Whole Health Library

Whole Health is built around the Circle of Health, which emphasizes the importance of personalized, values-based care that draws in mindful awareness and eight areas of self-care: Surroundings; Personal Development; Food & Drink; Recharge; Family, Friends, & Co-Workers; Spirit & Soul; Power of the Mind; and Moving the Body.  Conventional therapies, prevention, complementary and integrative health (CIH) approaches, and community also have important roles.  A Whole Health approach includes awareness that grief may affect a patient’s well-being and health.  In this clinical overview, you will learn how to 1) recognize the possible role of grief as a cause or in the exacerbation of clinical symptoms, 2) increase your ability to support a grieving patient within your own time limitations, comfort level, and knowledge in this area, and 3) know when to refer a patient to a grief specialist, empowering patients to optimally cope with their grief and integrate a loss into their lives.

Note:  This module especially focuses on grief related to a death loss with some pertinent information included on other types of losses.  A more complete focus on other types of losses (such as disability, divorce, job loss, effects of natural disasters) is beyond the scope of this overview.  However, you are likely to find the concepts and suggestions helpful and adaptable when working with a Veteran who has experienced a loss other than death. 

There are many emotional responses to loss.  Grief is a person's emotional response to loss. Mourning is an outward expression of that grief, including cultural and religious customs surrounding the death. Mourning is also the process of adapting to life after loss.  Bereavement  is a period of grief and mourning after a loss. Further,  terms to describe severe, persistent and disabling grief have been diverse over the years and across studies of grief.  These include complicated grief, prolonged grief, chronic grief, persistent complex bereavement disorder, and even pathological grief.  With the diagnosis of Prolonged Grief Disorder (PGD) in the DSM-5-TR and ICD-11, these terms might eventually coalesce.[46,47]

The narrative below shows what a Whole Health clinical visit could look like and how to apply the latest research on complementary and integrative health (CIH) to help patients when grief is a contributing factor in their health.

Jim is a 70-year-old Vietnam era Veteran.  He has been divorced for 25 years.  He does not have children.  He lives alone.  Jim works part-time in his state’s lottery office.  Over the years he has had a couple bouts of mild to moderate depression when relationships ended.  A knee injury has limited a few activities he previously enjoyed, such as bowling and softball.  He likes to watch sporting events and to spend time outdoors.  He came into the medical center with back pain (which he never had before), difficulty sleeping, and fatigue. 

Jim’s mission for appointment: To learn what is causing my symptoms of back pain, difficulty sleeping, and fatigue, and to eliminate them or at least reduce them

On his Personal Health Inventory (PHI), Jim rated himself a 3 out of 5 on all of the following: his overall physical, mental, and emotional well-being, and what it is like to live his day-to-day life.  In response to the questions, "What do you live for? What matters to you? Why do you want to be healthy? Jim wrote:

“What really matters to me is my sister and her family, being on friendly terms with the neighbors, and finding productive ways to spend my time when I retire.”

Jim rated himself on where he is and where he would like to be in each of the eight areas of self-care.  In all but one area, he rated himself lower now than he would like to be.  Finding no specific medical reasons for Jim's symptoms upon physical exam or lab tests, Jim's clinician used the PHI to learn more about Jim's life:

• Working the body. Fatigue and pain have resulted in Jim being sedentary.
• He has not been getting enough sleep, even though he tries.  He has been waking up much earlier than normal and not feeling refreshed by any activity.
• Food and drink. He has started picking up more carry out food and eating more than he should.  He has increased his intake of beer and soda.
• Personal development. His job is fine.  He has been thinking about things that he would like to do when he retires in a year.  He finds it hard to think about that now.  His nephew was in an automobile accident a month ago and may not live.  He was planning to do many activities, like woodworking projects, with him.
• Family, friends, and co-workers. He is close to his sister and nephew, has a few buddies at work, and some good neighbors.  He is not seeing them as much now.  He feels guilty when he does not go to the hospital to see his nephew.  “It’s very hard.  My throat feels so tight, it's hard to talk, and when I'm in his room, I feel physically weak.”
• Spirit and soul. Jim thinks that his best years may be over and says some of them were not so great.  He wonders if he will be healthy enough to enjoy 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 now my nephew, he's just a kid, 24.  It zaps your spirit.”  “It would be good to feel at peace.  I'll keep trying.”
• Jim feels better when he is outdoors in nature.
• Power of the mind. Jim learned some breathing exercises in the past.  He knows some guys who have tried tai chi and yoga.

For more information, refer to Jim’s PHI. 

Grief Reactions

Grief is more than emotion; it also encompasses behavioral, cognitive, physical, and spiritual elements.[10,11,51]  The grief experience varies widely and is influenced by many things such as a person’s age, gender, relationship with the deceased, culture, personality, previous experiences, coping skills, ethnic identity, education, circumstances around the loss, health and mental health,  financial or material losses, social support and even sleep disturbances [ ]. Cultural differences in grief are enormous, and it is very important to be aware of them to avoid compounding the individual’s distress when trying to help.[12]  What is considered typical in one culture may be seen as pathological in another. 

The military has its own culture that can greatly affect the grieving process.  Yet, it is important to note that there is no universal military culture.  Different branches of service, different ranks, whether one enlisted or was drafted, whether one served in combat, and in which war or conflict one served all affect someone’s experience.  However, one common trait seems to be stoicism. 

Soldiers are taught to handle anything and how to live in survival mode; they learn to disconnect from their emotions.[13]  Stoicism contributes to survival and military success but can cause problems after returning home.  It may later make grieving more difficult, hindering the process. However, stoicism can be applied to grief, especially after the time of acute grief.  In a healthier way, stoicism could be applied to work on  accepting the facts (losses) and the universality of loss, even when we don’t like it, and the emotional states that go with grief.  Secondly, stoicism could bring courage for working towards engagement in the world despite losses and inevitable disappointments.[52,53]

Grief researcher William Worden has identified some grief reactions that are common in our society.[10]  Jim is showing a number of these reactions: 1) waking up too early, 2) eating too much, 3) withdrawing from others, and 4) fatigue.  When he is in his nephew’s hospital room, he feels 5) tightness in his throat, and 6) muscle weakness.  A study of 1,522 infantry soldiers surveyed six months following deployment to Iraq or Afghanistan in 2008 found that over 20% reported difficulty coping with grief over the death of someone close.[5] Controlling for confounding factors, researchers found that this grief contributed to a high physical symptom score (number of symptoms and their severity).  Jim is experiencing three out of the five most common symptoms reported by these soldiers: fatigue, sleep problems, and back pain [5] (The other two are musculoskeletal pain and headaches).  While Jim’s combat experience occurred decades ago, his grief reactions may be similar.  He also feels that he has lost direction in life, and he is searching for meaning in loss—these are the types of spiritual adjustments that grieving individuals often work through.[10]

For most individuals experiencing an important loss, the initial period of acute grief is followed by “integrated” grief as the individual adapts to the loss . This allows the grief to begin to be more in the background and the bereaved can emerge from their loss with a life engaged without the deceased. Integrated grief outcomes, from multiple longitudinal studies population studies, show this occurring approximately 6-12 months following the loss.  However, there is no true timetable of grief. 

Unless the person sustains prolonged or complicated grief, the initial acute grief lessens in severity over time, although “waves” of grief can still occur whenever grief triggers are encountered. Grief triggers are variable and personal and may include holidays and anniversaries of various types, as well as the many reminders of the deceased that can pop up such as seeing an item purchased together, having to learn something the other partner typically did, hearing a special song, etc.

As you read further in this Grief module, consider Jim’s situation and what might apply to him.  For more information on common grief reactions, refer to “Grief Reactions” Whole Health tool.

Prolonged Grief Disorder

Prolonged Grief Disorder (PGD) has been presented as a new diagnostic criteria in the American Psychiatric Association’s DSM-5-TR, which was released in March 2022.[54]  PGD also exists in the ICD-11.[55-57].  Over several decades, studies suggested that many people were experiencing persistent difficulties associated with bereavement that exceeded expected social, cultural, or religious expectations. After reviews and public comment, the disorder was added to DSM-5-TR.[58]  The criteria includes that distressing grief continues for at least 12 months following the loss of a close attachment and that the grief response is characterized by intense longing/yearning for the deceased person, and preoccupation with thoughts about the loss to an impairing degree to social, occupational or other important areas of functioning nearly every day for at least the past month. Further, three of the following eight symptoms have been experienced to a clinically significant degree:  1) feeling as if a part of oneself has died, 2) a marked sense of disbelief about the death, 3) avoidance of reminders that the person has died, which can often be connected to intense searching for things reminiscent of the deceased person and/or evidence that they are still alive, such as mistaking others for the person who died, 4) intense emotional pain such as anger, bitterness, sorrow, related to the death, 5) difficulty with reintegration into life after the death, 6) emotional numbness, especially as it relates to other emotionally connecting with others, 7) feeling that life is meaningless as a result of the loss, and 8) intense loneliness as a result of the loss.

PGD is a serious mental disorder that puts the patient at risk for intense distress, poor physical health, shortened life expectancy, and suicide.  An estimated 7%-10% of bereaved adults will experience the persistent symptoms of prolonged grief disorder.  Some experts in the field believe that the absolute number of PGD cases is likely to increase and the prevalence rate among bereaved will rise as part of the aftermath of the COVID pandemic.

Risk factors for PGD include pre-loss grief and depressive symptoms, as well as poorer pre-loss mental health, major depressive disorder, anxiety disorders and trauma-related disorders, death of a child, social isolation or loss of social support systems, alcohol and substance use, smoking, or alcohol misuse for those with bipolar disorder, and long term poor sleep.  Caregivers, especially if they were caring for a partner or had experienced depression before the loss, are also at greater risk.[58]  The risk for PGD is also increased when the death of the loved one happens very suddenly or under traumatic circumstances.[58,59,106-110]

In research of post 9/11 service members and veterans with combat related PTSD, complicated grief (CG) was associated with lower PTSD treatment response and remission, greater severity of PTSD and trauma-related guilt at baseline and endpoint. In addition, those with CG/PGD were more likely to experience suicidal ideation during intervention.[60]  Thus, those military members or Veterans with PGD/CG may benefit from additional assessment and interventions.  Literature notes that complicated grief (or PGD) is critically under recognized and unaddressed in Servicemembers.[28]  A nationally representative study examined the point prevalence and correlates of prolonged grief disorder (PGD) in 2,441 United States (U.S.) Veterans[61].  A total of 158 (weighted 7.3%) veterans screened positive for PGD. Adverse childhood experiences, female sex, non-natural causes of death, knowing someone who died from coronavirus disease during the pandemic, and number of losses were strongly associated with PGD. Veterans with PGD were significantly more likely to screen positive for posttraumatic stress, major depressive, and generalized anxiety disorders; endorse suicidal thoughts and attempts; and utilize mental health treatment. Results underscore the importance of targeting PGD as an independent risk factor for psychiatric disorders and suicide risk. In two other studies of Servicemembers and Veterans who served after September 11, 2001, it was found that about 80% had experienced the death of someone important to them and almost one-third of those met criteria for complicated grief.[29,30]

Anticipatory Grief

Jim acknowledged that his nephew’s condition is “killing” him.  Jim is experiencing anticipatory grief. 

Anticipatory grief occurs when a death or other loss is perceived as imminent and an individual begins grieving before the actual loss occurs.[6]  Mostly, it is a healthy experience safeguarding against the impact of the loss; anticipation allows for preparation, development of coping strategies, and mobilization of assistance.[14] However, anticipatory grief can be its own stressor associated with an increased risk of psychological distress.  Individuals who expect the impending loss of a loved one may feel uncertainty, fear, and sadness, which can lead to a number of adverse health outcomes. Therefore, management of this feeling is important to maintaining overall health.[111]

Rando has clarified that often anticipatory grief includes mourning over a series of shifting current losses as well as the eventual death, as an individual’s health, abilities, and plans for the future fade.[15]  A systematic review and qualitative meta-synthesis identified four stages of anticipatory grief: time of diagnosis, transition to hospice care, nearing death, and the moment of death.[112]  Anticipatory grief does not lessen the grief reactions that occur following the loss.[15] One is a reaction to the expectation of loss and steps along that pathway; the other is a reaction to the finality of the loss. 

Those who have more time before the impending loss, use a number of coping resources to process their grief, accept the situation and evolve with their loved one may experience less extreme adverse physical health outcomes during post-death grief.[112]  In contrast, a rigorous systematic review and qualitative synthesis of 34 articles showed that high levels of pre-loss grief coupled with low preparedness actually resulted in poorer bereavement outcomes for caregivers.[62] 

Awareness of the phenomenon of anticipatory grief allows the clinician to provide on-going support according to the needs of the patient and family and is considered best-practice care.[63]  The primary aims of successful interventions encourage efficacious closure of the relationship, reduce guilt, and reduce chances of awkwardness, pain, and excessive stress when the death occurs.[64]  A systematic review of interventions that lessened or adaptively guided the experience of anticipatory grief was completed.  It showed some positive outcomes such as lower depression and anxiety scores as well as improved quality of life. Moreover, decreased suffering, lower distress, improved preparation for death, and greater spiritual well-being were also reported.[65]

As individuals anticipate the forthcoming loss of a close relationship, grief may be rekindled over a significant previous loss that was not fully grieved in the past.  This may occur, for example, in Veterans with PTSD.[16]

Anticipatory grief can also be common at the end of one’s own life.  Dignity therapy has helped participants at the end of life to have enhanced dignity and improved quality of life, by actively discussing key aspects of their lives, experiences, and future hopes during the intervention.[66]  

Disenfranchised Grief

Bereavement care is part of good clinical care.[88]  Yet, many healthcare providers report a lack of confidence in providing support to family members at the time of death, especially in situations where death occurs suddenly.[89-91]  Time, resources, perceived lack of knowledge of what to say, and the complexities of emotion have been cited as realistic barriers to personalized condolences.[92]  To neglect bereavement outreach is to miss an opportunity for extending a caring connection.[93]

 Perhaps the most important thing health care providers have to offer grieving patients is their compassion, understanding and presence.  Validation of the person’s grief experience is important.  At a minimum, one can offer sincere comments such as, “I’m so sorry for your loss,” “I am so sorry that this has happened to your family,” and “From what you have told me, you have really gone through a lot.” Just being fully present with the person listening to whatever they want to express is therapeutic. Evidence suggests that supportive actions for those suddenly bereaved include health care providers conveying empathy, answering questions about the cause of death and allowing family members an opportunity to say goodbye.  Providing follow-up over time is important as the bereaved are at increased risk of illness in the months after a sudden death.[94]  It is best to avoid words that express the health care provider’s own belief systems if this is different from the Veteran’s belief system. Aloi identified a number of ideas that nurses can suggest to family members to help with Veterans' disenfranchised grief.[19]

Social workers at Louis Stokes Cleveland VA Medical Center, who noted increased stress for Veterans at end of life, added a grief/bereavement counselor to their Veterans Affairs Contract Home Hospice Program.[37] They then developed and implemented a three-pronged approach.  Anticipatory mourning support for both the Veteran and caregiver/family is a key component.  The other two foci are caregiver support and bereavement support.  The program has been well received by Veterans and families/caregivers.

Salutogenesis-Oriented Sessions (SOS)

Some patients will benefit from extra attention.  Rakel proposes the use of salutogenesis-oriented sessions (SOS) to facilitate health.[38]   Salutogenesis is by definition the focus on conditions and mechanisms that contribute to the maintenance of a healthy condition (Salud = health, genesis = creation of).[95]  It is opposed to pathogenesis, the mostly academic science aiming at unraveling the implications of strategic changes leading to disease.[96]  An SOS is an office visit, longer in length than a typical appointment, with a goal of fostering hope, to explore what may be at the root of a symptom, so that it can possibly be resolved.  He identifies five elements for the visit: 1) a comfortable, inviting, private physical space, 2) creating positive expectations for the session, 3) being fully present to listen to the patient’s story, 4) offering emotional support, and 5) writing out a simple plan for the future.   Such a healing session could be used to help assess whether grief is contributing to or causing a patient’s symptoms as well as to assist the patient with the tasks of grief.  Such a session has a great deal in common with a Whole Health visit, be it with a Whole Health Partner, Coach, or member of the clinical team.

Consider asking about:

• The person who died, their name and what their relationship meant to the Veteran
• The circumstances surrounding the death
• How the patient is coping
• The variety of emotions the patient has been feeling
• The challenges the patient is experiencing
• How the loss is affecting the patient's daily activities, social interactions, and work
• The patient's perception of the support provided by others[39]

The PLISSIT Model

The PLISSIT model can be a guide for primary health care practitioners in assisting their patients throughout the grief process.  PLISSIT is an acronym for Permission, Limited Information, Specific Suggestions, and Intensive Therapy, a model developed by Annon to address sexuality issues.[40]  It can be very useful in other health care situations as well.  The model includes four levels of intervention, ranging from basic to complex. The first three levels (Permission, Limited Information, Specific Suggestions) can be viewed as brief intervention and the fourth level as intensive therapy. It guides clinicians to support patients according to the clinicians’ own comfort level and expertise as well as the needs of patients. Referrals can be made at any time when patients’ needs exceed clinicians’ comfort, knowledge, and time.

Permission

Clinicians can initiate the topic of loss, giving patients the opportunity to talk about the experience.  Some patients may choose not to do so.  In our fast-paced, multitasking society, adults may feel pressured by themselves or others to resume their former lifestyle with minimal disruption.  Clinicians can offer “permission” to take the time to grieve as needed.  For many patients, this interest, encouragement and support will be the only intervention needed.

Limited Information

Limited information will be helpful to many Veterans.  Because there is a significant amount of information about grief available, clinicians must engage the veteran to determine what specific information would be most useful.  This second level requires more knowledge about grief to answer Veterans’ questions and dispel misconceptions.  Many people know little about grief reactions until they experience them.  People frequently ask if their reactions are normal and if they are going crazy.  They can be relieved to learn that their reactions and the duration of their grief are similar to the experiences of others with comparable losses.  If their experiences are different, they can be reassured that everyone grieves in her or his own unique ways.  When appropriate, the clinician can educate patients about anticipatory grief or disenfranchised grief, so that grievers will understand that their reactions are valid and the relationships are important ones, as well as receive reassurance that they have strength to cope.[41]  Factual information in patient handouts, a list of grief resources (e.g., support groups), and other products may be helpful.

Specific Suggestions

Fewer patients will require some specific suggestions. This level involves advanced knowledge and skill to understand a patient’s unique situation and develop a plan.  Clinician and patient can discuss the loss experience more thoroughly, collaboratively identify issues to be addressed, problem-solve, and choose helpful strategies.  For example, for a patient distraught over the pain of grief, a clinician could help develop a healthy plan to work through the pain. This might involve: reassuring the individual that the pain will not always be so intense; identifying one or more people who are good listeners in the person’s social circle to contact when emotions seem overwhelming; minimizing alcohol and other drugs; avoiding major decisions, which one might regret later; and choosing a form of physical activity that would be do-able with current energy level.

Intensive Therapy

A minority of patients will require intensive therapy. This final stage usually requires referral to a specialist in grief or a provider that is comfortable with the topic. For some, a referral to a grief support group may be helpful.

…people cope with loss in different ways and therefore may have different needs for intervention and different responses to a given type of intervention.[42]

Many strategies exist to help individuals cope with major loss. Following are a sampling of non-pharmaceutical approaches that can be recommended to individuals who are grieving. 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” Whole Health 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).

Moving the Body

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. Taking a walk may be a simple way to start.,  Doing the activity with others or in nature may be even more helpful.  For more information, refer to Whole Health overview “Moving the Body.”

Massage

Therapeutic massage may be helpful for someone who is experiencing tension or pain from “holding grief” or stress in the muscles. Receiving safe, physical touch during a massage might be helpful, also, for someone who has lost their source of safe, comforting touch.[98]

Surroundings

Nature

Spending time in nature can be soothing and healing. It brings benefits for physical, mental and psychological human wellbeing.

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. Adding new pleasure or activities can be a big part of integrating the grief and moving on, in spite of the loss.

Food and Drink

Healthy Food

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

Limit Alcohol and Other Drugs

Caution against using alcohol and unprescribed drugs for relief or to numb emotional pain.

Recharge

Good Sleep Hygiene

Educate about good sleep hygiene, if this is not something the individual generally practices.  Following the loss, the individual may have developed behaviors around sleep that are less than optimal such as staying up very late, sleeping with the TV on, or other activities that could disrupt a healthy pattern. 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.[10]  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.[43] 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 or an individual grief counselor.

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.  Vet Centers or The Tragedy Assistance Program for Survivors (TAPS) are two possible referrals to make.  There is more information in the resource section at the end of this document.

Spirit and Soul

Addressing Spirituality Concerns

Certain losses may challenge grievers’ spiritual beliefs, causing them to question their existential views.[11]  They may experience this as an internally chaotic time, feeling ungrounded or adrift. Some individuals might be angry at God or a higher power for the loss. It can also become a time when grievers reaffirm, deepen 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.[21]  A referral to a chaplain, clergy, or other spiritual leader may be helpful. Building Spiritual Strength is an 8-session group therapy that has been led by a chaplain and addresses concerns about relationship with a Higher Power as well as challenges with forgiveness.  There is evidence that it is safe, and that it reduces both PTSD symptoms and spiritual distress. It also appears to be more effective for our African-American and Latinx veterans who are sometimes underserved.

“Whether or not you are religious, there is a spiritual component of your being from which you connect with the earth, with yourself, with others, and, depending on beliefs, with a divine being. The spiritual self is also the place in which we find our meaning and purpose….. (this) is a primary piece of life that requires rebuilding in grief. “ Kate J. Meyer, MDiv., LPC., ordained minister and licensed professional counselor working with grief.

Rituals

Rituals are activities that symbolize feelings, thoughts  and spiritual beliefs related to a death that has special meaning to the individual.  They honor a person and recognize a change in status from living to deceased.[44]  Some rituals demonstrate that a bond continues to exist with the deceased.[44]  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.  Doka notes that those who have been in the military may express grief best in cognitive and physical ways, rather than through emotions.[44]  Finding one’s 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 or leaving a note at a memorial setting (e.g., at a Veteran’s memorial).  Grief literature emphasizes the healing potential of these practices but note the decline of rituals in North America.[99]  According to Bonanno, rituals are repeated because they are expected to have transformative powers.[100]  They offer a vehicle to become more connected to the mysterious parts of life and engage in human action to soothe emotional and mental suffering.[101]  It may be worth exploring the possibility of Veterans designing personal grief rituals.

Power of the Mind

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.[10]  Journaling can help develop stories about the life and death of the person who has died and these stories, also known as narratives, can be accessed and examined for meaning in loss.[102,103]  If grievers have unfinished business with the deceased, they might consider expressing their thoughts and feelings through writing a “letter” to the deceased individual.  They might even consider what the deceased individual would say back to them in their writings. This writing activity, also known as the last letter tool, has the potential to resolve bereavement-related regrets, facilitate meaning-making and say goodbye.[104]  For more information, refer to “Therapeutic Journaling.”

Forgiving

A death can leave a bereaved individual with “unfinished business” with the deceased, with a medical provider or others who they feel did not do enough, or with themselves for not having “saved” their loved one. Anger is an emotion that is meant to be felt for a short time, so when anger is experienced over a prolonged period of time, it can begin to impact well-being and health. When anger continues, the bereaved may benefit from working on forgiveness.

Self-forgiveness can be an important task for previous combat Veterans.  It can be difficult for patients to share morally injurious events because of the feelings of guilt and shame associated with them.  After returning to civilian life, they may feel the moral injury and horror at their behavior during wartime, even if they did what was required of them and it was considered heroic and a characteristic of a good soldier.  Feelings of guilt can be resolved through a ritual involving confession, forgiveness, compensation (e.g., helping other Veterans), and self-forgiveness.[20]  A clinician can help by creating a safe environment in which the Veteran can share any actions that may be the cause for feelings of guilt or shame.  It is important to neither push a Veteran into the topic of forgiveness, nor minimize feelings of guilt, if the Veteran brings them up.[45]  For more information, refer to “Forgiveness: The Gift We Give Ourselves.”

A grief counselor who is experienced with Veterans’ grief issues and moral injury can be helpful for someone who wants to work on forgiving.  This specialist may be a pastoral counselor, chaplain, psychologist, or social worker.  Mental health clinicians who have received specialty training in PTSD are usually trained in traumatic grief and guilt. They may use tools such as relaxation, mindful awareness, and guided meditation and can help Veterans overcome avoidance, a clinical symptom of PTSD that often keeps Veterans from engaging in therapy. Some studies have shown that trauma-focused PTSD treatment such as PE and CPT effectively reduce trauma-related guilt and shame.

There are several treatments under investigation that specifically target moral injury. These include:  an adapted Acceptance and Commitment Therapy (ACT).[105,113,114]  This 12-session group treatment focuses on helping patients live in accordance with values. Adaptive Disclosure is a 12-session individual intervention that helps Veterans process moral injury through imaginary dialogue with a compassionate moral authority, by apportioning blame, making amends and in some versions, self-compassion and mindfulness meditations.  The Impact of Killing intervention is a 10-session individual therapy that helps patients explore the functional impact of not forgiving oneself, develop a forgiveness plan (e.g., including letter writing to the individual(s) killed) and helps patients develop an amends plan to honor the values that were violated in the act of killing.  The Moral Injury Group is a 12-session group intervention that is co-delivered by a chaplain and psychologist and includes a ceremony where participants share testimonies of their moral injury with the public.  Trauma Informed Guilt Reduction Therapy (TrIGR)  is a 6-session individual therapy that helps patients identify and evaluate beliefs such as hindsight bias and responsibility that contribute to guilt and shame, identify important values including those that were violated during the trauma, and make a plan to live in line with those values going forward.[115]

Mindfulness-Based Stress Reduction

In the absence of personal awareness, grieving can often 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, as well as lower anxiety and depression and increase resiliency.  Mindfulness can increase the ability to shift attention, so that the bereaved can reframe their experience and move away from rumination. As well, mindfulness encourages the adoption of a curious, nonjudgmental stance around thoughts, feelings and experience which can help to overcome  numbing. 

For more information, refer to “Mindful Awareness.”

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 fully retires.)

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 Veterans are a population at risk for disenfranchised grief, that Vietnam Veterans were not welcomed home and often did not talk about their experiences, and that as they age symptoms related to these experiences may come bubbling up, his clinician gently asked, “Jim, is there anything from your years in service that is still troubling you?”  The timing was right.  Jim shared a difficult story that he had not shared with others at any time in his life.  The clinician noted similarities between Jim’s nephew and comrades in the service.  They were about the same age.  They faced possible disability or death years too soon.  Jim mentioned guilt over both situations—guilt that he was surviving and some of his comrades did not and his nephew might not.  He also expressed some guilt over behavior that he had witnessed in combat. 

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.)

Name: Jim

Date: xx/xx/xxxx

Mission, Aspiration, Purpose (MAP):

My mission is to 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:

• 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:

• Working Your Body
  • Investigate attending a weekly yoga class offered at work with co-worker, Bob. 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.
• Food and Drink
  • 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. Keep track of how many hours of sleep occur 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 Veterans’ group for support and information.
• Spirit and Soul
  • Consider scheduling a counseling session with my sister's minister who was a chaplain in the military. Visit High Ground, a Veterans’ Park developed by the Wisconsin Vietnam Veterans Memorial Project, Inc., whose mission is “Healing and Education.”
• Power of the Mind
  • Work on forgiveness for the following issues: some experiences during military service, the way some people treated me when I returned from Vietnam, 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) who is experienced with Veterans and grief issues. If I have difficulty with this, consider meeting with a mental health clinician who has specialty training in PTSD.

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

• Principal Professions
  • Acupuncturist
  • Grief counselor
  • Minister
  • Primary care clinician
  • Yoga instructor
• Personal
  • Co-worker
  • Neighbors
  • Nephew
  • Sister
  • Veterans 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 Veterans’ 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.  With the minister’s encouragement, Jim is purchasing a legacy stone to honor his best friend in the service, who was killed in action.  He will place the stone in a ceremony at The High Ground Veterans Memorial Park in a few months.

Literature Recommended for Professionals

Journal Article

• Aloi JA. A theoretical study of the hidden wounds of war: disenfranchised grief and the impact on nursing practice. i 2011;2011:954081. (Offers ideas nurses can suggest to families to help with Veteran disenfranchised grief.)
• Drescher, K. D., Burgoyne, M., Casas, E., Lovato, L., Curran, E., Pivar, I., & Foy, D. W. (2009). Issues of grief, loss, honor, and remembrance: Spirituality and work with military personnel and their families. In S. M. Freeman, B. A. Moore, & A. Freeman (Eds.), Living and surviving in harm's way: A psychological treatment handbook for pre- and post-deployment of military personnel (pp. 437–465). Routledge/Taylor & Francis Group
• Na PJ, Fisher IC, Shear KM, Pietrzak RH. Prevalence, Correlates, and Psychiatric Burden of Prolonged Grief Disorder in U.S. Military Veterans: Results From a Nationally Representative Study. The American Journal of Geriatric Psychiatry. 2023;31(7):543-548. https://doi.org/10.1016/j.jagp.2023.02.007.
• Prigerson HG, Shear MK, Reynolds CF. Prolonged grief disorder diagnostic criteria-helping those with maladaptive responses.  JAMA Psychiatry. 2022;79(4):277-278. doi:10.1001/jamapsychiatry.2021.4201
• 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)
• Finding Meaning: The Sixth Stage of Grief by David Kessler. Scribner. (2021)
• 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)
• Bereavement: Studies of Grief in Adult Life, Fourth Edition 2nd Edition, by Colin Murray Parkes (Author), Holly G. Prigerson (Author). Routledge, Taylor & Francis. First edition: 2010.
• Improving Care for Veterans Facing Illness and Death edited by Kenneth J. Doka and Amy S. Tucci. Washington, DC: Hospice Foundation of America.  (2013)
• On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss by Elisabeth Kubler-Ross and David Kessler. 2014.
• 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
  
  
• Grief.com
  Grief and loss resources and online grief support community
  
  
• Grief Share
  Grief and loss support groups to help move through the grief process
  
  
• 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

For Military Families and Veterans

• Peace at Last: Stories of Hope and Healing for Veterans and Their Families by Deborah L. Grassman. Vandamere Press.  (2009)
• The Warrior Poet Way: A Guide to Living Free and Dying Well (Audible Audiobook)– Unabridged by John Lovell & Rebekah Lovell. July 11, 2023.
• Once a Warrior: How One Veteran Found a New Mission Closer to Home Hardcover – Sentinel: November 10, 2020 by Jake Wood (Author)
• Tragedy Assistance Program for Survivors (TAPS)
  
  Provides peer-based emotional support, grief and trauma resources, casework assistance, and connections to community-based care for anyone who is grieving the death of a loved one in military service to America

• Vet Centers, U.S. Dept. of Veterans Affairs
  • Offers bereavement counseling at community-based Vet Centers to parents, spouses, siblings, and children of Servicemembers, reservists, and National Guard who died on active duty
  • Offers readjustment-to-civilian-life counseling for combat Veterans and families

Coping with Grief” was written by Charlene Luchterhand MSSW, LCSW and updated by Shilagh A. Mirgain, PhD and Janice Singles, PsyD (2014, updated 2024).

This Whole Health 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.