Grief, bereavement and other emotional pain

This section has a more practical flavour than the previous three sections. This is partly because it draws on the understanding of emotions and their effects, discussed in those sections, to develop a practical approach to the relief of emotional pain. And it is partly due to the addition of some other ideas – which are included for the very same purpose.

Although it may read a little differently, I do not see anything awkward in this transition from theory to practice. Indeed, I would see little value in any theory which could not usefully be applied in some way – though not necessarily a material way. This section is, in one sense, the most important part of the book. But it is also heavily dependent on the previous sections.

It would be more difficult to understand and practise the Emotional EEEEs technique described in this section, without the thorough understanding of emotions provided by the earlier parts of the book. And, as any readers who later practice Wanterfall work[60] will find, it would be very difficult to explore the mind in that way, without some means of resolving the emotional issues which it inevitably uncovers.

Importantly, this section begins with some more cautions, which are particularly important whenever there is any degree of emotional distress present, as only some cases can safely be approached in the ways which will soon be described.

More Cautions

There are some important cautions, which relate to the whole of this book, just before the start of Section 1. But I want to revisit my warnings about the limitations of the techniques described under Emotional EEEEs (also referred to as EEEEs work) before continuing with Section 4. Please read all the cautions very carefully, as skipping them, or ignoring them, could result in considerable unnecessary suffering. It could even, conceivably, cost you your life.

This section is entirely devoted to healing the universal suffering that has its roots in the "normal" emotional responses previously discussed in this book. However, similar suffering can occur as a result of various mental illnesses, in which case medical treatment is usually necessary – and is very effective.

A particularly important distinction is the one between grief and a depressive disorder. Many of the features are similar – but the cause is different, the complications are different and the treatment is different. Even grief which is initially normal may later be complicated by a depressive disorder, and the change can easily go unnoticed. Also, as discussed under the earlier Cautions heading, a variety of other illnesses, both physical and mental, can masquerade as emotional distress.

Making all these distinctions is a routine – though not always easy – part of modern clinical medicine. But thinking you can make them for yourself, no matter how clever and confident you may be (and perhaps especially if you happen to be a mental health professional) is a recipe for continuing suffering – and, if a serious illness is missed, sometimes death.

Even when the cause of suffering is clearly emotional, it is still essential to get professional help if things are going badly. Again, grief is a good example. Although it is a normal process in itself, that process can easily get "stuck". Then it is called pathological grief. Skilled intervention for pathological grief is very effective – but the lack of it may be utterly disastrous.

The intertwining of emotional and physical problems is not limited to grief. Emotional distress may occur in the context of any co-existing physical or mental illness. Sometimes, emotional distress can itself precipitate a physical or mental illness. At other times, the emotional distress may be an effect of some physical or mental illness.

In other words, these three things, physical illness, mental illness and emotional distress, may bear any and every possible relationship to each other. This can be difficult enough for a team of doctors to clarify – let alone the person who is unwell.

In summary, emotional distress occurs in very many situations, and you can never assume either that the Wanterfall model describes its cause, or that EEEEs work will be its cure. When in doubt, find out! And that simply means, seek medical advice whenever things are going badly. Because, by just hoping for the best, you are also inviting the worst.

Introduction

In describing the process that leads to the healing of any emotional pain or distress, I will use the compound emotion grief as my example, for four reasons. Firstly, grief is an almost universal experience, so many readers will have personal experience of it. Secondly, it is a very painful experience, so there is much to be gained by learning how to move through it. Thirdly, it is very amenable to assistance, so learning about it will make you a valuable resource, for the rest of your life. And finally, the process which leads to the healing of grief, can also be applied to any other emotional pain or distress.

Grief is the natural response to any loss. Most poignantly, it is the response to death – either the death, or impending death, of a loved one; or the knowledge of one's own impending death. However, any distressing deviation from a desired state can cause grief. Even the loss of a button can cause a miniature version of the same response – though we do not usually use the term grief unless we perceive the loss as being significant.

As you know, the components of grief are found on the lower right hand side[61] of the Wanterfall chart. However, charting them there does not make them any less painful. The journey through the grief caused by a great loss such as bereavement or incurable illness is always a tremendous challenge. So, although I am about to explain how to pass through grief and emerge, inevitably scarred but completely healed, I am not about to suggest that the passage is an easy one.

Perhaps grief is what you are experiencing right now – perhaps that is why you have turned to this page. If so, let me talk directly to you for a while. I wonder if you feel that everything that was good in your life is now over – that you will continue to exist, but you will never really live again.

Many people have shared that feeling with me, especially during my twelve years as a hospice physician. And, in a sense, it is exactly the right way to feel at this time. For that matter, the way you do feel is always the right way to feel. But feelings can change – even your present feelings might change.

It is certainly true that your life will never be as it was. However, that does not mean that your life is over. It will be a different life, of course. But there is no reason that it cannot include all the joy and love that human beings are capable of embracing. Now, I am quite sure you don't believe a word of that – and equally sure that I can show you how to discover it.

The very idea of cheerful activities, good company and pleasant days may seem disloyal, treacherous or just plain ridiculous, when grief has struck you down. The sun has set for you, and the darkness seems impenetrable. But sooner or later, you will see the first glimmer of an inner sunrise.[62] For there is still the same life within you that there always was. It is just that, for now and perhaps for some time to come, it is in hiding.

But as I said, I don't expect you to believe any such thing. I wouldn't believe it myself. Or at least, not until it had been demonstrated. So that is now my task. I will describe, in this section, how to move through grief until your love of life returns. You can start when you choose, and move at your own pace. Not everything described will apply to you – just take what you need. And I do not ask you to believe that it is possible, until you yourself become the living proof of it.

I will certainly not try to do your grieving for you – nobody can do that. Nor will I try to tell you how to feel, or when to feel better, or when to feel worse. And I will never, ever suggest that anything about grieving is easy.

What I will do, is remind you, from time to time, that it is possible. Because that is one of the few things that I know to be true, without a shadow of a doubt. I did not work it out by thinking hard, nor did I learn it through study. I discovered it more or less in passing, in the course of my somewhat unusual training and career, and my own experiences of grief. And I don't think it should be kept a secret.

Now, a few paragraphs back, I mentioned the idea of moving through grief. But why not just go around it? Well, it is a good idea. Or rather, it would be, if it worked. I expect you will try it, as most people do – that is part of grieving. But the path around grief is a bit too true to its name, to be of any use. Because it goes around grief, and around it, and around it. Indeed, it goes around in circles, for as long as you like.

In my experience, any attempt to avoid going through grief can never be more than a preparation for grieving – a way of learning what does not help. Sooner or later – and preferably sooner – it becomes necessary to look inside grief, and find out what makes it tick. This is of universal relevance, so I will no longer address myself directly to you, my grieving reader. But it will still be written for you. It is all written for you.

Looking Inside Grief

The first thing to notice about grief may seem too obvious to need saying, but I will say it anyway. Grief is made of emotions. Often, an overwhelming avalanche of them; at other times, more of an interminable glacier. Of course, it is always a response to one or more facts, it is usually associated with various physical effects, and many, many thoughts surround it – but its essence consists of emotions.

As mentioned previously, grief inhabits the lower right quadrant of the Wanterfall chart, where things either do not go as we want – or else do go exactly as we don't want. The primary emotions shown on this part of the chart are sadness and antipathy. The feelings found under these two umbrellas have been listed under The Six Primary Emotions, but I will mention some of them again now.

The primary emotion sadness includes many feelings, most of which are felt frequently during grieving. Examples are sorrow, misery, dejection, dissatisfaction, despondency, mournfulness, gloom, and depression[63].

The primary emotion antipathy also includes many feelings, of which the ones most often felt during grieving are anger, disapproval and hostility. Especially anger. The anger may be directed at the situation in general, or at one or more people who are considered partly or wholly responsible for the loss.

Doctors and hospitals are frequent targets for such anger. Whether or not they did their job well, they failed. Also, people who are even a little bit religious often feel angry with God, either in a general way, or for specific examples of action or inaction. This is a normal component of grief, and should never be confused with blasphemy.[64]

Grief is not content to be restricted to one quadrant of the Wanterfall chart, and is of course not alone in this. The bleak and uncertain nature of the future may awaken the primary emotion fear, with a sense that the future will be painful, just as the present is; and with an urge to escape from the pain, if only it were possible.

Often, friends and family offer warmth and kindness, or other feelings found in the primary emotion propathy[65], but in many cases the ability to enjoy the feelings found under that umbrella (or indeed to enjoy anything at all) is hibernating. Similarly, feelings found in the primary emotions happiness and hope are in short supply – and will remain so, for some time to come.

So grief consists of many emotions – mainly the painful ones. But do they all stem from the loss which has occurred? This is a very important question about grief – and the answer is no, not all of them. Some of the emotions which occur in grief are not directly related to the loss. Where, then, do they come from? There are two sources from which these important feelings can originate.

The first source has to do with the context in which the loss occurred. Anxieties about other family members, worry about financial problems, feelings of guilt about something or other that occurred before the person's death, or any of many other possible issues, may be superimposed on grief simply because they are part of the life of the grieving person. The process of arranging and taking part in a funeral, though usually therapeutic overall, may also be extremely stressful. And physical exhaustion or illness may be present, sapping strength, just when it is most needed.

The second source might also be considered contextual, but it involves an inner context. Our emotional experience inevitably occurs within the context of our emotional knowledge – in other words, our emotional memories. This means that past pains can often be brought to mind by current grief.

Considering how many emotions (virtually all the painful ones, and a few of the others at times) are involved in grief, it is not surprising that grief can awaken pains from the past. And this "unfinished business" is so important to a better understanding of grief, that I am going to give it a heading of its own.

Unfinished Business

The late Elisabeth Kübler-Ross[66] used the terms "unfinished business" and "pool of pain" for suppressed or repressed, leftover emotions which remain in the mind in a relatively dormant state. Along with many other psychiatrists, psychologists and therapists, she was convinced of the pivotal importance of these hidden emotions in understanding grief, or indeed any emotional suffering.

"Unfinished business" implies something that has already been encountered, but not completely dealt with. And "pool of pain" suggests that this "business", as well as being painful, might well vary in amount as content moves in or out of the pool. It does sound rather fanciful, doesn't it? But these metaphors point to an underlying reality that is not fanciful at all.

Indeed, the essence of the analogy, if not always the labelling, is accepted by most counsellors who work with people in emotional pain. It is also realised by most people who have worked their way out of emotional pain. And I'm sure you can guess that I have found it helpful during my own clinical career – otherwise, I would not waste your time by writing about it.

It is also quite common to speak of emotions being "bottled up" or "pushed to the back of the mind". The metaphor of an "emotional abscess" has also been suggested. These terms all point to exactly the same idea, though they may emphasise different aspects of it. And there are, in fact, a number of different aspects to this idea, which I would like to look at next.

In the first paragraph, I referred to a relatively dormant state. That was deliberate, because emotions in the pool of pain are neither comatose nor encapsulated. Barriers in the human mind are never completely impervious, so a metaphorical pool (or abscess) full of pain inevitably exerts an influence on our day to day experience. This could be visualised as a slow percolation of toxic matter from the pool, seeping into the rest of the mind and making it slightly (or sometimes very) unwell.

Another important aspect of bottled up emotions is that they may not necessarily remain unchanged over time – they may sometimes become distorted. For example, anger and fear may sometimes develop into hatred, when bottled up together for too long. Other examples of possible changes in stored emotions are given under Suppressed Emotions in Section 2.

So this somewhat leaky pool may become murkier with time. But a pool (or an abscess, or a bottle) does not always leak slowly. Old feelings can sometimes erupt with astounding intensity, when a current event provides a strong enough reminder of the circumstances which originally caused them. I think the analogy of an abscess is most appropriate here.

One possible result of the bursting of an abscess is an initially painful, but ultimately healing, process. But, if an abscess bursts, it is important that it bursts to the exterior. Abscesses which burst internally can cause serious illness, or sometimes death. So expert lancing of an abscess is preferable. It allows for choice of drainage path, as well as early drainage.

How does this relate to pent up feelings? Sometimes, experiences which awaken unfinished business can be a blessing in disguise – they can cause the release of toxic emotions which have been poisoning the emotional life of the host for some time. Considerable healing usually follows.

But an avalanche of painful emotions can be just as dangerous as a physical avalanche. There is a risk of harm to self or others during the acute phase, which could conceivably include suicide, murder or both. I will be discussing the safety aspects of emotional catharsis fairly soon, under Emotional EEEEs. For now, it is enough to note that the release of emotions, whether spontaneous or facilitated, cannot be treated lightly.

Of course, unfinished business has an effect on feelings whether grief is present or not. But its interactions with grief are important. Firstly, it may delay grieving, if a perceived threat of awakening old emotions discourages the expression of current feelings. Secondly, it may erupt unpredictably, as a result of stimulation by current feelings. And finally, the almost inevitable drainage work which occurs during grieving often results in the resolution of many past issues as well.

You might wonder how much reduction in unfinished business is enough. To be completely free of unfinished business, even if that were feasible, would surely be the tallest of tall orders. And it is certainly not necessary, from the point of view of grieving. The main thing is to understand and accept that you will sometimes feel old pains as well as new ones, and just let feelings surface when they are ready to do so.

This process can be helped along in various ways. But before I describe those ways, under Emotional EEEEs, I want to mention some important landmarks which may be encountered in the journey through grief. They are sometimes called the "stages" of grieving, but in fact they are neither strictly sequential nor particularly predictable.

Moving Through Grief

A number of "stages" of grieving were described by Elisabeth Kübler-Ross, in her book On Death and Dying[67]. This book focused mainly on people who were facing impending death, but the same elements can be seen in people grieving for the death of a loved one – or indeed, following any significant loss. Kübler-Ross used the terms denial, anger, bargaining, depression and acceptance for these "stages" of grieving.

She did not say that they all appear in every case, nor did she say that their order is fixed – though she was often criticised for allegedly saying those things. In fact, there usually is a general trend in the direction shown above, and most of the elements can be identified if they are looked for. However, the idea of discrete stages, occurring in a fixed order, represents a significant misunderstanding of her work – and of grief itself.

Indeed, the features of each "stage" may recur at almost any time. This implies that all the "stages" could conceivably be present at once. That would be quite unusual, though certainly not impossible if the expression of each was incomplete. Further recurrences, especially of anger and sadness, are also common at the times of the various anniversaries which remind the bereaved person of their loss. But despite their lack of regularity, the aspects of grieving listed above are worth a closer look, because they provide some insight into the process.

Perhaps I can safely look at these stages one at a time now, without any readers fastening a vice-like grip on the order in which they appear in the text. I am going to start with denial, just as Kübler-Ross did. However, some of her other stage names will have to share the limelight occasionally, due to the inclusion of ideas suggested by other authors.

I have mentioned previously, under The Anatomy of Emotions, that there is often a delay before sadness and antipathy are felt after a loss. This would be impossible unless the realisation of the loss was itself delayed. The temporary absence of realisation is usually called denial. When the distress would be overwhelming, as in the case of bereavement or incurable illness, denial is sometimes both profound and prolonged.

In some cases, this results in a bereaved person being completely oblivious to the reality of their loss. This is sometimes called unconscious denial, and is often, though not necessarily, complete. In other cases, there may simply be a strong preference for not facing the reality, even though it is at least partly recognised. This is conscious denial, and is less likely to be complete, though it may be. But whether conscious or unconscious, complete or partial, it is often referred to simply as denial. It is also, quite often, called (emotional) shock – or simply numbness.

The mechanism of denial is uncertain, but it is often considered to be a protective device, on the assumption that awareness of the full significance of the event would overwhelm the person's mind, with serious consequences. This theory cannot be tested, because denial cannot be switched on and off. However, it is clear that grief is capable of causing overwhelming emotional pain, and that the latter can have serious consequences, so the theory is plausible. What is certain, is that denial very often does occur, and is then an integral part of grieving.

The transition from complete or partial denial to a full recognition of the unpleasant reality can be gradual, sudden or relapsing. When there is an identifiable transitional phase, it often includes a search, sometimes quite a comprehensive one, for an acceptable explanation for the situation – or at least, an explanation less terrible than the obvious but unthinkable possibility – which might still account for the apparent facts.

Such behaviour is often called searching.[68] It may even involve a physical search for the person who has died, in the hope that there has been a mistake, and the person is simply lost. More often, though, it is less specific than that, though still analogous to it. It is important to acknowledge the normality of this behaviour – which would be far from normal in other circumstances – but it should not be artificially reinforced.

A behaviour which is closely related to searching may either take its place, or occur in addition to it. That behaviour is called bargaining. It is not the usual sort of bargaining, but rather a virtual bargaining – trying to make a mental deal, with any power the bereaved person considers might possibly exist, for the reversal of the apparent but utterly unacceptable reality.

When religious people bargain in this way, they engage in contractual negotiations with their God. This may seem strange to a third party, but bargaining is just as normal an aspect of grieving as denial or searching. And like them, it requires acceptance, but not reinforcement. It will run its course soon enough in most cases.

Now, looking back over the last few pages, you can see that I have given denial three words (denial, shock, numbness) and bargaining two words (searching, bargaining). I have also promoted bargaining, so that it appears before anger. And in just a moment I will explain that the primary emotion sadness provides the meaning of depression intended by Kübler-Ross.

As the last stage, acceptance, is not going to suffer any tampering at all, I think you will agree that the five stages have come through quite unscathed – an excellent result in all the circumstances. So, if you like the simplicity of denial, anger, bargaining, depression, acceptance, you still have it – sort of.

As [denial/shock/numbness] and/or [searching/bargaining] are replaced, gradually or suddenly, by an increasingly clear realisation of the terrible reality, sadness and antipathy move to centre stage.[69] In many cases, anger is the most evident emotion from the umbrella of antipathy, and it often makes its first appearance before the various emotions from the umbrella of sadness[70] emerge.

Or else it does nothing of the sort. Because, like everything else to do with grief, anger varies – sadness may come first, and in fact anger and sadness frequently alternate or coexist. Alternatively, anger may make its first appearance before searching and/or bargaining, despite the close connections between the latter two phenomena and denial.

There is another way in which anger may make its entry. If there is no noticeable denial phase, anger may be the immediate response. This is presumably why ancient kings and princes had a tendency to execute the bearers of bad news. We still talk of "shooting the messenger" – but nowadays, fortunately, it is usually a metaphor for aggressive reactions of a less permanent variety.

That brings us to acceptance. The very idea of acceptance is likely to seem ludicrous, if not downright offensive, to a bereaved person. That, of course, is part and parcel of the emotional voyage of grief. But, sooner or later, some sort of acceptance usually does occur. Or, to be a little less imprecise, at least three sorts of acceptance may be encountered. Each tends to come and go, erratically, for a variable period of time, gradually becoming more stable in most cases.

First, there is the acceptance that the loss is real – this is the acceptance which replaces denial, thereby allowing the emotions of grief to emerge. Then, there is the acceptance that life can go on – even though a hole has been left in it, which will never be filled. This is usually the beginning of a gradual but progressive improvement in wellbeing, leading to a life which, though still different, is no longer bleak and miserable.

Finally, and only in some cases, there is a much greater acceptance and appreciation of life than was the case before the loss occurred. This is a side effect of the EEEEs process described below, and is an example of the good which sometimes grows out of terrible experiences – even though we would never choose to have them, if we had that choice. This variety of acceptance is a great blessing – but it is a bonus, rather than a routine result of having moved through grief.

However we describe and classify it, there is tremendous variation in the process of grieving. Some people pass through it relatively calmly. Others seem to take forever, or go through hell, or both. I will mention a few factors which could influence these variations, but I am sure there are many others.

Various characteristics of the loss itself will inevitably have a significant impact on the process. However, it is the effect of these characteristics on the bereaved person which is important, rather than their external assessment. Therefore, while the importance of the characteristics of the loss can be presumed, it cannot easily be measured. Nevertheless, some characteristics, such as unexpected death, presumed but unproven death, child death, parent death, murder, and suicide, certainly appear to have some partially predictable effects.

The next major influence that comes to mind is the nature and quantity of the person's unfinished business prior to the loss. This, whatever it is, will be stirred up by every aspect of grieving – and will, in turn, have its own effect on every aspect of grieving. In a very imprecise way, you could say that more unfinished business means a bumpier ride through grief. But also, if it is addressed effectively, it means that more secondary benefits may accompany the grieving process.

Closely allied to the previous factor, is the importance of the way in which the person deals with the strong emotions of grief. If the EEEEs work described under the next heading, or something equivalent to it, is already known, or is now learned, by the grieving person, then these emotions can be safely expressed – which makes an enormous difference.

Finally, various choices that are made by the person during the grieving process can be of pivotal importance. The importance of a choice to accept the existence of feelings and work through them – which is much easier to say than to do – has already been implied. A choice to exact revenge can both slow the grieving process and create new problems. And many other choices can sometimes be seen as forks in the road of grieving.

Now, most of the above influences on grieving are either difficult or impossible to modify – but the way emotions are dealt with is an exception. A safe and effective method of doing this can be offered, taught and facilitated in various ways and at various levels of intensity. The ways might involve anything from a short chat to formal and prolonged counselling, and the intensity might also vary considerably.

While effective help with emotions is not the only thing needed by a person who is grieving, I am quite certain that it is the most valuable thing. Its beneficial effects grow like a living plant, and they can also be applied to other losses, past or future. Whether in the office of a grief counsellor, the home of a friend, or for that matter in solitary confinement in a prison cell – if the emotions of grief are dealt with effectively, grieving will proceed inexorably towards its invariable goal.

I do not advise talking of a "goal of grieving" to those who actually are grieving, but an onlooker may well perceive something of the sort. It could be thought of as a life which is again worth living, despite the fact of the loss. In some cases, that life is richer emotionally than it ever was before – though the change may not be admitted, or even noticed. Of course, this second suggestion is even less likely to be welcomed, by a grieving person, than the more general idea of a goal.

During the discussion of the nature of grief – and indeed throughout the book – I have made many references to the safe expression of emotions. It is now time to say exactly what I mean by this, and I will do so under the next heading. As with most things in life, there are various ways of approaching painful emotions. However, I think many of the differences have more to do with the details than the overall concept.

I have called the method which I describe in the following pages "Emotional EEEEs". The four Es stand for Encourage, Explore, Express and Evaluate. That is partly because I like mnemonics, and partly because I like the idea of easing pain. But it is mainly because the essential elements of the method fit very neatly under those four headings.

Of course, as explained many pages back under Denials, the name is emphatically NOT an attempt to imply ownership of the method. The name may be new (though not to everyone, as I have used it in lecture notes over a long period of time) but the method, in one form or another, can be derived from ideas which reach back as far as history itself. More recently, it has been used extensively by Kübler-Ross, Barham and colleagues[71], as well as many others. Consequently, while any errors in the text will indubitably be my own, the method itself is pretty well universal.

Some of the content under the next heading is so obvious that you may wonder why I bothered to type it at all. On the other hand, some of it may seem a little surprising, and you might instead wonder whether I should have culled it considerably.

But I suggest that Emotional EEEEs should be approached as if it were a tool kit, designed for the repair of emotional suffering. There are various different tools, each of which comes in a range of different sizes. And you only need to use the tools, and the sizes, required for the current repair job.

[60] Remember that the second pillar of Wanterfall work will not be solid until the whole of this book has been read and digested. It is wobbly until then!

[61] As before, when I refer to the left or right hand side of the Wanterfall or the Wanterfall chart, I mean that side of the printed chart, as you look at it.

[62] As mentioned under Cautions, pathological grief lacks this natural progression, and therefore requires professional help.

[63] Here, I am referring to a feeling of depression rather than a depressive illness. Sometimes, though, it is not easy to tell the difference – as discussed in More Cautions at the beginning of this section.

[64] See footnote to Antipathy under The Six Primary Emotions.

[65] Propathy is defined under The Six Primary Emotions.

[66] See footnote to Original under Denials.

[67] Kübler-Ross, E. On Death and Dying. Multiple publishers and dates, but first published in 1969 by Macmillan, New York. Also see footnote to Original under Denials.

[68] In the Kübler-Ross scheme, "bargaining" includes this searching behaviour as well as the bargaining behaviour next described.

[69] These are the only aspects of grief which are represented on the Wanterfall chart itself. But luckily, the chart always has this book wrapped around it.

[70] Kübler-Ross used the word depression to describe this deep sadness. She meant feeling depressed, not having a depressive disorder. However, feeling depressed is not always due to grieving, as discussed under More Cautions.

[71] See footnote to Original under Denials.

SECTION 4 The Healing of Emotions

More Cautions

Introduction

Looking Inside Grief

Unfinished Business

Moving Through Grief

SECTION 4
The Healing of Emotions