Sometimes, life just doesn’t seem fair.

Rob and Barbara lost their 30 year old daughter a year ago after she suffered a brain aneurysm. While every loss is difficult, I believe the loss of a child is uniquely difficult. Rob and Barb had supported their daughter and two sons through childhood, and then watched, nervously as we all do, while they manoeuvered their way through the teenage years with all the inherent dangers like driving cars, going to university and all the things that parents of teenagers  face.

As Barb said, “Just when we thought that they had survived childhood and adolescence, BOOM, and she’s gone just like that. Not a thing we could do.”

Hard enough to bear! But can you imagine the anguish of these two parents when their younger son, Adam, was diagnosed with an aggressive cancer, just 8 months after their daughter’s death. And the diagnosis is pretty dire. It is in his liver and other major organs and the prognosis is not great.

And on top of all that, the family pet, a 16 year old collie who had grown up with the kids had to be euthanized just as Adam was going through his first chemotherapy. Barb, with a look of stunned disbelief on her face, said “This is just unbelievable. It feels like my whole world is disintegrating, and I sit here every day wondering ’What next?’”

This experience of experiencing an additional loss before one has grieved the initial loss is sometimes known as “cumulative grief”, “bereavement overload” or “grief overload”. Cumulative Grief – Definition …. Then …

There are several expressions in the English language that reflect the idea that when one tragic thing happens other tragic things sometimes follow: “It never rains but it pours”; “bad things come in threes”. Turns out we in the English-speaking world are not alone. In Hebrew the phrase is “Bad things come in packages”. In Swedish, German, Spanish, French and others, “misfortune seldom comes alone”. In Latin, “troubles are followed by troubles” and “the abyss attracts the abyss” (Try to work that one into a conversation!!) In Polish, “misfortunes walk in pairs.” In Japanese, “when crying, I was stung by a bee.” In Chinese, “good fortune never comes in two; bad luck never comes alone.” In Russian, “when troubles come, leave the gate open.” Depressing to see all these expressions for such a painful phenomenon, but it shows we are not the first to be overwhelmed by multiple losses.

As wonderful as it would be to pretend that every time we suffer a loss we have time to process that loss and integrate it into our lives before we suffer another loss, these idioms found in languages around the world point to the sad fact that it is simply not the case. It is all too common that a death is followed by another death. Pain is piled on pain, suffering on suffering and fear on fear.

This results when a person suffers several losses or several deaths close together. This makes it impossible for the individual to recover from one loss quickly because another happens. It also occurs when there is not a healthy recovery from a first loss. Therefore, subsequent death years later can reopen the first wound. Recovery from the subsequent death can be extremely torturous and cannot take place until the first loss is healed.

Coping with Cumulative Losses

A reader writes: I lost my brother to brain cancer five months ago. After the funeral, I headed to my best friend’s home (in another state) for our annual visit. Her dad had been in a nursing home for Alzheimer’s for the past 7 years. The day that I’d intended to return home was the day that he passed away. So, I stayed for that funeral too. Barely two months later, this same friend’s mother (who for years has been like a second mom to me) suffered complications during surgery and developed a blood infection. I rushed back to my friend’s home and arrived in time to see her mom, although she was in already in a coma. She died two days later. Okay – that’s three major deaths within three months. I feel as if I can’t breathe. I don’t know anyone who this has happened to. Many people have no idea what I’m going through because the deaths of my friend’s parents “don’t count” for me. People think that I don’t have a “right” to grieve these deaths. They aren’t my “in-laws” and they aren’t technically related to me. Tell that to my broken heart. So, I thought that I would write and see if you could say a few words that might help me.

BTW–my dog is dying of brain cancer. We took her for radiation last summer and the vet says she won’t live another six months. Also, my 88-year-old Mom isn’t doing very well. My brother calls every week to give me an update but she’s going downhill rapidly. Any thoughts on how to deal with all of this?

My response: My dear friend, I’m so very sorry that you’ve endured so many significant losses over the last few months, including that of your brother and your best friend’s parents – I can only imagine how overwhelmed and traumatized you must feel.

It’s not surprising to me that, because you’ve been hit with one significant loss after another, probably with very little opportunity to process each of them separately and individually, you now find yourself in what I would certainly call a state of “grief overload.” Grief is like that — if it comes at us so frequently that we can’t give each death the attention it demands at the time of our loss, it doesn’t “go” anywhere, and it doesn’t get resolved — it simply builds and accumulates and waits for us to take care of it. And sooner or later, out it comes, just as if any or all of these losses had happened yesterday. As soon as you are hit with just one more loss, the anniversary of a past loss, or even the anticipation of a future loss (such as that of your own mother, or your beloved family dog who is dying of brain cancer) it is not at all uncommon for that event to trigger all the grief reactions you’ve been suppressing for a very long time – like the proverbial straw that broke the camel’s back.

Please understand that this is not “going out of your mind” or “having a nervous breakdown” — it is a normal reaction to a very abnormal situation! Also, since your losses have come so close together, I would expect that you are still in a state of shock and disbelief, not even ready to begin the work of grieving. That’s not necessarily a bad thing — denying the reality of what is happening can be nature’s way of cushioning all those blows because they are way too much for you to take in all at once, and it’s the only way you can continue to function on a daily basis right now. It may seem as if you must take a defensive posture, keeping yourself in a state of heightened alert to guard against the next onslaught of very bad news that surely must be waiting just around the corner. When a sibling dies, for example, it brings home to us that if it can happen to our own brother or sister, then surely it can happen to us, too, or to one of our other siblings.

It’s also completely understandable that you would feel the loss of your friend’s parents so deeply. Even though these parents were not your own and did not “belong” to you by blood, it certainly sounds as if you loved them as if they were your own parents. These two deaths ~ as well as the anticipated death of your dog ~ fall into the category of “disenfranchised” losses – Dr. Ken Doka‘s term for those instances in which grief is an entirely natural response to loss and yet, because the losses are not openly acknowledged, socially sanctioned, or publicly shared, the mourner is deprived of the catharsis and relief that shared grief can bring. Unfortunately, as Harold Ivan Smith points out in his lovely little book, When Your Friend Dies, it is also true that the death of a friend is often considered to be a less significant experience than that of a “real” family member. Friends often feel shunted aside or marginalized in the grieving process. They sometimes feel as if they don’t have permission to grieve – which can make it even more difficult to come to terms with their loss.

I want you to know that the pain you are feeling is real and worthy of your grief ~ and that includes the anticipated loss of your dog who is dying of brain cancer. We don’t grieve deeply for those we do not love. I encourage you to acknowledge the significance of your relationship with each of these individuals, and honor your grief as a measure of the love you felt for your friend’s parents as well as for your brother. I also invite you to read my post, Facing the Loss of a Cherished Pet.

I sincerely hope that you have someone to talk to about all of this — a trusted relative, friend, neighbor, clergy person or counselor — so that when you are ready to take the time to do so, your feelings about each of these losses can be explored, expressed, worked through and released. There are all kinds of resources “out there” in your own community — you just have to make the effort to pick up your telephone and ask for the help that you need. I encourage you to contact your local hospice organization, mortuary, church or synagogue, or even your local library, and ask what bereavement support services are available in your own city or town — and if you don’t have the energy to do this research yourself, I hope you will ask a friend or a relative to do it for you. As overwhelmed as you feel, you are in need of support, comfort and understanding, and I hope you will think of this as a gift you richly deserve — one that you can give to yourself.

Please don’t underestimate the impact of each of these losses you’ve endured; any one of them is significant, but when they are cumulative they can lead to a complicated grief reaction. You may be thinking that you “ought to” be able to handle all of this by yourself — but that just isn’t true. Friends and family oftentimes are finished with your grief long before you are finished with your need to talk about it, and unexpressed feelings can become distorted. It is essential that you find an understanding, nonjudgmental listener with whom you can openly acknowledge your feelings and experiences, express and work through your pain, and come to terms with each of these losses. If friends and family aren’t as available as you need them to be, or if your need exceeds their capacity to help, please consider seeking help from the other sources I’ve suggested. No one can take away your pain, but you certainly do not have to bear it all alone. Support for grief is all around you, and all you have to do is reach out and ask for it!

You have my deepest sympathy at the loss of your brother and both parents of your dear friend, and I send you my sincere condolences.

I can hear your question already: when another loss arises, how can you possibly know if you have “grieved the initial loss”? This is a tough question because grief is so individual for all of us. There is no checklist or timeline that works for everyone, as we have said time and time again. But one thing that is common to the many different grief theories out there and to the personal experiences of so many grievers is that grief requires time. Be it stages, tasks, or processes, we need time to attend to each loss. If we don’t have the time we need before another loss occurs we end up overwhelmed by these multiple losses and unable to give them the attention they need.

When we become overwhelmed by anything our mind kicks into an incredibly powerful defense mechanism, which is avoidance. There can be an inclination toward avoidance when experiencing just one loss, so it is not surprising that this inclination grows when losses are compiled on one another. Though avoidance, denial, and shock may seem like a really bad thing (and it can be if it is never resolved), it can be our body’s way of keeping us functioning in the short term. When we are overloaded with multiple losses, this avoidance allows us to maintain our day to day activities. What becomes important when losses have become cumulative is an awareness that we may need to make a concerted effort to begin the work of facing the reality of the loss, as this avoidance can’t continue indefinitely.

Unfortunately there is no magic answer for how to cope with cumulative grief. If you have suffered multiple losses, either all at once or before integrating the previous loss, some important things to remember are:

1) Be aware of the risk of cumulative loss/grief overload. Knowing is half the battle! Just being aware that multiple losses in a short period poses unique challenges and can put you at risk for a grief process that is especially complicated is important. Cumulative losses do put us at higher risk for prolonged grief. If you are worried your grief is no longer ‘normal’ check out our post on normal vs not-so-normal grief. And don’t panic – even if your grief is more complex, there is help out there!

2) Be sensitive to other friends or family members who have suffered multiple losses and are at risk for cumulative grief. When we lose someone we become absorbed in our own way of grieving. We can find it difficult to deal with people who are grieving differently. Being sensitive to the differences between all grievers is important. This sensitivity can be especially important when someone faces the unique challenges of cumulative grief.

3) Be aware of the increased possibility of avoidance or denial in instances of cumulative grief. To make it through, one day at a time, you may find yourself more prone to avoidance than you have ever been in the past. This can also increase your risk of alcohol or drug use, as these substances can be tempting to numb pain. Maintain an awareness that you must ultimately grieve both (all) of the losses. Professional support may be a good idea if attending to the grief of these losses is feeling impossible.

4) Keep in mind that time is not the only factor in cumulative grief. Though it may be tempting to assume that bereavement overload only occurs when deaths occur in immediate succession, this is not the case. A loss that was never fully attended to years before can be brought back up by a new loss and can be overwhelming.

5) Substance abuse can increase the risk for cumulative grief.

When abusing drugs or alcohol, or even becoming overly dependent on anti-depressants or prescription medication, people are prone to avoid grieving. Using drugs or alcohol to numb grief can result in never fully grieving losses. This means that when a person stops using drugs or alcohol they may face multiple losses that they failed to grieve over the course of years, or even decades. Once someone stops using drugs or alcohol they may find themselves facing multiple losses from the past that they avoided with substances, and hence experiencing grief overload.

6) Age can increase the risk for cumulative grief.

As individuals progress into their 70s, 80s, and 90s they may find themselves experiencing the deaths of friends and family members more regularly than earlier in life. This can put them at a higher risk for cumulative grief. (Willie Murray) This is without even considering the other losses they are prone to, like loss of home, independence, and identity, as well as the fact that their grief may be minimized by society if those they lose are elderly. Due to a stigma around seeking professional support, some people in this age group may still have a strong aversion to seeking counseling. A little therapy never hurt anyone, but if therapy doesn’t seem like the right fit, seeking other types of grief expression and exploration is important for people in this age group.

7) Grief is as unique as each person we lose, so we cannot rush grieving multiple losses. Though it can be tempting to think that grief is grief, and we can lump our grief work together if we have multiple losses in a short period, the reality is that we must grieve ever loss individually. Grief is not generic to any loss, but is specific to each person we loose, our relationship with that person, and the circumstances of that loss. Attention must be spent on each loss in order to integrate them into our lives.’

8) Cumulative grief can put a greater strain on our faith. One devastating loss can be difficult enough and can cause us to question our faith in a higher power. When someone suffers multiple losses, this feeling can increase. People can begin to feel they are being punished (remember Job?), have a harder time resolving a benevolent God with all the pain they have seen and felt, or struggle with repeatedly experiencing ‘bad things happening to good people’. This is certainly not true in every case of grief overload. Many will continue to find strength in their faith (again, remember Job?), but it is important to know it is normal if your faith shakes as a result of grief overload.

9) It is important for hospital, hospice, and other healthcare professionals to be aware of cumulative grief. Like compassion fatigue and vicarious trauma, the experience of building relationships (even professional relationships with appropriate boundaries) with patients and repeatedly experiencing the death of those patients can take a toll on healthcare providers. Though the grief of professionals may take a different form than friends and family, it is important for professionals to grieve these losses to avoid developing an unhealthy avoidance or detachment. Check out some info on self-care that isn’t totally unrealistic.

If you have had multiple losses, pretty pretty please consider some professional support. Just give it a try. You may be surprised by how much it helps. When you are already emotionally and physically exhausted from the pain of one loss, it can only help to seek support when more losses pile on. If that truly doesn’t feel right for you, consider other ways to attend to each of your losses. Learn about grief. Find a friend or family member to talk to. Write or journal. Find a creative outlet, like art or photography. Join a support group. Just make it something that works for you and that will allow you the opportunity to deal with each of these losses. And remember, even if the abyss attracts the abyss, tomorrow is a new day and hope springs eternal.