These words, spoken by a client dealing with death are typical of statements I have heard over the years in my work as a certified massage therapist. Oftentimes people come to us for massage when they are experiencing the stress of loss in their lives. Whether the loss is through death, divorce, or other significant life changes, we find ourselves in the role of supporting them through these challenging times. We can be most helpful by understanding some of the basics of the normal grieving process, as we allow our clients a safe haven in their time of need.
Beginning in 1990, I facilitated hospice bereavement support groups for 12 years. What I learned in that time, as I listened to people of all ages and backgrounds share their stories, has personally enriched my life and significantly informed my practice of massage. I grew to appreciate the perspective, fostered by the hospice movement, that bereavement is a natural, normal process—an integral part of life. With education to help people understand the process, along with social and emotional support, we can all become wiser, more compassionate, and happier individuals.
This study of bereavement has strengthened my understanding of losses associated with acute and chronic illnesses, aging, and other physical and psychosocial life changes. I’ve found that human beings are amazingly resilient and adaptable, all the more so with support from friends, family, and conscientious health-care professionals, including massage and bodywork practitioners.
Understanding Grief as a Response to Loss
Bereavement is most often thought of as the mourning of a death. But the process of grieving can be applied to many other life-changing events, including disability, divorce, job loss, financial loss, or other changes in physical circumstances or relationships. Aging, itself, is a process involving many changes, including losses for which a person may grieve. A person living with chronic illness or disability may undergo an extensive process of grieving over the loss of health or function.
Whether a loss is sudden and specific, as with a death, or prolonged, as with a gradual loss of function owing to illness, it is normal for the individual to move through a range of responses and reactions. While Sigmund Freud pioneered the study of bereavement in his essay “Mourning and Melancholia,”1 written in 1917, it was psychiatrist Elizabeth Kubler-Ross who advanced the study of bereavement in relation to the dying process. In her groundbreaking book On Death and Dying,2 published in 1969, she proposed five psychological stages of dying: denial, anger, bargaining, depression, and, finally, acceptance. Her passionate commitment to ease the psychological as well as physical suffering of the ill and dying compelled her to work to bring about awareness of these issues within mainstream medicine and psychology. Her work paralleled the growing hospice movement, which sought to bring compassion and dignity to the terminally ill.
British psychiatrist John Bowlby’s study of attachment behavior in children contributed to the understanding of bereavement.3 His theory of attachment, presented in the 1960s, provided an explanation for the common human tendency to develop strong, affectional bonds. Grief is an instinctive universal response to separation. In their study of adult grieving, Bowlby and fellow psychiatrist Colin Parkes described four phases of grief: numbness with intermittent anger; yearning; disorganization and despair; and organization.4
An understanding of the grieving process has continued to expand as it applies not only to death and dying, but also to the broader range of human experience. Grieving is not a simple linear process. It applies not only to losses incurred as a result of death or the anticipation of death, but also to other kinds of loss. For example, grief can be experienced when someone is diagnosed with a life-threatening and/or debilitating disease. The physical and psychosocial issues involved with aging and illness also contribute to the complexity of the bereavement process for many individuals.
More recent advances in the understanding of grief theory include the dual-process model developed by Margaret Stroebe and Henk Schut.5 While previous models focused on stages and phases of grieving, the dual-process model recognizes a dynamic in which the bereaved individual alternates between focusing on the loss—with all the associated reactions and responses—and avoiding focusing on the loss in order to cope with the stresses and practical requirements of everyday life.
In the dual-process model, it is recognized that both expressing and controlling emotion have value for the individual who is dealing with loss. The bereaved person is able to “take time off” from the intensity of emotional response to the loss in order to deal with the life changes brought about by the loss. For example, someone who has lost a loved one might still need to care for young children in the family, so will set aside her or his own feelings in order to attend to the needs of others. This person may also take a break from the intensity of emotion through other self-care measures that can include nutrition, rest, exercise, massage, and/or social interaction.
The Cycle of Grief
How individuals respond to loss depends on many factors, including their personal belief systems, their social and cultural conditioning, and the personal coping skills and support systems they have in place at the time of the loss. While people experience grief in many individual ways, there are general patterns of physical and emotional responses that frequently occur after a loss. The Cycle of Grief, at left, is a useful image for individuals to understand their own responses to loss. For massage therapists and those supporting people in times of bereavement, it is also a helpful way to understand the psychosocial experiences of their clients, as they move from the initial reactions to loss through a myriad of possible reactions and emotions, toward a healthy adaptation to change.
Shock and Protest
The first phase following a loss is characterized by shock and protest. In the initial hours, days, or weeks following a loss, the individual may experience numbness or actively protest the reality of the loss. Some people may be cheerfully present at the funeral of a loved one, only to be hit emotionally by the awareness of the loss later. It is common to function out of habit or act automatically just to get through this unfamiliar and often difficult time. Denial is a way that many people protect themselves from the painful reality of their new circumstance.
The bereaved may feel anxiety and fear. They may be afraid of the unknown in their lives now as a result of the loss, and feel confused about the next steps to take. Sadness, loneliness, and intense yearning for whom or what was lost are common experiences. The bereaved individual may also experience relief if, for example, the death of a loved one occurred after a long and painful illness. Joy may be felt where death is believed to be a release into a freer or happier state of being. Other kinds of loss can bring a feeling of relief, because the uncertainty of waiting has ended.
Another common reaction is anger, which may be a feeling of frustration directed toward oneself or others. Guilt may be present for some, as often occurs when death is by accident or suicide, and the survivors wonder what they could have done to prevent it. Regret is another feeling that surfaces when the bereaved individual wishes she or he had made different choices earlier in her or his life.
Physical reactions and symptoms may include insomnia, crying, muscle weakness, nausea, and/or loss of appetite. Some people experience difficulty breathing. Grief can be experienced as physical pain and has been described in many ways: dull, aching, stinging, biting, sharp, pressure, contracted, or constricted. Any or all of these reactions are normal parts of grieving. Just as people are individual in how they respond to everyday stresses and challenges of life, so will they respond in different ways to loss. Some feelings or reactions may be fleeting. Others will be of persistent intensity.
The helpful massage therapist or bodyworker best serves grieving individuals by allowing them to be present with their feelings. It is not necessary to diagnose bereaved people or judge their process; it is most respectful to simply be present and listen, acknowledging the significance of their experiences. If the client seems to be exhibiting reactions or behaviors outside of a normal range, it is wise to refer her or him for further evaluation and/or counseling with a mental health professional.
Disorganization
The next stage in the cycle of grief is characterized by disorganization. The loss has occurred and the initial shock has begun to wear off, but now the individual is left to cope with a reality that is different. Life is not organized the way it was before. The sense of disorganization occurs on different levels.
Disorganization often involves practical concerns, which may include financial and legal issues. Mentally, the individual can feel disoriented and overwhelmed with decisions to make. Sometimes even the simplest decision seems to take an inordinate amount of energy. Individuals may experience forgetfulness, or in some cases, become obsessive in their behavior, thinking, or feeling. Emotionally, some feelings may persist or intensify from the first phase; others shift and change. The range of emotions that might be felt during this time includes anger, sadness, depression, despair, anguish, and low self-esteem. Physical exhaustion tends to intensify many of these feelings.
Socially, the person who is grieving may feel detached, withdrawn, apathetic, or antisocial. Some people may feel needy and afraid to be alone. Disorganization also occurs within the family or social network of the bereaved individual. Differences in the way people communicate and deal with loss within their social groups may vary, contributing added pressures and distress to the individual.
Periods of grief are difficult times for people. In its intensity, grieving may last for several weeks or months, sometimes years. Whereas people often have the support of family and friends soon after a loss, they are often alone in their grief as time goes on. Typically, our culture does not give people time to grieve. Furthermore, it is not customary to talk about our most significant losses or share our feelings with the people we work with or interact with socially. Without adequate support during this time, bereaved people feel further alienation and the added burden of suffering their grief alone. In this time, nurturing massage and bodywork can provide much needed support, providing a steady and nurturing presence.
Reorganization
With time, the acute pain of loss begins to subside, and the bereaved individual begins to reorganize her or his life. Painful emotions carry over into this phase, but the intensity or duration of the feeling is usually less than in the previous phases. One begins to accept or understand that the loss is permanent, and begins to adapt to a new life, integrating the reality of the changes into present life.
The process of reorganization involves changes and adaptations on many levels. When the loss involves the death of a loved one, the survivor learns to reorganize her or his life physically, emotionally, and mentally without the presence of that special person. When the loss involves illness or disability, the person learns to adjust their physical surroundings, lifestyle, and health care to the current situation.
Loss of one kind—either of person, place, or quality of life—involves changes in other activities and relationships. For example, persons who are injured in a debilitating accident may find it difficult or impossible to participate in once-enjoyable activities such as hiking or skiing. As they reorganize their lives, they might find other activities they enjoy that are less physically demanding. Or if they regularly participated in activities with a loved one who has now left or died, they can adapt by finding other people with whom to enjoy social activities.
Reorganization and adaptation also involve an appreciation of the pleasant and/or valued memories of the past, while accepting the reality of the present circumstance. It becomes easier to celebrate and remember the past without feeling intense sadness. Many people learn the value of compassion, while opening to new possibilities for social connection with others who have suffered similar losses.
As bereaved individuals adapt to the change, they may begin to feel improved self-esteem and mental clarity. It becomes easier to make decisions and engage with others socially. Physical exhaustion gives way to renewed energy and confidence. During this time, therapeutic massage can continue to support the individual who is adapting to change. As a massage therapist, you can appreciate and validate the client for the steps she or he is taking to reorganize their lives.
Variables in the Expression of Grief
While the grief cycle is portrayed here as one phase that occurs after another, it is not really a fixed process, either in length of time, intensity, or sequence of emotional expression. The cycle shows the range of experience of people going through the normal process of grieving. Not only do people vary in their responses to loss, they may respond differently to different losses. Multiple losses complicate the picture. A person may be in one phase with one loss and in another phase with another loss. Or the experience of one loss may trigger unresolved feelings from a prior loss. Individuals may think they have come through the cycle only to experience an upsurge of anguished feelings, sometimes around an anniversary, birthday, or holiday.
Adaptation to Change
As the individual moves through the process of grieving, she or he may realize that loss is neither good nor bad, right nor wrong. Change and loss are inevitable aspects of the human experience. The pain of loss may never fully go away, but individuals are empowered as they learn to adapt to change. Helen Keller said, “What we have once enjoyed we can never lose. All we love deeply becomes a part of us.” Her words illustrate the concept of healthy adaptation to change and loss. It is our role and privilege as massage and bodywork professionals to provide a safe, open-hearted, nonjudgmental, and reassuring atmosphere to the bereaved individual.
Mary Kathleen Rose, BA, CMT, is an authority in holistic health education and is internationally known as the developer of Comfort Touch nurturing acupressure. An ardent advocate for the needs of the elderly and the ill, she provides training and support for massage in medical settings. Her understanding of the bereavement process developed as she facilitated hospice grief and loss support groups. She can be reached at 303-651-9375 and www.comforttouch.com.
Notes
1. Sigmund Freud, Mourning and Melancholia, The Complete Psychological Works of Sigmund Freud, 8th ed. (London: Vintage, 2001).
2. Elizabeth Kubler-Ross, On Death and Dying (New York: Touchstone, 1969).
3. J. Bowlby, Attachment and Loss: Loss, Sadness, and Depression, vol. 3. (New York: Basic Books, 1980).
4. C.M. Parkes, Bereavement: Studies of Grief in Adult Life (New York: International University Press, 1972).
5. M. Stroebe and H. Schut, “The Dual Process Model of Coping with Bereavement: Rationale and Description.” Death Studies (April–May 1999): 197–224.