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Why anxiety should be added to the 5 stages of grief


A few years ago, I began seeing a surge in anxious clients to my private practice as a grief therapist. They were reporting panic attacks and debilitating anxiety following the death of a loved one. Some of them had experienced anxiety before the loss, but the majority of them had never had anxiety before.

Granted, anxiety is on the uptick in our society. Xanax prescriptions are on the rise, more college students than ever are reporting anxious symptoms, and a proliferation of books and apps are hitting the shelves to address this prevalent symptom. But in the almost 50 years since Elisabeth Kübler-Ross published “On Death and Dying,” coining the now-famous five stages of grief (denial, anger, bargaining, depression, acceptance), anxiety has not usually been part of the equation.

But it should be.

Grief and anxiety are inextricably linked. We experience anxiety after a loss because losing someone we love thrusts us into a vulnerable place. It changes our day-to-day lives. It forces us to confront our mortality, and facing these fundamental human truths about life’s unpredictability causes fear and anxiety to surface in profound ways.

Loss is the perfect conduit for developing anxious symptoms, but the good news is that — using a combination of cognitive behavioral therapy, deep grief processing and meditation techniques — it’s highly treatable.

One of my earliest clients in this capacity came to see me about six months after his father died. He was in his 40s at the time, working successfully in the entertainment industry in Los Angeles. He had enjoyed a close relationship with his father, had attended to him throughout his illness and had been with him during his final days. After his father’s death, however, my patient had developed a significant case of anxiety that was playing out in the form of panic attacks and also bursts of sudden anger, both of which were affecting his work life and relationships. He was desperate to get a grip on these symptoms.

When I searched for information on how best to treat clients with such issues, I was dismayed to find little information about the correlation between anxiety and grief. I dove in anyway, and through my own experiential research treating these clients, I began to learn more about the connection between the two. I also relied on my personal background with grief and anxiety. I began having panic attacks, hypochondria and social anxiety after my mother’s death when I was 18.

What I quickly realized was that many of my anxiously grieving clients needed to begin by processing their grief on a deeper level. I know that much of my own anxiety had stemmed from not having the opportunity to explore the grief I felt about my mother’s death. Since I was a young college student, the adults in my life expected me to simply immerse in my studies and move on from her death, almost as though nothing had happened. Finding ways to talk about the loss of my mother and how it impacted my sense of self and safety in the world were things I had to go back and do only years later.

Unfortunately, this is a common experience for many people who lose a loved one. Our culture is not very adept at making space for grief. That was true over 20 ago when I was going through it, and is still largely true today. Sheryl Sandberg, the chief operating officer of Facebook, has been particularly vocal in the past few years, following the sudden death of her husband, about the lack of support and acknowledgment for grief in the workplace.

Still, clients show up in my office every week looking for guidance on how to incorporate grief into their lives. There is a cultural expectation that we will take a few weeks to grieve and then “get back to normal,” when in reality it takes a few weeks for the reality of the loss to even sink in. Most of my clients find me around the six-month mark when they are really facing the reality that their loved one is gone and find themselves grappling with overwhelming feelings of depression, anger — and anxiety.

In the case of my patient whose father had died, I found that he indeed had managed to push his grief away, under the presumption that he should be over it already. Yet as we talked, it was clear that he had not even begun to process much of his deep feelings of anguish and remorse around his father’s death. When we push away these feelings, as well as the impulse to resolve them, they often manifest in anger and anxiety.

So while I began our initial sessions together by helping him understand that his anxiety was a normal response to loss, and by giving him some basic tips for managing panic attacks, the main effort was to help him really process the loss itself. He had the loss of a close relationship to grieve, a sense of identity to rearrange, some guilt to unravel, other familial relationships to reconstruct in his father’s absence and a new perspective for the future to plan for. As he did these things he began to experience an immediate sense of relief and release for all he had been keeping pent up.

But there was still another aspect of the grief-related anxiety to work through. Namely, the way that loss calls on us to confront our mortality.

You see, this kind of anxiety that is specific to grief is brought on by two things. The first is the aforementioned unprocessed grief, but the second is simply the experience of getting close to death. When we lose someone significant, we are starkly reminded of how precarious life is, how the unexpected lurks at every turn and how wide-ranging the actual impact of loss can be.

For many of my clients, these existential truths about life — and death — are what send them spinning out into panic and anxiety. Before the loss occurred, they had been going about life as planned — making contributions to their 401(k) plans, arranging vacation travel, and expecting to attend upcoming events and anniversaries. But suddenly, in the face of such stark loss, all of that security and planning gets thrown into question. Not to mention having to reckon with the wonderment of what actually happens when we die.

Working through these components is vital to healing ­grief-related anxiety. As a culture, we tend to push away our thoughts, fears and questions about death. Given how reluctant our society is to deeply explore this topic, it’s no wonder that we falter individually when faced with it. After all, at the root of most anxiety is fear. And what are most people afraid of more than death?

Kübler-Ross wrote, “You will not ‘get over’ the loss of a loved one; you will learn to live with it. You will heal and you will rebuild yourself around the loss you have suffered. You will be whole again but you will never be the same. Nor should you be the same nor would you want to.”

The sooner we can accept these wise words and do the necessary work of moving through all the facets of grief, the sooner we can experience healing and relief from anxiety. Until then, I hope that the link between anxiety and grief can become a more widely recognized symptom so that those who suffer from this affliction can find ways to not only cope but also thrive.

Bidwell Smith is a Los Angeles-based therapist and author of “Anxiety: The Missing Stage of Grief,” her third book about grief and loss.