# Anticipatory grief

Anticipatory grief, also known as preparatory grief, refers to a feeling of grief occurring before an impending loss. Typically, the impending loss is the death of someone close due to illness. This can be experienced by dying individuals themselves and can also be felt due to non-death-related losses like a pending divorce, company downsizing, or war.

## History

Psychiatrist Erich Lindemann introduced anticipatory grief in his analysis of acute grief and grief reactions, studying the prevalent case of anticipatory grief in the wife of a deployed soldier. He found that the wife experienced the impending grief as she expected her husband not to return home alive. She processed the death entirely and adjusted to the idea of a future without her husband. However, many returning soldiers found their wives wanting a divorce as soon as they returned home as a result of fully processed grief.

## Stages

The five stages model of grief – denial, anger, bargaining, depression, and acceptance, as proposed by Elisabeth Kübler-Ross – describes the process people undergo after learning of their own diagnosis of terminal illness. Anxiety, dread, guilt, helplessness, hopelessness, and feelings of being overwhelmed are also common. However, anticipatory grief is not simply normal grief begun earlier.
Freud used the term “grief work” to describe the process of severing the tie between two individuals through the stages of grief.

## Identifying features

Features identified specifically with anticipatory grief include heightened concern for the dying person, rehearsal of the death and attempts to adjust to the consequences of the death. The period can allow people to resolve issues with the dying person and to say goodbye. It may provide some sense of orientation and access to the grieving process. For some, it prompts conscious closure before the end/loss.
Symptoms of anticipatory grief for another individual may include changes in appetite and sleep, fatigue, helplessness, anxiety, and fear. Specific mental functions may be compromised, including forgetfulness, compromised attention, and difficulty concentrating and decision-making.
Grief happening prior to a loss presents a compounding issue of isolation because of a lack of social acceptance. Anticipatory grief does not usually take the place of post-loss grief: there is not a fixed amount of grief to be experienced, so grief experienced before the loss does not necessarily reduce grief after the death. However, there may be little grieving after the loss due to anticipatory grief.
How often anticipatory grief occurs is a subject of some controversy. For example, a study of widows found that they stayed with their husbands until the death and could only mourn once the death had occurred. Researchers suggest that to start to grieve as though the loss has already happened can leave the bereaved feeling guilt for partially abandoning the patient.
Many family members can find themselves in a caregiving role during their loved one's process of death. During the progression of the illness, the security and protectiveness of the caregiver also increases. Bouchal, Rallison and Sinclair discuss that, "the strong need to offer protection was part of the anticipatory mourning experience of striving to be with in the present".
In the process of anticipatory grief, family members also begin to prepare and reflect on how their lives will be once their loved one passes. There are many ways in which to perform reflection. These ways include: "...reading, journaling, thinking, and reflecting about how life might be like without their partner." The journal also expands on the premise that the preparation process is not an individual process. Those who are affected by the impending death often look towards one another for support as well as others who are involved in care such as nurses and social workers.
A direct correlation exists between anticipatory grieving and the caregiver's quality of life. In a quantitative study conducted by Al-Gamal and Long, the effect of a pediatric cancer diagnosis on parents had a negative impact on the majority of study participants. More specifically, parents reported experiencing increasing stress and a decrease in physical and mental health – all of which affect the process of anticipatory grief.
Ultimately, anticipatory grieving is an extremely dynamic process that differs between individuals. The outcomes of the grieving process depend on the preparation of death and the anticipatory grief process.

## Navigating anticipatory grief

Researchers examine therapeutic models that support families and individuals experiencing anticipatory grief. The individual approach centralizes the client's experience outside the family or grieving group by focusing on their needs. During the grieving process, group dynamics include various reactions to the situation, allowing other people’s feelings to mask or comprise one’s own feelings. Individual therapy is beneficial for helping the client understand what they feel outside of the group dynamics and practice coping skills to aid their own journey through grief. Clinical psychologist Therese A. Rando (2000) describes six dimensions of anticipatory mourning: perspective, time focusing, influencing factors, contextual levels, generic operations, and major sources of adaptional demands. The first three determine the experience of grief, and the last three are experiential dimensions.
The family approach observes group dynamics during the grieving process to identify which individuals could most benefit from therapeutic intervention. Kissane, Lichtenthal, and Zaider (2007) constructed the Family-Focused Grief Therapy (FFGT) model to evaluate group functioning and identify the members most affected. This model targets family cohesion, conflict resolution, and communication by optimizing mutual support in grief. FFGT includes 90-minute meetings for 6-10 sessions to understand the group dynamic interactions alongside the individual identity of the patient. Another group model is the Family Systems-Illness model (Rolland, 1990), which highlights family challenges in addressing death by creating a psychosocial map.
Hospice and palliative care (HPC) workers may experience their own grief while supporting patients, including anticipatory grief. Professionalism may be compromised throughout this process, which calls for self-monitoring and using supervisors and peers for support. The internal process of HPC professionals impacts the relationship between themselves, the patient, and the patient’s family. HPC Professionals must remain aware of the changing dynamics of grief within the families of dying patients. Tension and conflict may appear but remain hidden while navigating loss, affecting the patient’s experience. Evidence suggests that hospice and palliative care facilities may benefit from further training on anticipatory grief regarding their interpersonal relationships, financial decisions, and other aspects of the grieving process.