I had never even heard the term 'suffocated grief' the first time I witnessed it. Or perhaps I should say the first time I was consciously aware I was witnessing . . . something. Something troublesome. I was in my twenties, a social worker working with families in the hospital at the time of a family member's sudden and unexpected death. I'd been working with a family for most of the afternoon. Their father had been injured in an accident and was not going to survive. As more extended family arrived, the nurse I'd been working with for hours approached me to say she was thinking of calling security. She explained that if the family couldn't 'contain' their grief, it was too 'risky' to have them on the unit.
I was stunned and confused. We were working with the same family but experiencing them entirely differently. And don't get me wrong, this isn't some 'I was such a great social worker, she was such a bad nurse' story. This is a 'being present with human suffering is complicated' story. Where I saw pain, crisis, and grief, she saw a threat. Where I saw a need to provide space and support, she saw something requiring restriction and containment.
Nearly a decade before that moment, when I was still a teenager, my father had died in another ICU in a hospital ten miles away. The man in this ICU bed had kids, a bit younger than my sister and I were when our dad died. This family spilled out of the small ICU hospital room and tiny waiting room, as ours had. They stayed through the night, as we had some nights. They looked as lost and helpless and devastated and angry as I remember feeling.
Where my family and this family differed was in the expression of our suffering. As I watched family member after family member walk into this patient's ICU room, I could hear wailing. It was that visceral crying that comes from one's gut in grief. Extended family members would arrive and learn that there were no more treatment options. Their pain, anger, disbelief, and demands to talk to a doctor echoed from the room.
Working with that family I saw everything I’d felt in my own losses, that my family also felt. But no one ever saw that emotion in the hospital from my family. Because we'd followed the 'rules' - the unwritten grief rules that I hadn’t even been consciously aware of when my father died. I'd come to understand these rules only as I worked with other families. I learned that not everyone holds emotions in. I saw the huge range in people's personalities, cultures, communication styles, and religions. I saw the breadth of grief expressions and I saw how others responded to those expressions. It didn't take long to understand that not all suffering was treated equally, especially when it violated the rules and expectations of the healthcare team.
My mother was in the medical field; she'd worked in a trauma center. She spoke the language of healthcare. Without conscious awareness or discussion, we followed the 'rules' of an ICU. The explicit rules – no visitors after a certain time, leave the room when the doctors and nurses ask, be quiet even when you want to scream. And we followed the unspoken rules too. We'd wait endlessly for meetings with the doctors without complaint, no matter how late they were. We kept our emotions quiet, in meetings and at the bedside, so as not to disturb anyone else. Be polite. Say thank you when the social worker offers you the 37th glass of orange juice that you don’t want. Make sure your pain doesn't cause distress for anyone around you.
We crammed our grief into the social rules and it never felt like a conscious choice. It felt excruciating, but required, part of some tacit social agreement that no matter how bad things are, you hold it in. When I started working with other families and learned it wasn't actually required, part of me envied them. I was I didn't envy their loss, of course. I envied that they were able to outwardly express their anger and despair in a way that I never could. But of course, it came at a price.
For a long time I thought 'disenfranchised grief' defined what I was seeing in situations where medical staff imposed rules on families who were 'too much' in their pain, limiting visitors and making security calls. Ken Doka, who first defined disenfranchised grief, explicitly described one example of it as situations when society is unaccepting of the way one expresses their grief.
It wasn't until years later, sitting in a conference listening to Dr. Tashel Bordere, that I realized it was more than that.. I heard the phrase 'suffocated grief' for the first time, a term she coined. She explained that for some, their expression of grief is not simply unacknowledged or stigmatized, as in disenfranchised grief, but it is punished. As she described normal grief reactions being penalized, all those calls to security flashed in my memory. I thought of all the times that, despite my assurances that there was no threat and this was simply grief, families were punished with security and restrictions on visiting. This limited who could come to the bedside within their last days with a dying family member. These were all subtle and not-so-subtle ways of saying, your grief is not acceptable. Your grief is too much, it doesn't follow the rules. You will be penalized if you can't contain your pain.
Often these sanctions came against families whose grief seemed least understood by the healthcare team. Families whose race, religion, culture, or socioeconomic status didn't align with that of the hospital staff meant that their expressions of grief were more likely to be interpreted as threats than the expressions of families like mine, families who grief expression stayed within the confined rules of a US healthcare system.
Who bears the brunt of suffocated grief?
Unsurprisingly, suffocated grief impacts certain people more than others. Dr. Bordere's finds these disparities impact grieving children in the classroom. The natural grief response in children is not always what people expect, even teachers. It can show up many months and years after a loss, as kids process the loss as they age and their brains keep developing. Rather than sadness or tears, it can show up as kids coming to school sleepy, distracted, having difficulty regulating their emotions, showing signs of regression, or being disruptive.
These are all normal grief responses that we would want to be met with care and support from adults. But like misunderstood families in the ICU, unfortunately, in a school setting they are often misread and met with discipline. Boys exhibiting these types of behaviors are more likely to be punished than girls exhibiting the same behaviors. And lest you think this is just touchy-feely emotional stuff, the impact is tangible.
Studies have found that these differences in discipline starting as early as ages 4 and 5 reduce the likelihood of these boys graduating from high school and college as compared to girls who exhibit the exact same behaviors. Black, Latino, and lower-income children, who are more likely to experience childhood bereavement, are also more likely to be punished and to receive more severe punishments than their white, more affluent peers with the same grief reactions and behaviors. As they get older, these same kids end up more likely to experience incarceration.
It is perhaps no surprise then that when 2,400 incarcerated adults were surveyed about what they believe could have helped keep them stay out of prison, 36% said counseling, with many saying grief counseling specifically. Counseling was tied as the most common response, alongside affordable housing. It was ranked above making a livable wage, completing high school, or going to college. Though the impact of suffocated grief in children can be difficult to directly measure and it certainly doesn't lead to dropping out or incarceration for all students who experience it, many adults bereaved as children can clearly identify its' ripple effects.
Suffocated grief at work
In the US, countless jobs don't offer bereavement leave. For those who are lucky enough to have it, three days is the average allocation. Some can couple that with vacation time and sick time after a death, but many grieving have already used that time when serving as a caregiver before the death.
Returning to work just days after a death works for some people. It can be a nice distraction. But for many, the normal reactions of early grief make it nearly impossible to function at peak capacity at work. Understandably! Memory difficulties, diminished attention and focus, difficulty regulating emotion, and fatigue are expected in early grief. Layer on things like hopelessness, new logistical struggles that come with parenting alone or settling an estate, and it is no surprise employees struggle.
Implicit in these bereavement leave policies is a message from the workplace - we think after three days you should be capable of returning to work and competently doing your job. Where does that leave us when our grief doesn't allow that?
Much of what follows depends on workplace culture. Everything from company policies, the relationship one has with their boss, and how grief-literate a workplace has an impact. We've heard from countless people who experienced disciplinary action and even termination in the early weeks or months following a loss. It is a catch-22 in which limited bereavement leave policies force some people back to work well before they feel able, while then penalizing them for the impact grief has on their job.
These disciplinary actions can leave people's confidence damaged, fearing they're never going to learn to cope. More, it reinforces the idea that grief is a failure or needs to be hidden at all costs. It can create more loss, confusion, and shame - for kids and adults alike. And it can leave those most exposed to death and grief the most vulnerable.
So what do we do?
There isn't some magic answer to the problem of suffocated grief. But it can help your own understanding of your grief if you've experienced this, as a child or an adult. It may have impacted everything from the support you did (or didn't) receive, your perception of your grief reactions, and how your grief shows up now. You might benefit from support in rebuilding your self-confidence or feeling safe to express your grief to others. And sometimes it just helps to have some acknowledgment that if you experienced suffocated grief and it complicated your trajectory after loss, you're not alone and it's never too late to find support.
As a human being - be it a parent or caregiver, an employer or coworker, a teacher or school administrator, we can all be more aware of suffocated grief. Consider how a lack of understanding of grief in schools and workplaces can lead to the punishment of grief, especially for those who might be shouldering the most loss. Check-in on your grieving colleagues. Remember that students may be grieving new losses, but also might still be deeply impacted by old losses. Advocate for better bereavement leave policies. Our greatest hope to improve the culture of grief to collectively become more understanding and empathetic of the many faces and expressions of grief.
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What’s Your Grief? Lists to Help you Through Any Loss is for people experiencing any type of loss. This book discusses some of the most common grief experiences and breaks down psychological concepts to help you understand your thoughts and emotions. It also shares useful coping tools, and helps the reader reflect on their unique relationship with grief and loss.
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