There is probably no more profound suffering in the spectrum of human experience than that occasioned by loss. In its aftermath, the very word can produce a feeling of anguish that is almost physically painful. Which of us on hearing it, does not recall a once present, now vanished person or thing – or even a beloved place from which we are exiled? The images leap into the consciousness unbidden, oddly unaltered by time, as vivid and fresh and they were when our relationships with them were most current. Over and over again, the mind turns to the repetitious tasks of grieving, working laboriously at the painful business of assessing the reality and extent of the catastrophe, of leave-taking and finally, of repair of the self.
Loss is inevitable; sooner or later we must all endure it. Although it would seem that persons are well defined units, quite separate and distinct from the world and all it contains, the boundaries of the self are actually quite fluid. We make attachments throughout the entire course of our lives. They are the occasions we use to extend, amplify and perfect ourselves. In others, we find echoes of earlier experiences which still resonate with meaning for us. Some bondings are attempts to fill up our blank spaces and emptiness. All of them place us at risk: in making them we expose ourselves to the possibility of losing them and having to deal with retrieving our investment.
To be alive is to be aware, even if only dimly, of the striking paradox of the human situation. We are fragile creatures: walking contradictions – on the one hand a person may be capable of monumental intellectual feats which illuminate the lives of whole generations and, on the other hand, at risk of being felled within an instant by one of life’s random, savage blows. We make attachments to lessen that sense of vulnerability and evanescence: when we suffer loss, we experience an intensification of that sense. Mourning in some way is always connected to the fear of our own extinction. In grief the adult feels old, empty, vulnerable and terrified that his newly diminished self cannot stand alone without the protection, strength and contribution of the beloved other. Indeed, there are losses one does not survive; as a human cannot tolerate the destruction of critical masses or areas of his corporeal body, there are also psychic wounds in which the insult is overwhelming and cannot be negotiated. Physical death from loss is a reality. But if we can muster the resources to take the first steps into the paralyzing sorrow that bereavement produces, we can start the work of mourning. Effective grieving not only ensures survival, it leads to development that would have been impossible had it not occurred. The task is to do the work as economically and constructively as possible. The process is long and complicated. It is exhausting and full of effort, especially in the beginning. One can feel that it will never end; that one is trapped in it forever. Ultimately, though, it can be finished. Effective grieving augments self-knowledge and develops new capabilities. Most important, since we are such creatures of habit, all our attachments have been woven of similar threads. In a real sense, to grapple with the problem of any loss is to make progress in the recovery from all the others. I was once asked to see a famous theologian, who, as it happened, was nearing the end of his life. He had spent the hour before I met him lecturing to an audience of thousands on the wisdom of the divine plan for created life. He pointed out with moving conviction that the significance of any individual’s life and death was miniscule in comparison with the vital energy of the world, full as it is with renewal and rebirth. He spoke of the eternal nature of the universe, saying that we all live out our lives within a vast, benign and masterfully ordered plan that ensures a continuum of existence so exuberant that any one of us, whatever our age, is myopic if we do not perceive it and draw comfort from it.
Not an hour after he finished his sermon, he was overcome with exhaustion and I was called to see him. I sat by his bedside, watching his face. His eyes were fixed on mine, and I understood at once that he was waiting to know from me whether in fact this was his last episode before death or whether it was to be postponed for him a while longer. After a few simple maneuvers which made him feel stronger, I said to him: “First of all, you are not dying.” An expression of profound relief transformed his face. There was an immense difference between the person who had dealt so reassuringly with those cosmic realities that morning and the man facing the spectre of his own individual death. Even he, who had measured and understood quite accurately his own dimensions in the scheme of the universe, when facing the end of his personal life was engaged in a long, laborious struggle to accept and deal with it. I don’t know whether he was near the end of his grieving for himself at the moment, but I know that the necessity to acknowledge the impending loss and to deal with it was no less necessary and personal for him than it was for any other person. Indeed, the brilliant sermon of that morning must have been informed by his sense of his own mortality: doubtless, it was part of the work he had already accomplished in coming to terms with it. He died within a few months of that incident.
The Phases of Grieving
Grieving has three distinct phases, each concerned with a different kind of work. In the first, immediate period the task is to acknowledge the loss and to decide whether or not it is irrevocable. In an allied but separate process, the mourner must then agree to do the work of leave-taking, which involves an assessment of the scope and meaning of the loss. Finally, in the last phase the survivor builds new resources and attachments.
Acknowledging the Loss
One of the capacities of the human mind that suits it so admirably for survival is its ability to absorb a shocking or overwhelming new reality piecemeal and over time. In this way, great disasters (and great joys) can be processed gradually enough so that they do not swamp us all at once with such stunning impact that we disintegrate. The first reaction to a significant loss, therefore, is always disbelief or denial that it is so. Like a child on the brink of a dreadful experience, the psyche hangs back, averts its eyes and until it can muster some resources, refuses to begin the work of dealing with the reality thrust upon it. Even when families are apparently well prepared for the loss of one of their members, I have watched relatives respond to the actual announcement of death with an anguished, vehement cry of denial: “You’re lying!” “That isn’t true!” And the next question (verification): “How do you know?” Slowly, and only as it is able to do so, the mind, even the prepared and anticipating mind, admits to the reality and begins the task ahead of it. There is no predictable schedule for the time required to acknowledge the simple fact of loss. For some, the more resilient (or less attached) persons can admit the truth within moments. At the other end of the spectrum are those who are unable to begin the grieving process at all and refuse to deal with loss by continuing to deny that it is so.
One of the mechanisms we use to adjust to a loss is to review the events surrounding the catastrophe over and over again. Each time we change the scenario by one tiny but essential detail – a detail that reverses the outcome so that in our fantasy the loss never occurred. “If I hadn’t bought her that car, she would be alive today. “If I hadn’t gone early…” “If I hadn’t been on that corner…”
This replay and editing does two things. First, it makes the loss less real; we fantasize that it almost didn’t happen. Second, it helps us deal with our lack of control in the face of random or senseless events.
One of the most painful aspects of these first stages of grief is the fear that one is insane or will become insane. There can be episodes of a feeling of unreality or of being in a dream: this is simply another way in which the mind says “I can’t believe or accept this. It isn’t so; this loss never occurred and is not real because I am not real.” With great pain, the body shuts down, conserving all its energy for the business of survival and repair. All luxury functions stop: only the activities necessary to maintain life are operative and even these can become quite distorted. Sleep patterns are reversed or shattered; eating becomes impossible or may become unmanageably persistent. Sexuality may seem suspended or uncharacteristically enhanced as the injured person seeks relief from pain. The obsessive nature of grief – its omnipresence – the intrusion of pain into every conscious moment of life, can become tormenting. Learning to deal with the distortions of this period is vital. Grief, like any work, requires periods of rest. The sufferer must learn to find some temporary relief from sorrow. Compartmentalizing the time devoted to mourning is useful: “I will not think about this now; I must do the ordinary work of this hour, but I will think about it again when the hour is over.” Exhausting physical effort also buys relief: it is difficult to grieve running or playing a vigorous game of tennis or swimming laps in a pool.
The death of a person or the absolute destruction of a thing makes it easier to accept the irrevocability of a loss. This is the reason people need to actually see the body of the beloved dead person “with their own eyes.” That act of personal verification is very helpful. An equivocal or perhaps reversible loss is much more difficult to deal with. While a lost lover still lives, can I get the person back? When an important object is lost or has been stolen, can I find it again or replace it with an identical or equivalent piece? The decision that loss is final and definite must be made before grieving can proceed; until that happens, no further work is really effective. It is inappropriate to try to hurry some suffering person through this process: if a woman cannot leave an abusive lover, to harass herssh is cruel. It is ultimately she who must decide when, in her particular circumstances, the bargain is too painful to be borne any longer and when she has the necessary resources to address the issue of its loss. If a woman seems foolish in her attempts to find some piece of jewelry or clothing she has misplaced, and for which she feels compelled to search, it is useless to tell her to stop. When she has accumulated enough disappointment so that she can give up the task, she will do so. The searching, the repeated tries at recapture, the many attempts at negotiation and reconciliation are all part of the work to be done; until it is finished the mourner cannot move on. No outside observer can ever know in detail all the factors that constitute an attachment. Indeed, almost inevitably, the suffering person himself cannot tell exactly what all of them are. Because this is true, it is impossible to know when and why the attachment should be surrendered; only the person involved can decide. I have listened to patients tell me even when it is dangerous for them to stay that they cannot leave some painful but significant part of their lives. To ridicule such a person, to chide him for his “foolishness” is at best a waste of time and at worst, insensitive and tormenting. To reaffirm the danger, to delineate it clearly with the sufferer, to urge the person gently to consider the cost of staying in the painful situation are all helpful. But to censor him for weakness usually only silences and alienates him and compounds his difficulty by isolating him.
Once the loss has been acknowledged as an inescapable reality, the mourner faces a certain, irreducible bolus of recovery and repair that has to be gotten through. We must consent to grieve and enters the second phase of his task: leave-taking.
The Role of Memory in Grieving
This is the aspect of mourning that is probably responsible for the flood of memory that is so overwhelming and puzzling. An astonishing rush of images, events and fragments if incidents seem to come from nowhere—events we never even knew filed away. It is as though the sad mind sits down and in an amazing feat of data recall, reviews a thousand aspects of the loved, lost person or thing and says goodbye to each one. Over and over again, the psyche recalls, acknowledges as valuable or meaningful and relinquishes little by little all the investment it made in loving that lost person or thing. Even as we form attachments over time, experience by experience, it seems we must also give them up over time—piece by painful, loved piece, surrendering reluctantly and slowly what we had come to treasure.
While there may seem to be a tormenting sameness to the images that crowd the imagination, this is not the case. I am reminded of something pointed out to me once by a teacher of very young children. “Watch a child engaged in some repetitive task—putting a block into a box, for example. If you look at him only casually, he seems to be doing the same thing over and over again, exactly in the same way. But if you watch him very carefully, you will notice that each time he does it, he does it a little differently. Once he will turn the block to another side, another time he will hesitate a little before plunging it into the box. With every repetition, he is looking at some new aspect of the thing, learning some small new reality about what he is doing.” So it is with our sorting through that accumulated pile of experience: it cannot always be done quickly. The problems of leave-taking are solved with many small separate steps, even as we made the investment in the first place.
Some mourners cultivate memory. It is the only tool that can knit an absent person into the daily life of the grieving individual. For some, this involves less pain than acknowledging the end of the connection and the mourner will not move on to transfer the investment he made in the beloved object to another attachment; it is simply too painful or too difficult. Such a person learns to minimize the longing that accompanies recall. He concentrates instead on recreating or maintaining the most valued aspects of the character and essence of the lost individual in his recollection. He may surround himself with objects or other individuals who mirror or replicate characteristics of the lost person. These can be strikingly accurate. I spoke once to a woman who carefully nourished and counted very valuable the memories she had of her daughter who had died some years before in an accident. She felt that it was not only possible but desirable to store up all she could of her past life with her child and had even chosen a young woman to be her cook who had exactly the same shade of hair as had her dead daughter. It was she who pointed out to me that memory is not always a plague but can be a treasure-house of stored representations which keep a loss from being absolute. She used memory to keep what was most valuable in her life from disappearing entirely.
The phase of leave-taking is critically important. It can help us assess the real meaning of the attachment to the lost object. If we scan that flood of memory for common themes, they in fact are there and are important indicators of why we feel such pain. Apparently disparate and unconnected images may have a common theme: they may concern, for example, the value of family life. We may be recalling incidents that involved the communal effort and closeness that families provide: a picnic, the purchase of a house, the sharing of one or another ordinary daily pleasures only possible within the structure of life in the company of loved, familiar others. The loss of a jewel may unlock memories of an occasion it marked in our lives, of the person who gave it to us, of other, similar people and occasions, all of which have a remarkably identical psychic payload for us. It is not, in fact, the jewel alone whose loss we mourn; it is the significance of what it symbolized for us: that we ourselves, perhaps, were of enough value to someone for them to give us something rare and beautiful. Or perhaps that we wore that testimonial to our value on challenging occasions for reaffirmation and support. Perhaps that jewel was one of the reminders that we had a family and occupy a place in a known sequence of other persons who begot and loved us once, even as we beget and love others in our turn. It can be very complicated and understanding the real meaning of a loss requires a great deal of attention and work.
Every loss recalls other losses: in a sense, what we grieve over in the present is compounded and intensified by other older (and probably similar) deprivations. We are forever running old “tapes” that go on because we never relinquished them. Every period of grief and mourning is a new chance to discover what those old sorrows were about. Only by understanding and acknowledging them can we finally deal with them. Growing up and moving on to new development only happens if we can lay down the old baggage and finish the old tasks.
Recovery and Replacement
Once we have worked on why we loved some lost object or person and why we feel the loss so keenly, we can not only say goodbye, but we can set about replacing it. For example, in scanning the nature of an attachment we had to an important person, what can we learn about what we really admired? Was it their vocation? A talent for something we could not do? Was it some quality of humor or gentleness that we ourselves had never developed? Part of what we seek in other persons is what we most long to have ourselves. Did the lost person make interfacing with others easier for us? Then it would be good to try to perfect our ability to interface alone. Did he expand our social horizon, providing us with new arenas and populations of people with whom to festoon our lives? Then we must set out to find those expanded horizons on our own. Trying to get for ourselves what was provided once by that lost, cherished individual does two things. It develops our own resourcefulness and competence and it increases our own sense of strength and worthiness. Every deprivation throws us back on ourselves and forces us to look for ways of coping with the necessity for going it alone, at least for awhile, and to try to find within ourselves the necessary ingredients to make life bearable and valuable once more. It is a sad fact that broken relationships, even though they might never have been rich and useful, encourage us in some ways to look outside ourselves for satisfaction and fulfillment. We often wait for a beloved other to do for us what we really ought to be doing for ourselves. They also can preclude our undertaking new and difficult adventures because we have not needed to do so: adventures which, if successfully negotiated may lead to resources we would never have developed without a pressing need to do so.
Aging and Mourning
One of the most difficult kinds of mourning is what the aging do for the loss of youth, physical beauty and the dependable functioning of their own body. They must surrender that powerful sense of competence one feels at the height of his psychic and physical maturity, when he is responsible for and dispensing gifts on the one hand to those younger than he (his dependent children) and on the other, those older people (his aging parents) for whom he must also make provision. It is very hard to surrender that central position in the economy of society that providers occupy. And yet, when the older person turns to his maturing children and says, in effect, “Now it is your turn, and I will take from you all the things which I once provided you and for which you once looked to me,” he gives that younger, incompletely developed person the chance finally to function in his turn as an independent, competent adult. In relinquishing the role of gift-giver, the parent does an essential service to those coming behind him. An awareness of this can mitigate and make bearable the mounting limitations that aging inevitably brings to us all.
The Usefulness of Others
The mourner must assess carefully the usefulness or the destructiveness of others for his recovery. The spectacle of a disaster (and all of us count a loss of any significance as a disaster) provokes anxiety in the onlooker which is exactly proportional to the degree of fear he has that he too might be diminished by an identical blow. For some people, disaster is contagious. Does a man fear death? He will be terrified if he sees it at close quarters. Does he dread the loss of his job? Is he dealing poorly with his fear of his own aging? He will feel alarm at those catastrophes in the lives of the people close to him. Anxious people react in several ways: they can be harsh and even cruel to a grieving friend. Others avoid any contact with the bereaved person or are unable to refer to his loss when they do meet him. Even more astonishing are the looters, who, sensing vulnerability, rush in for the kill. These are the sexual opportunists or those who ask for loans of the money or possessions of the mourning person. Most helpful are the seasoned sufferers who have faced down and worked through pain of their own. Insofar as they have been successful, they have a steady strength and empathy that is immediately recognized by the grieving person and which can be very useful to him.
Anger and Loss
One of the most powerful emotions we have to contend with in loss is rage: rage at the vanished person who has left us. This anger is not mitigated in the least by reasoning about it: in fact, we can be completely aware of the fact that a sick or dying person is not responsible for or guilty of his illness and ultimately his own death and still be enraged by the pain those things have produced: the mourner feels that such an emotion is incongruous and even grotesquely inappropriate. In fact, anger at loss is utterly universal, inevitable and logical – how else can one feel after such a blow to the self? Underlying the anger is mortal fear: fear that the bereaved person himself will not survive; fears about his own vulnerability and extinction.
Part of the anger can be about the work the lost person once did for or with us and which we now have to do without him. Parents left alone to raise their children will exclaim, “How could he/she leave me like this?” That rage returns again and again at times of special pain and stress – sometimes dimly felt, but always very real. Anger can even be over the work the lost person began and which we never would have chosen to do, but which we feel we must now continue – a house they loved which we now manage, a business that has to be dealt with in which we have no interest and for which we may have no skills. The unwelcome, unwanted legacies of the dead can be an ominous reality. So can having to do alone what was much easier and better to do when the work was shared. Anger can even be about the loss of work that was full of joy and creative effort. Sometimes that is the worst part of the loss of a bright, expanding person who shared his problems, dilemmas and the excitement of personal growth – a person who called forth substantial and happily effective contributions from the bereaved person who now must abruptly surrender all those efforts. Once I spoke with a very beautiful woman who had spent most of her luxurious and very busy life with a husband who had suddenly died. There were many things she might have been grieving about, but as she talked, she suddenly stopped, looked up at me with an expression of utter desolation and said: “He told me absolutely everything. I know I was very important to him.”
There is a special poignancy to the bereavement of a parent who mourns the loss of that of a child to whom he was so central, so necessary and to whom he seemed so powerful. Sometimes the most devastating sadness has to do with the fact that the lost person was someone who saw us most clearly of all, with an ability to accept and admire us pretty much as we really were, or who liked in us those fragile, more delicately structured qualities we were only able to use or exhibit when we felt particularly safe or at home.
Anger at a dead or irretrievably gone person presents a double conundrum: how can one dispel anger when there is no way to reach the (as our mourning selves perceive it) abandoning person. A patient speaking of her long dead mother told me, “I get so mad at her, I’d like to go down to the cemetery and shake her bones.”
Anger like any other energy, can be a useful goal for growth and development. It can also be terribly destructive. Sometimes we displace it and even turn it back on ourselves. Feelings of guilt are part of the pain of grieving. Guilt at past unkindness, failure to deal effectively or lovingly with the other person; memories of small or large cruelties to which we subjected the other person. Some of the guilt comes from the realization that we are glad that we ourselves are alive and not dead. To be glad to have survived, though, is not inappropriate, unfair or injurious to anyone else. It is a part of a healthy psyche’s instinct to preserve itself. Other guilt is well founded and intensified by the knowledge that we will never have another chance to repair the damages and injuries we did, to express our regret and sorrow, to make up for what we took from or destroyed for another person. But no interaction happens between perfect people. All of us could have improved most of our performances on a second go-round. The past is unalterable and must be put down. We must agree that it is all over and move along into the present. The present, after all, is all we ever really have, and the only forum we can ever use to practice and develop our powers.
We can find ourselves furiously angry at a person who is not dying, but merely losing his usefulness to us. For whatever reason: our own increasing competence or the other person’s aging, illness or growing incapacitation, we may find ourselves unable to use or count on things that were previously helpful and on which we had come to rely in another person. To be angry about that is inevitable; acknowledging that anger and dealing appropriately with it is essential to solve the issues involved. I have heard daughter’s whose mothers had been citadels of strength and resourcefulness say, their voices full of pain and guilt: “I am angry with her for being sick – so sick that I can’t call on her or depend on her for all the things she has always done for me.” A husband told me once after his young wife had just died: “I missed her terribly all the time she was dying; she had no time for us anymore.” Once he acknowledges and accepts his anger, the grieving person can come to terms with it and begin to look to himself or to others for the things he needs.
As bitter and stormy as are anger and its twin, hatred, they can be harnessed like any other energy for useful work. Instead of being immobilized and swamped by rage, one can turn and look at it squarely: What is it about? If I find myself ill-equipped for work I must now do alone, how can I develop new skills or find them in someone else? Loss is a chance to expand our own power and the armamentarium of resources with which we do the tasks of our daily lives. When a life situation is suddenly changed (a marriage ended, a job lost) we have a chance to think about what it is we really want now. Many things in us and around us may have changed since those old contracts were made. Important choices and opportunities come along with loss. It is a chance to update, expand and redirect our lives.
Successfully negotiated grief, like any monumental human task, augments and fortifies the person who does the work. Such a person makes the next attachments of his life with powers he would not have developed except under the spur of extraordinary necessity and of near-fatal pain. Mourning, if it does not kill outright, and if we do not bog down, overwhelmed in doing the work, can be a tremendous occasion of growth. It is not an incomprehensible morass; if we are paying attention, we move forward (albeit at times with agonizing slowness) now succeeding for awhile, now faltering again in the jagged curve of recovery so characteristic of all healing, finally to emerge changed forever because of what we did with the pain we survived. Perhaps at the end of the process we might be able to paraphrase the old chant of childhood: losers, weepers; finders, keepers.
Marianne J. Legato, MD, Ph. D. (hon. c.), FACP is an internationally renowned academic, physician, author, lecturer, and pioneer in the field of gender-specific medicine. She is a Professor Emerita of Clinical Medicine at Columbia University College of Physicians & Surgeons and an Adjunct Professor of Medicine at Johns Hopkins Medical School. Dr. Legato is also the Director of the Foundation for Gender-Specific Medicine, which she founded in 2006 as a continuation of her work with The Partnership for Gender-Specific Medicine at Columbia University. She received an honorary PhD from the University of Panama in 2015 for her work on the differences between men and women.
At its core, gender-specific medicine is the science of how normal human biology differs between men and women and how the diagnosis and treatment of disease differs as a function of gender. Dr. Legato’s discoveries and those of her colleagues have led to a personalization of medicine that assists doctors worldwide in understanding the difference in normal function of men and women and in their sex-specific experiences of the same diseases.
She began her work in gender-specific medicine by authoring the first book on women and heart disease, The Female Heart: The Truth About Women and Coronary Artery Disease, which won the Blakeslee Award of the American Heart Association in 1992. Because of this research, the cardiovascular community began to include women in clinical trials affirming the fact that the risk factors, symptoms, and treatment of the same disease can be significantly different between the sexes. Convinced that the sex-specific differences in coronary artery disease were not unique, Dr. Legato began a wide-ranging survey of all medical specialties and in 2004, published the first textbook on gender-specific medicine, The Principles of Gender-Specific Medicine. The second edition appeared in 2010 and the third edition, dedicated to explaining how gender impacts biomedical investigation in the genomic era, won the PROSE Award in Clinical Medicine from the Association of American Publishers in 2018. A fourth edition is forthcoming.
She also founded the first scientific journals publishing new studies in the field, The Journal of Gender-Specific Medicine, and a newer version, Gender Medicine, both listed in the Index Medicus of the National Library of Medicine. She has founded a third peer-reviewed, open access journal, Gender and the Genome, which focuses on the impact of biological sex on technology and its effects on human life.
Dr. Legato is the author of multiple works, including: What Women Need to Know (Simon & Schuster, 1997), Eve’s Rib (Harmony Books, 2002), Why Men Never Remember and Women Never Forget (Rodale, 2005), Why Men Die First (Palgrave, 2008), The International Society for Gender Medicine: History and Highlights (Academic Press, 2017), and most recently, The Plasticity of Sex (Academic Press, 2020). Her books have been translated into 28 languages to date.
As an internationally respected authority on gender medicine, Dr. Legato has chaired symposia and made keynote addresses to world congresses in gender-specific medicine in Berlin, Israel, Italy, Japan, Panama, South Korea, Stockholm, and Vienna. In collaboration with the Menarini Foundation, she is co-chairing a symposium on epigenetics, Sex, Gender and Epigenetics: From Molecule to Bedside, to be held in Spring 2021 in Italy. She maintains one of the only gender-specific private practice in New York City, and she has earned recognition as one of the “Top Doctors in New York.”