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.