HOW DEATH COMES
I often sit with clients who struggle to feel the sorrow of their loss — they can’t stop thinking about the call in the middle of the night or are preoccupied with the mental image of their loved one’s lifeless body in the emergency room.
“You would think that after six months (or nine months or a year), I would have been able to put those things out of my mind,” clients will say.
That is when I suggest that they use a little more self-compassion as they allow themselves to reflect on the terrible, traumatizing experience they have endured.
“It’s totally understandable to me that the trauma is still following you around. That’s the way the brain works,” I might say. “That does not mean there is anything wrong with you.”
Again, a major goal of this book is to help reduce fear and self-criticism of your grief. The sorrow of grief is burden enough. An important part of normalizing the experience of grief is to take into account how your loved one died, as that could have a significant bearing on what you will experience afterward. In other words, the way death comes will probably be an important part of your narrative to explore and embrace.
All death is traumatic at some level. The moment of it brings us face to face with the mystery and finitude of life. It takes us back to the place where we are reminded that we, too, will die. But with death comes a broad spectrum of trauma. The more traumatic the death, the more shocking it is to the brain, and the more likely that the aftereffects of trauma will intrude upon or even monopolize grieving, possibly for a long time. That’s a hard reality, perhaps, but there is comfort in knowing that truth.
At one end of the spectrum is the so-called “good death,” a peaceful passing at the end of a long life that was well lived. With a good death, terrible suffering was minimal. There was time to resolve any lingering conflicts or hard feelings between the dying person and closest family member and friends. There were chances for important last conversations and goodbyes. The dying person had a say in how their dying went, such as being able to die in an environment familiar to them. There were times to give and receive expressions of love and gratitude.
Although the finality of a good death is inevitably jarring, there tend to be fewer regrets. There is a certain rightness, beauty, and sacredness to it. But that does not necessarily diminish the intensity of the sorrow, particularly if there was a great deal of love and attachment to the one who was lost. (I will talk about this in the next chapter.) However, fewer layers of pain, like remorse, guilt, and blame, are added on top of the grief.
If you were fortunate enough to experience a good death with your loved one, take a few minutes to reflect on it. Feel the pain of your loss, but also notice the grace notes that were probably part of the transition.
• What were the months or weeks like leading up to the death?
• How did your loved one feel or talk about their upcoming death?
• What were the responses of the others who were present in the days before and at the time of death?
• Although the death was anticipated, what, if anything, surprised you about the experience?
For ninety percent of the people I see, something about their loss complicated their sorrow. If I see one sixty-year-old adult child whose mother died a peaceful, pain-free death, I see ten other clients who experienced death in a more traumatic or complicated way. Most often, complicated sorrow happens when death is premature (before reaching the end of the natural life span) or suddenly — or both. I’ve personally experienced the spectrum of trauma in the three primary deaths I’ve suffered. And I know firsthand how the different levels of trauma affect grieving.
My mother, DeVere O’Malley, was a remarkable woman of limitless energy who was devoted to her children, her church, and her vast assortment of friends. Though diagnosed with leukemia in her later years, she continued to travel the world with friends much younger and to compete as a runner and cyclist into the last year of her life.
Although her disease finally would have its way, the end of her life was beautiful. On the night before she died, she and I sat on her bed watching TV. We reminisced about our old neighborhood, laughing together at the memories.
She took a turn the next morning.
“I love you, mother,” I said when I got to her bedside.
She barely had the strength to reply.
“I love you, too,” she said.
I sat on her bed, reading the Psalms. When she took her last breath, Mother was surrounded by her children and grandchildren. Even though her final moments were peaceful, I was heartbroken. It was a shock to have her gone. My mother was someone I had never not known. She was witness to my first breath, and I, to her last — part of the great mystery of life.
But I felt so grateful to be with her at the end. There is no more sacred intimacy than that. Although I still yearn for her, I also feel peace.
Ryan’s death was just the opposite. Even though he had been a sick little boy, we had expected him to live. He essentially died in our house. We were witness to it.
My father’s death was slightly less traumatic, because he was older. But it was still a shock — it was so sudden, and I had found his body. Also, the last time I had been with him, he had seemed healthy.
Over the years, as I’ve mourned my son and father, it has been impossible to banish the images of the paramedics who arrived to try to save my son and of my dad sitting in his chair that last time, a book open next to him. Those images are constant companions to my sorrow.
Trauma also often afflicts those whose loved ones died after a long physical decline or disability. A caregiver’s exhaustion and worry sap a family’s physical and emotional resources, adding another layer of weariness at the time of death and long into their mourning. The primary caregiver can feel emotionally unmoored after months or years of intense focus on the well-being of another. I have seen this in people of all ages, from parents caring for ill or disabled children, to those in midlife caring for spouses or parents, to elderly people who care for a husband or wife to the end.
Elderly people typically come to see me because their adult children believe it will be helpful. That was the case with Peg, who had just lost her husband of sixty-one years. Her daughter, Ruth, sat in on our first session and did much of the talking.
“Dad had Alzheimer’s,” Ruth said. “We all tried to help take care of him as much as possible, but Mom was the one who was there, all day, all night, for the last six years. I don’t know how she did it, but I never heard her complain.”
Ruth looked at her mother.
“I’m worried about you, Mom,” the daughter said. “All that time you took care of Dad. What do you do now? No wonder you seem depressed lately.”
“I’m just tired,” Peg replied.
“I think it’s more than that,” her daughter said.
In our second session, I asked to see Peg alone.
“Would you tell me about your husband?” I said.
Peg paused, as if she weren’t prepared for the question. But she began to describe a wonderful marriage, years of caring for her husband through his devastating illness, and the confusion she felt since his death. She said she would not change a thing about their lives together, except for the anguish at the end.
“I read a magazine article the other night that said widows can feel they’ve lost an arm or a leg,” she said. “They generally get along okay, but a part of them is always missing. That’s how I feel.”
“Of course you do,” I said. “It makes perfect sense you would feel that way. It also makes sense you feel so tired. Anyone would be after what you’ve been through.”
I remember how she reached for her purse, pulled out a tissue, and dabbed at her eyes.
“What will I do now?” she said.
“I can’t answer that question for you,” I said. “But it seems to me that after you rest, you have a lot of life left to live.”
In a subsequent session, Peg told me she had begun to volunteer at a local center for Alzheimer’s patients. “It gives me a reason to get out of bed in the morning,” she told me, chuckling.
If your loved one died after a long illness and you were a caregiver, reflect on these questions as they relate to your story:
• Did you suffer from caregiver fatigue? If so, how did you attempt to manage it?
• Did your loved one suffer terribly? If so, how did that affect you?
• Did you experience any level of trauma or shock when the death occurred?
• Did others assist you in caregiving?
• Was hospice care available to your loved one? Did you find that helpful?
• Did you need time to physically recover after the death of your loved one? Did you get the time you needed?
At the severest end of the spectrum are bereaved clients who suffer from what is known as post-traumatic stress disorder (PTSD), which accounts for about twenty percent of all grieving people who come to me.
Among them was Kara, whose husband, Luke, had gone off to run a mundane errand, buy milk, and put gas in his car. An hour later, two police officers knocked on her door. They told her Luke was dead, caught in the crossfire of a shootout between rival street gangs. Kara insisted that the officers had the wrong address, that there was some horrible mistake. He was just going out for milk.
They described her husband and his car. They handed her his wallet.
“I remember looking at them and seeing their lips move, but it was like my brain had completely shut down,” she told me in our first session, two months after her husband’s death. “I had no thoughts, no feelings, nothing. I just stood there like a zombie. Then I felt like I was going to faint.”
Her living nightmare was just beginning. The horrific way her husband died added layers of mental chaos and suffering on top of Kara’s feelings of loss. Because of PTSD, associated thoughts and images overwhelmed and preoccupied her long after her husband’s death. Kara, as many who suffer in that way, wondered whether she was losing her grip on sanity.
If the loss you’ve experienced was sudden or traumatic, your story of grief will almost certainly include emotional pain and mental upheaval beyond sorrow. This does not mean you are crazy or defective; it just means you are grappling with a natural by-product of an experience that will be difficult to sort through alone. I’ll describe the symptoms of PTSD in just a bit. But as you explore your story, if you have any doubts about whether you are suffering from PTSD, or if your thoughts or feelings are overwhelming, it’s important that you seek professional help. Acute trauma heightens the risk of numerous psychological symptoms.
Trust your own instincts on this score. There is no shame in putting down this book and picking it up again with a therapist.
The diagnosis of PTSD was created in 1980 to describe psychological and physical symptoms that lingered long after a person had endured a traumatic event. At the time, it was most often applied to veterans returning from the war in Viet Nam. In the decades since, however, clinicians have applied it to survivors of car crashes, natural disasters, mass shootings, and child abuse, as well as a number of other intense psychological events.
In PTSD, the fight, flee, or freeze mechanisms — chemical triggers in the brain set off by a traumatic event — do not shut down after the danger has passed. The brain continues to operate as if the threat were still present.
The three most common symptoms are known clinically as hyperarousal, intrusion, and avoidance. Hyperarousal compromises the brain’s ability to accurately evaluate danger. Everyday aspects of a person’s environment are now seen as threats. An afflicted person startles easily, can have difficulty sleeping, and is often moody and irritable. Another word for intrusions is flashbacks, or images from the traumatic event intruding upon awareness with no warning, creating a sudden change in mood or state of mind. Avoidance is the chronic and often unreasonable attempt to steer clear of anything, even the subtlest reminder, of the traumatizing event. Substance abuse and other compulsive behaviors are means of avoidance. Other behaviors include avoidance of funerals, social isolation, and detouring away from a place where a traumatic event occurred.
How do I treat clients suffering from PTSD? First, there is education to let them know that what they are experiencing is neither unnatural nor unexpected. Many are relieved to hear that what they are experiencing is similar to what those who have gone through the horror of war suffer. Clients ask, “Why do these things cause me to melt down?” or “Why are these terrible thoughts playing in a loop in my head?” I tell them, “It’s miserable, but this is your brain’s attempt to sort through what happened and reorient itself. You are not going crazy.”
Clients who have suffered traumatic loss certainly present a more complicated therapeutic challenge, because both trauma issues and the underlying anguish of loss need to be addressed. Clients are often unable to fully touch the pain of their grief until the symptoms of trauma have lessened. And that often doesn’t come until after the story of the trauma has been talked through many times in a safe therapeutic environment. The repetition of the story allows the brain to assimilate the images and memories of the traumatic event. With familiarity, the brain’s defense mechanisms trigger less and less. Life is no longer one continuous nightmare.
More and more innovative therapies are being developed to help with trauma, and I predict that more will be developed. For example, I often refer my PTSD clients to biofeedback and neurofeedback therapies as an additional support to deal with the complex physiology of traumatic loss. In the past several years, I have also written supportive documents for traumatized clients who have benefited from an emotional support animal.
In the months after Luke’s death, Kara could not sleep, lost her appetite, could not concentrate, and had no energy. She was haunted by the notion that her husband’s killer had not been caught. She checked four and five times to make sure her doors were locked before she went to bed.
“Every stranger I see could be Luke’s killer,” she told me. “Everywhere I go, I wonder. Loud noises freak me out. When I do sleep, it is very lightly, and I can barely get up the next morning. I don’t even feel like I can grieve for Luke, because my mind is always racing. This is not my usual way to be. I am usually very calm.”
Kara and I met regularly for two years. In session after session, Kara talked about the last time she saw her husband, the knock on her door, the shock. Each time that she talked of the horror, it became a little less dreamlike, a little more real. Her brain gradually assimilated what had happened, as terrible as it was.
Nine months after Luke was killed, police arrested a seventeen-year-old boy, a member of a local street gang. Kara felt more secure almost immediately. It wasn’t until then that she could actually “be with” her grief for Luke, as she put it. She and I started to talk more about her life with her husband and less about the terrible way it had ended.
The daughter of my clients Jack and Tara was killed when a drunk driver broadsided their car. The parents, who suffered minor injuries, were haunted by the image of their daughter’s lifeless body in the backseat as paramedics tried to save her. That image played on an endless loop in their minds, especially when they attempted to sleep. Tara had been driving at the time of the accident and could not get behind the wheel without suffering a panic attack. The couple veered back and forth between intense sorrow of loss and the horrifying mental images.
“It really feels like I’m losing my mind,” Jack said. “I see her lying in the car. Then I find myself in Missy’s room, remembering her as a little girl and all the wonderful times we had. One seems like a nightmare; the other, a bittersweet dream. It really does feel like I’m losing my mind.”
We met for more than a year, intentionally moving back and forth between the story of the horror and the story of their grief. Helping them understand the complex nature of PTSD alleviated their fear that they were slipping into mental illness. I also taught them to assimilate the trauma symptoms into their lives.
Instead of, “It’s crazy that I’m afraid to drive. I’ve been driving for thirty years,” Tara would now say to herself, “No wonder I want to avoid driving. My brain can’t forget what happened that night in the car.” That repeated self-assurance eventually allowed her to get back behind the wheel. I taught both parents to understand why the images flooded their brains and to accept them when they did. That acceptance helped reduce a layer of stress.
Over time, the intensity of the trauma symptoms began to lessen. More and more of our time together was spent talking about Missy and the profound sorrow they felt at her absence.
If significant trauma was associated with your loss, looking at it directly and repeatedly is the way to reduce its power. You might find the following questions helpful in that regard. Again, set the book aside if you begin to feel overwhelmed. It might be better to think about the questions with the guidance and support of a therapist.
• How did you learn he had died?
• Where were you and what were you doing when you found out?
• Did you witness the death? Was your life threatened?
• How did you get to the emergency room? What did you see, hear, and smell when you arrived?
• Do you have intrusive images from what you witnessed or what you have constructed in your thoughts about the trauma?
In the case of interruptive and traumatic death, mourning is often complicated by another feeling — guilt — which can also be hard to untangle.
As I tell my clients, guilt is not necessarily a bad thing. When we have done something wrong or have hurt people, it is the sign of a healthy conscience. The key is to determine whether guilt is justified or whether a person is being overly responsible.
I often ask my clients to look at it this way: If they put the question before a jury of their peers, what would be the verdict? Yes, they did something for which they should feel guilty? Or, no, they did nothing wrong? Most times, the verdict would be the latter.
Acute guilt has afflicted every client of mine whose loved one died of suicide. Steven and Marissa came to see me shortly after the suicide of their twenty-four-year-old son, Jimmy. The couple had tried to return to their normal routines but remained sleep deprived and tearful.
“Our friends say they hope we can find closure,” Steven told me. “But how in the world can a person ever find closure with something like this? Where did we go wrong?”
“That’s the question I’ll try to help you answer,” I said. “We can talk about every part of Jimmy’s life. If we find something you should feel guilty about, I promise you, we will face it. But for now, I’d like to get to know Jimmy through your eyes.”
They told me the story of a little boy who suffered from developmental problems from the time he went to school and who never seemed to fit in with other children. They were conscientious parents who regularly sought the help of professionals. They sent Jimmy to special camps that might help build social skills. They made sure other kids were welcome in their home. But nothing really seemed to help.
“I’ve heard lots of stories of parents with challenging children, and you did all you could,” I said. “You didn’t miss anything. Did you get tired? Did you say some things to Jimmy that you might regret? Of course, but that is part of being a human family.”
“I can’t tell you how important that is to hear,” Marissa said.
The couple eventually started sleeping better and reengaged socially. They joined a support group and eventually became leaders of it, using their experience to help others.
With sudden death, relationships are frozen in time. That is an invitation to another form of guilt that comes with the thoughts of “what if” and “if only.”
“I never took him fishing like I promised. If only I had.”
“What if I had kept her at home for another five minutes?”
“I wouldn’t have said that if I had known I would never see her again.”
I’ve worked with hundreds of clients like Carol, who was haunted with regret because of her last words to her older sister. She is also an example of a person who had something to feel legitimately remorseful about.
Carol’s relationship to Rebecca had always been a roller coaster of love, admiration, frustration, and, at times, outright animosity. Carol had always believed that Rebecca was flighty and chaotic, which led to frequent arguments when the two went into business together. Their last conversation came on the telephone, after Rebecca had missed another important deadline.
“You’ve always felt that the rules didn’t apply to you,” Carol said. “I’ve had it. I’m going to find another partner.”
Then she hung up. A few hours later, Rebecca suffered a brain aneurysm and died. Carol said she replayed the last conversation over and over with every waking hour, and it kept her up at night.
“My God, it all seems so trivial now,” she said. “I mean we had that same argument ten times, and we always figured it out. We would have this time, too.”
I encouraged Carol to tell me the whole story of life with Rebecca. The grieving sister came to understand that there was much more to their relationship than the way it ended. But it was also necessary for Carol to own up to the fact that her last words were cruel and that she was overly judgmental about Rebecca’s way of being in the world.
I encouraged Carol to journal about her regrets and to write herself a letter of forgiveness. With her regrets addressed head on, she could connect more with her deep sorrow about losing her sister.
What is known as survivor’s guilt can be particularly difficult; it often has no basis in logic but can be a powerful emotional response. Why did one soldier step on the land mine and not another? Why did one person survive the attacks of 9/11 when so many others did not? Why did one passenger survive an automobile accident and two did not? Survivor’s guilt requires a careful examination of the story behind it. Doing so helps survivors see that, practically speaking, they had no control or responsibility over who died and who didn’t.
When I work with people wrestling with these questions, I invariably suggest that some questions just don’t have good answers and will remain in their loss story as unanswerable.
My client, a combat veteran named Terry, was standing ten yards away when his best friend, Will, was killed by an explosive device. Terry’s severe guilt completely impeded his mourning for his friend.
We carefully talked through the combat death. In doing so, Terry came to accept that his behavior did not contribute in the least to what happened. But then we had to wrestle with more cosmic questions.
“But he was a much better person than me,” Terry said. “It’s not fair that he’s dead and not me.”
“I can’t say whether Will was a better person or not,” I said. “But so many things aren’t fair. There really isn’t anything we can do but accept that life can seem awfully random and very fragile. What’s the reason Will died and you didn’t? There isn’t one.”
Terry gradually came to accept that fact. His feelings of sorrow for the loss of Will increased as his guilt subsided.
If you struggle with survivor’s guilt, the following questions might help you explore it and find some acceptance.
• Do you believe there is something you could have done that would have prevented her from dying?
• What medical decision did you make for him that you wish you could change?
• What were your last words with him before the accident?
• What was the level of conflict or peace in your relationship with her?
• Why him and not you?
• What do you need to forgive yourself for in your relationship with her?
Finally, blame is also common in traumatic loss, and it complicates grieving. Richard came to see me because he was “obsessed” with anger toward the truck driver and the trucking company he held responsible for his son’s death. The truck driver had been cited several times in the past for speeding and other traffic violations, to the point that his driver’s license had been suspended. Yet the trucking company had allowed him to drive anyway.
By any reasonable standard, Richard was justified in his anger. He sued the company, poured a great deal of emotional and physical energy into the court fight, and won a sizable financial settlement. But his anger remained and would only abate with several glasses of Scotch at the end of the day. It was after Richard was arrested for driving while intoxicated that he sought me out.
It was a hard road for him, but I helped Richard experience his anger in its purest form, without the anesthesia of alcohol. As with trauma victims, I assured him that, under the circumstances, his anger was understandable. But I also explained that he had done all he could to make sure the company suffered the consequences. As I would with someone who suffers from survivor’s guilt, I suggested that there was no explanation for why his son had been victimized by the trucking company’s neglect, as opposed to some other innocent driver. Richard eventually accepted that the only person being harmed by his lingering anger was himself.
If your loss was the result of the action of others, reflect and write about these questions:
• How did you think about the person or persons responsible for her death at the time it occurred?
• Have your thoughts or feelings changed over time?
• Was the person held accountable for his death and did justice occur? If not, how does that feel?
• Have you been able to forgive the person? Do you feel any need to forgive the person?
If your loved one died from any circumstance that created physical or emotional experiences beyond sorrow, that is also part of your grief story. Whether or not you require professional help as you process the multiple layers of thoughts, feelings, or physical responses, be assured that you are not wrong or defective for what you are experiencing.
Before we move on, I want to share this account from my own life. It speaks to many of these dynamics, such as guilt, self-blame, trauma, and remorse. It also speaks to how these emotions can last for decades when the story is withheld because of a family secret about the loss.
Several years ago, on a business trip to the East Coast, I took a detour to my dad’s hometown of Scranton, Pennsylvania. I found the cemetery where my grandparents and uncle were buried. Standing there, I suddenly fully understood the enormity of the losses my father had suffered. It was my inherited story of loss.
I had been twenty when I heard the story for the first time. I was home from college, and Nancy and I were engaged. I guess my father felt like he could finally speak to me, man to man. We were standing in the kitchen, and I don’t remember how exactly it came up.
“You know my mother committed suicide, right?” he said. “That has haunted me my whole life.”
My father had never been so vulnerable with me. He said he was ten when his mother died. His father said the cause was pneumonia, but even as a boy, my dad knew better. He knew his mother had not been sick, but no one would tell him the truth.
What he did not know he attempted to imagine, an example of the need to create stories so that we can try to make sense of our world. But my father was haunted by the story he created: A few months before her death, his mother had tripped on one of his toys and fell, crushing the crystal glass she had been carrying. Her hand was permanently deformed. Dad’s story was that his mother had committed suicide because he had left his toy on the floor.
His anguish was obvious as we talked that night. After she died, no one mentioned his mother’s name, which was a source of even more guilt for him. He lived in the lie and held himself responsible. That night in the kitchen, I felt deep sadness and compassion for my father.
“I really want you to be happy,” I said.
Dad returned to Scranton a few years after that conversation and found the doctor who had falsely certified his mother’s cause of death. My father’s father, who had been a physician, had asked his colleague to cover up the cause.
“I’ve got one question for you,” Dad said. “How did my mother die?”
“She committed suicide,” the doctor said. “We should have told you boys. I have carried that with me ever since.”
My dad also learned that her death had nothing to do with the toy on the floor. Just that quickly, he had the truth and an apology from a member of the conspiracy of silence. My dad also found a measure of understanding. At the time of his mother’s death, suicide was considered a mortal sin in the Catholic Church. She could not have received the rites of the Church, nor could she have been buried in the Catholic cemetery. My dad’s father had chosen secrecy over public shame.
When he came home from that trip, my dad seemed like a different man. A weight that he had carried since he was ten years old was finally gone. He had lived with guilt and confusion for a lifetime because of the secret that was kept and the story that was never told. Once he knew the true story, he could step out from the shadow where he had lived and be more present to his life.