Understanding Grief and Adaptation
Grief is a natural response to loss. It’s the emotional suffering you endure when someone you cherish or love dies, or whenever close ties are irrevocably broken. Grief comes from many varied losses. These might include divorce, loss of a job you enjoyed, loss of financial stability, or even the death of a loved pet. Even subtle losses in life can spark a sense of grief. For example, the company for which you work might require you moving to a different city or state. Relationships with friends and coworkers may end or change because of the geographical changes. You might have to leave the house you built, in which you raised your family, that gave you a powerful sense of “home.” These are all things that can spark grief in your life.
In today’s podcast, the context and source for grief differs from those types of things just mentioned. For the rest of the podcast, the context from which I’ll speak is that of lifestyle changes forced by chronic pain, that may cause you loss of function or mobility, losses resulting in significant lifestyle changes for you and your family, or those close to you. Grief is a personal and fundamental experience of life, carrying many meanings, revealed by emotional, cognitive, behavioral and bodily manifestations and expressions.
The emotional and physical pain you feel from loss can overwhelm you. You may experience a cadre of difficult and unexpected emotions. These may include shock, anger, disbelief and guilt accompanied by a profound sense of sorrow. Grief can disrupt your physical health making it impossible to sleep, function or even think straight. These are normal reactions to loss—and the more significant the loss, the more intense your experience will be.
As with most aspects of chronic pain, grieving is a highly individual experience. If someone tells you there is a specific or right way to grieve, or there is one model or process you should follow in order to grieve and move on, kindly smile, say thank you and walk away. They will be of no help to you.
So, What Does Grief Look Like?
In 1969, Swiss-American psychiatrist Elisabeth Kübler-Ross introduced a model for grief in her book “On Death and Dying.” Her ground-breaking model describes the often repeated “5 Stages of Grief” as denial, anger, bargaining, depression and acceptance. It is important to realize her model for grief specifically and appropriately addressed those plagued with terminal illness such as cancer. This model could apply to both the person with cancer and their survivors. However, the applicability of this model has been a point of contention, and rightly so, when universally applied to situations outside of terminal illnesses, especially in chronic pain management. Ross’ model has a somewhat sequential or linear series of experiences through which one must work before arriving at the last stage called “acceptance.” Others interpret or view Ross’ model of the five stages to that of a roller coaster ride, starting with denial. The “ride” cycles through anger, bargaining and depression multiple times and in no particular order before the rides ends at acceptance.
While there are similarities between grief from chronic pain and that of death, there remain significant differences. There seems to be little recognition of the differences between the grief experienced from losing a loved one from terminal cancer vs. that of a person living in chronic pain. This might be due in part to unreported intervention in cases related to chronic pain. One major difference in the two is the grief from a loss by death is primarily emotional or psychological with some social considerations. Chronic pain is a complex multidimensional biopsychosocial and subjective phenomenon. All biopsychosocial domains (physical, psychological and social) come into play when one experiences grief. Also, with death, there is finality, not so with chronic pain, as grief is perpetual. Some consider the grieving process from loss of a loved one as a pseudo-linear healing process, describing how one moves from shock and denial, moving through the stages, eventually arriving at acceptance. With chronic pain however, losses experienced are not singular nor finite, but repeated throughout one’s life.
Take, for example, the person who played golf with their friends regularly in a course in their neighborhood but can no longer do so because of a back injury. Every time they drive by their favorite course, the potential for experiencing that loss manifests itself again and again. Losses experienced because of chronic pain, unlike death, is everlasting. One limits the potential for reliving those losses only by one’s life journey, their choices, and ultimately their passing.
Birth and death, grief and loss are all fundamental human experiences. While these phenomena are typical of human life, each conveys life experiences differently and uniquely. The painful movement through grief requires continual readjustment and hope for future life situations. We view this process as circling through two major concepts, “relearning the world” and “adaptation.” This understanding is crucial for both those who experience loss caused by death of a loved one and loss produced by chronic pain, where the grieving person might need support in this process. Relearning the world and adaptation comprise a steady movement through four spectrums, continua or sub-themes. These are “despair to hope”, “lack of understanding to insight”, “meaning disruption to creating meaning”, and “bodily discomfort to reintegrated body.” Grief may require repeated movements along each of these continua and between “relearning the world” and “adaptation.” Here the continuous movements include a sequence of experiences of similar type in which the unique experiences vary in strength and endurance. Movement in this model is both circular and vertical. To see a graphic representation of this model, go to strivingtothriving.com in the “articles” section. It will help you conceptualize what I’m presenting here.
Let’s Examine the Sub-themes in this alternative model by first examining the Despair to Hope continuum.
We can view despair as an expression of lack of meaning and discontinuity in life. It is a multifaceted experience encompassing grief expressions such as fright, guilt, loneliness, indifference, anger and emptiness. These expressions are likely change in strength and duration. If we look at grief as described in classic theories, it is a predictable reaction and a process passing through several phases which can intensify feelings of despair. Chronic pain is concomitant with a variety of life issues causing despair. The manifestation of despair often includes personal stress, psychological disruptions such as depression, maladaptive and dysfunctional behavior, and social isolation. Thus, the patient involved often experiences brutal circles where one symptom leads to the other and loss of hope may lead to unbearable suffering.
Despair – Hope
We must see and appreciate the grieving person’s respective situation of despair. However, being seen and understood is not the same at any point in time because life situations present themselves in ever-changing, unpredictable ways. The phenomenon of hope, the opposite of despair, is a state of being, future-oriented and essential for adaptation. Hope incorporates positive, forward looking and optimistic attitudes toward the future that are independent of the original cause. Multiple aspects of grief work to create hope through articulating grief, specifically what they lose, acknowledging it, while still preserving ties to what they lose. To maintain hope in the presence of chronic pain means our chronic pain must take a backseat to those enjoyable pursuits of life which, in contrast, must remain front and center of our consciousness. Viewing the world from a new life situation is like walking backwards and living forwards on the “despair–hope” continuum. This adaptive movement is future-oriented with a hope for a meaningful life.
Lack of Understanding – Insight
The next continuum describes the spectrum of a lack of understanding progressing to insight. Grief may disrupt continuity and confront the sufferer with vulnerability leading to decreased understanding and losing part of him or herself. Furthermore, the situation often limits the person’s concentration, sensuality and cognition. When our ties to our present life as we know it are disrupted, we experience new challenges that force new insights that become our reality. This means we have to relearn the world creating a new paradigm for daily life. A major difficulty that many patients with chronic pain face is their confusion and decreased understanding regarding the nature and extent of their losses. This may be because many of the losses are not temporary and that they often increase over time as the situation worsens. The grieving person may become unable to maintain their previous levels of functioning and previous roles they held. Faced with such unpredictable situations, it is impossible to know what losses may occur and when they may happen. Support and help must affirm the person’s awareness of these losses and encourage the abilities and resources available for that person.
A clear and positive focus is critical in cognitive reorganization and adjustment. To make room for grief, conceptualization is of great importance. Expressing grief and realizing the loss is an important part of self-understanding. This means that expressing and narrating grief experiences will contribute to new insights. Patients studied in a pain management program expressed several pain related losses and saw the value of expressing them. In this way the grieving person in pain may discover new perspectives and connections which may contribute to coping and adaptation to an altered life situation. This emphasizes how important it is for pain patients to realize they are in a grief situation and that they must determine what their grief experience includes. Understanding pain, grief and loss in a first-person perspective may offer new insights for patients and health care workers.
Disruption to Creating Meaning
We can associate loss with expressions and feelings like anger, resentment, despair and disorganization which show that the person experiences disrupted meaning and calls for alternative ways of coping with life. The experience of incompetence, hopelessness and dejection are often present and may disturb everyday life and important social ties. Loss caused by death is finite, creating feelings of helplessness and the experience of frustration. Anger often accompanies loss in bereavements situations.
We consider loss caused by chronic pain to be one of the most common and difficult emotions that chronic pain patients experience. Here, the underlying source of the person’s anger may be unclear, and they often relate despair to issues of loss. They may relate these losses to identity, the ability to work, and engaging in recreational or family activities. Feelings of despair that life has been unfair to them can cause anger and frustration.
Let me introduce a term used throughout the remainder of this podcast. That term is “reconstruction.” In this context reconstruction means progress in coping with feelings and thoughts as part of the adaptation process. Loneliness, suffering, depression and weakness may prevent meaningful reconstruction which would lead to decreased ability to engage in life and the world about them. As a result, the grieving person often finds it difficult to experience life as meaningful in the complex and changed life situations. The losses experienced may influence engagement in valued social life, an important aspect of brain hygiene. There is an important challenge to help the grieving person put anger and despair in the background and instead focus on acceptance and hope which would create meaning. As this understanding is further deepened, grieving persons will see and experience the process as a continuous movement toward creating an enriched identity and seeing the world with fresh eyes.
An important task for family members, health care workers or caregivers assisting grieving people is to establish and maintain a positive attitude sustained through meaning construction. The grieving person’s existence depends on creating an attitude to handle situations in order to establish meaningful reconstruction. As mentioned above, grieving and adaptation related to different loss situations involve taking an alternate life course. Relearning as meaning reconstruction is a cognitive skill and an important emotional and social skill which must be supported and encouraged. The person in grief has to take an active part and find new meaning in several complex and difficult situations. In the grieving process, valuable memories from the past must be preserved as an important first step in an adapted life situation. We attribute memories of the past as giving important power to life and encouragement for the future. This adaptation is important for those losses caused by chronic pain. The extent to which living a meaningful life is possible seems to depend on many complex factors. These factors include a person’s belief system and attitudes, early life experiences, illness, personal resources and one’s meaning of pain.
Bodily Discomfort to Reintegrated Body
We exist in the world as complete bodies. Here this means that the grieving person carries the whole grief and pain situation bodily. This naturally leads to a commitment that the grieving person must feel viewed and met as a whole situated person. If we base our approach only on theories categorizing grief or stating grief as observable symptoms and reactions, we may exclude the integrated body. Such beliefs may lead health care workers and caregivers to ignore grief as a unique experience.
If so, we may convince the grieving person his or her experiences are unimportant and unreliable.
We may describe specific bodily reactions as “grief attack” followed by discomfort. Grief experiences caused by death may comprise bodily discomfort such as chest pain, nausea, headaches, limpness and sleep disruption. During chronic pain the unpleasant perceptual experience may become the center of mental awareness and the person loses positive bodily perception as physical pain may fill the consciousness. Here, there is often a complex mixture of various types of pain such as physical pain, neuropathic pain and psychogenic pain causing bodily discomfort. Thus, grief may imply a stiff body and loss of movements showing that their relation to the body is changed. Moreover, this may bring a feeling of “losing oneself” and a sense of discontinuity with the world experienced.
To narrate enables meaning reconstruction and a way to establish continuity in the world. We have learned through narration and supervision that the grieving person will express impressions related to grief and loss as part of the relearning and adaptation process. It represents a challenge to move toward a reintegrated body showing the person can meet this through alleviation and organization of thoughts and feelings.
What Does Living with Grief Mean?
Coping with loss is vital to your mental and physical health. It is entirely natural to experience grief when you experience loss. The best thing you can do is allow yourself to grieve. There are many ways to cope effectively with your pain.
As I stated earlier, grief can affect all biopsychosocial aspects of your life. Physical complications associated with grief include:
- Impairment of immune response system
- Increased adrenocortical activity
- Increased serum prolactin
- Increased growth hormone
- Psychosomatic disorders
- Increased mortality from heart disease (especially in elderly widowers)
Psychiatric complications can include:
- Depression (with or without suicide risk), anxiety or panic disorders
- Post-traumatic stress disorder
- Delayed or inhibited grief
- Chronic grief
- Complex grief which is a topic for another day
So, you might ask yourself, “What should I do or not do to move from striving to thriving?”
Seek relatives and friends close to you who can understand your feelings and experience of loss. Join support groups with others who are experiencing similar losses.
Take care of your health and make sure you get enough rest and maintain sufficient amounts of activity to stimulate both body and mind. Maintain regular contact with your family physician and be sure to eat a balanced diet while getting plenty of rest. Educate yourself on the dangers of developing dependence on medications. Avoid alcohol as it is a depressant and can contribute to needless struggles in life while you deal with your grief.
A common approach some take is numbing themselves to the pain of grief; this prevents one from moving through and resolving challenges. An underlying truth is eventually the grief of a significant loss will demand attention and resolution. People sometimes refuse to grieve and instead they stuff it down somewhere and pick themselves up by their bootstraps and move on, pretending or denying the loss ever happened. This behavior (or choice, if you will) has the potential of causing dysfunctions potentially harming interactions with others. Instead, allow yourself the freedom to express your grief in healthy ways. Share your experience with others; doing so can help you work through the grieving process, create meaning in your life, and move toward a fulfilling life.
Accept that life is for the living. It takes effort to live again in the present and not dwell on the past.
Until you process through the spectrums of grief or losses, postpone major life changes or making any major decisions as they may compound your grief with unexpected challenges. It is wise to hold off on making any major changes such as moving, remarrying, changing jobs or having another child. Allow yourself time needed to adjust to your loss and discover new insights.
Give yourself some grace in handing your grief; it can take months or even years to absorb and process major loss and accept your changed life. Be patient and give yourself permission to navigate through life during this troublesome time and do so with imperfections along the way.
Seek outside help or guidance when necessary. If your grief completely overwhelms you, seek professional help to work through your grief. Asking for help is a sign of strength and wisdom, not weakness.
Grief may stem from moving away from home, graduating from college, or other things not necessarily associated with death, but are by nature temporal. As discussed, grief and loss stemming from chronic pain is quite different. Reject the notion it’s somehow inappropriate to grieve for certain things. If the person, relationship, or situation was significant to you and chronic pain somehow changed or ended that relationship, it is normal to grieve the loss you’ve experienced, it’s expected. Whatever your loss, it’s personal to you, and as such, don’t feel embarrassed or ashamed about how you feel, think or believe; in fact, embracing the experience is part of the process to re-establishing your “normal”, whatever that might be, and establishing meaning in new life experiences. Regardless of the cause of your grief, there are healthy ways to cope with the pain. Given time and support, the pain eventually lessens and sadness eases. For many, the support they received is what enabled them to come to terms with their loss, find new meaning, and eventually move ahead in life. The same holds true for you. If you find yourself mired down by grief or some significant loss and need some supportive coaching to help you re-create your new normal, call me so I can coach you as you continue your journey, finding your way from striving in loss, grief or despair to a new refreshing thriving existence.
Until next time, be well and take care of each other.