When my widowed grandmother was in her 90s, her circle of family and friends was much diminished. The youngest of 8 children, she had outlived all her siblings – and their spouses — and many of their children. Her network of old friends seemed to become smaller by the day as one after another of the people she held most dear became one of the dearly departed. Ironically, Margaret, a woman she’d known for almost 70 years, was someone she politely hated for her theatrical personality. The feeling was politely mutual. Margaret found my grandmother humorless in her conservativism. Nonetheless, the two would get together periodically to marvel that they were still among the living.
While having tea with me one day, the two talked about all the people they had known who had passed on. I asked what it was like. My gentile grandmother sighed and said something about it being God’s will and that, anyway, they would all be having a grand reunion some day. Her flamboyant and irreverent frenemy said, “Honey, it sucks!” — which only goes to show that everyone is who they are regardless of age.
Cumulative Grief: When people lose parents, a spouse, children, other family members, and/or friends unexpectedly and in quick succession, it can be overwhelming. There is no time to process one grief without being struck by another, and then another. Emotional numbness can be functional – at least for a time. Depression is common. Some people have difficulty concentrating or are distracted by thoughts of death or suicide. Untreated, it can lead to an inability to reconnect with the living and to emotionally reinvest in relationships. With time and treatment, many find a way to attribute meaning to the loss and create new direction for the remainder of their life.
Cumulative Grief and the Elderly
Although Cumulative Grief can happen at any age, it is predictable and inevitable as people grow old – and older still. The impact may be similar in many ways to multiple losses experienced by younger people, but there are unique elements that need to be understood and perhaps explored during treatment.
Social support is a powerful mitigating factor for grief. Good friends offer a qualitatively different support than anyone new. With each passing friend and relative, there are fewer people who lived, laughed and cried with each other through life’s experiences and who can share in the grief.
In addition to the loss of a specific friend, is the mounting loss of the peer group. There may be no one left to talk to about the music of their teen years, about mutual friends, about how they felt on significant national events, about what it was like to be new on the job, newly married, newly with children, newly anything in the time and in the context in which these things happened.
People are true to themselves. They cope with the challenge of increasing loneliness in much the same way they have always handled challenges. Some feel cheated of their friends’ company. Some focus on appreciating what they once had. Some are angry and irritable. Still others become philosophical. Those with a strong spiritual life may draw comfort and hope from it, though some become angry with their god. And yes, some become depressed. There is no point it trying to change the coping style of someone in their 90s but we can identify it and work within it. Sometimes people surprise us and challenge the notion that “old dogs can’t learn new tricks”.
Whatever their style, they have in common is the poignant awareness that there is no time left to create long-term friendships. As much as they might take pleasure in younger people they mentor or befriend or how much they like people they connect with in a retirement community, those relationships can’t replace those of 30 or more years. Therapy cannot replace peers but it can provide a safe place for remembering and honoring relationships and for sharing stories. Seniors can be helped to invest in those relationships as different but still valuable.
For some, one of the hardest things about losing yet another friend is that there is no one local with whom to celebrate the person’s life. Their circle of friends may have dispersed – some to live near adult children and grandchildren, some to live in warmer climates or where it is less expensive, some to return to wherever they had once called home. The ritual wake where people laugh and cry and tell stories and share in the loss isn’t possible. It can leave a sense of incompleteness to the mourning. “Listening to a eulogy by a priest who never knew my friend made things worse,” my grandmother once said bitterly. “It was impersonal and stupid. Why bother?” Therapy sessions may be the only opportunity to personally “wake” the deceased.
Complicating things further is that the loss of people they love is experienced by seniors within the context of multiple other losses. They may be struggling with the loss their professional identity, their ability to be physically and practically supportive of friends and family, their health, their sexuality, their ability to participate in social and recreational activity, and their independence. Many are also grappling with the loss of their homes and their possessions. Because those losses may have happened over the course of many years, the cumulative impact may not be understood by caregivers and family.
Family members, often busy with their own jobs and children, may not be sensitive to the toll of mounting losses for an elder. Not having known each deceased person well, or at all, it may be difficult for them to take time to listen or to empathize. Sometimes they don’t understand how important it is to provide transportation to a funeral when yet another of their grandmother’s friends dies. Family sessions can provide the space to talk about how to balance the elder’s emotional needs with the demands of family life. Identifying local resources can provide practical help. Places of worship, elder services, and local service organizations sometimes offer bereavement groups or have volunteers who are willing to drive seniors.
It’s important that we clinicians not take a prior diagnosis by other professionals as fact without exploring the impact of Cumulative Grief. The normal symptoms of Cumulative Grief can be masked by what seems to be physical illness or mental distress or even dementia. Incorrect diagnosis leads to treatment that misses the underlying issue. Studies have found, for example, that the feelings of hopelessness and helplessness that are hallmarks of depression may in fact be a consequence of untreated grief. In such cases, one important study showed that direct treatment for complicated grief resulted in significantly better outcomes than treatment for depression.
Cumulative Grief seems to be an under-recognized problem in the elderly and is not yet well-researched. Unless and until it is, it’s important for those of us who are asked to treat an elder to be mindful of the unique challenges of multiple losses that come with old age.