February 2026: Complexities of Bereavement: The Situation of Loss

by William G. Hoy

No person grieves in a vacuum. In other words, people grieve in the same manner with which they live, and the issues that complicate life before loss tend to follow us right into the loss. Often, the stresses of grief magnify the life difficulties with which one struggles. This phenomenon is what I call selfhood, and it is one of the constellations of factors that potentially makes grief more complex. For counselors and others who support bereaved individuals, identifying these factors early in the experience can prove pivotal to success in the healthy integration of loss into the rest of the bereaved individual’s life. While not everyone needs the help of a clinically-trained, grief-informed professional to work through this aspect of grief, the complex nature of these factors will necessitate professional help for many (Hoy, 2016, 2025).

In my work, I have seen selfhood as one of the three inter-related constellations of factors that impact the grief experience. The other two are support (what systems are in place to help the bereaved find their way) and situation (the circumstances of the loss and the life situation of the bereaved). Like the diagram indicates, these overlap and contribute to one another in the process (Hoy, 2016, 2025). For example, a person diagnosed with borderline personality disorder predating the death has likely alienated much of her support system, long before needing those family members and friends in the grief process. 

Some of the issues of selfhood become evident in a thorough initial assessment which is a principal reason I believe this is so pivotal to good work with bereaved individuals. I will not receive a person into a bereavement group I lead, for example, without a thorough initial assessment (at least by phone if not in person), utilizing the questions at the end of this article and the other articles in this series (GriefPerspectives, January and March). During this “getting to know you” period, the bereaved individual has an opportunity to talk about the good, the bad, and the ugly of the relationship. Though many bereaved individuals tend to put their deceased loved ones on a pedestal, listen for “chinks” in the story such as, “She tried to be a good mom…” or “I guess he did the best he could.” I try to not let such comments pass lightly; “What did you mean a few minutes ago when you said, “I guess he did the best he could?’” is one way I follow up later in the conversation.

A history of substance addiction and physical, sexual, or verbal abuse might also emerge during the assessment, though in my experience, these often do not show up until a later conversation after trust is gained. Many colleagues have heard me talk of “Mike,” the 24-year-old who sought my help after his father’s death. Weeks into our work, he revealed that his father had sexually abused him for several years in his pre-teen years, and the young man told me something I have quoted hundreds of times: “I guess one thing I am learning, Bill, is that sometimes grief isn’t so much about what you lost as it is about what you never had.” 

When I am supporting a bereaved individual dealing with the death of a parent, for example, I ask questions about what life was like years ago and how that changed over the decades. One woman with whom I was working seemed to be dealing with intractable guilt because her father had lived in a nursing facility the last several months of his life. Several weeks into our work, she explained that he had been an abuser of alcohol in her childhood and teenage years, and after her mother’s death my client was a youngster, she had become the person who “always rescued” her dad after his drunken binges. He had been sober for a number of years by the time of his death but she had never escaped her need to rescue him and that seemed to be an important key in the guilt she was experiencing. Like with many of these issues, collaborating with the bereaved person to label the disturbance is much of battle to finding a place for that emotional experience.

Knowing a bereaved individual’s mental health history is also vital in the initial assessment with someone new with whom you are working. When an individual has a diagnosis and/or is already in treatment for clinical depression, generalized anxiety disorder, or PTSD, you can be sure those issues will not magically disappear because of a new loss; usually, they are exacerbated by the loss. This is especially key for hospice bereavement counselors because the routine follow-up offered by the hospice might reveal a need for the person to schedule a follow-up with the professional who is already managing their care, especially when their mental health disorder has been well-controlled for a long period. 

One person I worked with had been treated for an anxiety disorder years before his wife died, but many of the symptoms reappeared a few months after his wife’s death. His physician prescribed the same medication used the first time and he reconnected with his therapist. A month or so later in our support group, he reported that he felt like what he had most needed was a “tune up” and had gotten it by reaching out to the professionals who had managed his care a few years earlier. Listen for these background elements in the story and help people find existing or new resources to help.

A thorny issue with bereaved persons involves “unfinished business” in the relationship with the person who died. Though I have seen this more often after traumatic and unexpected deaths, unfinished business can occur in any circumstance. This sometimes surfaces as guilt, regrets, or unfulfilled wishes that things would have been different. Never assume you know what the bereaved person means when she says, “I wish I would have been there when he died…” Rather, inquire, “What do you most wish would have been different about that?” or “How would you have liked to have responded in that situation?” This line of questioning can often grant permission to talk about words left unsaid or actions that one wishes one could undo. 

One value to professional support after a loss is that we do not try to minimize the bereaved person’s lived experience in the ways that well-meaning friends and family members might with responses such as, “Well, I never saw that side of mom’s personality…” or “That is not how mom behaved; you are making that up!” While history cannot be reversed, talking with a trained professional about these issues can often lead to an emotionally appropriate place to hold these memories, and finding such a place becomes the goal in this kind of treatment.

Perhaps the most overlooked area of selfhood, however, is the physical well-being of the bereaved individual and the treatment one is getting for those maladies. While the old adage, “the cure is worse than the disease” might not be entirely accurate, it is vital that clinicians understand the potential mental health side effects of physical illness and its treatment.

In a compelling study published a few years ago in the Journal of the American Medical Association , for example, researchers found that more than 200 medications commonly used for pain, cardiac illness, high blood pressure, and common gastric ulcer and chronic indigestion/GERD treatments have depression as a known side effect (Quato, et.al., 2018). Though much older, Tango’s (2003) study demonstrated wide psychiatric side-effects in common medications, the use of which grows exponentially with older patients who may be on multiple drugs for cardiac rhythm, hypertension, and other common older-age maladies.

In my experience, patients are almost never told to expect these outcomes. While it is clearly “out of scope of practice” for me to advise bereaved individuals in my care about using or discontinuing medications, what I can do is refer them back to their pharmacist and the prescribing provider for more information. Clinicians who treat large numbers of bereaved people who likely have multiple health conditions should learn all we can about these drug interactions through reading articles such as these and availing ourselves of specialized training online or in person. I am grateful that my doctoral advisor had a specialization in pharmacology and exposed us to these resources early in my training. 

The point is I cannot know any of these factors that potentially complicate grief if I do not ask. Some questions are effective when used later in the therapeutic relationship, after rapport is established, and I will often follow up on a question from weeks ago by saying something like, “A few weeks ago, you and I talked about things you wish you could change. Have you thought more about that since our first conversation?” Nevertheless, I take a thorough history which includes questions like the following as part of my initial assessment with a bereaved individual. 

• What have been the hardest parts of this experience for you so far?

• Where do you sense you are having the toughest time with this loss?

• Would you tell me a bit about how you and N. were connected?

• Would you tell me about your experience with counselors before now? (This often yields important clues about mental health history).

• Before this loss, what was the worst thing that happened to you? How did you get through that?

• What were the best parts of your relationship? What do you wish you could change?

• Believe it or not, physical illness and its treatment can have a big impact on how you process grief. Would you tell me about the illnesses you have experienced lately and the medications you now take?

One of the adages I heard often as a child was that “leopards don’t change their spots.” This proverb was quoted in our home about a dizzying array of issues, but the basic truth is helpful for grief counselors: a person grieves as he or she lives. We do not instantly get a personality transplant the moment a loved one dies, and stress tends to reveal much of the psychological damage that has remained dormant, perhaps for many years. Be vigilantly on the lookout for these significant complexities of loss.

References. 

Hoy, W.G. (2016). Bereavement groups and the role of social support: Integrating theory, research, and practice. Routledge. 

Hoy, W.G. (2025). Creating meaning in funerals: How families and communities make sense of death. Routledge. 

Qato, D.M., Ozenberger, K., & Olfson M. (2018). Prevalence of prescription medications with depression as a potential adverse effect among adults in the United States. Journal of the American Medical Association, 319 (22), 2289–2298. https://www.doi.org/10.1001/jama.2018.6741(available free at the JAMA website by following the hyperlink).

Tango, R.C. (2003). Psychiatric side effects of medications prescribed in internal medicine. Dialogues in Clinical Neuroscience , 5 (2), 155–165. https://doi.org/10.31887/DCNS.2003.5.2/rcasagrandetango  

The Author: For more than 40 years, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide more effective care. After more than 17 years in hospice care, he served as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas from 2012 to 2024. In his semi-retirement, he continues to write and provide resources and training seminars to colleagues who care for the bereaved. He can be reached at Bill_Hoy@baylor.edu.