"Everyone can master a grief but he that has it . . ." William Shakespeare, "Much Ado About Nothing" "It isn't the mountains ahead that wear you out. It's the grain of sand in your shoe . . . " From a posterin Marcia Lattanzi's office
They are the people called "the caring ones." Sometimes they are members of the "caring" professions: nursing, social work, religion, medicine. Perhaps they are born with just a little extra compassion. Sometimes they have gained it out of their own anguish.
It was the caring ones who stripped away the heavy curtains of hush-hush and secrecy and taboo of death and dying. And now it is the caring ones who are looking beyond death to those left behind.
Grief, bereavement--the words conjure black veils, whispers, tiptoes, long faces and longer, and uncomfortable, silences. But from the people who brought this country the concept of hospice, "quality" of death and pain "management," there is now emerging the concept of grief "management."
"You don't recover from grief," says psychiatric nurse Marcia Lattanzi. "You manage it." What is more, as she told hospice workers, other professionals and volunteers at a Hospice Care of the District of Columbia seminar, "it's really important to realize that grief is a very, very difficult thing to manage."
Lattanzi, who helped found the Boulder County, Colo., hospice--one of the first in this country--believes that "grief is the central issue in hospice care . . . and if there is one issue that is really central to our lives, it is grief and loss."
That issue is the focus of her work as the hospice's director of "education and bereavement." Her "Bereavement Care Manual" is a model for professionals in the field throughout the country.
The basic core of grieving, says Lattanzi, is redefining. "And redefining our lives, who we are as individuals, is the major task involved in grieving.
"Basically," she says, "people are mirrors in our lives. We spend our lives getting close to people, and certain people reflect dimensions or parts of ourselves as we'd like to see ourselves. So when we lose someone who is important to us, it's like a piece of ourselves taken away. And the way we have once seen ourselves is no longer the way we are now.
"We don't always fit with everyone in life, and it is a rare and good experience to find some people who fit into our lives and with whom we reflect good things. And when it is taken away from us, it takes a long time for us to re-establish and redefine ourselves as human beings."
Although she does not like to categorize the grieving stages as such, Lattanzi does feel that "grief is a process, because life is a process," and certain things happen at certain points along the way. "The one thing we should do in bereavement," she says, "is offer people information about what the process is like, because so much of grief is feeling out of control, feeling like you're the only one this has ever happened to."
The grief process has been identified and studied in infants separated from their mothers, as well as in terms of "any loss that makes us redefine who we are, a major move, a job change, a divorce, loss of a body part, all these experiences that make us set new images of ourselves.
"And the more important the relationship or the loss, the more profound the experience will be. It is not easy," says Lattanzi, "and we don't do it in a day or two."
Most people who have studied grieving suggest that it may take up to two years before self-image is fully restored. And even then, says Lattanzi, "even though we re-establish and re-define ourselves, it impacts us for the rest of our lives. We are changed by the experience of loss; we are changed by the experience of grief. Every major loss leaves an imprint on our lives, just as people leave an imprint on our lives."
In charting the grieving process, Lattanzi says it begins with shock, a woodenness, an inability to absorb reality.
Then there is protest--anger, "an entirely appropriate response, when something has happened quite outside the realm of our control," along with shock, confusion and denial.
Next comes despair, agony and depression. Towards the end of the process there is detachment, sometimes with apathy, indifference and withdrawal. Eventually there is recovery.
During the early stages there can be profound physical symptoms because "grief affects us in all the dimensions of our person--spiritual, social, psychological, emotional as well as physical." There can be pronounced changes in sleep patterns, loss of appetite, nausea and sometimes breathing problems.
"Grief," says Lattanzi, "is a tremendous assault on who we are."
Lattanzi and her colleagues at the Boulder Hospice discovered early on that the regular hospice nurses and volunteers--those who helped the patient--were not necessarily the right people to help the survivors. "There seems to be a different set of skills involved."
She offers these reminders for those who would help the bereaved:
* Never try to take a person's defenses away.
"People behave in certain ways for good reasons. We have, perhaps, given denial a bad name. People will accept as much reality as they can deal with at a given moment of time. The more you dissuade them out of their denial or anger, the more difficulty they will have with their experience of loss."
* During the period of despair, it is useless--although the desire to attempt is often irresistible--to try to take away the pain. "In fact, at this point people are inconsolable."
* People who are grieving "are consuming all their energy in day-to-day survival." They will take no initiatives. The time-honored cliche', "call me if you need me, if I can help," is useless; when people most need outside support, they are least able to seek it for themselves.
* Never diminish someone's pain by telling them how much worse someone else's is. Or how it could have been worse. "The most negative thing you can do is try to help by saying to someone, 'There, there, you have three other children,' or 'Well, you're young, you can remarry.' Whatever we say that minimizes their experience at that moment is a disservice."
Probably the most important thing, says Lattanzi, is being accessible--emotionally and physically. A physical presence, even a silent one, is "what we can offer out of our hearts, the comfort of our presence . . . it has great meaning for the bereaved."
What happens at the end of the process, says Lattanzi, is a matter of choice, all focusing on the quality of the experience.
"In that re-defining process we can choose to redefine ourselves as the Widow Jones or Bereaved Person Smith. We can choose to become sad the rest of our lives and have this be a shroud over our time. Or we can choose to welcome life again.
"What hospice care tries most to do is help others and ourselves welcome life again."