By Mary Kathleen Rose
Originally published in Massage Bodywork magazine, July/August 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.
"Your
touch was so reassuring. It helped me know I could survive this loss.
Being touched helped me stay with my feelings. It helped me so much just
to know you were there."
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.Notes1. 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.
