What Is Anticipatory Grief?

Published by HNC at March 1, 2022

How much we struggle to keep that which we’re soon to lose.

It was so hard being on the receiving end of a daughter’s anger. It wasn’t the profanity nor the frontal attack on the care her father has been receiving but the intensity of it, the felt urgency, the palpable shock of the grief just underneath it all.

Rochelle’s dad was nearing his seventh hospital day and I’ve been his doctor since he was admitted. He was 83 years old and was recently re-hospitalized with another bout of infection. It wasn’t clear what the source was but it did lead to sepsis and bacteria in the bloodstream. He was also on hemodyalisis, had heart failure, had very little appetite, and could not get out of bed due to his frailty that had started long before he was re-admitted.

His wife of 30 years, Mandy, had been through so much within the last year with him with multiple doctor visits and his mutiple hospitalizatons. On the one hand, she understood the situation and on the surface knew that he was not doing well, especially now. Her daughter, Rochelle, however, had an especially hard time with her father’s slow decline. She tended to avoid engaging with the medical system for as long as she could. Every time her father would need medical help, she saw it as a sinister omen that he was not all right, something that she believed could not really be the case. She needed to remain at a distance because of the pain it caused her.

She felt always the closest to her dad. She was the youngest of her siblings and somehow just happened to have developed a very special bond with her dad. He was her life, her rock in life, and when his health started to deteriorate, underneath her conscious understanding she felt abandoned by his lack of presence. She started to suffer and although her dad was still around, unknowingly she became immersed in anticipatory grief.

Anticipatory grief is the process of grieving that starts prior to a loved one passing. It is the realization on a conscious or an unconscious level that a loss is or will be coming. The closer and deeper a relationship is, the higher the probability of anticipatory grief being present. On one level, it allows one to start processing the loss prior to the start of bereavement. To allow the mind to adapt to the situation and not have to face the utter shock of imminent death. During this time, the anticipatory grief, while allowing one to be present with the aspect of loss, provides a possibility of mindfully coming to terms with the dreaded reality. As there are no landmark rules for this process, the normal process is the reliance on one or multiple defense mechanisms to help us cope with the trauma.

Defense mechanisms are psychological strategies that are unconsciously used to protect a person from anxiety arising from negative thoughts or feelings. According to Freud, defense mechanisms involve a distortion of reality in some way to allow us to better handle our predicament. Some of the very normal but potentially maladaptive ones that come into play include denial, repression, projection, displacement and regression. We must also remember that all of these are unconscious and are not willed into existence willingly.

Let’s handle these one by one.

Denial is very common and allows one to deal with a difficult situation by not accepting it altogether. The mind will do whatever it can to not accept the unacceptable reality facing us and so the mind denies reality in favor of a different narrative that allows for a better scenario. Instead of being able to see a frail elderly father who is rapidly declining, the mind holds on to the fact that he is still eating and taking his medications. That he has recovered from setbacks in the past and so will do so again.

Repression is the workhorse of the conscious mind in that it fast tracks things that we don’t want to see into the unconscious. That way we don’t have to deal with the cognitive dissonance of seeing the awful reality and needing the reality to be very different.

Projection comes into play when we unconsciously attribute our own repressed thoughts and attribute them to someone else. Instead of seeing our helplessness as our loved one’s body gets more frail and starts to break down, our thoughts gravitate to the doctors or nurses who are “killing” the loved one or the nurses who just don’t know what they are doing or are incompetent.

Regression can occur when we need to feel safe and revert to a time when we did in fact feel safer. It’s a form of retreat to a psychological time and place when we did feel secure.

Displacement is very common—I would say equally as common as denial. It’s the mind’s way of externalizing the immense stress placed on itself which it cannot handle and as a pressure valve allowing all that energy to be delivered onto another person. Typically it’s the doctor, nurse or other close relationships in our lives that just happened to be nearby and receive the explosion of emotion. It can be a very shocking thing to witness but it has to be understood for what it is, which is a need of a loved one to externalize emotion at the horrific experience of loss and anger they are feeling.

Elisabeth Kubler-Ross, a physician pioneer in the modern field of hospice, introduced us to the now well-known five stages of grief: denial, anger, bargaining, depression and acceptance. Typically relevant to those who are battling with a terminal illness but not limited to the person with a terminal condition. These stages (which should not be thought of as needing to be on a continuium or on any sequential order) can also be experienced by the loved one during anticipatory grief.

In summary, anticipatory grief exists and can be the precursor to grief and bereavement. Having an understanding of it is important as the more we know about what to expect, the more we can normalize the experience. Anticiaptory grief, just like grief itself, is deep anguish of our soul that shows us just how much capacity we have for love in this world, how much we can give of ourselves and connect to another. It’s the price we pay for that connection.