Understanding Anticipatory Grief

Anticipatory grief is a form of grieving that occurs before a death or loss. It can present at the end of life, during the time of a terminal diagnosis, the end of a meaningful relationship, or a significant life shift. For some clients who have experienced trauma, anticipatory grief can appear at any time during the life cycle, being triggered by traumatic stimuli. Clients, families, caregivers, counselors, and even individuals who are facing death or a life change can experience anticipatory grief. Anticipatory grief is a normal response to an upcoming loss. 

Anticipatory grief has not been widely researched. Due to the lack of research and discussion in society, clients often feel anticipatory grief is not as valid as post-death grief. A part of the counseling process will be normalizing and validating this form of grief. Observations by counselors in practice and some studies have shown clients experience grief reactions similar to those grieving after a death. Majid & Akande in 2021 state, 

The majority of grief research has focused on the experiences and perspectives of individuals after loss. Grief can be expected or unexpected depending on the nature of a loved one’s death. Like post-death grief, individuals who expect the impending loss of a loved one may feel uncertainty, fear, and sadness, which can lead to a number of adverse outcomes on their health.

Does Anticipatory Grief Lessen Post-death Grief?

Each client case will need to be assessed on an individual basis. Anticipatory grief can be a positive or supportive factor in the grieving process for some clients. Being prepared for a loss may help begin the grieving process earlier than an unplanned death. These clients develop coping skills before the loss, which they can utilize after the death occurs. In these instances, it can be a pre-release of emotional pain for some individuals and assist the bereaved in the process of meaning-making. A 2023 study conducted by Feigelman, Bottomley, Titlestad found 

Death-shocked respondents showed greater PTSD, other mental health, and grieving problems; those anticipating the death had less PTSD, grieving problems, and engaged in more meaning-making. 

For others, anticipatory grief worsened the grieving process. Some clients may brace for the death or loss and create defenses to avoid feeling the emotional pain of a loss. If the feelings experienced in a pre-death grief are not processed, this can lead to complicated or prolonged grief. 

Shear et al discusses four key features of complicated grief: 

1) A sense of disbelief regarding the death 

2) Anger and bitterness over the death 

3) Recurrent pangs of painful emotions with intense yearning and longing for the deceased

4) Preoccupation with thoughts of the deceased that often include distressing and intrusive thoughts related to the death 

What are the Phases of Anticipatory Grief?

The information below directly relates to a child’s death but can be applied to all ages of clients. Anticipatory grief is similar to post-death grief in that clients travel through various emotional stages as they heal. As in all stages of grief, these do not run in any particular order, and clients may repeat certain stages many times. 

The University of Rochester Medical Center Health Encyclopedia outlines the phases:

Phase I. In this stage, the person realizes that death is inevitable and has no expectation for a cure. Sadness and depression often occur with this first stage.

Phase II. The next phase is concern for the dying person. Family members may regret arguments or disciplining the dying child. For the dying child, concern may increase for themselves their own fears of death. The child may also be worried about the emotions expressed by loved ones.

Phase III. In this phase, the actual death may be “rehearsed.” The physical process of death and what may happen after death are concerns in this phase. Funeral arrangements and saying goodbye to loved ones may occur as a result of some anticipatory grieving.

Phase IV. In the last phase, loved ones may be imagining what their lives are going to be like without the person who is dying. Parents may be thinking about the unused toys left behind, missed proms and birthdays, or even what they are going to tell the child’s teachers when school is missed. Siblings may wonder what it will be like to lose their brother or sister.

What Underlying Factors Are Involved with Developing Anticipatory Grief?

Although anticipatory grief is a normal reaction to an impending death or loss, it was found that certain factors can complicate this type of grief or worsen it. Clients may experience a fear of the unknown when facing death, this can block their expression of grief. The younger a client is in age or a person who has not faced many previous deaths or losses may experience anticipatory grief. Those clients who have experienced a traumatic death previously can be on guard for future losses, such as those who develop post-traumatic stress disorder.

Research about anticipatory grief was conducted by Burke et al., 2015 for 57 family members of terminally ill, hospice-eligible veterans who were receiving palliative care services: 

Of these families who completed the measures assessing psychosocial factors and conditions, elevated anticipatory grief was found in families characterized by relational dependency, lower education, and poor grief-specific support, who also experienced discomfort with closeness and intimacy, neuroticism, spiritual crisis, and an inability to make sense of the loss.

Counselors who Experience Anticipatory Grief for their Clients

Counselors who work with end-of-life clients or have a client diagnosed with a terminal illness may experience anticipatory grief. Often, this type of grief is not acknowledged or discussed in the workplace, but it can occur to counselors. Unfortunately, there is not much research on this specific topic. Counselors need to develop self-awareness regarding their reactions to their clients and discuss these in peer or one-on-one supervision sessions. Some counselors may need additional support by attending their own individual counseling sessions to process anticipatory grief. 

Kimberly Strom-Gottfried, PhD, LISW & Nikki D. Mowbray, MSW, P-LCSW state

Nurses, physicians, social workers, and other caregivers frequently encounter patient deaths in the course of their professional responsibilities. Although the literature in these fields addresses the cumulative effects of such losses in burnout and vicarious traumatization, scant attention is given to the manifestation of grief in professional caregivers and the strategies available to acknowledge and address the losses experienced in the course of professional practice.

Special Considerations in Treating Anticipatory Grief

Trauma and Grief

When anticipatory grief is an expression of past or current trauma, it may develop into complicated grief if left untreated. A thorough assessment is warranted to determine if the grief is current or connected to an unresolved trauma or grief. If time allows, consider treating the initial trauma before the anticipatory grief. If a client is at the end of life, time may not allow for intensive treatment. In these instances, look to reduce individual trauma symptoms or grief.

The Use of Acceptance Therapies 

Acceptance-type therapies can help ease symptoms or distress in clients who experience anticipatory grief or patients with palliative care. It is often the resistance or avoidance of feelings that leads to suffering. Counselors can encourage clients to express all their feelings about anticipatory grief while holding the space and listening non-judgmentally. When clients feel safe to sit with the grief feeling and experience it, the sensation often moves out of their body and their mind. Through this process, clients learn to stop avoiding or denying their grief. 

As reported in Davis et al., 2017, 

Correlations revealed that acceptance had a strong relationship with anticipatory grief, anxiety, and depression. A hierarchical regression analysis on anticipatory grief showed that acceptance was the largest predictor and accounted for an additional 13 [percent] of variance in anticipatory grief over and above anxiety and depression. The present study provides preliminary data suggesting that interventions that target acceptance may be indicated in patients in palliative care.

Using a Narrative Approach

When those with anticipatory grief speak or write about their experiences, it helps to externalize the pain, and healing can occur. These stories about their lives can develop meaning. By writing or telling their stories, clients can craft a new narrative in which their strengths and values are included while acknowledging their upcoming loss. 

When clients carry multiple roles, such as caregiver and family member, narrative work can help them discover and process both roles.  The role of caregiver and family member carry different feelings and experiences, even though both exist within one person.

A 2016 research study by Toyama & Honda found: 

The narrative approach was effective in clarifying how the anticipatory grief of family members providing end-of-life care at home represents a conflict between the individual’s role as a caregiver and their role in relation to the patient. The narrative approach was effective in freeing family caregivers from the feeling of being trapped in their caregiver role, which resulted in them recognizing their own emotions and, in so doing, shift to the role defined by their relation to the patient. This shift helped them to better accept the loss and begin to grieve.

Exploring the Client’s Social Supports

Social supports are protective factors in all types of grieving. The counselor is one source of support for clients, but it is important to explore a wider range of assistance. For example, grief support groups, friends, family, or hospice care can help connect the client to additional resources beyond counseling sessions. When a client knows they are not alone in their experience, it creates healing. This is also true for anticipatory grief.

Rogalla 2018 reports, 

Practicing professionals should also examine the current levels of social support and support-seeking behaviors reported by clients faced with anticipatory grief. It is logical to assume that proactive copers accumulate social support resources when faced with anticipatory stress when it is most needed to optimize an opportunity for growth. It can therefore be inferred that social support is an outcome of the proactive coping process and the strongest positive predictor of growth during anticipatory grief. 

Lisa Hutchison, LMHC

Lisa Hutchison, LMHC

Writer & Contributing Expert

Lisa Hutchison, LMHC, is a licensed mental health counselor for the Commonwealth of Massachusetts. She works for professionals who want to treat and prevent compassion fatigue. With over 20 years of psychotherapy experience, she helps her clients assert themselves, set boundaries, and increase their coping skills. Her specialty is decreasing stress, anxiety, and depression while increasing realistic methods of self-care for those who help others. Ms. Hutchison’s psychological advice has been featured in Reader’s Digest and the Huffington Post. Her articles have been published in numerous magazines, including Grief Digest and Today’s Caregiver.

Lisa is the bestselling author of I Fill My Cup: A Journal for Compassionate Helpers and a faculty member writer for NetCE. Her latest continuing education unit publication is “Setting Ethical Limits for Caring and Competent Professionals.” She has taught creative writing in colleges and presented on boundaries for the compassionate helper; the use of expressive art to heal grief, anxiety, and depression; inspirational and motivational topics; and creative writing techniques.