Grief Work with Older Adults
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GerontologyA Training Resource By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Losses Older Adults Experienced in their lives which impact them in later years
(Messina, 2023:Tools For Handling Loss at: http://www.coping.us/toolsforhandlingloss.html)
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Having an “abnormal” childhood Loss involved: Loss of the childlike experiences due to the need to grow up too soon, taking on an adult role prematurely.
Being unable to make it better in a new family Loss involved: Loss of the expectation or desire for things to be better in the new nuclear family than they were in their own family of origin; since trans-generational destructive patterns re-emerge.
Living in an ”abnormal” or “dysfunctional” family Loss involved: Inability to achieve their fantasy or the dream expectation of “normal” family life while in their family of origin.
Having an unhappy, nonproductive marriage Loss involved: Loss of the expectation of a happy, “normal” marriage when they confront the realities of the present or past marriage.
Having other than “normal” healthy children Loss involved: Loss of the expectation of having children who are going to be better off than they were. When their children have ill health, a developmental disability, or have emotional or behavior problems, they grieve even more.
Death of a spouse or child Loss involved: Loss of the loved one who was going to help them make their life better
Death of a parent Loss involved: Losing the chance to make it right and get close to parent. Continued feelings of neglect, hurt, of not being “good enough” to get parent's attention, recognition, approval.
Divorce Loss involved: Loss of the “ideal” marriage that was going to make things better. Loss of the idea of and hope for a lifelong partner.
Financial troubles Loss involved: Loss of self-respect. Belief that one should provide financial security for self, spouse, and family is shattered.
Loss of job, failure of private business or failure in school Loss involved: Loss of trust in self and others. Belief that one should provide a source of financial security or high-grade point average for family is shattered.
Realization that stressful families of origin influence their current behavior Loss involved: Loss of comfort in memories of the past. Thoughts of the past become colored with the realities of delusion and denial present in families of origin.
Confrontation of addictive behavior in their lives (e.g., alcohol, drugs, gambling, food, shopping, sex) Loss involved: Loss of ability to hide behind the denial and delusion that things in their lives were “normal.” Destructive patterns become clear
Entering a treatment or rehabilitation program Loss involved: Loss of privacy, loss of being able to continue with non-confronted denial, repression, or delusional behavior.
A family member enters a treatment program and responds well to the program Loss involved: Loss of expectation of problem behavior of person as being “normal” or characteristic of the person; loss of predictability of the person's behavior. Realization that “family secrets” are out in the light to others as a result of the family member’s recovery process.
Occurrence of natural disaster or accident Loss involved: Loss of property, health, and security in things, people, or life.
Physical or mental illness in family Loss involved: Loss of expectation of natural course of events for self and others. Family life turned upside down.
Lack of recognition for accomplishments on the job, at school or in the community Loss involved: Loss of belief in their own self-worth and loss of incentive to continue trying. Reinforcement of the feeling that no matter what they do, it is not “good enough ”
Realizing their loss of productivity on the job as they grow older Loss involved: Loss of self-worth and meaning based on the belief that their worth is built solely upon what they do on the job or for others.
Older children move out of the house Loss involved: The “empty nest” is a sign of their no longer being needed, and they lose the “meaning” gained for themselves by rearing their children.
Retirement Loss involved: Loss of self-worth and meaning of life based on their “work” which was their sole identity.
Being personally moved into a Residential Treatment Center for either Independent Living, Assisted Living, Memory Unit or Nursing Home Loss Involved: Loss of independence and often personal identity due to being labeled as needing 24 hour care away from one’s personal home and/or family.
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What are the stages of the loss process?
A loss experience involves the following five stages of emotional response: (1) denial, (2) bargaining, (3) anger, (4) despair, (5) acceptance.
- These five stages can occur in either the sequence presented or in any variety of sequence.
- The stages do not present themselves in order or sequentially
- The stages can occur concurrently and unexpectedly
- The stages can recur during a loss experience.
- One stage can last a long time, uninterrupted.
- The loss process can last anywhere from three months to three years and in some situations for a lifetime
- These stages of grief are normal and are to be expected.
- It is healthier to accept these stages and recognize them for what they are rather than to fight them off or to ignore them.
- Working out each stage of the loss response ensures a return to emotional health and adaptive functioning.
- Getting outside support and help during the grieving process will assist in gaining objectivity and understanding
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Grief’s Stage 1 Denial
People deny that the loss has occurred.
People ignore the signs of the loss.
People begin to use:
- Magical thinking- By magic this loss will go away.
- Excessive fantasy - Nothing is wrong; this loss is just imagined; when I wake up everything will be OK.
- Regression - People feel childlike and want others to reassure us that nothing is wrong.
- Withdrawal - People avoid facing the loss and avoid those people who confront us with the truth.
- Rejection - People reject the truth and those who bring us the news of our loss.
Grief’s Stage 2 Bargaining
People bargain or strike a deal with God, themselves, or others to make the loss go away.
People promise to do anything to make this loss go away.
People agree to take extreme measures in order to make this loss disappear.
People lack confidence in their attempts to deal with the loss, looking elsewhere for answers.
People begin to:
- Shop around - They look for the “right'' agent with the “cure'' for their loss.
- Gamble - They begin to take chances on “cures'' for their loss.
- Take risks - They put themselves in jeopardy financially, emotionally, and physically to get to an answer or “cure'' for their loss.
- Sacrifice - In their pursuit of a “cure'' to change the loss they ignore their real needs
Grief’s Stage 3 Anger
People become angry with God, with themselves, or with others over their loss.
People become outraged and incensed over the steps that must be taken to overcome their loss.
People pick out “scapegoats" on which to vent their anger, e.g., the doctors, hospitals, clerks, helping agencies, rehabilitation specialists, etc.
People begin to use:
- Self-blaming - They blame themselves for this loss.
- Switching blame - They blame others for this loss.
- Blaming the victim - They blame the victim for leaving them.
- Aggressive anger - They vent their blame and rage aggressively on the closest target.
- Resentment - Their hurt and pain turns into resentment toward those involved in their loss event including the victim.
NOTE: Anger is a normal stage. It must be expressed and resolved; if it is suppressed and held in, it will become “Anger in” leading to a maladaptive condition of depression that drains people’s emotional energy.
Grief’s Stage 4 Despair
People become overwhelmed by the anguish, pain, and hurt of our loss; they are thrown into the depths of their emotional response.
People can begin to have uncontrollable spells of crying, sobbing, and weeping.
People can begin to go into spells of deep silence, morose thinking, and deep melancholy.
People can begin to experience:
- Guilt - People feel responsible for their loss.
- Remorse - People feel sorry for their real or perceived “bad past,'' deeds for which this loss is some form of retribution or punishment.
- Loss of hope - The news of their loss becomes so overwhelming that People lose all hope of being able to return to the calm and order their life held prior to the loss.
- Loss of faith and trust - This loss can make People lose and trust their belief in the goodness and mercy of God and mankind.
People need support to assist them in gaining the objectivity to reframe and regroup their lives. If People are not able to work through their despair, they risk experiencing events such as mental illness, divorce/separation, suicide, inability to cope with the aftermath of their loss, rejection of the family member who has experienced the loss, and detachment, poor bonding, or unhealthy interaction with the parties involved in their loss.
Grief’s Stage 5 Acceptance
People begin to reach a level of awareness and understanding of the nature of their loss. They can now: 1. describe the terms and conditions involved in their loss, 2. fully describe the risks and limitations involved in the treatment or rehabilitation for the loss involved, 3. cope with their loss, 4. test the concepts and alternatives available to them in dealing with this loss, 5. handle the information surrounding this loss in a more appropriate way.
People in the Acceptance Stage begin to use:
- Rational thinking – People are able to refute their irrational beliefs or fantasy thinking in order to address their loss from a rational perspective.
- Adaptive behavior - People begin to adjust their lives to incorporate the changes necessary after their loss.
- Appropriate emotion – People begin to express their emotional responses freely and are better able to verbalize the pain, hurt, and suffering they have experienced.
- Patience and self-understanding - People recognize that it takes time to adjust to the loss and give themselves time to “deal” with it. They set a realistic time frame in which to learn to cope with their changed lives.
- Self-confidence - As people begin to sort things out and recognize the stages of loss as natural and expected, they gain the confidence needed for personal growth.
People can be growing in acceptance and still experience denial, bargaining, anger, and despair. To come to full acceptance, they need support to gain objectivity and clarity of thinking. It is often useful to gain such assistance from those who have experienced a similar loss. For example, groups of parents who have experienced the death of a child or who have had a child with a developmental disability. Peer support from strangers is often the best way for a person to deal with the grieving process.
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Overview of Prolonged Grief Disorder
Although the concept of pathological grief dates back at least as far as Freud’s “Mourning and Melancholia”, there has been opposition to its recognition as a distinct mental disorder. Resistance has been overcome by evidence demonstrating that distinctive symptoms of prolonged grief disorder (PGD) – an attachment disturbance featuring yearning for the deceased, loss of meaning and identity disruption – can endure, prove distressing and disabling, and require targeted treatment. In acknowledgement of this evidence, the American Psychiatric Association Assembly has recently voted to include PGD as a new mental disorder in the DSM-5-TR. (Prigerson et al., 2021)
This research also found that the DSM-5-TR PGD diagnosis was distinct from post-traumatic stress disorder major depressive disorder and generalized anxiety disorder. Temporal stability was remarkable for this diagnosis (Prigerson et al., 2021).
This research also found that PGD symptoms were significantly associated with symptoms and diagnoses of major depressive disorder, post-traumatic stress disorder and/or generalized anxiety disorder, suicidal ideation, worse quality of life and functional impairments at baseline(Prigerson et al., 2021).
Overall, the DSM-5-TR criteria for PGD and the PG-13-R both proved reliable and valid measures for the classification of bereaved individuals with maladaptive grief responses.
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Dealing with Complicated Grief
Losing a loved one is one of the most distressing and, unfortunately, common experiences people face. Most people experiencing normal grief and bereavement have a period of sorrow, numbness, and even guilt and anger. Gradually these feelings ease, and it's possible to accept loss and move forward.
For some people, feelings of loss are debilitating and don't improve even after time passes. This is known as complicated grief, sometimes called persistent complex bereavement disorder. In complicated grief, painful emotions are so long lasting and severe that people especially aging seniors have trouble recovering from the loss and resuming their own life.
Different people follow different paths through the grieving experience. The order and timing of these phases may vary from person to person:
- Accepting the reality of one’s loss
- Allowing oneself to experience the pain of their loss
- Adjusting to a new reality in which the deceased is no longer present
- Having other relationships
These differences are normal. But if aging seniors are unable to move through these stages more than a year after the death of a loved one, they may have complicated grief. If so, they need to seek treatment. It can help them to come to terms with their loss and reclaim a sense of acceptance and peace (Mayo, 2022).
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Signs and symptoms of complicated grief
Signs and symptoms of complicated grief of aging seniors may include:
- Intense sorrow, pain and rumination over the loss of their loved one
- Focus on little else but their loved one's death
- Extreme focus on reminders of the loved one or excessive avoidance of reminders
- Intense and persistent longing or pining for the deceased
- Problems accepting the death
- Numbness or detachment
- Bitterness about this loss
- Feeling that life holds no meaning or purpose
- Lack of trust in others
- Inability to enjoy life or think back on positive experiences with their loved one (Mayo, 2022)
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Complicated grief may be indicated if Aging Seniors
- Have trouble carrying out normal routines
- Isolate from others and withdraw from social activities
- Experience depression, deep sadness, guilt or self-blame
- Believe that they did something wrong or could have prevented the death
- Feel life isn't worth living without their loved one
- Wish they had died along with their loved one (Mayo, 2022)
Risk factors for Complicated Grief
It's not known what causes complicated grief. As with many mental health disorders, it may involve one’s environment, personality, inherited traits and one’ body's natural chemical make up.
Complicated grief occurs more often in females and with aging seniors. Factors that may increase the risk of developing complicated grief include:
- An unexpected or violent death, such as death from a car accident, or the murder or suicide of a loved one
- Death of a child
- Close or dependent relationship to the deceased person
- Social isolation or loss of a support system or friendships
- History of depression, separation anxiety or post-traumatic stress disorder (PTSD)
- Traumatic childhood experiences, such as abuse or neglect
- Other major life stressors, such as major financial hardships (Mayo, 2022)
Unintended Consequences of Complicated Grief
Complicated grief can affect aging seniors physically, mentally and socially. Without appropriate treatment, complications may include:
- Depression
- Suicidal thoughts or behaviors
- Anxiety, including PTSD
- Significant sleep disturbances
- Increased risk of physical illness, such as heart disease, cancer or high blood pressure
- Long-term difficulty with daily living, relationships or work activities
- Alcohol, nicotine use or substance misuse (Mayo, 2022)
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DSM‐5‐TR criteria for prolonged grief disorder
(American Psychiatric Association, DSM-5-TR Update, September 2022}
A. The death, at least 12 months ago, of a person who was close to the bereaved (for children and adolescents, at least 6 months ago).
B. Since the death, there has been a grief response characterized by one or both of the following, to a clinically significant degree, nearly every day or more often for at least the last month:
1. Intense yearning/longing for the deceased person
2. Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death)
C. As a result of the death, at least 3 of the following 8 symptoms have been experienced to a clinically significant degree since the death, including nearly every day or more often for at least the last month:
1.Identity disruption (e.g., feeling as though part of oneself has died)
2.Marked sense of disbelief about the death
3.Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders)
4.Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
5.Difficulty with reintegration into life after the death (e.g., problems engaging with friends, pursuing interests, planning for the future)
6.Emotional numbness (i.e., absence or marked reduction in the intensity of emotion, feeling stunned) as a result of the death
7.Feeling that life is meaningless as a result of the death
8. Intense loneliness (i.e., feeling alone or detached from others) as a result of the death
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration and severity of the bereavement reaction clearly exceeds expected social, cultural, or religious norms for the individual’s culture and context.
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Description of Prolonged Grief
- Grief is a common, normal human emotion, and a natural reaction to loss.
- Grief affects everyone differently, It may be difficult to concentrate, perform normal activities, or sleep may be impaired. There may also be intense waves of different emotions or feeling intensely overwhelmed.
- Grief typically resolves within 6 to 12 months, but some people may continue to experience the symptoms of grief and develop prolonged grief disorder.
- Over time, they may see a decline in physical, emotional, or spiritual health. Symptoms of prolonged grief disorder include emotional numbness, intense emotional pain and loneliness, identity disruption, and disbelief about the person’s death.
- Grief can completely derail functioning. It is not linear and often shows up in unexpected ways. (Ries, 2022)
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Contrast between PTSD and Prolonged Grief Disorder
As both diagnoses of PTSD and Prolonged Grief Disorder are categorized as trauma and stressor-related disorders in the DSM-5 TR, they have some degree of overlap. However, distinguishing features exist.
For example:
- the predominant emotion in PTSD is fear, whereas yearning and sadness are more common in prolonged grief disorder
- the content of intrusive thoughts in PTSD is related to the traumatic event; in prolonged grief disorder, the content is related to the circumstances of the death, although this content may overlap in the case of a violent or accidental death.
- avoidance in PTSD is typically related to safety concerns or reducing potential threat, whereas avoidance in prolonged grief disorder is related to avoiding painful reminders of the loss and its permanence.
- the presence of hyperarousal and hypervigilance has been more typically associated with PTSD, whereas challenges reengaging in life without the deceased (e.g., meaninglessness, wish to join the deceased, loneliness) are associated with prolonged grief disorder (Szuhany, 2021)
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Cognitive behavioral therapy used with Aging Seniors dealing with their Grief
Cognitive behavioral therapy (CBT) is a common treatment approach for mental health conditions like depression, anxiety, and post-traumatic stress disorder (PTSD).
During a CBT session, the therapist will help Aging Seniors identify negative thought patterns that can affect their behaviors. The therapist will look for symptoms like PTSD including :
- reexperiencing the traumatic event
- avoidance
- feeling emotionally numb
- hyperarousal
The therapist may ask the client to explore thoughts related to grief and loss or other unhelpful thoughts to address how these thoughts affect their mood and behavior. This can help Aging Seniors lessen the impact with strategies such as reframing, reinterpreting, and targeting behaviors. (Orentas, 2021)
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Acceptance and commitment therapy helps Aging Seniors with Grief and Loss
ACT may also be helpful with prolonged, complicated grief by encouraging clients to use mindfulness to accept their experience.
ACT uses the following six core processes for grief counseling:
- Acceptance of negative emotions. This step involves a willingness to experience and accept negative emotions and thoughts.
- Cognitive defusion. This process involves distancing from emotions so that it’s easier to examine and understand them.
- Contact with the present moment. By teaching mindfulness, ACT encourages people to focus on the present as that is when change is possible and when they experience life.
- Self as context. This step involves observing oneself having one’s own experiences or becoming an observer of the experiences in their own life.
- Values. These are the principles people hold that helps direct their lives.
- Committed action. The culmination of ACT, this step involves taking action and overcoming obstacles by working through the previous steps. (Speedlin et al., 2016)
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References on Helping Aging Seniors with Grief
American Psychiatric Association (2022), DSM-5-TR Update, Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Psychiatric Association Publishing, 800 Maine Ave. SW, Suite 900, Washington, DC 20024-2812.
Prigerson, H.G., Boelen, P.A., Xu, J., Smith, K.V., Maciejewski, P.K. (2021). Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry 20, 96–106.
Reynolds, C.F. (2017). Evidence-Based Treatment and Prevention of Major Depressive Episodes in Later Life. In Halter, J.B., Ouslander, J.G., Studenski, S., High, K. P., Asthana, S., Supiano, M.A., Ritchie C. (Eds.). Hazzard’s geriatric medicine and gerontology (7th ed., pp.1071-1088). Essay. McGraw-Hill Education Medical.
Shear, K., Frank, E., Houck, P.R. & Reynolds , C.F. (2005). Treatment of complicated grief. JAMA, 293(21), 2601
Szuhany, K.L., Malgaroli, M., Miron, C.D., Naomi, B.A., & Simon, M. (2021). Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. Psychiatry Online Focus. https://doi.org/10.1176/appi.focus.20200052
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