Grief Counseling and Bereavement Services

What are signs that I am grieving?

Signs of grieving are as varied as we are as individuals. Grief can even vary throughout your life and different losses. Although grief varies based on the individual, there are general signs that include:

• Feeling empty, hollow, or numb.
• Being angry and impatient. This can come out of nowhere, leaving you confused.
• Needing a lot of alone time and withdrawing from people and activities that usually make you happy.
• Feeling tired and physically exhausted so much of the time. It may feel like you’ve lost your energy and motivation.
• Being worried about your memory and ability to focus on your tasks at hand. An example would be beginning to close your passed loved one’s financial accounts and twenty minutes later have nothing done.
• Emotional swings like crying at the drop of a hat. It may feel like you’re fine one minute and sobbing the next.

What is grief?

Grief is a natural part of life. It is a complex emotion, meaning it has more layers than a basic emotion such as sadness. This helps to explain why grief varies from person to person, and based on the type of loss. In addition to dealing with the loss of a loved one, you or people you know may have experienced grief in the past because of:

• Divorce
• Loss of a job
• Having to move from a beloved home or community
• A change in health

Each loss in life can bring about various emotions, thus complicating how we feel and understand grief. Even the death of a loved one is accompanied by different grief feelings. These affect you physically and emotionally, and can be different before and after your loved one passes.

As you review these varied feelings, remember that what you experience is unique to you. The discussion about different types of grief is followed by a Caring for yourself as you grieve section. It offers simple suggestions to nurture and sustain yourself in the coming weeks.

Grief that precedes death is called anticipatory grief

It may begin before a diagnosis of terminal illness when you suspect something is terribly wrong with your loved one’s health.

• This type of grief has differences from the grief people experience after a loved one has died. Anticipatory grief is not often discussed, perhaps leaving you feeling confused about the emotions you’re experiencing.
• Symptoms include changes in your usual patterns of sleep, eating, and daily routines. Examples are:
  • Being unable to sleep or sleeping too much.
  • Lack of appetite, nausea, or eating lots of junk food.
  • Trouble focusing on work and household tasks.
• Emotional signs of anticipatory grief include:
  • Feeling detached during social interactions you usually enjoy.
  • Being anxious or depressed. Things that rarely bothered you before now get on your nerves.
  • You’re sad more than usual.
  • You feel a great need to talk about what’s happening to your loved one.

Grief that follows a death

It can be similar or quite different than anticipatory grief depending on the person. Each person’s grief experience is unique to them. That includes if and how grief changes before and after death. Some common aspects that change the grief experience after death are:

• Adjusting to a new routine as your days and hours suddenly take on a different pace. You may consider returning to work now that you are no longer busy with your loved one’s care and household matters.
• Being your loved one’s executor, or helping that person with the will and financial matters associated with settling the estate.

Physical signs of grief

May change after your loved one passes. Part of this may be associated with the change of pace that recently happened. Other grief symptoms include:

• Trembling or weakness. This can also be associated with lack of appetite.
• A dry mouth, nausea, or feeling like you can’t catch your breath which may be associated with anxiety.

Emotional signs of grief

Often come in waves. Sometimes it seems like they’re on hold for days at a time. This is especially true when there are events and tasks that need your attention right after your loved one has passed. Some common emotional signs of grief after a loved one has passed include:

• Experiencing deep sorrow or feeling empty and numb. Any of these are normal.
• Grief spilling over as anger with yourself or others, including what could have been done differently for your loved one.
• A spiritual crisis, especially if your faith beliefs are challenged by the loss of a beloved person.
• Upsetting dreams as your sleeping mind tries to process the changes in your life. Reflecting about these with a friend, or writing about them, can help you to process.

Your emotional responses to grief may change over time. There are stages of grief, although these are guidelines and not rules. People have different emotional responses as they grieve. These may not be related at all to the depth or type of relationship you had with the departed.

Acknowledging your grief and finding a genuine support network is an important part of the grieving process. Discussion about bereavement services and grief support groups is presented later on.

What are the different types of grief?

There are several types of grief. You and your family members may experience grief differently. It helps to be aware of this because of the various people affected by your loved one’s passing. They will be grateful for your support and acceptance of their grieving process.

Typical or normal grief is what many people think of when they hear that someone is grieving.

• Emotional responses gradually decrease in intensity and frequency, even though this can take weeks or months.
• The grieving person gradually accepts the loss of their loved one. A sign is that they can talk about the person who has passed without becoming choked up.
• They are able to return to everyday activities, even to the point of showing outward pleasure in former interests.

Delayed grief is a common occurrence in modern culture.

• It happens when a person or family delays their grief for a period of time, often because of another significant life event. Most likely you’re aware of this in relation to an upcoming marriage, graduation, or someone in the midst of a job change.
• These delayed emotions can seem overwhelming or out-of-step with life in the present moment.
• Grief has been basically walled away in order to go through the motions of what is needed to be done.

Complicated, cumulative, and chronic grief have similarities, as each deepens and extends what a grieving person experiences.

• These forms of grief occur when a person has multiple losses in close sequence or at the same time, or is having difficulty accepting the death.
• They can feel hopeless, guilty, or find it hard to believe their loved one is gone.
• The emotional toll can be high, requiring extended time and support to process the losses.
• People living with these forms of grief are at risk for depression, outbursts, and potentially harmful behaviors.

Sudden loss grief occurs with an unexpected death.

• Although one associates this with a cardiac arrest or accident, it can occur with some illnesses too.
• Some cancers have a very late diagnosis. This leaves the person and their loved ones little time to begin to adjust or prepare for death.
• People affected by the sudden loss of a loved one often:
  • Are in a state of disbelief and find it hard to function. They feel like they are in shock.
  • Experience physical symptoms such as lack of appetite, trembling, headaches, and trouble sleeping.
  • Feel emotionally distraught with periods of crying and difficulty thinking.

Ambiguous grief is when other people do not recognize or accept why someone is grieving.

• This can be associated with the loss of someone others don’t see as being close.
• This happens frequently when a pet dies. The loss is real yet can be minimized by some.
• Feelings of loss can precede death such as when a loved one declines because of dementia.
• This is often referred to as disenfranchised grief because of others’ inability to relate to another’s feelings of loss.

Absent grief is noticeable as there are no signs a person is grieving.

• Remember that everyone grieves differently. For some the signs may not be apparent, yet they are present in select moments.
• This happens when a person is still in shock after a loved one’s passing. Or perhaps they continue to be in a state of disbelief.

Collective grief is when a death, or multiple deaths, are felt throughout a community, a family, or a country.

• The reserves of those affected are limited because of the overall effect of the loss.
• Outside resources are often called upon to help people with their losses. This is what occurs to assist those harmed by devastating storms and community tragedies.

In addition to the different types of grief, you may be wondering about the stages of grief. The following content describes those and leads into information about how long grief lasts. As you’ll read, all of this varies by person and situation. Later on you’ll read about services that are there to support you and your family as you grieve.

Signs for concern associated with grief

Anyone can become overwhelmed or consumed by grief. They didn’t plan it to be that way. It’s what happened and hard for them to function or reach out for help. Regardless of the type of grief someone may be experiencing, signs that professional support is needed include:

• Behaviors that don’t improve over time, such as:
  • Time is passing yet you don’t feel any better at all.
  • Nightmares, insomnia, sleep, and appetite concerns are not readily resolved.
  • An increase in use of substances such as drugs or alcohol.
• Language and behaviors that indicate the potential for self-harm or harm to others.
  • Stating that it would be better if it all would end.
  • Increased anger and lashing out at others.
  • A desire to escape your current life. This can include rapid and dramatic changes, such as taking a long trip or wanting to move far away.
• Feelings that things just won’t get better.
  • Your emotions are interfering with your daily life.
• Continuing to feel depressed and withdrawn without signs of improvement.
• Talk of guilt and feeling that you somehow failed the person who has passed.

When you or some you care about has these signs, talk with your primary care provider. They may prescribe medications and/or suggest counseling. Remember, there are a number of options for working through grief. It is wise to seek them out before too much time goes by.

What are the stages of grief?

The five stages of grief have been the topic of articles for decades. Dr. Kubler-Ross who originally wrote about them states that there is no particular order in which you may experience these. In fact, you may have a couple and completely skip others. The five stages are:

1. Denial: When you first learn about a loss.
   • You may feel emotionally numb or empty.
   • Your appetite may shut down and you may feel weak or shaky.
   • The shock you feel is a defense mechanism the body uses for protection.
   • A sign that you are moving through this stage is when your feelings of loss start to come to the surface.
2. Anger: Which is associated with the deep ache and hurt from your loss.
   • Your anger can be directed at anyone or anything, including toward yourself.
   • You might be mad at life and wonder about its meaning.
   • For some, their beliefs and faith can be shaken to the core.
   • It’s important not to suppress anger. Acknowledging it and being able to express how you feel helps with acceptance of your feelings. This leads to being able to move on.
3. Bargaining: Involves your attempts to resolve what has happened.
   • You may ask yourself “what if I had only done this or that…”
   • You and other loved ones turn to each other with questions that are hard to answer.
   • People may reach out to a higher power.
   • This stage can include feelings of guilt. Being able to talk about these supports your realization that you can move on, as you did the best you could.
4. Depression: A deep sadness with feelings of hopelessness.
   • This includes feeling overwhelmed and unable to move forward.
   • You may sleep too much or have trouble falling and staying asleep.
   • You lose interest in things that usually bring you pleasure.
   • It’s hard or impossible to engage in everyday tasks and personal care.
5. Acceptance: Coming to terms with the reality that your loved one is gone.
   • You may still feel sadness, yet you realize you have the ability to move on.
   • You find peace in the memory of your loved one as you accept the changes in your life.
   • You are able to move forward day by day, enjoying interests and time with others.

How long does grief last?

Think back to people you know who have lost someone whom they deeply loved. Over time, they have brightened a bit. Yet there is something about them that has changed. At times you notice it when they seem to drift off during a conversation.

Although the duration of grief can last but a matter of weeks, your friend may be experiencing grief that can last for years. You realize this too could happen to you or a family member.

• It’s possible to feel more like yourself after six weeks or two months.
• Then again, the whole process can extend to three or four years.
  • You may begin to feel better, then hit a plateau where nothing seems to change.
  • Or your life seems to ebb and flow like ocean tides. Your outlook improves, then recedes somewhat.
• Special dates and events like holiday celebrations can be rough for you.

As you live with grief, remember that your relationship with your loved one who has passed was unique. Because of this the grief you are feeling may seem different than those around you. There is no need to go by anyone else’s timing for when grieving should end. Give yourself time and space to honor your feelings and keep an eye on emotions or behaviors that are troubling.

Be sure to read on to the sections about bereavement services, grief support groups, and therapy for those who are grieving.

Will my loved one grieve as they prepare to pass?

As a caregiver you assure that your loved one is receiving the best of care. You’re providing for their comfort and safety, plus emotional support for family members. As you reflect on your loved one’s needs, you realize that they might be grieving. They likely have anticipatory grief as they prepare to pass.

• Your loved one in hospice care grieves for themselves and for those they will leave behind.
• People who are dying don’t want their loved ones to suffer because they are departing this life.
• Fortunately, there are ways for you to gently and openly deal with anticipatory grief.
  • Briefly mention how you are feeling with your loved one.
  • Then turn the focus to them, inquiring if they too are experiencing grief.
    • “How do you feel about leaving?”
    • “What will you miss the most?”
    • “We will be okay, though we will be sad that you’re not with us.”
    • “Tell me what you want us to remember most about you.”
    • “Is there something special from your past you’d like to talk about? Or have me talk about?”

When done, ask your loved one for permission to share their thoughts with others. Tell them how their words and memories will help family members and friends work through their sadness.

• If it seems suitable, you can ask permission to record these thoughts on video, audio, or paper.
• You or your loved one may like to have a beloved someone join you during your conversation.

Is it normal for a caregiver to grieve before their loved one passes?

As discussed above, anticipatory grief happens before your loved one is gone. You, other family members, and your loved one are each likely to experience anticipatory grief each in your own way. You can consider using the same remembrance approach shared with your loved one as you reflect on the loss you are already feeling.

• You may want to have a conversation about your loved one’s passing with someone close to both of you.
• Simply alter the statements or questions used with your loved one to share how you feel, such as:
  • “This is how I feel about your leaving…”
  • “This is something special we remember doing with you…”
• If possible plan the conversation ahead of time, and then sit with your loved one to share your reflections.
  • They may not be able to talk.
  • Hold the conversation even if you are unsure they can hear you.
  • Holding a hand or touching a shoulder during the conversation helps communication.
• Sharing like this can happen every day, and even when your loved one appears to be asleep.
  • Memories of simple pleasures can bring both of you peace.
  • Speaking gently and slowly is calming for those who are preparing to pass.
  • The caring manner you show helps others follow suit.

Does everyone grieve the same way?

We are each a unique human being. This is one reason why the grief process is very individual. You’ve read about the variable physical and emotional effects of grief. The same applies to how each of us grieves. Here are some guidelines to think about as you process the grief you are living with.

• You won’t really know how the loss of a loved one will affect you or those around you until it happens.
  • This is true even if you have had losses in the past, as each relationship is different and recent losses can make a person more vulnerable to the next.
• You may need to delay some of your own grief to support others who are having an even harder time than you.
  • This is often the case with the death of one parent, leaving the other alone.
  • Certain people close to your loved one may have unique needs that make this loss difficult to bear.
• The depth of grief you feel does not define how much you love and have loved a person.
  • It is possible to grieve and feel a sense of relief as your loved one is no longer suffering.
  • You come to realize that your relationship with your loved one is still an important part of life. You may find comfort honoring their memory, contributions and devoting yourself to values you had in common.

Even as individuals, we are each affected by how our family and community approach grief. This may include:

• Mourning and grief associated with your loved one’s faith.
  • Religious burial practices and traditions.
  • How celebration of someone’s life is woven within grieving and time to mourn.
• Workplace bereavement policies and their effects on you and family members.
  • Many companies give a person three to five days of bereavement time.
  • Consider talking with your supervisor or employee assistance program if you need more time to grieve before returning to work.
  • When you go back to work, it’s wise to allow yourself time to grieve.
    • Work self-care into your work hours.
    • Stay in touch with those who support you with a quick call or text.

Just as grieving varies from one person to the next, so too does moving through grief. Even though your sense of loss may never fully leave, you’ll become aware that you are doing better as the days go by. Some signs of a healthy grieving process include:

• Your energy gradually returns, along with a better appetite.
• Sleep slowly but surely improves.
• Periods of crying, sadness, and anxiety shorten and happen less often.
  • Even when these seem like barely noticeable signs of progress, keep track of them by writing down every improvement.
• You find yourself wanting to do your favorite activities again. That might be reading a good book, walking in the park, or playing sports with your friends.

Try not to let stalls in progress or a step sideways bother you if they’re of short duration, like a couple of days. If the gains you have made feel stuck, it’s time to check in with a therapist.

What bereavement services does hospice offer?

Bereavement services are available for you and your family as soon as your loved one’s hospice plan begins. The hospice team and you should discuss which of these services you may want to make use of when creating the plan of care. These services vary from one hospice program to the next so it is important to make sure the hospice you chose has the bereavement services your family requires.

How can bereavement services help caregivers and the family?

Benefits of bereavement and grief services include:

• Being able to speak with a counselor or chaplain who is experienced in supporting people before and after their loved one passes.
• Group support with others experiencing the death of a loved one.
• Individual and family support, including in the home or setting in which your loved one is receiving care.
• In-home volunteers who offer companionship, respite, and support.
• Having services available for your family for up to one year after your loved one has passed.

What are the Medicare requirements for bereavement services?

Medicare-approved hospice agencies must have an organized program led by a qualified professional that offers:

• Bereavement services before your loved one passes and for up to 1 year following their death.
• Grief and loss counseling are included as a Medicare benefit when they are part of the plan of care written by your loved one’s hospice team. This includes details about bereavement services.

Do different hospice providers have different bereavement services?

Yes, hospice agencies have various grief support services, though each is required to have a program of some sort.

What is a grief support group?

A grief support group includes people who come together to support one another. This is especially important as you think about losing a loved one and what life will be like when they are gone. Grief support groups offers you and others experiencing loss with:

• Professional support that is there for the group as a whole and each person within the group.
• Opportunity to share your story and concerns while hearing the stories of others.
• A feeling of community and empathy that comes from other people who can relate to your journey with grief.
• A time to step away from what each day of grieving brings. As you listen to others, you learn how to move forward. You may begin to realize that you are doing better, even if your progress seems slow.

How do you find a grief support group?

Each community and hospice agency varies with grief support availability. First, check with your loved one’s hospice agency.

• Ask if they have a grief support group and let them know about your interest in joining.
• If they do not have one, ask if there are other types of support groups. Also ask if your loved one’s care plan will cover reimbursement of any fees to be in the group.
• Keep in mind that some community and faith organizations have grief support groups.
  • If one of these is your only option, be sure that the faith group leader is qualified to provide bereavement services.
• Your community may have mental health agencies that sponsor grief support groups.
• To find a grief support group in your area, visit the Hospice Foundation page. Scroll to the bottom where you will find links to several organizations’ links for finding a support group.

Can therapy help with grief after a loved one passes?

Therapy after your loved one passes is valuable because a qualified professional is available to support, listen and respond as you process the many feelings that can arise because of loss and grieving.

They may guide you in finding ways to deal with uncomfortable or unhealthy thoughts and behaviors. A therapist or counselor is there to:

• Help you be safe with yourself and others.
• Intervene when necessary.
• Offer you ideas and tools for how to manage your grief.
• Act as a sounding board as you reveal anger and learn how to work with it in ways that are not destructive.

How long should you wait for bereavement counseling?

Consider beginning bereavement counseling before your loved one passes. The caregiving role is emotionally and physically exhausting and can cause pent up emotions. Being tired when you begin to grieve can be hard on your physical and emotional health. This can happen even before your loved one passes.

Beginning bereavement counseling as soon as possible gives you the chance to process any emotional and physical changes as they occur. It also gives you insights to share with other family members that may benefit from having the services available to them as well.

Caring for yourself as you grieve

The path to well-being as you grieve takes time. As discussed earlier, grief ebbs and flows. One way to balance these feelings of one day feeling better, and the next being off, is to be as consistent as possible with self-care behaviors.

Ideas for managing these specific grief symptoms

Trembling or weakness: be sure to take in enough food and beverages to avoid low blood sugar and dehydration.

• Whole foods like fruits, vegetables, and whole grains assure you are eating good nutrients even if your appetite could be better.
• Drink water every hour you are awake to help balance your fluid levels.

Anxiety: A dry mouth, nausea, or feeling like you can’t catch your breath may be associated with anxiety. Consider nurturing yourself with brief spells of pleasurable activities, comfort food, and time outside. Simple steps to reduce anxiety are to:

• Slow down and focus on your breath.
• Think of a word or passage that is meaningful to you. Repeat it throughout your day.

When done regularly, practices like these can reduce tension and troubling thoughts.

Sleep disruptions:

• Go to bed at a regular time, having turned off electronic devices at least one half hour before getting into bed.
• Make sure your room and bed are prepared for comfort and temperature the way you like it.
• Limit alcoholic beverages in the 2 hours before you get into bed.
• If you awake and can’t easily get back to sleep, get up and read, meditate, or pray.
• Being physically active during the day helps one to sleep well.
• Writing about things that bother you and your sadness can actually help to relax you. This is just for you so you can write however you wish!

Being gentle with yourself supports your overall well-being as you grieve.

• Spend time with friends and family who let you grieve in their presence.
  • These are the people who are okay if you cry, laugh, or be quiet.
  • Doing favorite activities with these people lets you see glimmers of hope amidst sadness.
• Do things that give you meaning, even if for just moments at a time.
  • This gives you a sense of normalcy, the way life was before your loss.
  • Doing this for a few minutes each day moves you toward a sense of hope for the future.

How can I find meaning in the passing of my loved one?

The meaning of another person’s life needs to be viewed over the decades or years they were with you and your family. It may have been long or short.

• Regardless of the relationship you had, and your history together, you and others can find all sorts of meaning. Think about:
  • Stories of your loved one as a child and young adult.
  • Their favored activities, even those with questionable behaviors.
  • What they were good at, or believed they did well.
  • Adventures you had together, nearby or far away.
  • Common phrases and words they used that were unique to them.
  • What they contributed to your life and the world around them.
• Mementos of your loved one are a concrete reminder of your time together.
  • Go through photo files or prints of special times.
  • Drag out that old worn piece of clothing that your loved one refused to part with. Keep it around for as long as you wish…it’s now yours!
  • Do you remember their favorite music? Play it every once in a while and see what you recall from years gone by.
• Maybe you and your loved one shared common interests or values.
  • These can be called upon to honor your loved one in ways that seem fitting.
  • Thinking of your loved one as you do so lets you know that even though your relationship has changed, it’s living on through you.

Grief is one of the hardest emotions you’ll ever experience. It is complex and often hard to explain to others. Yet doing so, even just a little, can help both of you. Taking care of yourself and those who bring meaning to your life is one step toward lifting grief’s shadow. It honors those who have gone before, and those yet to follow in your footsteps.