GRIEF: LOVE REARRANGING ITSELF

To live was worth it. To love was worth it.

Gonzaguinha

Today’s subject is not merely a sensitive one— it's far more present in our lives than we tend to realize. Grief, as we will see, does not arise only when someone close to us dies. It is a natural and expected human response to the many kinds of loss we will inevitably encounter throughout life.

Some of the things I hear from patients going through it: “Sometimes I still reach for my phone to call my dad, as though he hadn’t died”; “Will I ever be able to give away the toys my daughter—who is now 28—played with as a child?”; "I know I need to get over this divorce, but today I feel more than ever that she was everything to me."

Naturally, I offer a different answer to each. No two losses are the same, no two people react in quite the same way, and no bond of affection is perfectly comparable to any other.

Even so, the three questions have something in common: suffering over what, or who, was lost. That's why this conversation about grief matters — not so much focused on "When will this pass?" as on how to go on living when a particular bond ceases to exhist.

First things first: the brain

The American neuroscientist Mary-Frances O'Connor, who studies the grieving brain, said something that changed the way I first approach grief: we don't find our way through the world by sight alone; over the years, the brain draws a kind of map of reality. That is why most of us can walk through our own homes in the dark, knowing where the doors, furniture and light switches are.

The people we love are mapped into that reality as well. We know where they usually are, when they are expected home and how far away they might be. We know that we can send them a message, share some news, ask for help or simply picture them, even if they've moved far away, still existing in a concrete way. They are a living emotional presence, held within us and shared between us as long as we're part of each other's lives.

When someone close to us dies, the fact of their death reaches the rational mind relatively quickly. We grasp at once what has happened, make the arrangements, receive the condolences. But at a deeper level—the part of the brain where the full map of the relationship was drawn, the storehouse of the feelings that ran between us and the one who's gone —it takes much longer to catch up with this new reality.

It's common for a grieving person to glimpse, for an instant, the face of the one who died in a crowd; to expect them through the door at any moment; or to think, for a split second before reality returns, that they need to tell them something.

The seemingly lost brain is trying to reconcile two incompatible facts: a person has died, yet remains deeply alive inside me. For a while, the griever inhabits both worlds — what they know and what they feel. This is part of what grief does: it puts back in order the emotions that have been turned upside down.

Real or symbolic death, real pain

It isn't only in the sense described above — the physical death of someone close — that a significant bond can break and open into grief. Devastating as it almost always is, the concrete death of a person is not the only loss we face throughout life. There is also symbolic death: the end of a marriage; the loss of a once-healthy body to a diagnosis; the loss of a job, a home, an opportunity, an idealized "youth" we realize is behind us. A teenager can grieve the loss of childhood, an immigrant the loss of their roots, someone newly bankrupt the loss of a former identity as a person who had made it.

Nor can I forget the patients who have grieved deeply— even severely, and not without reason — the death of a beloved pet, suffering twice over: once for the absence of a faithful companion, and again because almost no one around them acknowledges the legitimacy of their pain. "Oh, that really a really old dog anyway"; “Come on, what is all this about? It was just a cat!”

The possibilities for symbolic loss are endless. I'd add that perhaps only the person living through it can name a loss as such.

There's no measuring grief

Following this line of thought, each loss strikes us differently because each bond had a story of its own. The intensity of someone’s pain may tell us something about How someone suffers also depends on what the bond was like, on how the loss came about, on questions or explanations around it that were never made clear, on earlier experiences, and on whether or not there's support to get through the period.

Some cry every day; others spend weeks handling practical matters before they can cry at all. Some talk about what happened over and over; others withdraw. Some feel anger, relief, guilt, and longing almost at once. There is no reliable way of translating grief into a measure of how deeply someone loved, how attached they were or how completely they had made a person—or something else— their very reason for living.

Nor does grief move up and down a staircase

At a time when much of medicine preferred to look away from such conversations, she had the courage to sit beside patients who knew they were dying and listen to them.

But human suffering tends to come more like waves off the sea. Some are relatively predictable if we read the way the wind is blowing: the first anniversary of a death, or the first Christmas, or any meaningful date without the person. Others break without warning, in a supermarket aisle or in the middle of an ordinary afternoon. Grief is neither the staircase nor the flowchart drawn up by those who oversimplified Kübler-Ross's profound work.

I've had patients distressed not by the loss itself but by the sense that they were "grieving wrong": "I should be past the anger stage by now"; "I still haven't managed to accept it"; "I was fine until yesterday, so why am I crying again today?"

Well, just as there's no scale to measure grief, there's no grief test either: no one can be failed, and no one passes with honors.

The back-and-forth is part of the process

Since we're talking about waves, grief can be understood as a continuous movement between the life that has been lost and the life still to be lived, searching for somewhere to place the affection that didn't disappear with the loss.

At some moments the person plunges painfully into the absence; at others they return to practical reality with barely enough energy to face it.

Freud called this process the “work of mourning”. The phrase still holds, because grief really does take energy. The brain has to revisit, one by one, the situations that made up the ordinary texture of daily life and learn that reality has changed: the chair is empty, the message will go unread, the advice once asked for won't even be heard.

Each new occasion updates the loss while the brain redraws the map point by point. That's why even simple tasks can demand enormous effort from someone learning to live in a world that no longer works the way it did.

Pain doesn’t need to be erased

Love, finitude, the passing of time and grief cannot be cut in half. To pretend otherwise would be to alter the meaning of all four.

Pain is the most immediate response to loss: the longing, the tears, the emptiness and the impossible wish that the person—or the life that existed before— would come back. A bond that has ended can’t simply be erased as though it had never existed.

Even in, say, a separation a couple later reversed, the moment of rupture did actually happen. The pain felt during the distance was real. And when the loss is irreversible — well, all the more so.

Hence my quarrel with those well-meaning words of comfort: "at least he didn't suffer", "you'll forget all this and be happy again", "you can always plan another baby", "it was for the best." No one is born knowing how to support a grieving person, but a warm embrace or a compassionate look may be far more helpful than words that could come across to the grieving person almost as an insult, by failing to recognize that the pain is real and that nothing, however kind, will erase the mark it leaves.

Sadness is not the same as depression

This is where I speak most directly as a doctor. We live in a culture that's in a hurry to feel better. Sometimes that hurry takes the form of offering medication before anyone has truly listened to the person living through the grief.

Someone loses a partner, cries for a few weeks, and in that time sleeps badly, has no appetite, feels adrift. The family understandably worries and asks the doctor to start an antidepressant right away. A natural, expected sadness shouldn't be medicated automatically just because it makes those around us uncomfortable.

Reactive, adaptive sadness is not the same as a depressive disorder. The question we doctors should be asking ourselves is whether, alongside the grief, there is also a depressive illness that needs treating.

Freud (here he is again — so towering that even a non-psychoanalyst like me can hardly leave him out) drew the distinction like this: in mourning, it is the world that becomes poor and empty; in melancholia, it is the self.

What he probably meant was that, in grief, the pain tends to revolve mainly around the person or the part of life that has been lost. between the waves I mentioned, there can still be moments —however brief—of interest, pleasure and connection. In clinical depression, the negativity tends to spread across the whole of life. Work, relationships, the future and the person’s own worth all begin to feel empty. Persistent feelings of worthlessness, hopelessness, or self-reproach may set in.

These borders aren't always clear. A grieving person may develop depression, and someone who is already depressed may experience a loss. That is why it is important to look carefully at the history, the severity of the symptoms, their ability to function in daily life and the risks involved. Further down, I'll come to Prolonged Grief Disorder, which is another matter.

Anticipatory grief

If the previous section is where I spoke most as a doctor, this is where I'll show my own humanity — as fragile as anyone else's.

In the early 2000s, my father faced, without success but with great courage, a prostate cancer that in the end spread to several other organs, carrying him through surgeries, hospital stays, and palliative care until the admission that would be his last. This one lasted weeks, and during that time I stepped up my own therapy, both because I needed support in the face of that hard reality and because of the ambivalent relationship I'd had with him throughout my life.

During one session, my therapist stopped me mid-sentence:

“Luiz, have you noticed the tense you use when you talk about your father? It is always he was, he used to, he did. You speak as if he had already gone. But in fact, terminal as he is, he's still alive. Is your story with him really over?"

I don't need to spell out how deeply that landed, how it filled me with shame at my own disrespect toward a man who was, yes, hanging by a thread, but still as alive as I was. He was conscious, awake and able to communicate in his own way, despite the difficulty.

Realizing that I was living an anticipatory grief turned out, in the end, to be a gift for my father and me. On the visits that followed, I showed him affection in a way I never had; we spoke to each other about the qualities we admired in one another (a rare thing until then) and told each other how we loved one another on the nights I stayed by his side. I even heard an unprecedented "I'm proud of you" as I spooned hospital soup into his mouth.

He died shortly afterwards. Was the pain there? Of course it was. But beside it was the relief of having been given a last-minute opportunity to repair something between us, thanks to my therapist’s observation—an intervention for which I could not be more grateful.

I wish his illness had never taken him from me. Yet, paradoxically, it brought a kind of healing to our story at its very end. I am still trying to understand and mend the son I was to him. But the father he was to me, I'm sure, left in peace.

When to seek help

As a rule, people move through grief with the resources they already have: time, rituals, faith, friends, family, and, if they want it, the chance to talk about the one who's gone. That doesn't mean the process is easy; it means only that not every grief calls for professional help.

But the healing I described through my own story, however, wouldn't have been possible without help. Help has to come when when someone remains trapped in what has been lost or even runs out ahead of the loss, as I was doing. Months pass, yet life stays frozen. The longing doesn't ease; the suffering blocks work, self-care, relationships; and any flirtation with happiness feels like a betrayal of the one who's gone.

When the grief that follows a death stays intense, disabling, and prolonged, what has set in may be what's called Prolonged Grief Disorder. In adults, the diagnosis is only considered after at least twelve months, and involves other specific symptoms. This is one more situation in which a grieving person can benefit from specialized help.

Grief therapy isn’t intended to teach someone to forget but to help them acknowledge the reality of the loss, care for the pain, adjust to a world that has changed, and find a new place for the bond within the life that goes on. To help redraw that map. For a long time, grief was understood as a process that should end in complete detachment from the person or situation that had been lost. The mourner was expected to withdraw all the emotional energy invested in that bond and, only then, become available for new attachments.

But we now understand it doesn't have to work that way. The goal isn't to erase the bond that was lost, but to give it a new meaning. Just as the pain we have experienced doesn’t simply disappear, neither does the love. It simply needs to to honor what was shared, take comfort in the happy memories it left behind, and find new ways to express itself.

That is what Brazilian composer Gonzaguinha invites us to consider in his song Viver, amar, valeu (“To Live, To Love, It Was All Worth It).

Love remains

We are made, in part, from the relationships we've had. Whether the loss is literal or symbolic, whether it involves a person or something else, the affection contained within that bond was real, moved through us, helped shape who we became, made a home within us and remains there as energy that hasn’t dissipated.

When the bond goes, the love that sustained it is simply left adrift for a while, not quite sure whom or what it should go towards now. Given time, care and tenderness, we eventually come to find out what to do with it.

Grief may well be exactly that: love finding a way to rearrange itself.

 

 

 

 

 

 

Image created with ChatGPT from a prompt by the author.