When we train physicians, nurses, and other hospital staff on providing good end of life care, we always start and end by reminding them of one thing. The care they provide and the interactions they have with families will stay with family members forever. This isn’t hyperbolic. In grief, many people will play back the circumstances immediately before, during, and after a death over and over again. They will revisit those moments and replay them, sometimes picking them apart. Grief and guilt (or at least grief and regret) can become deeply intertwined in those moments.
We have talked about grief and guilt or regret many times before. If you want to check out some of those other articles, we have a full list of guilt, grief and regret articles here. Today we are specifically going to talk about some of those regrets that come up around a death. To understand this chronic replay of events that can happen in grief, there are a couple of concepts you should know.
The Acute Stress Response
In the immediate time of crisis surrounding a death, our brains often flip into crisis-mode. That crisis mode is more formally known as an acute stress response. It is our brain’s evolutionary mechanism for helping us out in times of danger – we release stress hormones. We go into a fight, flight, or freeze response. This was incredibly useful when being threatened by predators. When the danger we feel is the deep emotional risk of losing a loved one and having to live without them, the acute stress response isn’t always so useful.
We aren’t going to get into the details of the acute stress response, because we have a whole article about it. We strongly recommend you read this post on The Role of the Acute Stress Response in Grief before you go any further. It digs into some of the common acute stress experiences like shutting down, derealization, depersonalization, arousal, avoidance, and dissociative amnesia.
Cognitive Appraisals in Grief and Guilt
A cognitive appraisal is our subjective interpretation of a given situation. In the 1960s Richard Lazarus explained that cognitive appraisals impact the stress of a given situation. He said the stress a person experiences is subjective and correlates to their unique interpretation or “appraisal” of the event. We naturally appraise things like whether a situation is a threat or challenge (what Lazarus called a primary appraisal) and whether we have the resources or ability to cope (a secondary appraisal).
Let’s look at this in practice. Imagine that my coworker and I both are laid off from our jobs due to budget cuts. Our circumstances outside of work are largely the same. We both have some savings, family support, and strong skills in high-demand fields. We were both good employees. When learning about the layoff, she reflects on the situation and thinks, “wow, this is awful. But I have savings, so I will be able to pay my bills for a couple of months. I have been through hard stuff before, so I can get through this. My work experience is strong. I just need to start looking for another job”. I, on the other hand, think, “wow, this is awful. Without a paycheck, I’ll never be able to pay my
bills. It’s a tough job market right now, I probably won’t get hired. I’ll never fully recover from this”.
In this situation, the same thing happened to each of us. But I am likely going to experience a more intense stress response because my appraisal of the layoff is that it is a greater threat and that I have fewer resources to cope with it. The objective reality of the situation is not what created the different intensities of stress. The way we appraised the situation did. These appraisals can have a significant impact on grief and guilt.
Counterfactual Thinking in Grief and Regret
We have an entire article that digs into hindsight bias and counterfactual thinking that I strongly suggest you read. But the Cliff Notes can be summed up with a description found in that piece: “counterfactual thinking is thinking things like ‘what if?” and “what might have been?”. It is the act of coming up with alternative outcomes that are counter to (or different than) the facts. Many times our counterfactual thinking follows an “if-then” pattern. Some examples:
“If I hadn’t slept late, I wouldn’t have missed the bus.”
“If I had gone to that party like I wanted, then I wouldn’t have aced my math test.””
When it comes to grief and guilt, these ‘if-then’ thoughts often come up around the thing we did or didn’t do. We think if something had been different, the outcome would have been better. It is easy to imagine that the alternate reality would be the perfect outcome we wish for, instead of the reality we’re living. We look back and think things like:
“If I had gone on that business trip with my husband, I would have been with him to call 911 more quicly and he wouldn’t have died”.
The reality, of course, is that the alternate ending in this counterfactual reality might not have actually been a better outcome. I might have been on the trip and he still might have died.
How do these things come together to impact guilt or regret? Let’s walk through some of the common situations people share with us. Even if none of these applies to you exactly, there is a good chance you may be able to extrapolate to your own thoughts of grief and regret or guilt.
Why didn’t I do CPR?
My thoughts: In a circumstance where my loved one collapsed in front of me and I didn’t start CPR, my appraisal might be that I was not a responsive or capable person. I am fearful of what this means about me and my ability to care for others. I might blame myself, telling myself that if I had started CPR my loved one would have survived.
The reality that is missed in this appraisal: the acute stress response often causes a person to freeze, leaving them feeling unable to act and sometimes depersonalized from a situation. This is a result of a normal biological response, directly resulting from the surge of stress hormones. It is not a personal failure or a sign that I am not a responsive or capable person. It is a sign that I had a normal stress response to witnessing a trauma. The other reality my appraisal misses is that, even if I had done CPR, I don’t know what the outcome would have been. My loved one still might have died, as 9 out of 10 people who have a cardiac arrest outside of a hospital do (according to the American Heart Association).
Why did I run for help instead of calling 911?
My thoughts: I can’t believe I had my phone in my pocket, and yet instead of thinking to pull it out and call 911, I ran to find someone else to help me. What is wrong with me? I am a terrible person that I didn’t try to help myself and just ran for someone else. How can I ever be trusted in an emergency again? If only I had called 911, she probably would have made it.
The reality that is missed in this appraisal: Though I said to myself ‘I didn’t help’, the reality is that I was trying to help by finding someone else. That acute stress kicked in and my brain was not working the way it normally would. My flight response kicked in. I feared I couldn’t fix the situation and ran for help. With hindsight bias, it is easy to look back and think the alternative thing to do was either easy or obvious. But in the situation, I was doing the best I could with what I had at the time (including that brain full of stress hormones!). I did try to help my loved one, even though it was in a way that my calmer brain doesn’t agree with.
Why did I push agressive treatment for so long?
My thoughts: I was so selfish. The doctor told us after the accident that there was no hope for a meaningful recovery. Why did I keep him on the machines for so long? I just prolonged his suffering. How could I have been such a terrible wife and decision-maker?
The reality missed in this appraisal: The acute stress response sometimes includes our instinct to “fight”. This was such a shock to me when it happened. It is normal that I fought back against what the doctor was saying. I wanted to fight for him if there was any hope. That wasn’t me being selfish or wanting him to suffer. Though he may not have made a decision to be on the machines for himself, he also would understand that I made a decision that was important for me. I needed to know we gave him a chance to recover. That is not being a terrible wife.
Why didn’t I go in to see his body at the hospital/funeral home
My thoughts: I am such a terrible sister. How could I not have gone in to see him? What does it say about me that I didn’t want to say goodbye to him? If I had gone in to say goodbye to his body, I wouldn’t be suffering this much now. My grief and regret would probably be lessened.
The reality that is missed in this appraisal: Crisis, stress, and sadness turn us inward. Our evolutionary drive for survival means that, when we are scared or suffering, we often become intensely self-protective. This does not make me uncaring or terrible. It means I was trying to protect myself so I could still be present for other family and just survive those impossible days. Right now, when I am still feeling this incredible pain, I want to think if I had don’t something differently I wouldn’t feel this immense grief. The reality is that grief is always immense. I don’t know what it would have meant had I done things differently. It might have brought up other, even more difficult, things. I might have been less present for other things. There is simply no way to know.
There are countless other examples and these are just a few. If you have had something that you have gone back to time and again, questioning your action or inaction, please share in the comments. And consider how the acute stress response, your own appraisal of the situation, and counterfactual thinking may contribute to feelings of grief and guilt.
Want to read more about grief and guilt or grief and regret? Check out these articles: