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Self-Care

…people cope with loss in different ways and therefore may have different needs for intervention and different responses to a given type of intervention.1

Many strategies exist to help individuals cope with major loss. Following are a sampling of non-pharmaceutical approaches to recommend to grieving individuals. Note that while listed here under a particular self-care area, some strategies cover several self-care areas. For example, nature is listed in “Surroundings” overview. Depending on how an individual spends time in nature, it may also fit under the categories of Working Your Body; Recharge; Spirit and Soul; and Family, Friends, and Co-Workers (if others accompany the individual).

Physical Activity

Exercise

Suggest a form of physical activity that the grieving individual has enjoyed in the past or encourage the person to try a new one. Doing the activity with others may be even more helpful. For more information, go to the “Physical Activity” overview.

Massage

Therapeutic massage may be helpful for someone who is experiencing tension or pain from “holding grief” in the muscles.

Surroundings

Nature

Spending time in nature can be soothing and healing.

Personal Development

Leisure Activities

Encourage activities that the individual has enjoyed in the past. As grief becomes less acute, encourage exploration of new leisure activities.

Nutrition

Healthy Food

Encourage a good balance of healthy foods. Overeating and undereating are common grief behaviors. For more information, refer to “Nutrition.”

Limit Alcohol and Other Drugs

Caution against using alcohol and unprescribed drugs for relief.

Recharge

Good Sleep Hygiene

Educate about good sleep hygiene, if this is not something the individual generally practices. For information on insomnia, refer to “Recharge.”

Provide Reassurance

Reassure the grieving individual that sleep disruption, especially difficulty falling asleep and early morning awakening are common experiences during the first few months of grief.² In normal grief, this symptom usually resolves on its own. If it continues, it may indicate depression.

Healing Touch

Healing Touch is a form of energy medicine. Practitioners place their hands near or gently on the body to clear, energize, and balance the energy fields; the goal is to restore balance and harmony, so the receiver is placed in an optimal position to self-heal.³ To find a certified practitioner refer to the Healing Touch Directory.

Family, Friends, and Co-Workers

Facilitating Support from Family and Friends

People benefit from social support of their losses. Some grievers may be hesitant to seek the support they need. Others may need to repeatedly tell the story of their loss as they come to terms with it. This need to retell may clash with the needs of people in their support system whose patience, time, and energy can become taxed. In the first situation, encourage grievers to contact family, and in the second situation help them to identify individuals in their social circle who are particularly good listeners with time available or to locate a grief support group.

Grief Support Groups

Grief support groups are available in many communities and also online. Hospices are usually good sources for information on their availability. If grief is military-related, a grieving individual may want to connect with others who are familiar with military culture. The Tragedy Assistance Program for Survivors (TAPS) can be a useful resource.

Spirit and Soul

Addressing Spirituality Concerns

Certain losses may challenge grievers’ spiritual beliefs, causing them to question their existential views.⁴ They may experience this as an internally chaotic time, feeling ungrounded or adrift. It can also become a time when grievers reaffirm or redefine their belief systems and grow in new directions. Those in the military may have been in situations which caused them to perform or witness behavior that was in conflict with their personal moral beliefs or religious or spiritual beliefs.⁵ A referral to a chaplain, clergy, or other spiritual leader may be helpful.

Rituals

Rituals are activities that symbolize feelings and thoughts related to a death. They honor a person and recognize a change in status from living to deceased.⁶ Some rituals demonstrate that a bond continues to exist with the deceased.⁶ Rituals may be related to one’s cultural traditions, or they may be created by individuals themselves. Perhaps the most familiar rituals are those of a visitation/wake and a funeral/memorial service. Many kinds of informal rituals can be created based on the interests and needs of the bereaved. Finding their own unique ways to memorialize loved ones may be very helpful. Examples of informal rituals include lighting candles or toasting the deceased on special dates, sewing a memory quilt (which may be created from clothes of the deceased), building something as a memorial to the deceased individual, planting a tree or a memory garden, sharing a memory dinner to celebrate the life of the deceased, leaving a note at a memorial setting.

Mind and Emotions

Writing or Journaling

Writing or journaling about one’s grief experience can help facilitate the expression of feelings and help focus on the meaning of the loss to the griever.² If grievers have unfinished business with the deceased, they might consider expressing their thoughts and feelings through writing a “letter” to the deceased individual. For more information, refer to “Therapeutic Journaling.”

Forgiving

An unexpected death can leave a bereaved individual with “unfinished business” with the deceased. If the bereaved have a sense of previously being “wronged” by the deceased, they may benefit from working on forgiveness. This may include working on self-forgiveness. Feelings of guilt can be resolved through a ritual involving confession, forgiveness, compensation (e.g., helping others with similar experiences), and self-forgiveness.⁷ A clinician can help by creating a safe environment in which people can share any actions that may be the cause for feelings of guilt or shame. It is important to neither push a people into the topic of forgiveness, nor to minimize feelings of guilt, if someone brings them up.⁸ For more information, refer to “Forgiveness: The Gift We Give Ourselves.”

A grief counselor, pastoral counselor, psychologist, or social worker may be helpful. Mental health clinicians who have received specialty training in PTSD are usually trained in traumatic grief and guilt. They use tools such as relaxation, mindful awareness, and guided meditation and can help people overcome avoidance, a clinical symptom of PTSD that often keeps people from engaging in therapy.

Mindfulness-Based Stress Reduction

In the absence of personal awareness, grieving can be disenfranchised. Mindfulness-Based Stress Reduction (MBSR) is based on Eastern philosophies and uses meditation to calm the mind and body. It is a practice that helps individuals live in the moment and become more self-aware. For more information, refer to “Mindful Awareness.”

Back to Jim: Personal Health Plan

During the appointment, Jim’s clinician talked with him about the mind-body connection. The clinician described that stress can cause or exacerbate back pain. He educated Jim about common grief reactions and anticipatory grief. He pointed out that a number of the symptoms Jim reported were consistent with grief. He reflected back to Jim how important the relationship with his nephew was to him. (Jim had said that fishing and going to baseball games with his nephew brought him joy and happiness. Jim was also looking forward to starting new activities—like setting up a woodworking shop—with his nephew when he retired.)

Jim and his clinician have a good relationship. Jim has often said that he trusts his clinician. Jim’s responses to questions about purpose and meaning in his life—“It’s hard to find purpose and meaning sometimes when you’ve seen some of the things I’ve seen in the service,” and, “It would be good to feel at peace; I’ll keep trying”—caused his clinician to question if Jim has ungrieved losses from his combat years that are compounding his anticipatory grief reactions over his nephew.

Knowing that Jim could be at risk for disenfranchised grief his clinician gently asked, “Jim, is there anything from your years in service that is still troubling you?” The timing was right. The clinician noted similarities between Jim’s nephew and situations Jim had seen during his work as an EMT. Jim mentioned guilt over both situations—guilt that he was surviving and many of his patients did not and his nephew might not.

Jim’s clinician asked Jim the five questions in the Brief Grief Questionnaire. Jim scored a 3, which is not indicative of complicated grief. While Jim’s diagnosis did not indicate a strong need for a referral to a mental health specialist, he has some issues that he may want to explore to promote future health and happiness.

Together Jim and his clinician developed a Personal Health Plan (PHP) that was do-able with Jim’s current energy level. They will revise it as needed.

(Note that this is an elaborate PHP; the level of detail will depend on the amount of time available, what else needs discussion during a visit, and how well Jim’s clinical team members know him.) Even setting 1-2 initial goals is a great start to a plan.

Name: Jim

Meaning, Aspiration, Purpose (MAP):

Increase my awareness of how grief is affecting me and to focus on ways to increase my health so that I can enjoy my retirement and be actively involved in the lives of my sister and nephew.

My Goals (will focus on the first three to begin):

• Increase awareness of mind-body connection when experiencing symptoms.
• Keep track of amount of sleep each night.
• Explore issues of grief and forgiveness.
• Start gentle yoga.
• Receive acupuncture treatment.
• Balance providing support for my family with taking care of myself.
• Improve nutrition and limit alcohol intake.
• Explore new leisure activities.
• Spend more time with others.
• Spend time outdoors.

Strengths (what’s going right already)

• Family, friends, neighbors.
• Not giving up.

Challenges

• Nephew's condition and sister's well-being.
• Fatigue and pain.

My Plan for Skill Building and Support

Mindful Awareness:

• Pay attention to my thoughts, especially when symptoms are worse.

Areas of Self-Care (will focus on one at a time, but these are all the potential options):

• Physical Activity
  • Attend a weekly yoga class offered at a local senior center. Ask the instructor about her credentials and tell her about my back pain and the limitations with my knee. If her responses feel right, join the class or inquire about other classes focusing on gentle yoga.
• Surroundings
  • Spend time outdoors in a restful setting (my yard or near a lake) at least 30 minutes twice a week.
• Personal Development
  • Plan new leisure activities for retirement. Purchase trade magazines to research the woodworking tools I may want to purchase.
• Nutrition
  • Pay attention to the amount I eat. Focus on something other than food when I am worried. Gradually add more healthy foods to my diet—fruits, vegetables, healthy fats (such as olive oil), and whole grains. Have no more than one drink containing alcohol per day
• Recharge
  • Continue to follow good sleep hygiene practices. Track how many hours of sleep I get each night and bring to next appointment.
• Family, Friends, and Co-Workers
  • See sister three times a week and visit nephew in the hospital twice a week, which allows me to be supportive without daily hospital visits. Chat with a neighbor at least once a week. Contact a grief support group for information.
• Spirit and Soul
  • Consider scheduling a counseling session with my sister's minister
• Mind and Emotions
  • Work on forgiveness for the following issues: some experiences during work as an EMT, the person who caused the crash that sent my nephew to the hospital, and myself for mistakes I’ve made in my life. Consider seeing a grief counselor (pastoral counselor, psychologist, or social worker).

Professional Care: Conventional and Complementary

• Prevention/Screening
• Up-to-date
• Treatment (e.g., conventional and complementary approaches, medications, and supplements)
• Acupuncture to prevent lower back pain from turning into a chronic condition
• Grief/forgiveness counseling (future)
• Yoga
• Skill building and education
• Forgiving
• Grief rituals
• Leisure activities for future retirement
• Nutrition
• Spirituality

Referrals/Consults

• Acupuncturist
• Grief counselor—pastoral counselor, psychologist, or social worker

Community

• Minister
• Veterans’ group
• Yoga class

Resources

My Support Team

• Acupuncturist
• Grief counselor
• Minister
• Primary care clinician
• Yoga instructor
• Co-worker
• Neighbors
• Nephew
• Sister
• Support group

Next Steps

• Professional and self-care as outlined above. Return visit in 8 weeks, sooner if symptoms worsen.

Please note: This plan is for personal use and does not comprise a complete medical or pharmacological data, nor does it replace medical records.

Follow-Up with Jim

Jim returned for a follow-up visit in eight weeks. He reports his back pain is mostly gone, his sleeping has returned to normal, and he has more energy. His nephew survived and is in a rehab facility. Jim has identified two unexpected ways to help his family and increase his own health. As his back pain decreased, he took over the care for his nephew’s dog and is now going for daily walks. He has decided to plant a garden (which he did years ago with his wife); helping with the garden will also be good therapy for his nephew. Jim’s nutrition has improved somewhat. He does not feel ready to cook most meals. But he is now motivated to eat from the salad bar at the local grocery store at lunchtime on workdays. While there, he has been purchasing oranges, berries, carrots, and peapods that he adds to the meals he eats at home. He is no longer consuming alcoholic drinks daily. To his surprise, Jim has enjoyed the yoga class with his co-worker and practices a few poses at home between weekly sessions. He has had three acupuncture sessions with several more planned. Jim has obtained the contact information for a grief support group in his area. Jim met with his sister’s minister twice. The sharing they did was cathartic for Jim, and he is now ready for a referral to a grief counselor to work on issues of forgiveness.

Integrative Health Tools

• Screening for Complicated Grief
• Grief Reactions, Duration and Tasks of Mourning
• Health Care Professional as Griever: The Importance of Self-Care

Resources

Literature Recommended for Professionals

Journal Articles

• Aloi JA. A theoretical study of the hidden wounds of war: disenfranchised grief and the impact on nursing practice. i 2011;2011:954081.
• Shear MK, Muldberg S, Periyakoil V. Supporting patients who are bereaved. BMJ 2017;358:j2854 doi: 10.1136/bmj.j2854 (Practice advice for clinicians.)
• Simon NM. Treating Complicated Grief. JAMA. 2013;310(4):416-423. (Excellent clinical review.)

Website

• The Center for Complicated Grief, Columbia School of Social Work

Books

• Ethnic Variations in Dying, Death, and Grief: Diversity in Universality edited by Donald P. Irish, Kathleen F. Lundquist and Vivian Jenkins Nelsen. Washington, DC: Taylor & Francis. (1993)
• Good Grief: Healing Through the Shadow of Loss by Deborah Morris Coryell. Inner Traditions/Bear & Company. (2007)
• Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4th Edition) by J. William Worden. New York: Springer Publishing Company. (2009)
• Improving Care for Veterans Facing Illness and Death edited by Kenneth J. Doka and Amy S. Tucci. Washington, DC: Hospice Foundation of America. (2013)
• Living with Grief: Before and After the Death edited by Kenneth J. Doka. Washington, DC: Hospice Foundation of America. (2007)
• Treatment of Complicated Mourning by Therese A. Rando. Champaign, IL: Research Press. (1993)

For the General Public

• Hospice Foundation of America

Brief articles on grief topics

• AARP

Grief and loss resources

• GriefNet.org

An internet community of persons dealing with grief, death, and major loss

• The Compassionate Friends

Assists families following the death of a child of any age

• Survivors of Suicide

Website created by a survivor of suicide

• The Center for Complicated Grief, Columbia School of Social Work

Information and resources on complicated grief for the public

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

“Coping with Grief” was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original written by Charlene Luchterhand MSSW, LCSW (2014, updated 2019).

This overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

Originally Created: 2014, Updated: 2019

References

1. Larson DG, Hoyt WT. The bright side of grief counseling: Deconstructing the new pessimism. In: Doka KJ, ed. Living with Grief: Before and after the Death. Hospice Foundation of America; 2007:157-174.
2. Worden J. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner. 4th ed. Springer Publishing Company; 2008.
3. Hansell AL, Blangiardo M, Fortunato L, et al. Aircraft noise and cardiovascular disease near Heathrow airport in London: small area study. BMJ. 2013;347
4. Doka KJ. Challenging the paradigm: new understandings of grief. In: Doka KJ, ed. Living with Grief: Before and After the Death. Hospice Foundation of America; 2007:87-102.
5. Weller R. Coping with trauma and posttraumatic stress disorder (PTSD) at life's end: managing life review. In: Doka KJ, Tucci AS, eds. Improving Care for Veterans Facing Illness and Death. Hospice Foundation of America; 2013:71-83.
6. Doka KJ. Sacred ceremonies, sacred space: The role of rituals and memorials in grief and loss. In: Doka KJ, Tucci AS, eds. Improving Care for Veterans Facing Illness and Death. Hospice Foundation of America; 2013:161-169.
7. Paquette M. The aftermath of war: spiritual distress. Perspectives in Psychiatric Care. Jul 2008;44(3):143-5. doi:10.1111/j.1744-6163.2008.00168.x
8. Grassman D. Forgiveness: A reckoning process that facilitates peace. In: Doka KJ, Tucci AS, eds. Improving Care for Veterans Facing Illness and Death. Hospice Foundation of America; 2013:95-102.