A Guide to Grief and PTSD

Grief is a normal response to loss. It can be the loss of a home, job, marriage or a loved one. Often the most painful loss is the death of a person you love, whether from an illness, an accident or an act of violence. Grief is one of the most difficult aspects of human existence. While all people experience grief, those with PTSD may find it especially difficult and feel the grief more keenly than others. It is a challenge, but it is important to allow yourself to feel all your feelings, and surrender yourself to those feelings, if you wish to continue your healing.

If you have PTSD, a major loss can throw a wrench in the works of all the healing and therapy you have accomplished thus far. And since PTSD itself can be described as a problem of unwept tears or unresolved grief (Matsakis, 1992), fresh losses can add a difficult and even unbearable dimension to previous unresolved grief. You may find yourself feeling confused about what you are actually grieving for, experiencing flashbacks and other memories of your trauma while grieving the new loss. You may find yourself feeling uncontrollable anger and rage at little annoyances, people and situations that have little to do with the loss itself. Normal feelings of guilt that everyone feels during grieving may be exaggerated and irrational. Setbacks in your healing process may occur. Whether those setbacks are temporary or more long term is entirely up to you, and how hard you are willing to work on yourself. Getting in touch with your grief may be the most challenging thing you do in life, but it is well worth the struggle and the effort.


The Grieving Process

Grief is painful and at times the pain seems unbearable. It is a combination of many emotions that come and go, sometimes without warning. Grieving is the period during which we actively experience these emotions. How long and how difficult the grieving period is depends on the relationship with the person who dies, the circumstances of the death, and the situation of the survivors. The length of time people grieve can be weeks, months, and even years. One thing is certain: grief does not follow a timetable, but it does ease over time.

Because grief is so painful, some people try to "get over" a loss by denying the pain. Studies show that when people don’t deal with the emotions of grief, the pain does not go away. It remains with them, and can turn up in unrecognizable and sometimes destructive ways. Understanding the emotions of grief and its feeling and symptoms are important steps in healing and in helping others who may be grieving.


The Feelings and Symptoms of Grief

Experts describe the process of grieving and the emotions of grief in various ways. Some of the most commonly described reactions are: Shock, Denial, Anger, Guilt, Depression, Acceptance, and Growth. While some people experience the grieving process in this order, most often a person feels several of these emotions at the same time, perhaps in differing degrees. A person with PTSD will experience all these emotions just as a "normal" person would, but because of the added stress of PTSD, will likely experience them more intensely, and for a longer period of time. Symptoms will likely be more pronounced. Being patient and kind to oneself during the grieving process is therefore even more vital in a person who has experienced prior trauma.

Shock - If the death comes suddenly, as in an accident or murder, shock is often the first response people feel. Even if the death is anticipated, there may be disbelief at its finality. A person may be numb, or, like being on "automatic pilot", be able to go through the motions of life while actually feeling little. At the same time, physical symptoms such as confusion, cognitive difficulties, and loss of appetite are common.

Denial - Shock and denial are nature’s way of softening the immediate blow of death. Denial can follow soon after the initial shock. People may know their loved one has died, but some part of them can’t yet accept the reality of the death. It is not uncommon to fantasize that the deceased will walk through the door, as if nothing has happened. Some people leave bedrooms unchanged or make future plans as if the loved one will participate, just as in the past.

Anger - Anger is normal. It may be directed at the deceased for leaving and causing a sense of abandonment, or at the doctors and nurses who did not do enough, or at a murderer who killed without remorse. People of faith may feel anger at God, for allowing so much pain and anguish. Anger may also be directed at oneself for not saving the life of the loved one. It can be a mild feeling or a raging irrational emotion. It can test one’s faith in religion or even in the goodness of life. It can be "misplaced" or misdirected onto other people or events which seemily have nothing to do with the tragedy. It can cause longterm physical problems, such as stomach ailments or high blood pressure, if not dealt with adequately.

Guilt - Few survivors escape some feeling of guilt and regret. "I should have done more" and "I wish I would have said such and such" are words that haunt many people. Were angry words exchanged and never resolved? Was the last thing you said to the person less than desirable? Most people are very creative in finding reasons for guilt. So many things could have been done differently "if only I had known it was the last time."

Sadness - Sadness is the most inevitable emotion of grief. It is normal to feel abandoned, alone and afraid. After the shock and denial have passed and the anger has been exhausted, sadness and even hopelessness and depression may set in. A person may have little energy to do even the simplest daily chores. Crying episodes may seem endless. Or one may be so sad that they are unable to cry at all, "beyond" crying.

Acceptance - Time alone will not heal grief. Acknowledging the loss and experiencing the pain may free the survivor from a yearning to return to the past. Accepting life without the lost loved one may give way to a new perspective about the future. Acceptance does not mean forgetting, but rather using the memories to create a new life without the loved one. Hoping for things to be as they were may be replaced by a search for new relationships and new activities.

Growth - Grief is a chance for personal growth. For many people, it may eventually lead to renewed energy to invest in new activities and new relationships. Some people seek meaning in their loss and get involved in causes or projects that help others. Some people find a new compassion in themselves as a result of the pain they have suffered. They may become more sensitive to others, thus enabling richer relationships. Others find new strength and independence they never knew they had. After the loss, they find new emotional resources that had not been apparent before.


Dealing with Grief

Grieving people have two choices: they can avoid the pain and all the other emotions associated with their loss and continue on, hoping to forget. This is a risky choice, since experience shows that grief, when ignored, continues to cause further pain, and eventually physical problems as well. The other choice is to recognize grieving and seek healing and growth. Getting over a loss is slow, hard work. In order for growth to be possible, it is essential to allow oneself to feel all the emotions that arise, as painful as they may be, and to treat oneself with patience and kindness. You may find the following suggestions helpful:

Feel the Pain - Give into it... even give it precedence over other emotions and activities, because grief is a pain that will get in the way later if it is ignored. Realize that grief has no timetable; it is cyclical, so expect the emotions to come and go for weeks, months or even years. While a show of strength is admirable, it does not serve the need to express sadness, even when it comes out at unexpected times and places.

Talk About Your Sorrow - Take the time to seek comfort from friends and family who will listen. Let them know you need to talk about your loss. Those who really care for you will understand, although they may not know how to respond. If they change the subject, find the strength to explain that you need to share your memories and express your sorrow. If family and friends are unavailable to you, you may consider seeing a grief therapist, speaking to a priest, minister or rabbi, or joining a grief support group.

Forgive Yourself - Forgive yourself for all the things you believe you should have said or done. Also forgive yourself for the anger and guilt and embarrassment you may have felt while grieving.

Get Help - Bereavement groups can help you recognize your feelings and put them in perspective. They can also help alleviate the feeling that you are alone. The experience of sharing with others who are in a similar situation can be comforting and reassuring. Sometimes, new friendships grow through these groups - even a whole new social network that you did not have before. There are specialized groups for widowed persons, for parents who have lost a child, for victims of drunken drivers, etc. There are also groups that do not specialize. Check with your local hospice, funeral home, or other bereavement support groups for more information. If you find that you are in great distress or in long-term depression, individual or group therapy from a counselor who specializes in grief may be advisable. You can ask your doctor for a referral.

Eat Well and Exercise - Grief is exhausting. To sustain your energy, be sure to maintain a balanced diet. Exercise is also important in sustaining energy and alleviating depression. Find a routine that suits you - perhaps regular walks or bike rides with friends, or in solitude. Clear your mind and refresh your body.

Indulge Yourself - Take naps, read a good book, listen to your favourite music, buy yourself a gift, get a manicure, go to a concert, rent a movie. Do something that is frivolous, distracting and that you personally find comforting.

Prepare for Holidays and Anniversaries - Many people feel especially "blue" during these periods, even moreso if you have PTSD. The anniversary date of the death can be especially painful and triggering. Even if you think you’ve progressed, these dates may bring back some of your most painful emotions. Make arrangements to be with friends and family members with whom you are comfortable. Plan in advance activities that give you an opportunity to mark the anniversary.

Visit or Create a Memorial - You may wish to take time to visit the gravesite, place where the ashes were scattered, or special place the two of you shared, to talk to the person, cry, or simply sit and relax. You may make it a habit to go to that special place once a week, once a month, or on certain anniversaries. If you have no access to the actual internment site, or even if you do, creating a special place in your home can be helpful as well. In our house we have a memorial to Brian, located on a dresser in our family room. It has a photograph of Brian, a votive candle, flowers, Brian's medals from the military, and family members have left various articles there that remind them of Brian. Brian's son left a small toy car for his dad. My aunt wrote a poem on special paper and tied it up with ribbon. I left an object that is part of an "inside joke" that Brian and I once shared. Be imaginative and create something meaningful for yourself and your family.

Write in a Journal or Diary - I have written about my grief in my own personal trauma diary, but I have also found that a paper journal is particularly effective. Personally I use a simple hard cover black scribbler with lined paper. Blueline is the particular brand of scribbler that I use, and it can be found in most office supply shops for a reasonable price. The plainness of it allows me to personalize the cover by pasting stickers or taping drawings and magazine clippings, to make the diary totally my own. Inside I write, draw, paint, paste, whatever I like. I do all these things with the intent of not sharing the journal with anyone, as I find that helps me to be more free and open in what I record there.

Write a Letter to the Deceased - Write a letter to the person who died, and explain to them how you feel about their death. Tell them all your feelings, good and bad. If you are angry with them for dying, explain to them why. Share jokes, stories or memories with them, whatever you feel like. Say all the things you wish you could say if they were still alive and standing before you.

Write a Letter to Yourself - Write a letter to yourself, telling yourself it is okay to grieve as you are, that it is normal and healthy. Give yourself permission to experience all the feelings you are experiencing. Compliment and comfort yourself the way you imagine a good friend or loving family member would do.

Art Therapy - You needn't be an artist to make use of art therapy in dealing with grief. Drawing, painting, making collages, working with clay and so on, can be very cathartic, especially if you don't put pressure on yourself to obtain a certain outcome. To begin, set aside a specific amount of time in an area where you are unlikely to be disturbed. Set out paper and crayons, scissors, old magazines, glue... whatever medium(s) you have chosen. Then simply think of the person or situation you are grieving, and begin drawing, pasting, sculpting, etc, without trying to consciously think about what you're doing. Just use your instincts and do what seems right at the time. Later on, if it feels appropriate, you may wish to share your art with a trusted friend, family member or therapist. You may explain to them what the art means to you, how it makes you feel. It can be an excellent way to express your grief feelings.

Create an Anger Ritual - This can be helpful in dealing with unresolved anger or other unpleasant feelings surrounding the grief or situations occurring simultaneously. A family member and I recently purchased several sets of chipped porcelain plates at a garage sale, and then went to the landfill and smashed the plates. It was surprisingly cathartic to throw the plates down into the pit of rubbish and watch them smash into thousands of pieces. Another time recently, when I was especially angry at someone, I drew a picture of that person, and wrote why I was angry with them next to their picture. I then crumpled up the paper, burned it on the beach, and sat watching the water carry the ashes out to sea. Whatever you decide about your anger ritual, make it meaningful for yourself, and be sure it doesn't harm yourself or others.

Take Active Steps to Create a New Life for Yourself - Give yourself as much time to grieve as you need. Once you find new energy, begin to look for interesting things to do. Take courses, donate time to a cause you support, meet new people, or even find a new job. It is often tempting to try to replace the person who has been lost. Whether through adoption, remarriage, or other means; this form of reconciliation often does not work. Many people discover that there is hope after death. Death takes away, but grief can give back. It is possible to recover from grief with new strengths and a new direction. By acting on our grief, we may eventually find peace and purpose.

A Word of Caution - In those with PTSD there is often a tendency to overdo things, so be cautious when applying these suggestions, and be sure to do all things in moderation. For example, watching a sad movie to encourage tears can be beneficial, but watching several sad movies over the course of a weekend and doing little else in the way of self-care could be damaging. Exercising is wonderful for depression, but exercising to the point of exhaustion or illness will only create more problems, more grief, guilt, and worry for yourself and your loved ones.


Helping Those in Grief

You may know someone who has experienced a loss. Many of us feel awkward when someone dies, and don’t know what to do or say. The suggestions below are designed to help you help friends, family and coworkers who are grieving.

Reach Out to the Grieving Person - Show your interest and share your caring feelings. Saying the wrong thing is better than saying nothing at all. At the same time, avoid clichés like "It was God’s will," or "God never gives us more than we can bear", "At least she isn’t suffering" , or "Things could be worse". Do not say you know how it feels, although sharing your own experiences of grief and loss may help the other person to open up and not feel so alone. Do say you are sorry and that you are available to listen. Be prepared for emotional feelings yourself. A death generates questions and fears about our own mortality.

Listen - Your greatest gift to a grieving person can be your willingness to listen. Ask about the deceased. Allowing the person to talk freely without fear of disapproval helps to create healthy memories. It is an important part of healing. While you can’t resolve the grief, listening can help.

Ask How You Can Help - Taking over a simple task at home or at work is not only helpful, it also offers reassurance that you care. Be specific in your offer to do something and then follow up with action. Don't simply say, "Let me know if you need anything", as it may be difficult for the grieving person to articulate their needs. For example, if a loved one's things need to be put in storage, bring your grieving friend some boxes or even offer to help with the packing or cleaning. A simple gesture such as this will mean so much to your friend.

Remember Holidays and Anniversaries - These can be a very difficult time for those who are in grief. Do not allow the person to be isolated. Remember to share your home, yourself, or anything that may be of comfort.

Suggest Activities That You Can Do Together - Walking, biking or other exercises can be an opportunity to talk, and a good source of energy for a tired body and mind.

Help the Grieving Person Find New Activities and Friends - Include grieving persons in your life. Grieving people may require some encouragement to get back into social situations. Be persistent, but try not to press them to participate before they are ready.

Pay Attention to Danger Signs - Signs that the grieving person is in distress might include weight loss, substance abuse, depression, prolonged sleep disorders, physical problems, talk about suicide, and lack of personal hygiene. Observing these signs may mean the grieving person needs professional help. If you feel this is the case, a suggestion from you (if you feel close enough to the person), or from a trusted friend or family member may be appropriate. You might also want to point out community resources that may be helpful.

Don't Ignore or Avoid the Grieving Person - Remember that doing nothing, ignoring or avoiding the grieving person is the worst possible thing you can do. If you have been a part of the person's life prior to the loss, it only creates more hurt and hardship for them. You needn't act as therapist or constantly feel the need to be available to the person; a simple expression of condolence or offer of prayers or thoughts is enough. Be creative in thinking of ways in which you can show support without increasing your own symptoms. If even writing a card or note to the grieving person is too difficult for you, enlist a friend or family member to help. Be sure the grieving person knows you care, even if you can't be present for them due to your own symptoms. Part of healing PTSD is thinking of the feelings and needs of others and not just one's own, and doing so in a healthy and balanced way. A simple act of kindness towards another, even when difficult, will only make you feel better about yourself in the long run, and increase your healing and self-esteem.


A Final Note

Death can be a painful and permanent loss experience, and one of the hardest from which to recover. Death takes away, but facing it and grieving can result in peace, new strengths and purpose.


A portion of this article was adapted from a funeral home pamphlet.