Before the Loss: Understanding Anticipatory Grief

Before the Loss: Understanding Anticipatory Grief

When considering grief, we typically think first of painful emotions resulting from a loss or transition. In fact, we also experience anticipatory grief about upcoming events or situations we realize will bring disappointment—even expectations that we learn or sense will result in a different, unexpected outcome at some point in our lives.

“Anticipatory grief most often appears in caregivers who are caring for a loved one living with a life-limiting illness, advanced dementia, or a terminal diagnosis, though it can also occur in other circumstances where loss is expected,” says Charlotte “Carla” Archuletta, NCC, BC-TMH, LPC/MHSP, FT, a former Hospice Grief Counselor who is a Clinical Trauma Professional, Certified Grief Recovery Specialist, Fellow in Thanatology, and instructor in the University of Vermont’s End-of-Life Doula Professional Certificate Program. “In these situations, individuals begin to emotionally prepare themselves for the anticipated loss while the relationship with the person is still ongoing.”

Smaller, simultaneous disappointments along the way often heighten emotions and prolong this grief, she says.

“For example, a spouse caring for a partner with advanced dementia may continue sharing daily life with them while also grieving the gradual loss of communication, memory, shared roles, and aspects of the person they once knew, even as their loved one remains physically present. The incremental changes can create a prolonged grieving process that unfolds alongside the caregiving experience.”

Anticipatory grief also occurs in situations aside from death and dying.

“Examples include progressive conditions such as dementia, the anticipated end of a relationship through divorce or separation, loss of health or physical functioning, job loss, major life transitions, migration or displacement, and identity shifts such as children leaving home,” Archuletta says. “In these situations, individuals may find themselves grieving the future they expected, the roles they once held, or the life they imagined would unfold. In this way, anticipatory grief reflects the deeply human experience of facing change and uncertainty when something meaningful is at risk of being lost.”

Clients may present a range of emotions within session, and those feelings may evolve over time, she says, including “persistent worry, emotional exhaustion, and the emotional strain of living with the awareness that a significant loss is looming.” In session, “They oftentimes describe hypervigilance in constant scanning for signs that their loved one’s health is declining or feeling overwhelmed by the uncertainty of what lies ahead. Others report feeling emotionally numb or shut down, while others describe feeling constantly on edge. Many express feelings of guilt about imagining life after the loss. Difficulty concentrating, disruptions in sleep, and heightened vigilance about medical appointments, medical updates, or changes in a loved one’s condition are also common.”

Individuals experiencing anticipatory grief may also shift between seeking closeness to avoidance while coping.

“For example, at times they may feel an intense need for closeness, reassurance, and connection,” she says. “At other times, they may suppress emotions or distance themselves in an attempt to emotionally protect themselves against the pain or fear of the anticipated loss. This oscillation reflects the ongoing process of adapting emotionally to uncertainty and a changing reality.”

Some clients may not be aware of anticipatory grief or realize they are experiencing it, Archuletta says.

“A sense of isolation often accompanies these experiences. For example, because the loved one is still alive, individuals often feel that others in their circle of support do not recognize the grief they are already carrying and experiencing. As a result, many clients will describe their grieving experience as stress, anxiety, or caregiver burnout rather than grief. Part of the clinician’s role is gently recognizing and naming the grief that is already unfolding and that the client is experiencing.”

Providing clients with psychoeducation is a good start to fostering a better understanding, Archuletta says.

“It can be extremely helpful for clients, because many will experience relief simply learning that what they are going through and experiencing has a name. I share with my clients that grief has a language all its own, and when they learn the language, it helps with integration. I find that providing language and conceptual frameworks helps clients understand their reactions and recognize them as a natural and normal human response to loss rather than a personal failing.”

She typically starts this work by explaining the differences between loss, grief, bereavement, and mourning to provide context and normalize the experience, she explains.

“Loss refers to the real or perceived deprivation of someone or something meaningful and includes both death-related and non-death–related experiences; grief describes the emotional, cognitive, physical, and spiritual responses that arise following a loss; bereavement refers specifically to the period of sorrow following the death of a loved one and is always associated with a death; and mourning involves the outward expressions of grief and may include cultural practices, rituals, and personal acts of remembrance.

“Naming the experience as anticipatory grief can help individuals understand that their reactions are not a sign of giving up hope or thinking negatively. Rather, their hearts and minds are attempting to process the reality that a significant loss may be approaching and is inevitable.”

Like other types of grief, anticipatory grief can have a tremendous impact on an individual’s mental health and well-being.

“Grievers experiencing anticipatory grief move though waves of sadness, anxiety, fear, anger, and guilt; however, many describe the confusing experience of grieving someone who is still alive, which can lead to feelings of shame or self-judgment about their grief reactions,” Archuletta says. “Simultaneously, they often feel the emotional pull of wanting to remain present while managing the stress of anticipating an uncertain future.” Trouble sleeping and effects on concentration, mood, and emotional regulation are common, she says, adding that caregivers often experience stress, compassion fatigue, burnout, and social isolation.

It’s important for Counselors to understand that anticipatory grief can manifest in adaptive and maladaptive ways, she notes.

“For some clients, it allows for the emotional preparation and gradual integration of the impending loss. For others, it may intensify anxiety, contribute to caregiver exhaustion/burnout, or lead to premature emotional detachment from the dying person,” Archuletta says. “Factors influencing these responses may include caregiving demands, illness trajectory, attachment dynamics, and the availability of financial, social, and emotional support.”

She shares that despite the pain of anticipatory grief, it can provide space for beneficial, comforting opportunities only available before their loss.

“While the emotional strain is significant, this period can also provide an opportunity for intentional connection and shared meaning. Anticipatory grief can create space for meaningful emotional work to take place. For example, it can provide time to complete unfinished business, allow time for relationship repair, expressions of love, legacy conversations, and intentional presence. When people receive meaningful support, these experiences can provide a sense of emotional preparation and psychological resilience.”

A variety of evidence-based approaches are effective when counseling these clients, Archuletta says.

“Meaning-centered and narrative approaches can help clients explore the significance of their relationships and the values that shape how they navigate this period of life. Attachment-informed work provides insight into how relational bonds influence the intensity and form of grief response. Acceptance-based and mindfulness-oriented interventions can support clients in remaining present even while uncertainty about the future remains unresolved,” she says. “Emotion regulation strategies and coping skills are particularly helpful for caregivers managing prolonged stress and emotional fatigue.”

Additionally, “Legacy work and life review are frequently meaningful interventions during this stage,” she continues. “Encouraging storytelling, memory sharing, and reflection on the relationship can foster connection and meaning. In situations where anticipatory grief intersects with traumatic stress, trauma-informed approaches such as Eye Movement Desensitization and Reprocessing (EMDR) may also be beneficial.”

Lastly, she offers some suggestions to help Counselors better support these clients.

“Encouraging self-compassion and realistic expectations can support caregivers who may be holding themselves to impossible standards. Counselors can also help clients explore boundaries, identify sources of support, ask for help as needed, and prioritize moments of rest and restoration,” she says.

“Facilitating conversations about meaning, legacy, and connection can help clients remain grounded in what matters most during this time. Ultimately, the act of being witnessed in the uncertainty of anticipatory grief can itself be stabilizing. In many ways, anticipatory grief reminds us that grief does not begin at death, but in the human heart’s recognition that love and loss are often intertwined long before goodbye.”

Carla Archuletta, NCC, BC-TMH, LPC/MHSP-S, FT, is a Licensed Professional Counselor and Approved Supervisor in Tennessee specializing in grief, trauma, and health-related transitions. She is a Fellow in Thanatology (FT) through the Association for Death Education and Counseling and integrates clinical counseling with end-of-life care and grief education. She is also an EMDRIA EMDR Certified Therapist, EMDRIA Consultant-in-Training, and EMDR Basic Training Facilitator with ConnectEMDR. She is also a trained end-of-life Doula and serves as an instructor in the End-of-Life Doula Professional Certificate Program at the University of Vermont. Archuletta teaches and presents nationally on grief, end-of-life care, and meaning-making after loss. She is the coauthor of “Health-Medical Challenges and Grief: Group EMDR Therapy for Patients and Caregvers” in EMDR Group Therapy: Emerging Principles and Protocols to Treat Trauma and Beyond (Springer Publishing). For more information visit her website.

Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.  

Recommendations

Books

• Clinical Dimensions of Anticipatory Mourning: Theory and Practice in Working with The Dying, Their Loved Ones, and Their Caregivers – Therese Rando

• Grief Counseling and Grief Therapy, 5th Edition – J. William Worden

• Death & Dying, Life & Living, 9th Edition – Charles Corr, Donna Corr, Kenneth Doka

• The Handbook of Thanatology, 3rd Edition – Heather L. Servaty-Seib, Helen S. Chapple

• EMDR Group Therapy: Emerging Principles and Protocols to Treat Trauma and Beyond – Regina Morrow Robinson, EdS, and Safa Kemal Kaptan, PhD

• What Matters Most – Diane Button

• Grief One Day at a Time: 365 Meditations to Help You Heal After Loss – Alan Wolfelt

• The Grieving Brain – Mary-Frances O’Connor

• Moving On Doesn’t Mean Letting Go: A Modern Guide to Navigating Loss – Gina Moffa

• Preparing for End of Life – Virginia Chang, PhD

• Final Gifts – Maggie Callanan and Patricia Kelley

Professional Development and Training

• ConnectEMDR

• University of Vermont End-of-Life Doula Professional Certificate

• Association for Death Education and Counseling (ADEC)

• American Academy of Grief Counseling

• PESI 2-Day Grief Treatment Certification Course: Evidence-Based Strategies for Helping

Clients Make Meaning After Loss (Carla Archuletta)

Professional Journals

• Journal of Loss and Trauma

• OMEGA – Journal of Death and Dying

• Journal of Hospice & Palliative Nursing

• Journal of Pastoral Care & Counseling

• Illness, Crisis and Loss

• Bereavement Care