by Deborah Grassman
The stages of ritual also correspond to how we interpret time: past, present, and future. The first stage of a ritual (separation phase) reflects a new willingness to abide with the past, acknowledging the specific brokenness that was incurred. The next stage (transition) highlights the present, where a releasing of the past is done and there is a reckoning with the uncertainty and ambiguities of the present. The last stage of integration expresses a decision that beholds hope for a different future.
I have used rituals professionally when difficult transitions were needed. When our oncology unit developed the hospice program, we didn’t anticipate the strife and division it would cause the staff. Creation of new programs with different patients upset the usual pattern of care. Tension and arguments ensued as staff coped with the change. Staff were reluctant to let go of their identity as oncology nurses and expand into the identity of oncology and hospice nurses. The new identity was necessary for the unit to function successfully.
I designed a therapeutic ritual to promote the inward changes needed to incorporate the larger identity that was needed. During the separation stage of the ritual, each staff member recalled a cherished memory, said good-bye to “the good old days,” and acknowledged the difficulty and pain of doing so. Each proclaimed a desire to grow into a new identity that included hospice nursing. Each brought spiritual readings and songs that reflected letting go and saying good-bye. During the transition stage, the anxiety of journeying into unfamiliar territory was acknowledged. Songs and readings that reflected a willingness to stay open to the uncertainty were articulated as well as a willingness to suffer required changes. Each person acknowledged the difficulty of changing and identified something they needed to do to make the transition into hospice nursing. A circle was formed with each person lighting a candle, saying, “A heart that is willing to suffer is a light to the world.” The integration stage included receiving a small footprints pin with the words, “Know that your journey is sacred and that your footprints are holy.” Songs that appealed to the hope of living from our larger selves were sung; a final blessing dispensed.
There were many tears during this ceremony. There was also much change because there was no longer a need to fight or resist. Problems still arose, but they were dealt with openly and with understanding. I subsequently modified the ritual and used it at the conclusion of each “Living and Dying Healed” course I teach.
Rituals are enacted at time of death on our Hospice unit. These rituals are especially important in our under-ritualized, death-denying, “we-don’t-need-a-funeral” culture. A flag quilt replaces the blanket on the bed while family has time with their loved one’s body. The body is then transported to the morgue under the flag quilt. As the body passes down the hallway, people often turn toward the passing guerney and pay respect with a salute. The patient is also honored with a rose and footprint with his/her name and date of death placed on the empty bed. The six-inch footprints are made by staff from baked dough. When the dough hardens, it is painted. These footprints honor the veteran and also highlight their separation from us. Other patients see the footprint and anticipate that they, too, will be remembered and treated with respect. This footprint also acts as a trigger in the environment for them to anticipate and prepare for their own deaths. The footprint remains on the bed until another patient comes to occupy the bed. Then it’s moved to a wall in the hallway that depicts a rainbowed road with the inscription, “Together we walk, one step at a time.” The wall with all the collected footprints acts as another trigger in the environment for death preparation. In November, the footprint is moved to a holiday tree and later given back to the family members at a holiday bereavement program.
Another important ritual occurs with the family at time of death. After a loved one’s death, an electric candle is lit with the family. The pain they are feeling is acknowledged. The courage to let go is affirmed. Family members are encouraged to tell a few of their favorite stories about their loved one. Each is then asked to write a message to their loved one on the back of the patient’s namecard, one more opportunity to address “unfinished business.” The card is placed on a stand in front of the candle. A prayer or reading that offers hope and support for continuing without the loved one is provided. Marianne Williamson’s book of spiritual prayers, Illuminata, is often used. It has one section devoted to prayers for use in therapeutic rituals. A pin with three footprints is then pinned on each person with staff providing a message of hope. “One footprint is yours. One footprint is your loved one’s. The third footprint represents all the people who are willing to help you walk this painful part of your journey. May each time you see these footprints, you know you are not alone. May you have the courage to ask for help when you need it.” As modern culture continues to devalue grief, as mourning is shortened from months to days, and as funeral services are eliminated, this ritual becomes increasingly valued.
We use ritualized formats that incorporate the three stages of change for several bereavement events. On Memorial Day, we use a ritualized format to provide bereavement care at a picnic. We hold a Memorial service every four months to honor all the veterans who died in the Medical Center. Pat developed the following ceremony that has been particularly effective:
(Pat) “When I look at all of you here today, I feel very grateful both for this opportunity to honor your loved ones and to be able to share with you in your grief journey. Gerald May, an authority on grief said that, “although grief may be the single greatest pain you will experience in a lifetime, it is a pure expression of love.”
“Love in our culture is frequently depicted as warm summer days at the beach without bugs or blowing sand. You all know that love is much more than that. In the circle of life, love is experienced as joy and happiness at times, familiarity and routine at other times, and painful bumps in the road at still other times. Each of these needs forces your love to resiliently change shape to accommodate. Sometimes these adjustments come so fluidly and imperceptibly that we hardly notice.”
“At the close of the circle of life however, the transformation of love to grief is profound. This hospice team is privileged to walk with many of you as your loved one’s circle reaches completion. We are there as the very stuffing of the heart begins to pour out and the transformation begins.”
(I begin to turn the heart inside out, spilling out denial, anger, jealousy, and guilt) “Feelings we don’t want to feel begin to spill over as we fight the inevitable. Finally at the moment of death, the heart strings which are so entwined with one another are tugged and tugged until the heart that is left behind is turned inside out. Love has changed form to grief.” (I hold the inside out heart with it’s strings dangling for all to see.)
“I have spoken with many of you since the deaths of your loved ones. You describe the many symptoms that you are experiencing. You question your very sanity. There are many symptoms of grief.” (The final stuffing to leave the heart contains the physical, emotional, and spiritual symptoms of grief. I discuss each.)
“Ok, your love is turned inside out, your tears are beautiful expressions of the love, and you are not crazy. But now, how do we adjust to the world without our loved one in it? How do we deal with this pain and loneliness? What will help you get through? Who can help?” (The healing tools have been distributed in advance to staff and volunteers in the audience. When I say “who can help”, they begin to bring helpful tools like grief groups, tears, friends, etc. which I discuss while they place stuffing back into the heart. Some of the things they bring (drugs, isolation, denying feelings) do not fit in the heart and actually prevent any of the healing components from getting through. Eventually, the heart regains its shape, it does not look the same, but it looks like a “Heart”)
Denial – “This can’t be happening!”
Anger- “Why is this happening?!?”
Jealousy – “Why can’t my life be like ________?”
Guilt – “If only ______, this would not be happening.”
SYMPTOMS OF GRIEF:
Spiritual – doubt or anger at God
Emotional – depression, panic, anxiety, hallucinations,
Physical – Pain, insomnia, forgetfulness, restlessness,
lack of concentration, confusion
Describe when these things are normal and when they are not.
Goodbye – it’s never too late to say goodbye. We say goodbye to the
physical presence, not the love.
S.T.U.G.s – Sudden, Temporary, Upsurges of Grief
Healing Grief Groups – free at most hospices
Gracious Receiver- people want to help, let them, tell them what
Tears – The only bad tears are the ones you do not shed. Healing
Anniversary/Holidays – hard to get through. Make a plan.
Memorial Services – come together with others to honor/share pain
Laughter – heals
Forgiveness – never too late to forgive. Letter writing.
Rest – emotional surgery
Prayer and God – crying in church
Small pleasures – sunsets, candles, flowers
Good and bad days – let yourself feel good when you can
Friends and family – double edge sword (choose who can help)
Precious memories – those that hurt the most at first may be most
THINGS THAT PREVENT HEALING:
Isolation – OK to be alone, but people need people
Denying feelings – “we weren’t close” can’t heal what we can’t feel
Drugs/Alcohol – prevents healing, keeps us stuck in grief.
Closing (Pat): “Grief will be different for each of you. It will take as long as it needs to take. It is work! Perhaps the goal of the work can be a tribute. The greatest tribute we can give a deceased loved one, a full and happy life. You will never forget your loved one. A Native American medicine man once said, “If the dead be truly dead, why should they still be walking in my heart.” Love is resilient. Love transcends death and the love you shared will live on with you forever.”
The Grief Recovery group also uses rituals to process grief. Bereaved group members finger paint a picture that reminds them of their loved one. One by one, they light a candle and explain the picture to the group. They also tell their loved one whatever they want them to know or they speak any unfinished business. Then they blow the candle out, while being affirmed that they can meet the challenges of a new world without their loved one in it.
When employees die, especially if it’s an unexpected death that leaves unfinished business, I meet with the employees on that unit. A candle is lit, and a memorial card with the person’s name and date of death is given to each person. They write their good-byes on it during the opening separation stage. During the transition phase, a picture of the deceased or some other object is passed and each person recalls a story about the deceased person. In the integration phase, each person identifies one quality of the deceased they are willing to let inspire them.