Coping with Grief

Whole Health is built around the Circle of Health, which emphasizes the importance of personalized, values-based care that draws in mindful awareness and eight areas of self-care: Surroundings; Personal Development; Food & Drink; Recharge; Family, Friends, & Co-Workers; Spirit & Soul; Power of the Mind; and Moving the Body.  Conventional therapies, prevention, complementary and integrative health (CIH) approaches, and community also have important roles.  The narratives below describe how the Whole Health approach could have an impact on Veterans with grief.

A Whole Health Approach includes awareness that grief may affect a patient’s health.  Learn how to 1) recognize the possible role of grief as a cause or in the exacerbation of clinical symptoms, 2) increase your ability to support a grieving patient within your own time limitations, comfort level, and knowledge in this area, and 3) know when to refer a patient to a grief specialist, empowering patients to optimally cope with their grief and integrate a loss into their lives.

Overview

Note:  This module especially focuses on grief related to a death loss with some pertinent information included on other types of losses.  A more complete focus on other types of losses (such as disability, divorce, job loss, effects of natural disasters) is beyond the scope of this overview.  However, you are likely to find the concepts and suggestions helpful and adaptable when working with a Veteran who has experienced a loss other than death.

Whole Health emphasizes mindful awareness and Veteran self-care along with traditional and integrative approaches to health and well-being. The Circle of Health highlights eight areas of self-care: Surroundings; Personal Development; Food and Drink; Recharge; Family, Friends, and Co-Workers; Spirit and Soul; Power of the Mind; and Moving the Body. The narrative below shows what a Whole Health clinical visit could look like and how to apply the latest research on complementary and integrative health (CIH) to help patients when grief is a contributing factor in their health.

Meet the Veteran

Jim is a 66-year-old Vietnam era Veteran.  He has been divorced for 25 years.  He does not have children.  He lives alone.  Jim works part-time in his state’s lottery office.  Over the years he has had a couple bouts of mild to moderate depression when relationships ended.  A knee injury has limited a few activities he previously enjoyed, such as softball.  He likes to watch sporting events and to spend time outdoors.  He came into the medical center with back pain (which he never had before), difficulty sleeping, and fatigue.

Jim’s mission for appointment: To learn what is causing my symptoms of back pain, difficulty sleeping, and fatigue, and to eliminate them or at least reduce them

Personal Health Inventory

On his Personal Health Inventory (PHI), Jim rated himself a 3 out of 5 on all of the following: his overall physical, mental, and emotional well-being, and what it is like to live his day-to-day life.  In response to the questions, “What do you live for? What matters to you? Why do you want to be healthy? Jim wrote:

“What really matters to me are my sister and her family, being on friendly terms with the neighbors, and finding productive ways to spend my time when I retire.”

Jim rated himself on where he is and where he would like to be in each of the eight areas of self-care.  In all but one area, he rated himself lower now than he would like to be.  Finding no specific medical reasons for Jim’s symptoms upon physical exam or lab tests, Jim’s clinician used the PHI to learn more about Jim’s life:

  • Working the body. Fatigue and pain have resulted in Jim being sedentary.
  • He has not been getting enough sleep, even though he tries.  He has been waking up much earlier than normal and not feeling refreshed by any activity.
  • Food and drink. He has started picking up more carry out food and eating more than he should.  He has increased his intake of beer and soda.
  • Personal development. His job is fine.  He has been thinking about things he would like to do when he retires in a year.  He finds it hard to think about that now.  His nephew was in an automobile accident a month ago and may not live.  He was planning to do many activities, like woodworking projects, with him.
  • Family, friends, and co-workers. He is close to his sister and nephew, has a few buddies at work, and some good neighbors.  He is not seeing them as much now.  He feels guilty when he does not go to the hospital to see his nephew.  “It’s very hard.  My throat feels so tight, it’s hard to talk, and when I’m in his room, I feel physically weak.”
  • Spirit and soul. Jim thinks that his best years may be over and says some of them were not so great.  He wonders if he will be healthy enough to enjoy life.  “It’s hard to find purpose and meaning sometimes when you’ve seen some of the things I’ve seen in the service.  And now my nephew, he’s just a kid, 24.  It zaps your spirit.”  “It would be good to feel at peace.  I’ll keep trying.”
  • Jim feels better when he is outdoors in nature.
  • Power of the mind. Jim learned some breathing exercises in the past.  He knows some guys who have tried tai chi and yoga.

For more information, refer to Jim’s PHI.

Introduction: About Grief

One hundred percent of patients will experience major losses in their lifetimes.  While most people cope well with this universal experience and will not need clinical intervention, the health consequences of grief can be far-reaching.[1]  Studies have linked bereavement or grief to depression, anxiety-related symptoms and disorders, impaired immune function, poorer physical health, increased physician visits, increased use of alcohol and cigarettes, suicide, and increased incidence of and mortality from conditions such as cardiovascular disease.[2][3][4][5]

Depression is one explanation for Jim’s symptoms.  He experienced mild/moderate depression twice—the first time when he divorced 25 years ago and again when a subsequent relationship ended eight years ago.  When considering a diagnosis of depression, it is important to learn what, if any, major losses the patient has experienced.  Many grief symptoms are consistent with those of depression.[6]   In fact, it is likely that many patients are labeled as depressed when in reality they are grieving a major loss.[7][8]  One study based on survey data from more than 8,000 Americans suggests that the prevalence of major depressive disorder (MDD) may be reduced by almost one-fourth if individuals who are grieving major losses such as marital dissolution, job loss, natural disasters, severe physical illness, and failure to achieve important goals are excluded from depression statistics as are those who have experienced a loss through death.[9]

Grief Reactions

Grief is more than emotion; it also encompasses behavioral, cognitive, physical, and spiritual elements.[10][11]  The grief experience varies widely and is influenced by many things such as a person’s age, gender, relationship with the deceased, culture, personality, previous experiences, coping skills, and social support.  Cultural differences in grief are enormous, and it is very important to be aware of them to avoid compounding the individual’s distress when trying to help.[12]  What is considered typical in one culture may be seen as pathological in another.

The military has its own culture that can greatly affect the grieving process.  Yet, it is important to note that there is no universal military culture.  Different branches of service, different ranks, whether one enlisted or was drafted, whether one served in combat, and in which war or conflict one served all affect someone’s experience.  However, one common trait seems to be stoicism.

Soldiers are taught to handle anything and how to live in survival mode; they learn to disconnect from their emotions.[13]  Stoicism contributes to survival and military success but can cause problems after returning home.  It may later make grieving more difficult, hindering the process.

Grief researcher William Worden has identified some grief reactions that are common in our society.[10]  Jim is showing a number of these reactions: 1) waking up too early, 2) eating too much, 3) withdrawing from others, and 4) fatigue.  When he is in his nephew’s hospital room, he feels 5) tightness in his throat, and 6) muscle weakness.  A study of 1,522 infantry soldiers surveyed six months following deployment to Iraq or Afghanistan in 2008 found that over 20% reported difficulty coping with grief over the death of someone close.[5] Controlling for confounding factors, researchers found that this grief contributed to a high physical symptom score (number of symptoms and their severity).  Jim is experiencing three out of the five most common symptoms reported by these soldiers: fatigue, sleep problems, and back pain [5] (The other two are musculoskeletal pain and headaches).  While Jim’s combat experience occurred decades ago, his grief reactions may be similar.  He also feels that he has lost direction in life, and he is searching for meaning in loss—these are the types of spiritual adjustments that grieving individuals often work through.[10]

For more information on common grief reactions, refer to “Grief Reactions, Duration, and Tasks of Mourning” Whole Health tool.

Anticipatory Grief

Jim acknowledged that his nephew’s condition is “killing” him.  Jim is experiencing anticipatory grief.

Anticipatory grief occurs when a death or other loss is perceived as imminent and an individual begins grieving before the actual loss occurs.[6]  Mostly, it is a healthy experience; anticipation allows for preparation, development of coping strategies, and mobilization of assistance.[14]

Rando has clarified that often anticipatory grief includes mourning over a series of shifting current losses as well as the eventual death, as an individual’s health, abilities, and plans for the future fade.[15]  Anticipatory grief does not lessen the grief reactions that occur following the loss.[15]  One is a reaction to the expectation of loss and steps along that pathway; the other is a reaction to the finality of the loss.  Awareness of the phenomenon of anticipatory grief allows the clinician to provide on-going support according to the needs of the patient and family.  As individuals anticipate the forthcoming loss of a close relationship, grief may be rekindled over a significant previous loss that was not fully grieved in the past.  This may occur, for example, in Veterans with PTSD.[16]

Disenfranchised Grief

Disenfranchised grief—hidden sorrow—is grief experienced when a loss is not or cannot be openly acknowledged, publicly mourned, or socially supported.[14]

The importance of the loss is identified by the person experiencing the loss and cannot be determined by the opinion of others.  Examples of situations, which may lead to disenfranchised grief include the following:

Having an unrecognized relationship with the deceased

This might be an ex-spouse, same-sex partner, partner from an extra-marital affair, former friend, or co-worker.  Uniformed service members—especially those who served in combat with the deceased—have been greatly under-recognized.[17]  A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous than did spouses who were bereaved in the past six months.[18]  The investigators concluded that treating the symptoms of unresolved grief may be as important as treating fear-related symptoms of PTSD.

Experiencing types of losses that often are unacknowledged by others

Some examples are infertility, abortion, perinatal death, death of a companion animal, death of a very elderly person, loss of the personality in Alzheimer’s disease, loss of ability, and loss of a role or status.  The grief of family and friends of a Servicemember killed in action may be disenfranchised by someone who comments that death should be expected for those who are on active duty during a time of war.[17] Veterans may experience disenfranchised grief after returning to civilian life and feeling pain over the deaths of enemy soldiers or civilians for whose deaths they were responsible.[19][20]  Fear of judgment can increase reticence in sharing these experiences with others.[21] Unmourned grief together with unforgiven guilt/shame is known as “soul injury.”[22] Opus Peace founder, Deborah Grassman notes, “Learning how to self-compassionately connect with the part of self holding the pain and shame allows people to re-connect with their soul—with who they really are.”[22] This has led many Veterans to personal peace.

Facing difficult or unpleasant circumstances of the loss

This can occur when a death involves what some perceive as stigma (e.g., suicide, AIDS, or a criminal act), or when there are circumstances of the death too horrible to face (e.g., a wartime atrocity).  A survey of Iraq and Afghanistan Veterans in 2017 revealed that 58% of participants knew a Veteran who died by suicide.[23]  These unexpected deaths will likely be more difficult to accept.

Being excluded from social support because one is assumed by others to be incapable of grieving or perceived as not being strong enough to handle the loss, needing to be “protected”

Children, adults with intellectual disabilities, and the elderly can fall in this category.  Given the stoicism required in the military and the efforts to desensitize soldiers to taking life, others may view military personnel and Veterans as lacking the ability to grieve.[19]

Experiencing multiple losses in a short span of time, so that some have not been acknowledged

In the military, this may involve deaths of several comrades and frequent moves with separation from one’s family for support.[24]

Disenfranchised grievers may not recognize that their own symptoms are related to grief.  An important step is helping the person verbalize the importance and meaning of the relationship (or non-death loss).  Health care practitioners are in a unique position of trust to recognize disenfranchised grief and start the process of validation and support for the grieving person.[25]

Mindful Awareness Moment

Take a few minutes to sit in a quiet, peaceful, comfortable location where you will not be interrupted.  This might be by a lake, in a wooded area or flower garden, or your favorite chair at home.  Take some deep breaths, close your eyes, and when you are ready, turn your attention to any losses that you have experienced.  This might be the death of someone close to you, the death of a patient, the end of a friendship or relationship, a decline in health status for yourself or someone else, a lost career opportunity, the effects of a natural disaster.  Think back over the past month, year, or longer.

  • What comes up for you? Is there a loss that readily comes to mind?
  • Are you surprised by the particular loss that comes to mind or well aware of it?
  • How recent is the loss?
  • Is there more than one loss that feels particularly salient?
  • How painful is the loss?
  • What emotions do you feel as a result of that loss?
  • What thoughts do you have about the loss?
  • What physical sensations are you experiencing as you think about the loss?

If you have more time or during another quiet time, continue to explore your feelings related to loss:

  • In what ways (both negative and positive) does the loss affect your daily life?
  • How are you supported by others related to this loss? Is your loss disenfranchised (i.e., hidden from others)?
  • What do you need to help integrate this loss into your life?
    • Acknowledge this loss to yourself?
    • More time to experience and work through the pain of the loss?
    • Share your thoughts and emotions with someone else?
    • Honor the deceased individual or your loss experience through an activity such as writing, building something, planting a tree, shrub, or flowers, creating a work of art, singing a song or playing music?
  • If this exercise brings up particularly unsettling thoughts and emotions, what can you do right now to help yourself feel more at peace as you continue over time to cope with the loss? What characteristics, skills, and resources do you have that give you strength as you move through the grieving process?

* For more information, refer to “Health Care Professional As Griever: The Importance of Self-Care.”

Differential diagnosis requires talking with patients about known or possible losses, their reactions to those losses, and the time period involved.  For someone who has had a significant loss and whose symptoms are ongoing, differentiating “typical” grief from the more debilitating “complicated grief” or from clinical depression or PTSD can be tricky.  Shear offers clinicians a concise table comparing characteristics of these conditions.[26]  (Refer to “the “Resources” section at the end of this overview.)  Differential diagnosis may best be accomplished via referral to a mental health professional experienced in the area of grief for further assessment and facilitation/support of mourning.  Patients can experience grief reactions coincidentally with anxiety, depression, and PTSD.

Typical Grief

While universal, “typical” grief can be profoundly painful and disruptive and may feel anything but normal to the person who is grieving.

Complicated Grief

In complicated grieving, symptoms are long-lasting and may intensify over time; the person has trouble accepting the death and resuming life.  Something is getting in the way of the grief process and not allowing the person to adequately adapt to the loss.[10]

Estimates of the prevalence of complicated grief vary widely, based on circumstances and relationship with the deceased.  An estimate published in 2011 indicates that 2-7% of those bereaved in the general public experience complicated grief.[27]  Prevalence is high among Veterans, a group at risk for disenfranchised grief.  Literature notes that complicated grief is critically under recognized and unaddressed in Servicemembers.[28]  Two studies of Servicemembers and Veterans who served after September 11, 2001, found that about 80% had experienced the death of someone important to them and almost one-third of those met criteria for complicated grief.[29][30] For details of this research and more information on complicated grief, refer to “Screening for Complicated Grief” Whole Health tool.

This research indicates that Servicemembers and Veterans are at increased risk for complicated grief with associated sequelae and highlights the importance of screening for this condition, so that appropriate treatment can be offered.  Screening for complicated grief has been found to be feasible and useful in primary and behavioral health clinics and military mental health clinics.[31][32]   The Brief Grief Questionnaire developed by M. Katherine Shear, MD, and Susan Essock, PhD,[33] is an efficient tool to screen for complicated grief in health care settings.[34][35]  You can download a copy or also refer to “Screening for Complicated Grief” Whole Health tool.

To screen for complicated grief…

  • Ask the five questions in the Brief Grief Questionnaire during a patient’s appointment.
  • Use with adults bereaved for at least 12 months and children at least 6 months.
  • Screen all bereaved individuals who seek treatment for suicide risk, mood, and anxiety disorders as well. These conditions may require treatment earlier than 6-12 months post bereavement.

Major Depressive Disorder

Differentiating between grief and depression is complicated by lack of established criteria.  The two share common symptoms.  In complicated grief, longing and sadness are salient emotions.[34]  For patients with Major Depressive Disorder (MDD), treatment such as antidepressants may help lift the depression, so that an individual is better able to focus on tasks of mourning.[10]

PTSD

An individual may have PTSD if the circumstances of the death were violent or traumatic. Reactions might include recurrent disturbing recollections of the death, avoidance of situations associated with the death, difficulty sleeping, difficulty concentrating, and angry outbursts.[36]

How to Help

Perhaps the most important thing health care practitioners have to offer grieving patients is their compassion and understanding.  Validation of the person’s grief experience is important.  At a minimum, one can offer sincere comments such as, “I’m so sorry for your loss” and “From what you have told me, you have really gone through a lot.”

Aloi identified a number of ideas that nurses can suggest to family members to help with Veterans’ disenfranchised grief.[19]  (See the “Resources” section at the end of this overview).

Social workers at Louis Stokes Cleveland VA Medical Center, who noted increased stress for Veterans at end of life, added a grief/bereavement counselor to their Veterans Affairs Contract Home Hospice Program.[37] They then developed and implemented a three-pronged approach.  Anticipatory mourning support for both the Veteran and caregiver/family is a key component.  The other two foci are caregiver support and bereavement support.  The program has been well received by Veterans and families/caregivers.

Salutogenesis-Oriented Sessions (SOS)

Some patients will benefit from extra attention.  Rakel proposes the use of salutogenesis-oriented sessions (SOS) to facilitate health.[38]   An SOS is an office visit, longer in length than a typical appointment, with a goal of fostering hope, to explore what may be at the root of a symptom, so that it can possibly be resolved.  He identifies five elements for the visit: 1) a comfortable, inviting, private physical space, 2) creating positive expectations for the session, 3) being fully present to listen to the patient’s story, 4) offering emotional support, and 5) writing out a simple plan for the future.   Such a healing session could be used to help assess whether grief is causing a patient’s symptoms as well as to assist the patient with the tasks of grief.  Such a session has a great deal in common with a Whole Health visit, be it with a Whole Health Partner, Coach, or member of the clinical team.

Consider asking about

  • the person who died
  • the circumstances surrounding the death
  • how the patient is coping
  • the variety of emotions the patient has been feeling
  • the challenges the patient is experiencing
  • how the loss is affecting the patient’s daily activities, social interactions, and work
  • the patient’s perception of the support provided by others.[39]

The PLISSIT Model

The PLISSIT model can be a guide for primary health care practitioners in assisting their patients throughout the grief process.  PLISSIT is an acronym for Permission, Limited Information, Specific Suggestions, and Intensive Therapy, a model developed by Annon to address sexuality issues.[40]  It is very useful in other health care situations as well.  The model includes four levels of intervention, ranging from basic to complex.  It guides clinicians to support patients according to the clinicians’ own comfort level and expertise as well as the needs of patients. Referrals can be made when patients’ needs exceed clinicians’ comfort, knowledge, and time.

Permission

Clinicians can initiate the topic of loss, giving patients the opportunity to talk about the experience.  Some patients may choose not to do so.  In our fast-paced, multitasking society, adults may feel pressured by themselves or others to resume their former lifestyle with minimal disruption.  Clinicians can offer “permission” to grieve as needed.  For many patients, this interest and support will be the only intervention needed.

Limited Information

Limited information will be helpful to other patients.  This second level requires more knowledge about grief to answer patients’ questions and dispel misconceptions.  Many people know little about grief reactions until they experience them.  People frequently ask if their reactions are normal and if they are going crazy.  They can be relieved to learn that their reactions and the duration of their grief are similar to the experiences of others with comparable losses.  If their experiences are different, they can be reassured that everyone grieves in her or his own unique ways.  When appropriate, the clinician can educate patients about anticipatory grief or disenfranchised grief, so that grievers will understand that their reactions are valid and the relationships are important ones, as well as receive reassurance that they have strength to cope.[41]  Factual information in patient handouts and a list of grief resources (e.g., support groups) may be helpful.

Specific Suggestions

Fewer patients will require some specific suggestions. This level involves advanced knowledge and skill to understand a patient’s unique situation and develop a plan.  Clinician and patient can discuss the loss experience more thoroughly, collaboratively identify issues to be addressed, problem-solve, and choose helpful strategies.  For example, for a patient distraught over the pain of grief, a clinician could help develop a healthy plan to work through the pain. This might involve reassuring the individual that the pain will not always be so intense, identifying one or more people who are good listeners in the person’s social circle to contact when emotions seem overwhelming, minimizing alcohol and other drugs, avoiding major decisions which one might regret later, and choosing a form of physical activity that would be do-able with current energy level.

Intensive Therapy

A minority of patients will require intensive therapy. This final stage usually requires referral to a specialist in grief.

Self-Care

…people cope with loss in different ways and therefore may have different needs for intervention and different responses to a given type of intervention.[42]

Many strategies exist to help individuals cope with major loss.  Following are a sampling of non-pharmaceutical approaches that can be recommended to individuals who are grieving.  Note that while listed here under a particular self-care area, some strategies cover several self-care areas.  For example, nature is listed in “Surroundings” Whole Health overview.  Depending on how an individual spends time in nature, it may also fit under the categories of Working Your Body; Recharge; Spirit and Soul; and Family, Friends, and Co-Workers (if others accompany the individual).

Moving the Body

Exercise

Suggest a form of physical activity that the grieving individual has enjoyed in the past or encourage the person to try a new one. Doing the activity with others may be even more helpful.  For more information, refer to Whole Health overview “Moving the Body.”

Massage

Therapeutic massage may be helpful for someone who is experiencing tension or pain from “holding grief” in the muscles.

Surroundings

Nature

Spending time in nature can be soothing and healing.

Personal Development

Leisure Activities

Encourage activities that the individual has enjoyed in the past.  As grief becomes less acute, encourage exploration of new leisure activities.

Food and Drink

Healthy Food

Encourage a good balance of healthy foods.  Overeating and undereating are common grief behaviors.  For more information, refer to “Food & Drink.”

Limit Alcohol and Other Drugs

Caution against using alcohol and unprescribed drugs for relief.

Recharge

Good Sleep Hygiene

Educate about good sleep hygiene, if this is not something the individual generally practices.  For information on insomnia, refer to “Recharge.”

Provide Reassurance

Reassure the grieving individual that sleep disruption, especially difficulty falling asleep and early morning awakening are common experiences during the first few months of grief.[10]  In normal grief, this symptom usually resolves on its own.  If it continues, it may indicate depression.

Healing Touch

Healing Touch is a form of energy medicine.  Practitioners place their hands near or gently on the body to clear, energize, and balance the energy fields; the goal is to restore balance and harmony, so the receiver is placed in an optimal position to self-heal.[43] To find a certified practitioner refer to the Healing Touch directory.

Family, Friends, and Co-Workers

Facilitating Support From Family and Friends

People benefit from social support of their losses.  Some grievers may be hesitant to seek the support they need.  Others may need to tell the story of their loss over and over again as they come to terms with it.  This need to retell may clash with the needs of people in their support system whose patience, time, and energy can become taxed.  In the first situation, encourage grievers to contact family, and in the second situation help them to identify individuals in their social circle who are particularly good listeners with time available or to locate a grief support group.

Grief Support Groups

Grief support groups are available in many communities and also online.  Hospices are usually good sources for information on their availability.  If grief is military-related, a grieving individual may want to connect with others who are familiar with military culture.  Vet Centers or The Tragedy Assistance Program for Survivors (TAPS) are two possible referrals to make.  There is more information in the resource section at the end of this document.

Spirit and Soul

Addressing Spirituality Concerns

Certain losses may challenge grievers’ spiritual beliefs, causing them to question their existential views.[11]  They may experience this as an internally chaotic time, feeling ungrounded or adrift.  It can also become a time when grievers reaffirm or redefine their belief systems and grow in new directions.  Those in the military may have been in situations which caused them to perform or witness behavior that was in conflict with their personal moral beliefs or religious or spiritual beliefs.[21]  A referral to a chaplain, clergy, or other spiritual leader may be helpful.

Rituals

Rituals are activities that symbolize feelings and thoughts related to a death.  They honor a person and recognize a change in status from living to deceased.[44]  Some rituals demonstrate that a bond continues to exist with the deceased.[44]  Rituals may be related to one’s cultural traditions, or they may be created by individuals themselves.  Perhaps the most familiar rituals are those of a visitation/wake and a funeral/memorial service.  Many kinds of informal rituals can be created based on the interests and needs of the bereaved.  Doka notes that those who have been in the military may express grief best in cognitive and physical ways, rather than through emotions.[44]  Finding their own unique ways to memorialize loved ones may be very helpful.  Examples of informal rituals include lighting candles or toasting the deceased on special dates, sewing a memory quilt (which may be created from clothes of the deceased), building something as a memorial to the deceased individual, planting a tree or a memory garden, sharing a memory dinner to celebrate the life of the deceased, leaving a note at a memorial setting (e.g., at a Veteran’s memorial).

Power of the Mind

Writing or Journaling

Writing or journaling about one’s grief experience can help facilitate the expression of feelings and help focus on the meaning of the loss to the griever.[10]  If grievers have unfinished business with the deceased, they might consider expressing their thoughts and feelings through writing a “letter” to the deceased individual. For more information, refer to “Therapeutic Journaling.”

Forgiving

An unexpected death can leave a bereaved individual with “unfinished business” with the deceased.  If the bereaved have a sense of previously being “wronged” by the deceased, they may benefit from working on forgiveness.

Self-forgiveness can be an important task for previous combat Veterans.  After returning to civilian life, they may feel horror at their behavior during wartime, even if they did what was required of them and it was considered heroic and a characteristic of a good soldier.  Feelings of guilt can be resolved through a ritual involving confession, forgiveness, compensation (e.g., helping other Veterans), and self-forgiveness.[20]  A clinician can help by creating a safe environment in which the Veteran can share any actions that may be the cause for feelings of guilt or shame.  It is important to neither push a Veteran into the topic of forgiveness, nor minimize feelings of guilt, if the Veteran brings them up.[45]  For more information, refer to “Forgiveness: The Gift We Give Ourselves.”

A grief counselor who is experienced with Veterans and grief issues can be helpful for someone who wants to work on forgiving.  This specialist may be a pastoral counselor, psychologist, or social worker.  Mental health clinicians who have received specialty training in PTSD are usually trained in traumatic grief and guilt. They use tools such as relaxation, mindful awareness, and guided meditation and can help Veterans overcome avoidance, a clinical symptom of PTSD that often keeps Veterans from engaging in therapy.

Mindfulness-Based Stress Reduction

In the absence of personal awareness, grieving can be disenfranchised.  Mindfulness-Based Stress Reduction (MBSR) is based on Eastern philosophies and uses meditation to calm the mind and body.  It is a practice that helps individuals live in the moment and become more self-aware.  For more information, refer to “Mindful Awareness.”

Personal Health Plan

During the appointment, Jim’s clinician talked with him about the mind-body connection.  The clinician described that stress can cause or exacerbate back pain.  He educated Jim about common grief reactions and anticipatory grief.  He pointed out that a number of the symptoms Jim reported were consistent with grief.  He reflected back to Jim how important the relationship with his nephew was to him. (Jim had said that fishing and going to baseball games with his nephew brought him joy and happiness.  Jim was also looking forward to starting new activities—like setting up a woodworking shop—with his nephew when he retired.)

Jim and his clinician have a good relationship.  Jim has often said that he trusts his clinician.  Jim’s responses to questions about purpose and meaning in his life— “It’s hard to find purpose and meaning sometimes when you’ve seen some of the things I’ve seen in the service,” and, “It would be good to feel at peace; I’ll keep trying”—caused his clinician to question if Jim has ungrieved losses from his combat years that are compounding his anticipatory grief reactions over his nephew.

Knowing that Veterans are a population at risk for disenfranchised grief, that Vietnam Veterans were not welcomed home and often did not talk about their experiences, and that as they age symptoms related to these experiences may come bubbling up, his clinician gently asked, “Jim, is there anything from your years in service that is still troubling you?”  The timing was right.  Jim shared a difficult story that he had not shared with others at any time in his life.  The clinician noted similarities between Jim’s nephew and comrades in the service.  They were about the same age.  They faced possible disability or death years too soon.  Jim mentioned guilt over both situations—guilt that he was surviving and some of his comrades did not and his nephew might not.  He also expressed some guilt over behavior that he had witnessed in combat.

Jim’s clinician asked Jim the five questions in the Brief Grief Questionnaire.  Jim scored a 3, which is not indicative of complicated grief.  While Jim’s diagnosis did not indicate a strong need for a referral to a mental health specialist, he has some issues that he may want to explore to promote future health and happiness.

Together Jim and his clinician developed a Personal Health Plan (PHP) that was do-able with Jim’s current energy level.  It will be revised as needed.  (Note that this is an elaborate PHP; the level of detail will depend on the amount of time available, what else must be discussed during a visit, and how well Jim’s clinical team members know him.)

Name: Jim

Date: xx/xx/xxxx

Mission, Aspiration, Purpose (MAP):

My mission is to increase my awareness of how grief is affecting me and to focus on ways to increase my health so that I can enjoy my retirement and be actively involved in the lives of my sister and nephew.

My Goals:

  • Increase awareness of mind-body connection when experiencing symptoms.
  • Keep track of amount of sleep each night.
  • Explore issues of grief and forgiveness.
  • Start gentle yoga.
  • Receive acupuncture treatment.
  • Balance providing support for my family with taking care of myself.
  • Improve nutrition and limit alcohol intake.
  • Explore new leisure activities.
  • Spend more time with others.
  • Spend time outdoors.

Strengths (what’s going right already)

  • Family, friends, neighbors.
  • Not giving up.

Challenges

  • Nephew’s condition and sister’s well-being.
  • Fatigue and pain.

My Plan for Skill Building and Support

Mindful Awareness:

  • Pay attention to my thoughts, especially when symptoms are worse.

Areas of Self-Care:

  • Working Your Body
    • Investigate attending a weekly yoga class offered at work with co-worker, Bob. Ask the instructor about her credentials and tell her about my back pain and the limitations with my knee. If her responses feel right, join the class or inquire about other classes focusing on gentle yoga.
  • Surroundings
    • Spend time outdoors in a restful setting (my yard or near a lake) at least 30 minutes twice a week.
  • Personal Development
    • Plan new leisure activities for retirement. Purchase trade magazines to research the wood-working tools I may want to purchase.
  • Food and Drink
    • Pay attention to the amount I eat. Focus on something other than food when I am worried.  Gradually add more healthy foods to my diet—fruits, vegetables, healthy fats (such as olive oil), and whole grains. Have no more than one drink containing alcohol per day.
  • Recharge
    • Continue to follow good sleep hygiene practices. Keep track of how many hours of sleep occur each night and bring to next appointment.
  • Family, Friends, and Co-Workers
    • See sister three times a week and visit nephew in the hospital twice a week, which allows me to be supportive without daily hospital visits. Chat with a neighbor at least once a week. Contact a Veterans’ group for support and information.
  • Spirit and Soul
    • Consider scheduling a counseling session with my sister’s minister who was a chaplain in the military. Visit High Ground, a Veterans’ Park developed by the Wisconsin Vietnam Veterans Memorial Project, Inc., whose mission is “Healing and Education.”
  • Power of the Mind
    • Work on forgiveness for the following issues: some experiences during military service, the way some people treated me when I returned from Vietnam, the person who caused the crash that sent my nephew to the hospital, and myself for mistakes I’ve made in my life. Consider seeing a grief counselor (pastoral counselor, psychologist, or social worker) who is experienced with Veterans and grief issues. If I have difficulty with this, consider meeting with a mental health clinician who has specialty training in PTSD.

Professional Care: Traditional and Complementary

  • Prevention/Screening
    • Up-to-date
  • Treatment (e.g., traditional and complementary approaches, medications, and supplements)
    • Acupuncture to prevent lower back pain from turning into a chronic condition
    • Grief/forgiveness counseling (future)
    • Yoga
  • Skill building and education
    • Forgiving
    • Grief rituals
    • Leisure activities for future retirement
    • Nutrition
    • Spirituality

Referrals/Consults

  • Acupuncturist
  • Grief counselor—pastoral counselor, psychologist, or social worker

Community

  • Minister
  • Veterans’ group
  • Yoga class

Resources

My Support Team

  • Principal Professions
    • Acupuncturist
    • Grief counselor
    • Minister
    • Primary care clinician
    • Yoga instructor
  • Personal
    • Co-worker
    • Neighbors
    • Nephew
    • Sister
    • Veterans group

Next Steps

  • Professional and self-care as outlined above. Return visit in 8 weeks, sooner if symptoms worsen.

Please Note: This plan is for personal use and does not comprise a complete medical or pharmacological data, nor does it replace medical records.

Follow-up with Jim

Jim returned for a follow-up visit in eight weeks.  He reports his back pain is mostly gone, his sleeping has returned to normal, and he has more energy.  His nephew survived and is in a rehab facility.  Jim has identified two unexpected ways to help his family and increase his own health.  As his back pain decreased, he took over the care for his nephew’s dog and is now going for daily walks.  He has decided to plant a garden (which he did years ago with his wife); helping with the garden will also be good therapy for his nephew.  Jim’s nutrition has improved somewhat.  He does not feel ready to cook most meals.  But he is now motivated to eat from the salad bar at the local grocery store at lunchtime on workdays.  While there, he has been purchasing oranges, berries, carrots, and peapods that he adds to the meals he eats at home.  He is no longer consuming alcoholic drinks daily.  To his surprise, Jim has enjoyed the yoga class with his co-worker and practices a few poses at home between weekly sessions.  He has had three acupuncture sessions with several more planned.  Jim has obtained the contact information for a Veterans’ group in his area.  Jim met with his sister’s minister twice.  The sharing they did was cathartic for Jim, and he is now ready for a referral to a grief counselor to work on issues of forgiveness.  With the minister’s encouragement, Jim is purchasing a legacy stone to honor his best friend in the service who was killed in action.  He will place the stone in a ceremony to be held at The High Ground Veterans Memorial Park in a few months.

Resources

Literature Recommended for Professionals

Journal Article

  • Aloi JA. A theoretical study of the hidden wounds of war: disenfranchised grief and the impact on nursing practice. i 2011;2011:954081. (Offers ideas nurses can suggest to families to help with Veteran disenfranchised grief.)
  • Shear MK, Muldberg S, Periyakoil V. Supporting patients who are bereaved.  BMJ 2017;358:j2854 doi: 10.1136/bmj.j2854 (Practice advice for clinicians.)
  • Simon NM. Treating Complicated Grief.  2013;310(4):416-423. (Excellent clinical review.)

Website

Books

  • Ethnic Variations in Dying, Death, and Grief: Diversity in Universality edited by Donald P. Irish, Kathleen F. Lundquist and Vivian Jenkins Nelsen. Washington, DC: Taylor & Francis. (1993)
  • Good Grief: Healing Through the Shadow of Loss by Deborah Morris Coryell. Inner Traditions/Bear & Company. (2007)
  • Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4th Edition) by J. William Worden. New York: Springer Publishing Company.  (2009)
  • Improving Care for Veterans Facing Illness and Death edited by Kenneth J. Doka and Amy S. Tucci. Washington, DC: Hospice Foundation of America.  (2013)
  • Living with Grief: Before and After the Death edited by Kenneth J. Doka. Washington, DC: Hospice Foundation of America.  (2007)
  • Treatment of Complicated Mourning by Therese A. Rando. Champaign, IL: Research Press.  (1993)

For the General Public

For Military Families and Veterans

  • Peace at Last: Stories of Hope and Healing for Veterans and Their Families by Deborah L. Grassman. Vandamere Press.  (2009)
  • Tragedy Assistance Program for Survivors (TAPS)
    • Provides peer-based emotional support, grief and trauma resources, casework assistance, and connections to community-based care for anyone who is grieving the death of a loved one in military service to America
  • Vet Centers, U.S. Dept. of Veterans Affairs
    • Offers bereavement counseling at community-based Vet Centers to parents, spouses, siblings, and children of Servicemembers, reservists, and National Guard who died on active duty
    • Offers readjustment-to-civilian-life counseling for combat Veterans and families

Author(s)

“Coping with Grief” was written by Charlene Luchterhand MSSW, LCSW (2014, updated 2019).

This Whole Health overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation

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