When We Can’t Say Goodbye: Coping with Sudden or Unexpected Death

Editor's note: This text-based course is an edited transcript of the webinar When We Can’t Say Goodbye: Coping with Sudden or Unexpected Death, presented by Holly Nelson-Becker, PhD, MSW, LCSW, ACSW.

Learning Outcomes

After this course, participants will be able to:

• Consider sudden death within a spectrum of loss and bereavement experiences.
• Evaluate how to help someone dying in complex circumstances where communication is or is not possible.
• Develop skills in helping clients with mourning and persistent grief by applying knowledge of Prolonged Grief Disorder.
• Consider, anticipate, and adapt to intervals of collective mourning.

Introduction 

I want you to be able to consider sudden death within the spectrum of loss and bereavement experiences. I want you to be able to evaluate how to help someone dying in complex circumstances where communication is possible and when it is no longer possible. And I want you to develop skills in helping clients and possibly yourself with mourning and persistent grief by applying knowledge of prolonged grief disorder. So that is relatively new and was just recently published in the new version, the DSM-5-TR or Text Revision of the Diagnostic and Statistical Manual of Mental Health Disorders. And finally, I want you to consider, anticipate, and adapt to intervals of collective mourning, which we have always had throughout time in our society, but of course, we are just finishing the pandemic, and that was a very new experience for many of us.

Contextualizing Sudden Death

I wanted to begin by contextualizing Sudden Death. I want to place that in the broad spectrum of what we know when we think about death. And I want to tell you that I do enjoy speaking about death. Maybe I am one of the few, I do not know. But my students used to call me the death discussion ambassador because it is an area that I guess I feel so powerfully is one that we have neglected in our society. We have neglected it to our detriment, really. When there is so much, we need to learn. And it is really a coming area of growth for us in terms of development at the end of life.

 I am going to share a couple of poems with you.  I think poems can sometimes carry us a little more deeply into the topic area. The first poem is by a writer, Jandy Nelson. She is an American writer who writes primarily for young adults, and she says about grief, "Grief is a house where the chairs have forgotten how to hold us, the mirrors, how to reflect us and the walls, how to contain us." 

When you place this image in your mind, I want you to think about how grief unmoors us, how grief really makes us feel as if what was true and correct yesterday is no longer the same. Even the chairs no longer hold us. The second poem I wanted to share with you, and these are both part poems, is from a poem called "The Uses of Sorrow."

This is by the well-known poet and gifted writer Mary Oliver. And she says, "In my sleep, I dreamed this poem, Someone I loved once gave me a box full of darkness. It took me years to understand that this too was a gift."

 I would like to think that this poem signposts to us that even though we go through this time of darkness when we lose someone close to us that we love, as we move through grief will be another side. I do not know how many of you know that Mary Oliver lost her partner and had to live many years beyond the time of her partner's death. And Mary Oliver, at the time I was a professor at the University of Kansas, Mary Oliver came to speak to an auditorium full of people.

I was fortunate to be able to talk to her in a smaller group the next day. And she is like everyone's best friend or neighbor. Of course, she's deceased now, but she was just such a lovely inviting person with wonderful, wonderful insights that came out of her pain. So I think that it is also important to share that a lot of times, the way we deal with our grief is contingent on the other kinds of sorrows that we have experienced in our lives.

Loss-expanding Our Thinking

First, I wanted to begin by expanding our thinking about loss. And I want to share with you the idea that the extent of the impact of loss on any situation is often something that we do not recognize.

And as I share my ideas with you, I also want to tell you that some of these ideas are provisional. It is certainly for your knowledge and awareness. So if you disagree with anything I say, that is fine, and you are free to accept or reject what I have to share. And what I have to share is based on a lot of different kinds of information and my own personal experience, but it may not be the same as yours, and that is good. Our questions should always be larger than who we are and what our own experiences might be. So when I say to you the impact of loss is often largely unrecognized, what I am suggesting is we have the loss, and then we have all these different subsidiary losses that spool out from that.

Our particular constellation of loss is our loss signature. And that is unique to each person. And when I say this, I am thinking here about all of the things that make up each one of us. This lovely complex human being that you are, what have your cultural experiences been, what background do you come from, and how do people in your cultural background tend to grieve? What is your own history with loss and grief? Have you faced this often? Have you had no major losses in your life? That is probably unlikely at this point in time since we have all gone through the pandemic. But when I was teaching my classes on grief and loss, there were a number of people that had yet to lose a grandparent.

And they were really worried about what it would be like for them when they lost the first person in their lives, who they were close to. We know that grieving individuals may experience a sense of disconnection from family and friends, and they also tend to often experience a separation from their felt sense of who they are and were. They experience this of the unreal or unreality. And loss also can match with or be close to definitions of trauma when loss involves a person who is really rendered helpless by an overpowering force. So this is one of the definitions of trauma. When a significant loss comes to us that is so great that it is beyond our capability of dealing with successfully, then that can be trauma.

This includes disempowerment. So feeling like in the situation, we have lost our sense of control, we are vulnerable, we are vulnerable to further losses and to further upset. So once we are rocked off our stable platform, then we have lost or begun to lose our sense of a foundation underneath us. We often feel inadequate. We might feel abandoned by our friends or family members. And also, there is what we call a shattering of our worldview or the world that we assumed would be true. And the natural trust that we typically would extend to anyone around us or our background to others is no longer there. We are more cautious about how we see and perceive the world.

Think About Losses in Your Life

For a moment, as far as you can without going into a place of deep hurt, I want you to think just broadly about some of the losses you have had in your life. Although we prioritize death, other losses may be just as meaningful or more meaningful. I have a sort of trick exercise I use with my students where I have them identify all the kinds of losses they can think of, and they start, at the beginning, it is just the losses through death. And then, they begin to think of other kinds of losses that they might have experienced.

 Independence is a loss of a sense of safety if they have been a survivor of an assault. Assumptions about how the world is and will be. They may have lost income or their financial security through losing a job. They may have lost their faith when someone in their faith tradition acted in a way that they felt was not helpful or that disappointed them deeply. They may lose their sense of identity; perhaps they are a person who is transgendering or changing other forms of identity. They may lose their dreams, and this is a very hard loss when people lose hopes and dreams or find that the dream that they had can no longer, for some reason, be accomplished. They may lose meaningful objects; they may lose their health, mental health, and friends; they may experience betrayals. And we know for many young people and people in marriage or partner relationships, this sometimes happens when a mate or a partner has been unfaithful.

They may have, on the ability disability spectrum, have very difficult disabilities, which they may have to live through throughout life. And some of those disabilities may be able to be accommodated, and others less so. You know, I am thinking about cystic fibrosis and how decades ago, when people had that, it was basically a death sentence. People only lived to the age of 30 or so. I have a good friend Ed Candace; some of you may know him, who works in the area of spirituality and religion, and he has had cystic fibrosis from birth. But just very recently, over the past year, they have developed some new therapies, and he is starting, and his health, after so many years, is finally starting to really improve, which is a wonderful thing.

But we also carry regrets. Regrets are kind of a low-level loss, I would suggest. And they require agency and imagination. So, if we know that we could have chosen differently, then that can be a regret if we see ourselves as having made the wrong choice. And we then sometimes carry with us long through our lives. If we chose differently, would some kind of result have been approved or been different? And drawing here on, before I went back to the university after my master's degree and before I got my doctorate, I worked as a counselor with older adults, both in nursing homes and in the communities. And I learned so much; it was just really a great learning experience.

So, I want you to bring this to your own losses a little further. Are your losses considered? Would you consider them primary? Losses of a loved one through death? Are they secondary? For instance, if you, I'm just going to say theoretically here, if the father of a family died and that father was the primary earner in the family, then other secondary losses around that might be that the family has to move and relocate because they can no longer afford the mortgage where they are living. If they are relocating, that means they lose their immediate community and friendship groups, and that can be very difficult. So, some losses are non-death, some losses are ambiguous, and some losses are disenfranchised.

And we should also think in terms of losses being cumulative. So if you haven't dealt with a particular loss, as you move on, those losses sort of pile in, and it can be more and more difficult for you. And you do not always when I say you, I am also speaking of your clients and those you work with. You do not always realize the nature of all those losses that you have experienced. So as we go through the material today, I would like you to think in terms of how your losses relate to the material that I am sharing and also to how you might be able to share it with some of your clients. I want to draw on several foundational ideas about loss that are a little bit newer.

Ambiguous Loss

And one of these is ambiguous loss by Pauline Boss. Now, she was writing in the early two thousands and she suggested that people who are physically absent may remain psychologically present such as a soldier in war or a family member who is incarcerated.

I am currently living in England, working at Brunel University, and the interesting thing is, I was here in 2017 for the hundred-year remembrance, which we are coming up to Veterans Day. What was so impressive to me was the extent of the grieving that was expressed. I mean, there were installations so many places of not just the poppies at memorials in towns, but there were unique installations where people had shrouded figures, tiny shrouded figures, 77,000 of them to represent the number of Brits who were killed in one of the first battles of the sum, and other kinds of unique things.

When I talked to my colleagues about this, they shared with me that part of the reason for this is that there were many losses that had never been grieved within families. So soldiers disappeared to war and never returned, and that family member was never talked about again. So you can imagine that sort of correlates with what we know about the British style of the “stiff upper lip.” Those engraved losses move through generationally through the people and can be very difficult.

The other type of loss that we think of with ambiguous loss is when someone is physically present but psychologically absent. So commonly, we think of a family member with dementia who may be living in the home with the rest of the multi-generational family. Sometimes they are able to be fully present for a conversation, and other times, they are not. So in these situations, the status of the loved person is unclear. And when there is no closure or no timeline, when someone goes off to war, we do not know if they are going to come back.

 When someone has dementia, we do not know what things are going to be like for them and how the illness is exactly going to unfold. Cultural beliefs influence how we tolerate this ambiguity. Some cultures can embrace it better than others, and we think about some of the memorials, the cultural days when people who are gone are remembered. The day of the dead in Mexican culture is a day when people often go to cemeteries and remember together their loved ones.

There is little control in these conditions of ambiguous loss. We do not choose them; they happen to us. And so often here, coping must be primarily emotion-focused. What can we control? Well, it is our emotions and how we deal with the loss rather than actively figuring out what to do in a task-based way. And that task-based grief is one of the key ways that certain people like to grieve. And it has often been attributed to men, but it is not necessarily a male way of grieving.

Disenfranchised Grief

Then we have disenfranchised grief. A grief that does not meet the norms in a culture. And this is grief where the relationship is not legitimated. So formally, it used to be people who were in LGBT partnerships. If their loved one died, sometimes they would not even have a house because the house was in only one name of the partnership. They would not have access to the funds from the sale of the house or the objects that were in it.

In grief, when an ex-spouse dies, there is often still the degree of caring and love with ex-spouses. And if the partner remarries to someone else and dies, then the ex-spouse is often totally ignored unless the newer spouse is willing to bring them into the funeral ceremonies.

 Sometimes loss is not legitimated, for example,  in situations of a pet dying. If people do not have pets and do not really appreciate that animal-human connection, then they cannot really understand fully the loss of someone who has lost their dog. And there are griefs where death has caused a stigma. If someone has died due to alcoholism or sometimes to suicide, and in a Christian tradition at the service, they are not fully acknowledged or appreciated because of that behavior that they had. That can feel very disenfranchised to the grieving people who cared about them. And then grief that is expressed in non-socially sanctioned ways; too loud,  too reserved, too flat. We think of in the Greek culture, for instance; there are paid mourners hired to wail and to mourn to help people express those feelings of grief. Whereas in England, I look around, and aside from the people that have immigrated here, grief tends to be very restrained.

Continuing Bonds

Then we have the continuing bonds idea from Dennis Klass. His idea was that we do not ever fully let go of grief. This was in opposition to Freud's idea that people would work hard to disconnect or let go of the attachment to their loved one who died, and then the grief would be done. But interestingly, in his own life, when his daughter died, he could not do that. And it said that he mourned her throughout the remainder of his life.

So, I guess his personal learning was a little bit different than his theory. But Dennis Klass said and suggested that when we can emotionally relocate the person who died, that is really important. But we should not expect that they will always be out of our view. That emotional relocation involves continuing a bond or continuing the connection with that individual, and the person who is bereaved will continue to relate.

In this situation, there is an active reconstruction of the deceased person so that it may change over time, but they are perceived as a support. Often also, shortly after a death or even longer, the bereaved person will continue to talk to their loved one who has died for. During those years when I did counseling, I had many cases of people who were mourning very difficult deaths. And one woman talked to me about talking to her loved one in the garden every morning. Was she psychotic? No, it was a normal grief reaction. And I spoke before about cultures and religions that support this kind of grieving.

Loss is Ongoing or Sudden

Ongoing

Is the loss ongoing or sudden? When it is ongoing, such as in palliative care, people can prepare for it and make adjustments. But it often changes the tenor of how people live their life. The one with the loss tries to find the meaning and the significant other or caregiver can feel burdened and overwhelmed. So that is more of a palliative care situation.

Sudden Death

I want to focus for the rest of the presentation on sudden death. Sudden death can involve a direct personal experience of an event that threatens or involves actual injury or death, and it may involve persistent re-experiencing of the event and may cause clinically significant distress or impairment and functioning.

The COVID-19 pandemic actually gave us both. I also wanted to suggest to you that the idea for this presentation was based on a short article that was published in Social Work Today called "When We Can't Say Goodbye Loss, Grief, and Dying during the COVID19 pandemic."

 I wrote this just after, or as my dad was dying in hospice care in an assisted living. And he was at the time in Arizona, and I was here in London, so I would call him every night. But that separation was difficult, and my brother was able to be with him, but I was not able to be there at the time he died. But writing this article was really therapeutic for me in helping me to think, well then, how can I help others in the same or similar situations? So what are some of the questions we might ask? We might ask:

• How do we begin to understand and manage our own thoughts about death?
• How can we prepare for our own and the deaths of others about whom we care deeply?
• How can we communicate at times when our clients, significant others, family, and friends are dying?
• Finally, how do we say goodbye when we cannot say goodbye and have that kind of closure?

Death and Loss for the One Dying

Death for the Person Dying

So now I wanted to talk with you a little bit about death and dying for the one person who is dying. So when someone is dying, we might think in terms of the good death. We want the best thing possible for them. And historically, in the Middle Ages, the traditional image of a good death was a dying person who did not suffer. We see pictures of them, drawings of people who were at peace, they were surrounded by loved ones, and there were probably angels around their heads. It was definitely a different situation from someone in a hospital who was with strangers wearing personal protective equipment.

A good death we think about as bringing healing and emotional closure, and social workers support closure in many forms, including when loved ones cannot be present at the death. This begins with addressing our own fear of death, which is always fear of the unknown. And that kind of fear is the universal fear. 

So, what I am suggesting to you is that before you can effectively work with death with others, it is really good to address it in yourself and begin to think about your own questions and what keeps you from working in an easy and comfortable way with death and dying.

In the pandemic, we know that there was a lot of craziness. There was no uniform trajectory to death. People brought to the hospital their prior medical health problems and their new one of having COVID-19. What seemed to be improvement turned out often to be decline and then death. Here in the UK, there was one person that was in the hospital for just over a year. And while some of that time was in a coma, that person finally did recover and leave the hospital. And I understand is doing well now. From the comas, certain people slipped into death. And if you remember, at the early start of the pandemic, when they were still exploring remedies and technologies for helping people were often turned frequently to help them with their breathing. 

Folks experienced little control, and at certain periods there were very few primary grievers allowed at funerals, and people had to participate online or in a virtual way. And for many, this made those very difficult losses to grieve. One of my students in a palliative care class that I taught here at Brunel was telling us that she was working at the hospital during this time, and she often found moments to sit with people as they were dying and hold their hands. And she said, "You know, I know their family never knew that, but I had the time, I would go sit with them during the break, and I wanted to do something to help, and that was my way of helping."

If Death is Approaching

When communication is possible, then we want to first assess. Is there fear present? One way to help with that is to begin to help the dying person. And if their loved ones are there too, to slow their anxious breathing. And so we can breathe together, and what this does when we breathe together, we can help them mirror our own breathing. And physiologically, when the body slows down, then that begins to slow our thoughts and provide calm and peace, which I think is quite important. When communication is possible, we should ask, what will help? Is there any practical help needed? If a person is in a hospital or a care home, often there are staff there to help, but sometimes because of the busy nature of lives, not all of the immediate needs are easily attended to.

And so, a social worker can work as an advocate in that place and help the staff understand exactly what is needed or facilitate communication. Are there concerns about relatives needing care? If so, and when I am talking about relatives, I am talking about a person who may be dying and have young children and be very worried about who is going to take care of them, what is going to happen to them after I die, or as I am very ill?

What the social worker can do is ensure referrals to the many different kinds of agencies that can assist in those kinds of situations. Is emotional help needed? Ask whether the person feels anxious, worried, or sad and work to ease that anxiety or depression with cognitive shifts or changes in thinking, helping them reframe the setting or reframe the circumstance. Meditation, imagining a preferred place of peace.

If death is approaching, would a specific item or object provide comfort? For instance, a photo of family members or a meaningful stone. If social support is not available or is available but not present, can you facilitate that by calling aunts and uncles, having them chat on the phone, or grandchildren, facilitating connections that way. Can new memories be created? Can you share a video or a screenshot? Ask someone to sing a favorite song or read words from an inspirational poet or inspirational or spiritual/religious text. Are there specific people the dying person wants to say goodbye to? Help to contact, or if contact cannot be made, document the dying person's thoughts and say that you will pass that on.

If death is approaching, what spiritual support is needed? Listen and bear witness to the concerns and struggles a person has. If time allows, call a religious or spiritual leader from their community or facilitate spiritual group participation or practices. Is the dying person afraid of dying alone? Explain that healthcare workers are there to assist. And I am thinking particularly here in the pandemic situation. Help them connect with people they know and love, and ask the one dying to imagine themselves surrounded by loved ones and their ancestors who have died before or whatever you think might comfort them. If death is approaching and communication is no longer possible, ensure physical comfort by attending to the body signs. Do they need an extra pillow? Do they need their body propped up? 

Play the person's favorite music. Speak of a life well lived. Everyone has regrets, but also moments where they shine. And speak what is true to what you know about this individual. If loved ones are not present physically, facilitate their words. Guide loved ones' family members to meaningful acts, which might be prayer, positive thoughts sent to the universe, surrounding the person dying in a white light, and also listening to favorite songs. The goal here is to decrease sadness and the inability to be present in the same room with the person who is dying.

Death and Loss for the Mourner

Sudden Death

So what about death and loss for the mourner? The questions that they might experience:

• What were the conditions surrounding the death?
• What was the death story?
• Did the dying person know he or she was dying?
• Was he/she afraid, did he/she suffer?
• Was anyone there to provide comfort?

 I want to share a quick story about a young woman that took one of my classes, and in her situation, it was her sibling who died. One of the things I noted and I thought was maybe is something unique to social work, but it seemed that so many of my students had experienced really very very difficult losses. And so I began to wonder, did students who came into a social work program were they sensitized to that partly because of losses they had experienced or faced or was their being in the social work program, did that elicit from them their own death experiences?

Anyway, in this situation, there were three siblings, and the oldest sibling, her older sister, they were all very close. The older sister went off to a party one night, and she never came home. She died in a car accident. And this left a lot of questions for my student. She wondered, did she suffer? What was that experience like? And what was also even more difficult for her was that her parents seemed to get all of the attention. So she and her brother were mourning, but her parents were just because they were deep in their own grief, they were not able to turn their attention to them. This was really a difficult thing. So, she and her brother came together and wrote a song in honor of their sister and were then able to share it at the memorial service, and that was helpful.

The other interesting thing happened, as life sometimes does, bringing these congruences. At the end of the term, she went home for Christmas break, and I saw her the next term in January when she returned. And she told me, "Holly, it was amazing what happened. My boyfriend and I were on the way back to my home for Christmas, and we were driving through a place where there were miles and miles of empty countryside. And just in front of us, there was an accident. We stopped our car and got out, and rushed over. And then behind us, other people started stopping too."

One of the occupants of that car in front was dead, but there was a young woman, and she was in the process of dying. So my student talked to her during that process, provided comfort, and told her, "You are not alone. I'm here with you." The woman was no longer able to vocalize that. But being there, providing that support, offering herself, my student felt, was really healing because she was there in a similar situation for this woman where she could not be for her sister.

How the Mourner Feels

 How does the mourner feel? The mourner seeks to escape from overwhelming emptiness and shock. The mourner also experiences a sense of unreality. Was the notification an error? Was it someone else who died? The mourner feels the opportunity lost and yearns for the future he/she will never know with her loved one. Often the person who is mourning feels waves of shock.

In grief, there is no hierarchy. Is this grief better than this one? Is this one more difficult than that one? Then, with unexpected death or even expected death, the moment of the death is shocking. The complexity of sudden death is even more intense. We might say that the volume of the grief has been turned up. It can devastate our lives, and our bodies feel fragmented. There is a moment when everything before was okay, and everything after is not okay. This precipice that people feel they've been on, there's no chance to say goodbye. No chance to say I love you. No chance to say thank you for what you've done. No chance to say I'm sorry. And all of that is very difficult. 

In fact, sudden death can be crazy-making. As people deal with the immediate aftermath. The mourner will find fault in him or herself and experience guilt for not being there, for not planning for this. And also, in the pandemic, did the mourner pass on the virus unknowingly? That is often a question that people worry about. Healing through this type of grief requires time. It's a situation where everything you have trusted in the progression of life is torn up, and people often ruminate on what happened. If there are holes in the story that they cannot account for or do not know. Social workers can observe for signs of prolonged grief disorder. And I'll talk about that in a minute.

Can the mourner reach acceptance in response to what cannot be controlled? Can they find necessary control in their choice of coping style? The other thing about experiencing this sudden grief, people often feel very exposed. They feel like they are not the versions of themselves that they wanted to be. They feel like they're more impatient. And rather than calling on their social support, they often push people away. When all is going to plan, people may find them very appealing and fun to be with. But in this situation of grief, they find themselves, they find it very hard to be around others, even though that may be what they most need.

But I also think about it in terms of literature. There are so many fictional and nonfictional writers now that are writing on grief and loss, their own experiences. And Joan Didion is the one that wrote "The Year of Magical Thinking" about losing her adopted daughter Quintana to illness and then also losing her husband within a very short time. And how that grief became almost overwhelming for her. So these are difficult kinds of losses.

Prolonged Grief Disorder

 I wanted to turn now to share a little bit with you about prolonged grief disorder, which is now in the DSM-5-TR. And you can see some of those other comments. Previously in the DSM-5, we had something called complicated grief disorder that was listed under conditions not further specified. And so this was a period where people were studying this. Does it make sense to put this as a mental health category? And the concern was to refrain from unwarranted diagnosis and not to pathologize grief.

That was, on one side, not pathologizing grief, and on the other side, was getting people treatment and the help they needed, which would be easier if it could be considered a diagnosis. So over that period of time, from 2013 to, actually it was 2019, they made the decision to put it in as a regular category. There were a lot of studies, a lot of meetings were held, and the decision was made for it to go in. It includes people who continue to grieve one year after a loss. And it is expected to apply to about 4% of people who are bereaved. But we really do not know because it is so early in the trajectory.

There are concerns that people might be over-treated by medication and that people who are really experiencing what we might call normal lingering grief would be stigmatized by this. So people have to apply it very carefully. The definition of prolonged grief disorder, which is the first two key items in the DSM-5-TR, is it's considered an intense yearning or longing for the deceased person. And often, that involves intense sorrow and emotional pain. And secondly, it is a preoccupation with the thoughts or memories of the deceased. In children and adolescents, this preoccupation may focus on the circumstances of the death.

This is why it is important to always share honestly with children to the extent they can understand what happened, and not really speak in euphemisms like this person has gone to heaven because that is a more conceptual idea, which is harder for children to understand. And often, they may think that it is their fault that the sudden death has occurred. Therefore it is really important to speak to them and help them through this death experience.

Some of the warning signs of prolonged grief disorder may include the following:

• Feeling as though part of you has died
• A sense of disbelief about the death
• Avoidance of reminders that the person is dead
• Strong emotional pain related to the death (anger, bitterness, or sorrow)
• Difficulty moving on with your life (socializing with friends, pursuing interests, planning for the future)
• Emotional numbness
• Feeling that life is meaningless
• Extreme loneliness (feeling alone or separate from others)

 This list of eight items is in the DSM 5 TR criteria for this diagnosis. People have to have experienced these symptoms for at least 12 months. So it used to be thought that complicated grief would not be assessed until after two years, but now if they are considering 12 months, then let us consider it. And for children and adolescents, this can be a grief that it is experienced at least six months ago. So some of these warning signs, at least three of the following symptoms should be experienced to some clinically significant degree.

Feeling as though a part of you has died. This is called also called identity disruption. A sense of disbelief about the death. Did this really happen? Avoidance of reminders that the person is dead or efforts even to avoid the reminders can also include strong emotional pain related to the death, anger, bitterness, or sorrow. Difficulty moving on with your life, socializing with friends, pursuing interests that used to really engage you, or planning for your future. A sense of emotional numbness and feeling that life is meaningless. Also, extreme loneliness, feeling that no one can understand your situation. The duration and severity of these symptoms are also clearly meant to exceed any social, cultural, or religious norms for the individual's culture and context. Culture has to be a very firm part of this. And the symptoms are also not better explained by another mental health disorder. Those are key basics to understand.

Assessment in Mourning

In terms of assessment in mourning, what should we know? Well, we want to listen for areas and themes of concern in the narrative of the devastating loss. Most important of all is just being present with the person who has had this loss. We want to, to the extent that we can, explore the nature, circumstances, and meaning of the loss. What losses are triggered by this particular loss? So getting at the meaning is often really helpful because that may not be easy to always understand the depth of it on the surface.

We want to initially ask the mourner to assess their grief on a global scale of 1 to 10. Where would you say, with 10 being the best you've ever felt, how are you feeling right now? And other formal assessments may also be helpful.

Katherine Sheer has a short mourning or grief screen that she uses. Example questions include:

• How much are you currently having trouble accepting the death of, let's say, Susan is the person who's died; not at all, somewhat, a lot?
• How much does your grief interfere with your life now? Not at all, somewhat, a lot? This is really a key question.
• How much are you bothered by images or thoughts of when she or he died or other thoughts about the death that really upset you?
• Are there things you used to do when, let's say, Susan was alive that you don't feel comfortable doing anymore, things that you avoid? And how much are you avoiding these things?
• How much are you feeling cut off or distant from other people since Susan died? Even people you used to be close to?

You will see in these questions some of the items in the prolonged grief disorder that we have just talked about.

In addition, if possible, you want to encourage the mourner to speak with significant others and also help them explore their thoughts and emotions when they feel safe to do so. Also, to entertain unacceptable feelings and anger at the person who died. Normalizing, it is okay to have those kinds of experiences. Emotion is one of those really helpful learnings that when we can recognize our emotions and sit with them, they can help us go deeper and then heal those difficult emotions that we experience.

Persistent Grief Tasks

Some of the persistent grief tasks include working on improving our coping skills and suggesting people take a break from grief. Being in intense grieving is very difficult, but if we can break from it along with Stroebe and Schut's idea of moving from the loss orientation to the restoration orientation in their dual process model, that often can be very good. And losing ourselves in an enjoyable activity where we can. The grief will always be there, it can be resumed later. It is also helpful to let people know that time can lengthen between the moments of intense grief, and people can begin to live within those spaces and between those spaces.

Persistent grief tasks, reducing failings of self-blame and guilt, this can really block mourning. So if we can work with mourners to help them identify the reality of that self-blame and guilt that they experience and begin to unpack that further and deal with it, that can be really helpful. And further assisting in crafting a ritual of personal significance, which myself and colleagues have written about. And that references in your references today.

Gestalt Method for Grief

There is also a gestalt method for grief that is really, really helpful. I do not know how many of you have run across this. I actually use this in my class as a demonstration. And I would always ask for a volunteer, someone willing to participate in this in front of the class, and I always got the right person.

So the person who volunteered to do it, we would, first of all, do it as an exercise, but always afterward, they would tell me and share with the class, "Wow, something really did happen here." So this ca not be used immediately. But after the crisis is over, when people are still grieving, it can be very effective. And basically, what you do is use two chairs, one of them empty and one of them invite your volunteer, or in this case, the person with the deep grief, to sit in the other chair and help them vividly imagine or reimagine that person who is deceased by asking what did they wear, what did they look like, how did they refer to you, what was their pet name for you? And what were some of the common phrases they used to share?

So together, as that person begins thinking about this and out loud bringing the deceased person into reality, that person becomes more and more present in a way. And then you invite the mourner to observe. What does it feel like to sit with your deceased loved person? And they just think about what it was like to be in that person's presence. What was the felt feeling, the felt experience of being there? And again, they share this aloud. Then you begin to invite the person mourning to speak with the imagined deceased person. And they begin by sharing their appreciation. And then, if it is a complicated grief situation, they move to share their regrets, and they spend a few minutes discussing all of that.

Then you invite the mourner to switch chairs, and this turns the monologue into a dialogue. What happens here is, in a sense, as they move into the chair that was the image of the person who was deceased that they were talking to, they then become the deceased person in their mind, and they respond to themselves now seated in the other chair with their inner knowing. So what they are doing is they are accessing knowledge that they have but is typically not accessible. And out of that often comes words that are deeply, deeply healing.

Death and Loss for Communities

Death and loss for communities, I want to spend a few minutes on this because it's so often neglected and frankly because of what I saw during my experience of being here during the hundred-year commemoration of World War I and how people, families, who generationally had just stuffed their grief, were able to begin to let it out and reach this place of healing.

So these are some of the situations that we have experienced and are currently experiencing in the world. Of course, in the pandemic, many lives were lost. The world health organizations suggest that we had 14.9 million excess deaths. That means deaths, not due to any other reason but the pandemic. In the U.S., It was over a million deaths to the 12th of June when I found the stats. Other situations include the war in Ukraine and Afghanistan, the uneasy world situation, refugees who are living lives torn apart by war, and unwanted relocations to the US through Mexico from Central America and South America. And here, we see a lot of refugees coming from Africa and from Syria in the Middle East. Hunger, dun deaths, natural disasters, losses, fires, tornadoes, and flooding are on our doorsteps, and people are dying from these things. This can lead to a sense of collective mourning.

We will never return to the world as we knew it pre-pandemic, but I think it is important for us to be open to new possibilities and heal from those large losses that we share together. Death is no longer invisible. It no longer just happens in the hospital. It is there, and it is something that we begin to pay more attention to. We can broadly prepare through advanced planning, death conversations, or death preparation classes. One of the optional assignments for my students was to prepare their own advanced directives and share that with their parents.

In many cases, when they sat down with their parents to share them, their parents were not willing even to listen. They said, "This would be an untimely death. We want to be dying before you, and we haven't even prepared our advanced directives, so no, let's not have this conversation." So, for those students, I think, in a sense, it was a missed opportunity.

 We can live our lives with heightened awareness, recognize the value of relationships, and invest and reinvest in them, and when we can connect the arc of our lives, the beginning to the end, to look at our dying and the dying of our friends and family, rather than choosing not to consider death until it comes near, then I think we are in a much better shape in terms of dealing with this with a more resilient mental health outlook.

How Do We Remember

How do we remember? Well, memorials, when they are working well, do help us remember. We lost our jobs, we lost our time spent together during the pandemic, we lost friends and family, and for many people, they carried an increased sense of guilt due to the worry or fear that they had infected loved ones. But overall, we have come out of it in a very different place with a new understanding, and that is all good.

Solitude changed us that time being alone helped us understand how much we appreciated each other and how much it matters when we are present together in ways where we listen deeply. Gratitude expands our hearts. And I think living our lives with gratitude is also a key to helping us remember and work through our grief. Our community, which is all of us, wherever you are, whether you are in the US, whether you are in other places in the world, the community, all of us, is a witness that returns us to the center of who we are.

Conclusion 

In conclusion, I just want to say when we think of grief and think of the context of grief, we understand that a lot of the contexts are changing, but for each of us, our own grief DNA or our own signature of loss is really meaningful and important.  I think it is helpful when we review the cumulative losses in looking at a particular loss and helping us better understand behavior and what actions and tasks might be useful.

How can we help the person who is dying? How can we say goodbye? How can we share love and gratitude and give them our forgiveness and maybe receive theirs? How can we assist the mourner deal with the very difficult situations that they face? How can we help them work through their rage and their anger? How can we help them accommodate sudden death and help them understand that in a situation like this, there is always going be a hole from that great loss that was there? But they can grow around the edges in new and different ways.

One thing, over here in England, there are all these lovely ancient trees with huge girths, and I know in America we have them too. And I often see these trees that have lived so long that are really crooked, and yet they are beautiful, So beautiful, and I am so glad they are still there, and they are still alive.

So what do we learn from collective mourning? Well, we learn about the power of each other and the power of being together during the morning experience. Grief has much to teach us. And what I would encourage you is, as best you can, to open yourself to the learning that is there. Open yourself to the way that will change you, and that will change others with whom you work.

References 

A complete list of references is available in the course handout.