Coming to Grips with Loss - Sense Publishers

CONSTRUCTING KNOWLEDGE: CURRICULUM STUDIES IN ACTION

Normalizing the Grief Process Kate Cummings Coming to Grips with Loss is a theory that depicts how people heal from any type of significant loss. The strength of this theory is that it is grounded in data gathered from people who experienced a myriad of losses; of loved ones, physical and mental abilities, homes, careers, material goods, as well as safety, security, and other aspects that people hold dear. The theory is written in a very deliberate manner that is nonpathologizing, relevant to a wide array of audiences, and is transferable to various fields of study. It explains what people say they go through on their way from the initial discovery, assessing the possible impact, experiencing related feelings and choosing coping actions that can either move one closer or farther away from healing. It offers a road map to recovery for those in helping relationships, business managers, community leaders and people involved in self-care. Most importantly, it offers a perspective that normalizes the grief process and offers hope that healing is possible.

SensePublishers

CKCS 8

Kate Cummings

ISBN 978-94-6300-248-6

Coming to Grips with Loss


CONSTRUCTING KNOWLEDGE: CURRICULUM STUDIES IN ACTION

Spine 7.29 mm

Coming to Grips with Loss Normalizing the Grief Process Kate Cummings


CONSTRUCTING KNOWLEDGE: CURRICULUM STUDIES IN ACTION Volume 8 Series Editors Brad Porfilio, California State University at East Bay, USA Julie Gorlewski, State University of New York at New Paltz, USA David Gorlewski, D’Youville College, Buffalo, NY, USA Editorial Board Sue Books, State University of New York at New Paltz, USA Dennis Carlson, University of Miami, Ohio, USA Ken Lindblom, Stony Brook University, New York, USA Peter McLaren, University of California, Los Angeles, USA Wayne Ross, University of British Columbia, Canada Christine Sleeter, California State University, Monterey, USA Eve Tuck, State University of New York, Paltz, USA Scope “Curriculum” is an expansive term; it encompasses vast aspects of teaching and learning. Curriculum can be defined as broadly as, “The content of schooling in all its forms” (English, p. 4), and as narrowly as a lesson plan. Complicating matters is the fact that curricula are often organized to fit particular time frames. The incompatible and overlapping notions that curriculum involves everything that is taught and learned in a particular setting and that this learning occurs in a limited time frame reveal the nuanced complexities of curriculum studies. “Constructing Knowledge” provides a forum for systematic reflection on the substance (subject matter, courses, programs of study), purposes, and practices used for bringing about learning in educational settings. Of concern are such fundamental issues as: What should be studied? Why? By whom? In what ways? And in what settings? Reflection upon such issues involves an inter-play among the major components of education: subject matter, learning, teaching, and the larger social, political, and economic contexts, as well as the immediate instructional situation. Historical and autobiographical analyses are central in understanding the contemporary realties of schooling and envisioning how to (re)shape schools to meet the intellectual and social needs of all societal members. Curriculum is a social construction that results from a set of decisions; it is written and enacted and both facets undergo constant change as contexts evolve. This series aims to extent the professional conversation about curriculum in contemporary educational settings. Curriculum is a designed experience intended to promote learning. Because it is socially constructed, curriculum is subject to all the pressures and complications of the diverse communities that comprise schools and other social contexts in which citizens gain self-understanding.

Coming to Grips with Loss Normalizing the Grief Process

Kate Cummings

SENSE PUBLISHERS ROTTERDAM / BOSTON / TAIPEI

A C.I.P. record for this book is available from the Library of Congress.

ISBN 978-94-6300-248-6 (paperback) ISBN 978-94-6300-249-3 (hardback) ISBN 978-94-6300-250-9 (e-book)

Published by: Sense Publishers, P.O. Box 21858, 3001 AW Rotterdam, The Netherlands https://www.sensepublishers.com/

All chapters in this book have undergone peer review.

Printed on acid-free paper

All rights reserved © 2015 Sense Publishers No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work.

This book is dedicated to my friend, Nancy Whitehair who shared her journey of life and death with me. She demonstrated courage, vulnerability, insight, and humor as she went through the process of healing from the hand that Life dealt her. She shared her life with me as well as her process of dying of cancer. It was a privilege to be with her on her journey.

Aquani N’Dumba (Goodbye, my Friend)

TABLE OF CONTENTS

Preface

ix

Chapter 1: Introduction to the Theory

1

Pathology or Process?

5

Chapter 2: Discovering Loss

9

External Source Internal Source Types of Loss Summary Integration Activities

10 10 11 18 19

Chapter 3: Assessing Loss

21

Personal Life Experiences Summary Integration Activities

23 31 32

Chapter 4: Mourning

35

Initial Reacion Ongoing Responses Reminiscing Summary Integration Activities

35 37 42 42 42

Chapter 5: Coping

45

Delaying Resolving Summary Integration Activities

47 57 72 74

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TABLE OF CONTENTS

Chapter 6: Turning Points Types of Turning Points Completing the Process Summary Integration Activities Chapter 7: Implications for Use in Other Fields

75 77 85 86 86 89

Practical Application

90

Appendix A: Case Studies

93

Case Study 1

95

Case Description Treatment Planning Developing the Treatment Plan Using the Coming to Grips Theory Case Study 2 Case Description Developing the Restructuring Plan Integration Activities Case Study 3 Assignment Case Study 4 Assignment

95 98 99 100 103 103 105 108 109 109 111 111

References

113

Index

117

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PREFACE

A mind confused by Knowledge, Cleverness, and Abstract Ideas tends to go chasing off after things that don’t matter, or that don’t even exist, instead of seeing, appreciating, and making use of what is right in front of it. (Benjamin Hoff, 1983, p. 147) At the time of the original research study, I was the clinical director of a residential facility that provides treatment to women recovering from alcohol and drug addiction. I was also a doctoral student who wanted to contribute to the field of addictions treatment and provide some new insight into treatment for this devastating issue. Having already done work in quantitative research during my master’s studies, I wanted to learn a different approach to research and problem solving. Grounded theory (GT) seemed to be a good fit for me personally and professionally. I used the classic grounded theory methodology to look at what people were experiencing from a different perspective. As is common with a grounded theory research project, the project took on a life of its own, and the data led me in a surprising direction. I found that one of the common experiences that people with addictions shared was unresolved loss. The initial participants repeatedly stated that they used alcohol or drugs to insulate their feelings and, as a result, delayed resolving loss. They also talked about the myriad of losses they encountered in their active addiction and in the process of recovery from addiction—loss of homes, physical and emotional health, identity as an addict, lifestyle associated with active addiction, ways of coping, family, friends, etc. Once the pattern of dealing with loss emerged from the data, I left the insular world of addiction and interviewed anyone who would talk to me. The project became a study on how people come to grips with any significant loss. This study focuses on how people discover, assess, mourn, and cope with loss. It looks at the contributions that one’s personal life experiences have on the timing, pathways, and trajectory of coming to grips with loss. The research revealed that type of loss, age, race, and social conditions did not seem to change the overall process that people followed in coming to grips with loss.

ix

PREFACE

DOING THE RESEARCH

The initial area of study focused on how people deal with difficult situations. In keeping with the GT methodology, I started my research by asking a grand tour, or very open-ended question. I simply asked my participants to tell me about a difficult time in their life; they all talked about events related to a significant loss. As I collected and analyzed data, the focus narrowed to the development of a more holistic understanding of people’s experience with loss in a manner that may not have been documented in the past. I examined the overall experience of loss and found the common process that people go through to resolve loss in order to present the topic in a manner that may bring new insight to one of the most common sources of human suffering. I chose the classic grounded theory methodology because there has already been a vast amount of study in the field of loss using other research methodologies. This methodology has the potential to provide a fresh view of people’s experience with loss as it can offer clues for providing more effective support and treatment of this most common, but potentially devastating, experience. The purpose of the GT methodology is to generate sociological theory based directly on data, which allows both the professional and layperson to make relevant predictions, explanations, and interpretations of human behavior in a way that allows for practical application in a field of study (Glaser & Strauss, 1967). Grounded theory is a general research methodology that uses comparative analysis to create conceptual categories and their related properties based on data that contribute to the generation of an overall theory. These conceptual categories and their related properties show the systemic relationships of categories to each other and to the core issue that the participants in the study are attempting to resolve. The concepts are analytical and generalized enough to illustrate behaviors and provide a meaningful picture of what the participants are experiencing (Glaser & Strauss, 1967). Participants in this study stated that they were trying to deal with loss in a manner that would ultimately allow them to meet three goals: make sense of loss, integrate it into their daily life, and salvage something positive from the experience. The GT methodology differs from methodologies using verification approaches in that it allows the theory to emerge from the data. It does not seek to verify existing theory, but rather it focuses on making a unique contribution to sociological research. Grounded theory incorporates a holistic, systematic approach to generating theory that informs an area of study. This methodology ensures that the theory “fits” in a substantive area of study, “works” to explain the majority of behavior, is “relevant” to the x

PREFACE

people in the field of study, and is “modifiable” when new data are added (Glaser & Strauss, 1967; Glaser, 1998). Classic GT studies do not typically provide demographics or “face sheet” data unless it is relevant to the theory or accounts for some variation in the theory. Glaser (1978) states, “We are not comparing populations, we are comparing ideational characteristics of groups that in turn delineate behavioral and attitudinal patterns” (p. 44). Still, people want to know about the participants. In this study, I conducted 27 initial interviews with men and women who ranged in ages from 24 to 65. They were Caucasian, Native American, African American, and biracial. They came from all over the United States, including California, Louisiana, New York, New Jersey, Pennsylvania, Wisconsin, and Massachusetts. They were in several socioeconomic groups: Some were retired or on disability and living on fixed incomes; some worked at service jobs with moderate incomes; some were professionals in the upper-middle income brackets. None of these characteristics seemed relevant in the way people moved through the process of coming to grips with loss. I used case studies for aspects of the research project related to fragile populations’ experience of loss. I wanted to include relevant information without retraumatizing people who may still be involved in healing from trauma. The theory was then modified as it was presented to thousands of people at professional conferences, workshops, and healing groups. This may seem like a small initial sample size for researchers used to working with other methodologies. GT precepts do not base data credibility on sample size but rather on lack of new emerging patterns. When no new concepts or categories emerge in a particular area of the study, the researcher stops collecting data in that area and moves on to another area of data collection. When no new patterns develop, the data collection stops. During the interviews, the participants talked about a vast array of losses, which included external, easily recognizable losses of loved ones, material possessions, jobs, and relationships as well as internal, less easily recognized losses of identity, security, freedom, and faith. Even though there were many different types of losses, this variation did not seem to make a difference in how people moved through the loss process. There may have been a difference in the intensity of the feelings and the choice of coping actions, but, overall, people still stayed within the process as it is depicted in the upcoming chapters. After identifying the core variable of loss, I focused attention on how the participants went about coming to grips with loss. A process emerged from the data that comprised specific stages with consistent movement within the process. Subsequent interviews and case studies supported the consistency xi

PREFACE

of the process and identified those conditions that contributed to variations in timing, pathways, and outcomes of the process. Even though there were variations, the overall process remained the same, no matter who experienced the loss or what type of loss the participant experienced. The Coming to Grips theory was developed and compared to others in the field. Following the tenets of GT, existing literature relating to a particular study area is not used to validate theory, but rather to show the theory’s relevance to other works in related fields of study. In researching the literature related to loss, I found vast amounts of information related to death and dying or on specific aspects of a loss process. I found very little information that provided a holistic view of the process applicable to a wide variety of loss in the manner that this study portrays. There were in-depth studies done on specific parts but not on the whole experience. The overall concept of loss is so vast that it may make sense to focus on in-depth studies of individual segments of the whole. However, the strength of this study is the overall understanding that it can bring to the field of loss. The study’s theory on how people come to grips with loss is documented in the following chapters. These chapters describe in detail the stages of discovering loss, assessing value, mourning, coping, turning points, and finally completing the process. There are very personal examples provided by the participants that give further depth to the experience of coming to grips with loss. There is also a discussion on the effect that the psychological community and pharmaceutical companies have had on how people view loss and the resulting feelings that may be misdiagnosed as depression. The last portion of the book employs case studies to illustrate how the theory can be applied to therapeutic practice, business restructure planning, and community rebuilding projects, as well as possibly to help populations address historic loss. Coming to grips with loss is a roadmap that conceptualizes the way people navigate the process of loss. It is not a therapeutic approach or intervention technique. Practitioners can use this theory in conjunction with established best practices to help their clients move along the process. Community leaders can use it as a planning tool to help develop disaster restoration strategies. Business managers can use it to ease the process of change management. Human service practitioners can use it to develop effective treatment and service plans. After presenting this material to thousands of people in professional conferences, training sessions, and community education, the participants agreed that this work’s theory meets the grounded theory tenets of fit, workability, relevance, and modifiability in a wide array of applications. People continue to provide more data to the research each time I present the xii

PREFACE

theory to another audience. They continue to find other uses and other fields of study where the theory is relevant. People said they intended to use it with a multitude of populations dealing with various losses, including gang affiliated youth, domestic violence and hospice care workers, youth aging out of the foster care system, elder care service providers, addiction treatment specialists, mental health workers, first responders, and community activists helping to rebuild after political unrest or natural disasters. The common reaction to the presentation of this material to divergent audiences was the same—“We want more detail.” “Where can I get more information, more meat?” This book provides that “meat.” This book presents a theory that is written in a non-pathologizing manner that is intended to help normalize the grief process. It offers a theory on how people come to grips with loss; it is not necessarily a “how to” book. It assumes a level of experience with various therapeutic approaches or leadership expertise on the part of the reader. Readers are expected to use accepted practices in their specific fields to develop plans to aid the people with whom they are working. There are no “one size fits all” solutions to people’s pain—the most effective thing helpers can do is lead those in pain to find their own solutions and their own strengths. Let go of your preconceptions of what people need and let the people you serve lead you to their own path of healing.

xiii

CHAPTER 1

INTRODUCTION TO THE THEORY Coming to Grips with Loss

Then a woman said, speak to us of Joy and Sorrow. And he answered: Your joy is your sorrow unmasked. And the selfsame well from which your laughter rises was oftentimes filled with your tears. And how else can it be? The deeper that sorrow carves into your being, the more joy you can contain. (Kahlil Gibran, 1923/1993, p. 29) When people think of loss, most think of death, dying, and Kubler-Ross. Kubler-Ross devoted her life’s work to the subject of death and dying (1997, 2005), collaborating on her last book from her own deathbed. She developed the well-known five stages of grief: denial, anger, bargaining, depression, and acceptance. Her work was and continues to be the most recognized theory on loss and it is what most people talk about when I present the material in this book. Some audiences seem so conditioned to Kubler-Ross that they try to fit or translate this book’s theory into her model. However, other researchers have contributed their perspectives on dealing with ambiguous loss (Boss, 2000) and complicated grief (Strobe & Schut, 2005). There is also the wonderfully comprehensive Handbook of Bereavement Research (2002). These all address grief due to death, which may or may not be transferable to other loss experiences. The coming to grips theory differs from other researcher’s work in that it explains how people traverse the process of resolving any significant loss. No two people will experience loss in the same manner, nor will the same person necessarily experience loss the same way over time. However, people do appear to approach loss in a similar process consisting of discovering the loss, assessing the impact of loss based on one’s personal life experiences, experiencing feelings related to loss or mourning, and coping—the actions employed to moderate feelings. There are also turning points that help people who may be stuck in some aspect of the process in which they experience a change in perspective that allows them to start moving again. Moving through the entire process of loss feeds back experiences that will alter people’s beliefs about themselves and, ultimately, how they cope with current and future losses. Some people may 1

CHAPTER 1

not enter the process on a deep level, depending on the level of importance ascribed to a particular loss. As people move through the loss process, their perceptions of themselves continue to evolve based on how they navigate the loss process. Recycling through the discovering, assessing, mourning, and coping stages can be an exhausting experience requiring time, energy, and supportive resources that may be underestimated by those in helping relationships or by those engaged in self-care. People will recycle through each of these stages many times before they can ultimately come to grips with the entire loss experience. The process starts with discovering loss (see Figure 1). This discovery or recognition can come from some external source, such as a police report, a diagnosis, or a realization that material goods are missing or damaged. It can also come through an internal realization of illness, a change in heart about a relationship, or a career choice. There are numerous types of loss that people can experience, in both the external or physical world as well as in the mental or emotional world. The type of loss and method of discovery may have an effect on the intensity and duration of emotional upheaval. Participants in this study consistently reported experiencing an initial loss that in turn spawned other cascading losses, each of which had to be processed through the system of coming to grips with loss. In conducting this research, the pattern of cascading losses continued to reveal itself. There was never an instance where one loss was not followed by other related or cascading losses. This is significant in that each newly discovered loss must be assessed, resulting in emotional responses and choices of related coping actions. This process provides continuous feedback to one’s personal life experience. People in helping relationships would do well to understand the impact that cascading losses have on how people move through the process of coming to grips with loss. Exploring this concept with their clients will help everyone involved understand several issues. First, identifying and processing cascading losses allows for a more holistic view of loss and explains the amount of time and energy it takes to complete the process. Secondly, understanding the impact of the related losses aids in prioritizing the development of more effective interventions used to initiate turning points for the client, family, work group, or community. Lastly, it can be a relief for people to understand how cascading losses contribute to the feeling of being overwhelmed, exhausted, and sometimes out of control. Knowing that this is a normal part of the process may encourage them to move forward on the path to completion.

2

Figure 1. Coming to Grips Process Map

INTRODUCTION TO THE THEORY

3

CHAPTER 1

The second stage in the process is assessing loss. This is where people ascribe a level of importance to the loss based on their personal life experiences, possible consequences, impact, scope, and expected duration of the loss. Personal life experiences consist of all aspects of the human condition and have the biggest impact on how people perceive, assign value, experience feelings, and cope with loss. Personal life experiences include the physical, emotional, cultural, and environmental cues to which one is exposed on a regular basis as well as one’s personal history of dealing with previous losses or other stressors. Personal life experiences permeate every stage of the loss process and are the background on which the entire process functions. They are responsible for the most variation in the timing and course of action that people choose to use in addressing loss. Even though the timing and pathway that people take in completing the loss process may vary, the overall process remains the same. The third stage in the process consists of experiencing feelings associated with loss, or the mourning stage. People experience feelings related to loss in response to the level of perceived importance ascribed to the loss, the impact on the individual or group, the availability of resources, and the expected duration of the loss. People’s initial feelings may vary in intensity depending on the way they discovered the loss and the level of importance ascribed in the assessing stage. Feelings ebb and flow as people move through the loss process until they reduce in intensity and duration. The mourning process concludes with a form of reminiscing or a recounting of the incident with a decreasing level of emotional pain or disruption. Coping is the fourth stage and consists of actions or strategies that people employ to help deal with feelings that they experience as a result of loss. These actions contribute to progressive or regressive outcomes. Successful use of coping actions usually results in progress along the healing process, and related positive emotional responses may encourage coping strategies that can continue to move people toward resolution. Conversely, increasing stress, changing conditions, recognizing other losses related to the initial loss, or failing to engage in effective coping actions may result in delaying resolution of the process. This may seem like an overall failure or additional loss. Turning points are actions, contributing factors, or changes that make a difference in the way people view themselves, their ability to affect change, and their outlook on the future. Turning points usually come into play when people experience either difficulties along the way in the loss process or positive outcomes from successful coping strategies. People’s life experiences, feelings related to loss, changing conditions, or their chosen 4


coping strategies may contribute to becoming stuck in an aspect of the process or experiencing regression in coming to grips with loss. This may be a temporary situation while people amass necessary resources or it may be for a longer period of time in a behavioral pattern that may consist of insulating or even self-destructive behaviors. Some significant change or turning point may be required for people to resume movement in the process. Turning points move people out of a stuck position and back into action in either progressive or regressive movement through the loss process. Navigating the full experience of loss is an attempt for people to come to grips with the situation and regain their usual level of functionality. Participants in this research stated that successful completion of the process included three goals in healing from loss: They want to make sense of the loss, they want to integrate the loss into their ongoing life, and, lastly, they want to salvage something positive out of an otherwise painful experience. The result of going through the full process of loss may be the development of a different perspective of one’s self as well as an engendering hope for the future. All of these experiences operate within the context of one’s personal life experiences. Personal life experiences are the filter through which people assign a value to the loss, experience feelings, respond with coping strategies, and modify their assessment of themselves and their abilities as a result of having gone through the process of coming to grips with loss. There is always the possibility that people can become mired down in some aspect of the loss process. People who become stuck in a process that delays resolution of loss may be misdiagnosed with mental health issues. PATHOLOGY OR PROCESS?

This theory of coming to grips with loss was written with careful attention to language, meticulous data analysis, and a specific approach to documentation of the findings. People reported a consistent process of coming to grips with loss. The theory has been presented to thousands of people, and the reaction is the same—relief from self-deriding judgment of one’s grief process. The participants in the study stated repeatedly that they “should” be doing better and have said, “I just have to get over it, and get on with my life.” They have even asked, “What’s wrong with me?” This pressure to perform may be rooted in unrealistic expectations of what it takes to navigate the exhausting process of dealing effectively with loss. There is still the great debate over how people respond to loss and the connection to mental illness when the process does not go as planned on an 5

CHAPTER 1

arbitrarily assigned timetable. People are pathologized, given a diagnosis of depression, or possibly a less threatening label of adjustment disorder, and instructed to take medication and to essentially “get over it.” Fear mongering media would have us believe that the entire population is beset by an epidemic of depression, for which the pharmaceutical industry is the biggest benefactor. The Centers for Disease Control and Prevention website (http://www.cdc.gov/nchs/data/databriefs/db76.pdf) published a study by Pratt, Brody, and Gu indicating that 8% of the noninstitutionalized population over age 12 reported symptoms of depression lasting for two weeks or more, and 1 in 10 Americans in the same age group takes antidepressant medication, with women being 2.5 times more likely to take these medications. Less than one-third of the people taking these medications have seen a mental health professional in the last year. So what does this say about us as a population? Can it really be that simple, that we have lost our ability to deal with normally occurring life stressors or loss? Freud (1957) discussed the difference between mourning and melancholia in many of his works. He stated that mourning, while it is a departure from normal functioning, is not considered pathological. He stated that mourning is a process whereby the mourner detaches from the lost loved one and endeavors to attach to a substitute love over the course of time. He described melancholia as a collapse of the ego whereby the patient sees himself or herself as worthless, unable to achieve goals, and becomes self-abusing. Freud’s work became the standard for framing research on grief work in the psychoanalytical community. Horwitz and Wakefield (2007) trace the ancient history of bereavement back to writings of Hippocrates, Aristotle, Celsius, and Aretaeus, all of whom described the difference between normal and pathological mourning. Nineteenth and twentieth century writers continued the trend of separating normal and abnormal mourning processes. Horwitz and Wakefield also provide a brilliant discussion on the connection between the advent of antidepressants and the pathologizing of normal grief responses. They state: One argument against medicating normal sadness is that it treats as pathological what is actually an inherent and valuable part of the human condition. For thousands of years, people have used religion, spirituality and philosophy to understand how their unhappiness is tied into larger questions about life … Using pills represents an escape from truly confronting life’s problems … The promotion of antidepressants sets forth a view of the self that is feeble and fragile

6


and that requires the continuous intervention and protection of professional experts. (pp. 190–191) Horwitz and Wakefield warn of the current trend of pathologizing loss, a process that has continued to profit the pharmaceutical companies. They outline the history of the study of bereavement from ancient times up to the present day with the publishing of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. This manual was designed primarily for the research community to allow for consistent diagnosis for inclusion in research studies. The practice of separating mourning or depression with and without cause, following Freud’s approach, continued until 1972 when psychiatrists were attempting to improve the credibility of their research with the publication of the DSM-III (1980). This publication was the first to drop the contextual criteria for diagnosing depression. Demonstration of specific symptoms for more than a two-week period would have resulted in a diagnosis of major depressive disorder. Imposing an artificial time limit of two weeks on the mourning process can pathologize a person’s experience of dealing with loss and puts pressure on people to short-circuit the process. This definition of major depressive disorder continued until the most recent version of the DSM-5 was released in 2013. This version does include a small statement on significant loss and the similarities of depressive symptoms, which is certainly an improvement over past versions. Another option for diagnosis is adjustment disorder, which includes the diagnostic criteria of “marked distress that is out of proportion to the severity of intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation,” and is not associated with normal bereavement. Again, bereavement in this case allows only for death of a loved one. While it may be necessary for a health care professional to make a diagnosis in order to bill for supportive services, there is still a stigma for the client. Either of these disorders are likely to result in the health care professional prescribing medications to “take the edge off” the experience. Other therapies may or may not be included, but it seems more than likely not, according to the CDC data. The decision to use medication or not can be a very tricky balancing act. The combination of medicating away emotions, which can help propel people through healing, and pathologizing the normal grief process can result in people not being able to meet the goals vital in coming to grips with loss and participating in a full range of normal human experiences. This book’s theory on loss is offered as another perspective that people can use to normalize the grief process. 7

CHAPTER 2

DISCOVERING LOSS

Every one of us is losing something precious to us. Lost opportunities, lost possibilities, feelings we can never get back again. That’s part of what it means to be alive. (Haruki Murakami, 2005, p. 463) The first stage in the process is discovering loss. This discovery, declaration, or recognition of loss may come from many sources, either as an external statement or as an internal coming to know about one’s feelings, intentions, or expectations. The way people come to know about loss may make a difference in the level of intensity of their initial reaction to loss. Something that comes “out of the blue” may escalate the level of emotional reaction, while a loss that has definite warning signs may help people make emotional preparations. There are also various types of losses that people may experience, but, despite the variation, people reported a similar resolution process. Losses may be expected or unexpected, gradual or immediate, internal or external, personally experienced or vicariously experienced. They may be permanent or temporary, and they may be experienced by one person alone or by many others who may be mutually affected. Experiencing something positive can also result in loss. Choosing to follow a course of action can also result in the loss of other options. Loss can be a relief as when someone struggles through an illness and finally succumbs to the inevitable. There is a cyclical pattern of discovering other facets or cascading losses, assigning a value, experiencing feelings associated with loss, choosing a coping strategy, and assessing the results of each loss cycle or iteration of the process. Recycling through the cascading losses was a vital concept that people coming to grips with loss needed to recognize. Seeing this as a normal part of the process was a relief to people struggling with loss as well as to people engaged in helping relationships. It explains why people expend so much time and energy trying to either resist or resolve loss. The following sections provide more detail on methods of discovery and types of loss.

9

CHAPTER 2

EXTERNAL SOURCE

Discovery of loss may come from an external source such as a police report, medical diagnosis, management decision, or declaration from a spouse. An externally discovered loss that comes as a shock to the recipient may involve an intense emotional reaction of powerlessness, rage, or feeling victimized. There may be a more profound effect on the recipient if a loss is announced publicly or becomes known to others whom the recipient holds in high regard. People who have just been informed about a disastrous event may have an immediate and overwhelming need to be with others who are also affected by the event. They may feel that they want to do violence to the person or agency delivering the information regarding the situation. In this study, a participant whose job was eliminated due to budget cuts stated that he was shocked to find that his job was the one eliminated, because he worked with a team of people to analyze the situation and make recommendations for budget modifications. He stated that he was so enraged by what he saw as a betrayal that he wanted to do physical violence to the people involved in the announcement. The announcement of loss may also include other elements of danger. It can happen so quickly that people may have only a very short amount of time to think about how they will get themselves out of a very dangerous situation, such as in a robbery, assault, or accident. One participant recounted being robbed at knifepoint; another talked about coming home to find her apartment burglarized and not knowing if the person was still in her home. INTERNAL SOURCE

An internal announcement or realization is something that people perceive from within themselves. The participants in this study discussed examples of gradually coming to know themselves, as in recognition of a statement of faith, sexuality, illness, or commitment to a goal or relationship. People who are coming to recognize these situations may acknowledge that they are behaving in a manner that is not congruent with their expectations or hopes for themselves or that violates their personal values. It may also be the recognition of personal limitations or of a characteristic that was never acknowledged. This recognition may involve feelings of shame and alienation, which may make it more difficult to connect with others who can help with the mourning and coping processes. The depth of this loss may be a fundamentally shattering crisis that can affect people’s entire lives, including what they think of themselves and their sense of personal 10

DISCOVERING LOSS

identity. A participant stated that he worked with young men in an urban city while he was studying in the seminary. He stated that these young men lived in desperate poverty, and he hoped that his work would help them improve their circumstances. He said that he was becoming overwhelmed by the desperation and deprivation. He explained, “Whenever I thought I was getting somewhere with someone, the bottom would fall out. Something tragic would happen, and they would disappear.” He said that the environment of continual desperation was too emotionally exhausting for him to continue his work there. He stated that he had a spiritual crisis and lost his faith in God. He felt that the problems of the world were just so overwhelming for him that it took him several years to work through regaining his faith. He also stated that, in retrospect, he came to understand that he was becoming depressed, a condition that is common in his family, and that it continues to be a struggle in his ongoing life. TYPES OF LOSS

The type of loss did not make a significant difference in the way people moved through the process. People reported a wide array of losses that were consolidated into a selection of types of loss. The most significant concept was cascading loss. Cascading Loss Every participant in this research study stated that they experienced multiple losses initiated by a primary loss. This concept of cascading losses refers to a series of related losses that may not be recognized or even experienced in the initial iteration of the loss process. Cascading loss is the concept that explains why it takes so much time, energy, and resources to navigate the loss process. These cascading losses may start out as an external loss that creates a series of related internal losses. When people lose some physical ability, they may also lose the respect of others, career choices, plans for the future, or their own sense of dignity. To admit a personal limitation may also result in the loss of independence or self-esteem. Several participants in the study who were dealing with the loss of physical abilities stated that they felt that they were not “seen” or taken seriously by others, especially professionals who thought they knew what was best for the people involved. One participant discussed the impact that his physical loss had on his career options, something in which he was passionately engaged in prior to his accident. He also discussed the loss of his sense of independence, identity, 11

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and sexuality, as well as the loss of relationships with his family and romantic partner and his plans for the future. People recovering from addiction reported losing their identity as an addict when they got sober. They also said they lost coping mechanisms, friends, a type of lifestyle, family members who may have been invested in supporting the addictive lifestyle, jobs, homes, and ways of relating with other people. They talked about the crushing vulnerability and desperation they experienced when they were asked to give up alcohol or other drugs. Until they were able to develop effective coping skills and sober life skills, they remained at risk for relapse. Each of these cascading losses was dealt with via the discovering, assessing, mourning, and coping processes in a recycling manner before people reported feeling closure in the loss process. Dealing with these cascading losses may take varying amounts of time, depending on how people move through these processes, the emotional and physical resources available to them, and their motivation to complete the process. Expected vs. Unexpected Expected losses are those that can reasonably be anticipated given the circumstances and conditions in which people live, work, or recreate. In an expected loss, the mourning process may start before the actual loss occurs. This may give people some time to experience the feelings associated with the loss and initiate coping strategies that will allow the process of coming to grips with the loss to be less traumatizing. Participants in the research stated that expected or planned losses offered more of a sense of control for people incurring the loss. The fact that this was an expected event reduced the anxiety that people experienced and gave people time to make adjustments to deal with the situation. People who have experienced a similar loss in the past stated that they had less of an emotional reaction to another occurrence of a similar event. Other participants stated that an impending loss created more fear and anxiety, because they felt powerless to stop what they knew was ahead. The anticipation of loss was harder for some people to deal with than not knowing what was coming. Unexpected losses are events that cannot reasonably be anticipated and come as a surprise. These types of losses may have a consistent component of shock and loss of control associated with them. As a result, unexpected losses may be more initially traumatic to the people experiencing the loss. Participants in the research discussed examples of theft, suicide, accidental injury, death, and job loss.

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A loss can also start out as something that is planned or expected, but a turn of events may result in a loss of control over the timing or other aspects of the event. One woman who was interviewed for this project discussed her experience with elective surgery that had unforeseen complications. These complications turned something that she felt she had some control over into an event consumed with fear, stress, and anxiety. Impending Doom There may be situations where a person instinctively knows that something terrible is about to happen. It might be because officials are present in places where they normally would not be; it might be the expression or tone of voice that a person exhibits; or, it might be that something in the physical surroundings is just not right. People may notice something out of the norm about a situation, but they still move ahead with it anyway. There may be clues that something is definitely wrong in a situation, but the person has not been able to put it together to see what the problem is. Participants reported a heightened awareness of their surroundings and almost visceral “knowing” that something was about to happen. They reported being on edge until the discovery was complete and they could start the process of dealing with the situation. External vs. Internal External losses may be easy to recognize by anyone involved in the situation. External losses may have physical or material characteristics that may make it easier for other people to take more seriously and respond to than internal losses. External losses may engender more sympathy or support by other people in helping relationships. Some external losses examined in this research project included theft of material goods, loss of a job or physical abilities, loss of a position in a community or of a significant relationship, and suicide or death of a loved one. Internal losses may be less tangible and harder to identify, especially in the initial stages. These losses may only be known to people experiencing the loss and may only be known to others if people choose to reveal them. There is a multitude of internal losses that people may experience, all having characteristics of an emotional state of being or a conceptual ideal. Examples included the loss of peace, freedom, self-esteem, perception of social status, faith, privacy, identity, companionship, familiarity, comfort, security or safety, independence, emotional connection, respect, belief systems, love, self-sufficiency or choices, and many others. Internal losses 13

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may very often be the result of an external loss. Several participants discussed their divorces. They cited all the internal losses that resulted from divorce—sense of identity as part of a couple, mutual friendships, financial security, future plans, and loss of a belief in their ability to connect in a loving manner with another partner. Gradual vs. Immediate A gradual loss is something that happens over time in steps or by degrees. It may happen in a somewhat predictable manner or not. A loss may be a long-term eroding of abilities, conditions, or attributes. The loss may be ignored until some recognition or turning point forces one to focus on the situation. The person affected by the loss may not realize the gravity or impact of the loss until some time elapses or some outside condition brings it to their attention. The loss could involve a relationship with another person; a physical, cognitive, or emotional state of being; or a variety of other situations. The research data cited an incident where the gradual loss of physical abilities after an accident went unacknowledged until the person found that he was unable to make any further progress in his physical therapy. It was at that point that the man had to acknowledge his loss in a very real sense to himself and others, and the processes of mourning and coping began. In contrast to a gradual loss, an immediate loss is something that happens in a short interval or amount of time. The data showed that there was an element of shock, powerlessness, or fear involved in an immediate loss. Examples of an immediate loss were accidents, natural disasters, rape, theft, or other physical events. Permanent vs. Temporary A permanent loss is something that is not likely to change. It is a continuing or enduring condition without fundamental or marked change. It may be the loss of something material that is irreplaceable, or it could be the loss of some ability or condition. Some examples from the data included death, loss of jobs, theft of material goods, and loss of physical abilities due to accidents or disease. A temporary loss is something that could reasonably be expected to last for a limited amount of time. Knowing that a loss is temporary may encourage people to work through issues that might overwhelm them if they thought the loss would be permanent. People can also opt to ignore an issue if they think it will be temporary. People going through a temporary 14

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loss may feel that they just have to “muscle through” the situation in order to cope. Participants in the research stated that knowing the loss was temporary sometimes gave them the courage, motivation, and tenacity to keep working at the healing process. People who were involved in physical therapy after an accident, stroke, heart attack, or surgery stated they were able to persist through a difficult or painful period of time knowing their efforts would result in regaining some physical ability that was temporarily lost. Other participants stated they had a tendency to ignore temporary losses and not deal with the situation; they merely waited it out. They reported a residual effect of this practice. They stated that they might have been more prone to ignoring their feelings and self-care. They reported being “short,” easily frustrated, and some even had physical symptoms of stress-related health issues. Direct vs. Vicarious Losses can be directly experienced or vicariously experienced. A direct loss is something that specifically affects people experiencing the loss. Vicarious loss is when people identify so strongly with someone else’s loss that they suffer the emotional effects from a loss that they did not personally experience. Some people may know others in situations similar to their own who have experienced a loss. Identifying with others so strongly may cause them to think that, aside from chance circumstances, a similar experience could happen to them. This commonality may give people experiencing vicarious loss the ability to identify with what they think the other person may have been feeling. They may experience the emotional effects as if they had personally experienced the loss. One example comes from Dixon’s (1991) case study on sailors who experienced symptoms of post-traumatic stress disorder after the loss of a ship in a storm on the English Channel. Even though they did not know those who died, 17 crewmembers from other ships became so debilitated by the loss that they had to change careers or stop working all together. Recognizing and legitimizing vicarious loss may be a very difficult process. As with internal loss, people experiencing vicarious loss, and those in helping relationships, may not recognize the root of the pain, which is vital to starting the healing process. Mutual Loss Mutual loss is when one person’s loss creates loss for others. One person’s loss may result in the loss of security, future plans, or hopes for other 15

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people. The initial loss may result in a change for several other people as they all adapt to the loss. People who feel responsible for the initial loss may feel guilt, sorrow, anger, or other emotions, and they may have to perform some coping activities to deal with their own loss as well as the effect on others. People who lost their jobs and had others who were dependent on them talked about causing others to lose their sense of safety and financial security. The person losing the job had to deal with feelings not only related to their own loss, but also related to causing fear or pain for others. Another variation of mutual loss is when one person’s loss may be seen as a negative reflection on another person. Several participants in the research noted that when a child suffered a loss of material goods or personal safety, the parents felt that they should have been able to prevent the situation. The parents stated that they felt that they lost stature in the family or community because of the child’s loss. Other participants talked about their loss of the potential for grandparenthood when a child announced that they are gay. Partners of disabled spouses talked about their multitude of losses related to the changing future with their spouse. Making a Choice Deciding on a course of action can also result in a loss of perceived future benefits from other options. People reported feeling that making a choice to follow one path resulted in feelings of loss for other options, especially if there was some stress experienced with the choice or if the choice did not work out as expected. Residual resentments may affect how people feel in the current situation, which can lead to a spiraling effect of bringing on more resentment and less productivity, thereby making the decision seem less palatable. Participants also reported ruminating on what could have been if the choice was made in favor of a different option. People may choose a career or marriage that they are not confident is right for them but stay in the situation because of the amount of time, money, emotional investment, or expectations from others. They may look back on their decision and wonder how their life might have been different if they had made a different choice. Several participants stated that they questioned their decisions of career choice or marriage partner when their long-term hopes or expectations were not met. They discussed their rumination on what could have been if they had made a different choice as they decided to either leave their situations or try to reconcile themselves to the loss of hopes connected to their choices. Even if their choice was good, they still stated that they played the “what if” game. 16

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Positive Loss Positive loss is something that people may have worked towards, hoped for, or a change that people planned on making. This still can be considered a loss. Even a positive loss can include some downstream or cascading losses that can take people by surprise. Moving to a new home or starting a new job can result is mourning the loss of the old situation. Positive changes in health can bring alterations to one’s body that people will need to adjust to. People going through physical therapy stated that they tried to keep focus on the positive changes and of regaining the functionality they were experiencing, but they also had to deal with the loss of other functionality or the appearance of parts of their body. People who lost a large amount of weight rejoiced in their success but reported having to deal with the resulting changes in the physical appearance of their body. Loss as a Relief Several participants talked about loss as a relief. This could be related to the death of a loved one who suffered from a terminal illness, the loss of a job that what overwhelming, or the loss of some responsibility that was too difficult to carry. Several participants stated that they felt guilty or ashamed at feeling relieved and did not talk about it with anyone. Bearing their feelings in silence may keep people from connecting with helping resources who could help see that this can be a normal part of the healing process. This was especially true when familial or cultural expectations dictated behavior that was in conflict with how the person was actually feeling about the loss. Unresolved Loss There were several instances where people had not completed the process in dealing with previous losses. The level of vulnerability to stress and becoming overwhelmed may be related to people’s ability to move effectively through the cycles of mourning and coping with loss in a complete manner. People may come to realize in the process of dealing with a current loss that they must go back in time and process unresolved feelings about past loss experiences. These unresolved feelings might still have an impact on people’s current living situation, relationships, and their ability to move through the current loss process in a manner that allows for completion. Identifying, assessing, mourning, and coping with the cascading losses from the past may be helpful in resolving current losses. 17

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Each of the losses must be acknowledged, evaluated based on one’s personal life experiences, and processed through the discovering, assessing, mourning, and coping stages of the loss process. Acknowledging situations, conditions, and feelings related to previous loss can contribute to more compassion and healing for current loss. Several participants in the study stated that it was important for them to deal with loss as completely as possible so that other losses did not trigger unresolved grief. They stated that unresolved issues combined with the emotional reaction to new losses magnified the feelings that resurfaced years later. One participant stated that feelings still existed for him, even though he could not readily remember the events connected to the feelings. Another participant stated that she knew that her reaction to having her car broken into was more extreme than the situation warranted. She talked about feeling unsafe in her home, and she developed safety rituals that she finds disturbing but is not able to let go of yet. SUMMARY

Various ways of discovering loss may have significantly different effects on people experiencing loss. Acknowledging the implications that come with loss may help to normalize people’s experience of moving through the loss process. Understanding that one loss always results in discovering other related losses might explain why going through the healing process takes so much time and energy. A confirmation of the magnitude of what loss can entail may be comforting to people as they attempt to navigate the loss process. Conversely, examining all aspects of cascading or related loss can be overwhelming, resulting in regression in the process. People engaged in self-care can benefit from working with other healthy, supportive people. Those engaged as a helping resource can assist others by reminding them that this is a normal part of the process. They can help people prioritize what needs to be addressed and when. Lastly, they can keep track of cascading losses that may be forgotten or ignored, thus capturing the whole picture of what can seem overwhelming to people working their way through the loss process. Despite the variation in types of loss, people in this research study seemed to move along a similar path in attempting to come to grips with their losses. Some of the participants were satisfied that they were able to complete the process, others delayed their process and some never did complete the process and continue to be mired down in their suffering. There is an example in the Coping chapter where a woman describes her experience of losing a child while she was in active addiction. She moved 18

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along the same path to resolution, even though many years had elapsed between the event and processing the loss. She insulated herself against the feelings associated with the loss for 18 years until a turning point got her moving again on the path to resolution. In spite of the delay in her process, it was still similar to others who never took that “time out.” Other participants had not come to grips with their losses as of the conclusion of the research project; some may never come to full resolution of a particular loss. INTEGRATION ACTIVITIES

1. Pick a loss that you have experienced. Write about how you discovered it. Describe the surroundings and what led to the discovery. How did the way you discovered the loss influence your assessment of the loss? Share your writing in a small group with other study partners. 2. In your own experience, how have others reacted to some internal loss that you have experienced? Were they able to identify with your loss and support you? Did they downplay your loss, thereby making your process of coming to grips with loss more difficult?

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