of that illness or primary loss are therefore secondary losses.  So that in any situation of a life-threatening illness, accident, or other critical situation, the question is, what has been lost here? See the section on Primary and Secondary loss to elaborate on this concept.

Although anticipatory grief possesses the potential to offer therapeutic benefits to the dying person and concerned others, it is not without its problems. Whereas anticipatory grief can serve to bring people together and to heighten emotional attachment, too much of it or inappropriate application of its processes can result in premature detachment from the dying person. Too little anticipatory grief can compromise the griever’s participation during the patient’s hospitalization or the preparation a time of death and subsequent adjustments. It has been also been suggested that long-term anticipation of loss may appear at times to lead to LESS grief because the emotional exhaustion following a prolonged illness may be lead to  temporary numbness, to suppression of grief after the loss, or even to relief that the long struggle is finally over.

So how may we define anticipatory grief?

Anticipatory grief is the phenomena encompassing the processes of mourning, coping, interaction, planning and reorganization that are stimulated and begun in response to the awareness of the impending loss of a loved one and the recognition of associated losses in the past present and future.

By definition, the griever is pulled in opposing directions. On the one hand they moved toward the dying patient a consequence of wanting to devote increased attention, energy and behavior toward person as ongoing involvement with them continues. Directly coinciding with this, however, the griever is starting to move away from the dying person in terms of beginning to decathect from the image of the patient as someone who will be present in the future, and from the hopes, dreams and expectations for that patient and their relationship in future. The challenge in anticipatory grief is to balance these incompatible demands to cope with the stress their incongruence generates.

It must be remembered that anticipatory grief takes time to unfold and develop.  It is a process, not an all or nothing thing.

From the dying patient’s perspective becoming aware of a life-threatening illness means confronting the fact life as it has been known is not limited.  The dying person must reorient their values goals and beliefs to accommodate this realization. This may precipitate a crisis for them, because it poses a problem that is unsolvable in the immediate future to which the patient can only surrender.  It goes beyond their entire traditional problem solving methods, because they have no previous experience to draw from … they have never died before!! They are in a situation is perceived as a threat or danger to the life goals of the person.  Thus, it stimulates a crisis, during which there is mobilization of either integrative or disintegrative mechanisms characterized by a tension.

The anticipatory grief of the dying patient is in many respects similar to that all of the loved ones who are also grieving the forthcoming death and the other losses associated with it. The person will experience grief over the past, present and future.  They may also feel they are being treated differently now that they’re terminally ill.  Former roles and responsibilities may have been reassigned to others. Unfortunately, they may experience the gradual geek affects it is of loved ones, some of whom may start to invest in others. Unfinished business you further complicate the process.  Just because people have an opportunity to deal with unfinished business, ask forgiveness or put things right does not necessarily mean they do so.

Conclusion:

Anticipatory grief is an invitation to respond with care to a person that is ill, in need, or confronted by death, and to address our own emotional need that the situation creates. To the extent that healthy behavior, interaction, and processes can be promoted during this time, the individual’s post-death mourning can be made relatively better than would have been if the experience lack the therapeutic benefits of appropriate anticipatory grief.

So in conclusion, anticipatory grief is a complex and multidimensional set of processes that are called forth during the illness of a loved one.  They entail, not only grief over future losses, but over past and present losses as well.  However if the process is done positively, it does not have to result in premature decathexis from the dying loved one.  And in fact, it offers the potential for and capability of supporting and stimulating continued involvement with the dying patient. 

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