by Becky Zuckweiler

Anticipatory Grief

Grief is an unfolding process that consists of five basic stages. We start the grieving process as soon as we learn that a mastectomy is a possibility and continue grieving long after the surgery is over. Grief for an impending loss is referred to as anticipatory grief.

Stage 1 – Denial

When we first experience loss we go into the denial stage, during which we may feel shock, disbelief, and numbness. The denial stage is nature’s way of cushioning us from the bluntness of reality. Denial allows us to gradually absorb the painful truth. Many women who have grieved the loss of a breast describe their response in the denial stage as hearing the information the doctor is telling them as though the physician is ta1king about someone else. They find themselves thinking that cancer and mastectomies happen to other people, not them. This response can give you time to intellectually attend to the details, such as making appointments with the surgeon and oncologist, before emotion floods in.

Stage 2 – Protest

As our initial shock wears off we move into the protest stage, a phase of intense emotion, including anger, sadness, and confusion. As the facts start to sink in, our thoughts set off an emotional reaction. Our fear of surgery and of cancer is probably foremost in our minds. Before we are even sure we have cancer, we often start to think about dying and leaving our loved ones behind. We feel sad for our kids, our partner, and ourselves. We often feel betrayed and angry with our body. My clients consistently ask me what they did to deserve breast cancer. This is the time during which we tend to blame ourselves or others as we try to make sense of the loss. Anger at God, our doctors, or the relatives who passed on the bad genes is very common during the protest stage. Besides feeling the need to direct our anger at someone; it is also common to engage in unrealistic mental bargaining, such as promising to go to church every Sunday if our breast is spared. This bargaining is a combination of denial and our need to feel that we have some control over the situation. During this time, it is also common to experience physical symptoms from stress, such as diarrhea, constipation, neck and shoulder pain, rest-less sleep, and fatigue. Your stomach may ache or you may find yourself with a splitting headache that makes it hard to think. Your body may seem to be screaming out a message of emotional pain

Stage 3 – Disorientation

The third stage of grief is the disorientation stage. This stage is often accompanied by restlessness, confusion, and depression, as we have to change our routines and adjust to the changes the mastectomy has brought. We may also continue to experience the physical symptoms of stress during this stage. Disorientation is very natural after your chest has healed enough to begin to wear more normal clothes and you are feeling strong enough to go out in public. You can’t just go to your closet and pick out an outfit like before. Throwing on a bra and a T-shirt is not as simple at this point. Now, selecting an outfit means finding a top that your tender chest and restricted arm can tolerate, plus finding a way to fill in the missing breast. You have lost a breast, the freedom to wear a variety of clothes, the movement in your arm, trust in your body, some of your sexuality, restful sleep, and physical comfort, to name a few of your many losses. And even though most of these losses are temporary or become easier with time, making the adjustment to them is likely to cause you to feel confused and disoriented.

Stage 4 – Detachment

Following the disorientation stage we move into the detachment stage. During this stage we tend to isolate and withdraw ourselves, and possibly feel resigned and apathetic. It is as though we have to go off quietly by ourselves and sit with our loss. Too much contact with other people at this time often feels like an intrusion and a lot of work. We often feel we need to be left alone in our misery to fully absorb our loss and get used to the fact that a mastectomy has forever changed our life.

Stage 5 – Resolution

The last stage of grief is resolution and it is during this stage that we enter a renewed state of reorganization and acceptance. We are not happy about the loss or our breast, but we see that we can live without it. The resolution stage often brings us insight into our life and ourselves that builds character and produce wisdom. During the resolution stage our mood lifts and we find we are able to experience joy again. This is also a time when we become grateful for what we have and want to give back. Volunteerism, such as in breast cancer support organizations, frequently accompanies this last stage of grief. If you give yourself the room to go through the emotions, you will move forward into the resolution stage of grief where you begin to feel acceptance. You will want to take back control of your life by becoming pro-active again. Priorities become redefined and life goals are reestablished. Your overall reaction may actually be a blend of loss and gain. Initially it may have felt like a horrible loss but, as you move through the process, you discover some advantages that come along with your body changes.

Automatic Behavior

There is also something called automatic behavior that often accompanies the grief process. This is what is happening when we don’t get our routine behaviors quite right and we start to feel like we are going crazy. As we process our loss we become distracted from life’s little details, and this natural preoccupation results in poor concentration while attending to daily tasks. As a result of automatic behavior you may find yourself putting the cereal into the refrigerator and the milk into the cupboard, squeezing a tube of skin cream instead of toothpaste onto your toothbrush, or seeing that the traffic light has turned red but not really registering it, and driving right through. Your short-term memory can also be affected because good concentration is required for the memory to work well. Do not panic over these lapses. They are temporary. However, it is helpful to remember that automatic behavior can occur during the grief process, so you can safeguard yourself. When you set out to drive, remind yourself that you are prone to poor concentration and constantly remind yourself to tune into the “here and now.” During this time you should stay away from dangerous machinery until you feel your focus and concentration return.

Each of you will go through the grief process in your own way. The stages of grief are meant to give a general description of the grief process, but in reality they are not as clean-cut as I have described. You will move back and forth through the various stages and can experience more than one stage at a time.

The significance you attach to your loss will determine how long your grieving process will last and how intensely you will feel it. Grief from losing a small purchase you just made may last only minutes, whereas a significant loss such as the death of a close friend, a divorce, or a house burning down may take years. Significant losses are often brought to mind by special events and seasons associated with the loss and these triggers can create new emotional pain. Most women take about two years before they report feeling fairly resolved about the loss of a breast. Your most intense grieving will probably happen close to the time of your surgery but you will likely continue to experience some grief from your mastectomy for the rest of your life. You may feel that you have just started to accept your loss just when something else seems to set it off again. It may be three years later, when you are faced with having to find an evening dress for an elegant wedding that you suddenly feel the tears bubbling up again. You may want to scream and stamp your feet at the unfairness of only being able to consider a quarter of the dresses because of the changes to your body. Twenty years after your surgery your best friend or daughter may be diagnosed with breast cancer and you may find yourself reliving some of your own pain as you walk through the process with her. All of these feelings are normal. Every woman grieves in her own way and in her own time.