Research Research

Theoretical and philosophical

assumptions behind the concept of
anticipatory grief
Emilie Allard, Christine Genest and Alain Legault

Abstract
Anticipatory grief is a concept commonly used by researchers and clinicians when talking about the
experience before the death of a loved one. This article offers a critical perspective on the
disciplinary, theoretical and philosophical foundations of three distinct and frequently used
conceptualisations of anticipatory grief: Lindemann’s, Rando’s and one derived from sociology.
Lindemann’s perspective conceived anticipatory grief as an inevitable component of the grieving
experience in the situation of impending death. Rando’s perspective views anticipatory grief as a
multidimensional experience that facilitates post-mortem mourning. The third perspective, offered
by sociologists, defines anticipatory grief as an experience highly influenced by the social context of
the individual. This review explains how these different perspectives influence research and
concludes with a reflection for potential future research.
Key words: l Anticipatory grief l Anticipatory mourning l Preparatory grief l Palliative
care l End of life

D
uring the period between the diagnosis
of a terminal illness and death,
terminally ill patients and their relatives
are confronted with the disease, its impacts and
the anticipation of death. Anticipatory grief is
one of the most commonly used concepts by
researchers and clinicians from a variety of
disciplines to explain the experience prior to the
death of a loved one. While the literature
suggests that anticipatory grief could be
experienced by the family members as well as the
dying person, this article discusses anticipatory
grief related to the experience of families. Despite
Emilie Allard its broad acceptance, there seems to be no
Assistant professor, consensus on the actual definition of anticipatory
Faculty of Nursing,
Université de Montreal, grief. Therefore, the purpose of this article is to
Quebec, Canada critically analyse the disciplinary, theoretical and
Christine Genest philosophical foundations that might have
Assistant professor, influenced its definitions. A better understanding
Faculty of Nursing,
Université de Montreal, of these foundations can offer an explanation
Quebec, Canada about how the concept has been used in research
Alain Legault and professional practice. Indeed, as some
Method
A literature search on the concept of anticipatory
grief was undertaken using the following
databases: CINAHL, Medline {AQ: or PubMed
as in fig}, PsycINFO, Web of Science and
ProQuest dissertations and theses. A combination
of the following descriptors and keywords was
used: anticipatory grief, anticipatory mourning,
pre-bereavement, pre-grief, pre-loss grief,
preparatory grief, palliative care, terminal care,
end-of-life. The literature search was conducted
between January and July 2017 on the entire
published corpus of theoretical and empirical
writings addressing the concept since its
introduction in 1944.
A manual search was also conducted using the
same keywords, translated, in two non-indexed
French-language palliative care journals (Cahiers
francophones de soins palliatifs and Revue
internationale de soins palliatifs). After removing
duplicates and articles written in a language
other than French or English, a total of 541
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Adjunct professor, Faculty

of Nursing, Université de authors explain (Paterson et al, 2001; Risjord, entries was identified (Figure 1). By reading the
Montreal, Quebec, 2010), the development of knowledge is titles and abstracts, it was possible to exclude
Canada
influenced by the philosophical and disciplinary papers that did not specifically address the
Correspondence to:
emilie.allard.3@
perspectives of researchers, as well as scientific concept of anticipatory grief in family members,
umontreal.ca and social trends. as well as intervention studies and opinion pieces.

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 Research

Finally, 134 papers were retrieved for analysis.

Such a literature search does have limitations. Records identified through database searches
For instance, only the items listed correctly in the (n=853)
databases used could be identified. In addition, Databases searched:

Identificaation
only articles that were available were included in CINAHL (n=110)
the final sample. PsychINFO (n=256)
The selected papers were read, and various PubMed (n=179)
Web of Science (n=201)
elements were identified: the author’s discipline,
ProQuest dissertations (n=104)
the theoretical framework, the authors’
Manual and reverse search (n=3)
epistemological position (if mentioned), the goal
and questions of the research and the
methodology used. These elements were then
compared and similarities were drawn. At the
end of this process, it was observed that more
than one conceptualisation of anticipatory grief Records after deduplication and removal of those
in language other than French or English
existed. A critical analysis of three distinct and
(n=541)
frequently used conceptualisations of Screening
anticipatory grief is presented in this article.
More precisely, Erich Lindemann first introduced
After reading title and abstract, reasons for exclusion:
the concept, then, Therese Rando offered a new
• Subject not directly about anticipatory grief
definition of anticipatory grief and, finally, • Intervention study
various authors from the field of sociology • Opinion paper
offered critiques of the concept. More specifically,
th i s a rt i c l e e xam in e s s o m e d is c ip lin a r y,
theoretical and philosophical foundations that
might have influenced the development of each of
Included

these conceptualisations. It should be noted that Full-text articles in final review

philosophical positions were rarely explicit in the
articles. Nevertheless, the foundations were
hypothesised from contextual, disciplinary and
methodological information that showed an
association with a philosophical position.
However, the theoretical and epistemological
foundations deduced from these authors’ work
corresponds to our point of view and has not
been validated by the authors analysed. Finally,
readers are invited to consult the references used
to describe the philosophical stance to pursue
their own understanding.
Erich Lindemann’s concept of
anticipatory grief
The concept of anticipatory grief was first
introduced in the scientific literature in 1944 by
the psychiatrist Erich Lindemann. Interested in
the experience of grief, an emotional response to
a loss (Stroebe et al, 2001; Fulton, 2003).
Lindemann conducted a series of interviews with,
and made observations of 101 grieving people
who included psychiatric inpatients, relatives of
those who died in hospitals, survivors and
relatives of tragically deceased persons and some
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(n=134)
Figure 1. Flow diagram for literature search results (Moher et
al, 2009)
achieved by emotionally detaching oneself from
t h e d e c e a s e d p e r s o n , r e a d j u s t i n g o n e ’s ❛Grief reactions
environment and developing new relationships. It were
is only at the very end of the article that
unexpectedly
Lindemann introduces the concept of
anticipatory grief (Lindemann, 1994). Grief recorded in the
reactions were unexpectedly recorded in the family members
family members of soldiers who had been of soldiers who
deployed in the war, but who were still alive. The
had been
author suggested that these family members,
under the threat of a potentially impending deployed in the
death, experienced grief prematurely. It is this war, but who
phenomenon that the author called anticipatory were still alive❜
grief. Lindemann (1994) considered anticipatory
grief both as a reaction to protect oneself from
the negative impact of the announcement of the
death of a loved one, and also as a reaction that
is detrimental to the relationship if the death
does not occur.

relatives of deployed soldiers (Lindemann, 1994).

Inspired by psychoanalysis and Freud’s work, A conceptualisation influenced by
Lindemann suggested that to accept a loss, logical positivism
bereaved persons must go through a grieving Through some contextual information, such as
process (Granek, 2010). This grieving process is the discipline, era and research interests of the

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Research
author, an affiliation to the epistemology of
logical positivism can be deduced.
The period in which Lindemann was
conducting his study is an important factor. In
the early 1940s, logical positivism was at its peak
in the English-speaking world (Lecourt, 2010;
Risjord, 2010). This period also corresponds to
the desire for scientific recognition in the fields of
psychology and psychiatry, as well as to the
establishment of the biomedical model based on
positivism, among other concepts (Granek,
2010). Thus, according to Granek (2010),
Lindemann’s observational study made it
possible to go beyond the psychoanalytical
representation of grief to reach an objective
conception of the phenomenon, allowing
psychiatry to establish itself scientifically and to
mark the beginning of the medicalisation of grief.
The way in which Lindemann (1994)
conceptualised anticipatory grief rests on the
postulate of the existence of a shared reality,
which is coherent with positivism, where reality is
external to being. This assumes that anticipatory
grief happens independently of our action or
knowledge of it. Thus, the objective of science is,
using scientific methodology, to uncover this
reality (Guba and Lincoln, 1994). Positivism is
based on objectivity, meaning that scientific
knowledge must be derived from sensory
experience to be verifiable (Guba and Lincoln,
1994; Risjord, 2010). Despite methodological
limitations that reduce the ability to verify the
knowledge produced, such as the lack of
information about participant groups or the
interview process, Lindemann’s (1994) study was
still an attempt to objectify the phenomenon. For
example, he suggested that certain symptoms are
predictive of anticipatory grief, like the loss of
appetite or depression. At the end of the study,
Lindemann (1994) was able to produce a
framework for apprehending and predicting the
experience of grief, represented as a list of
symptoms illustrating normal, complicated and
anticipatory grief.
This conceptualisation represents a
simplification of the experience of grief to what
is observable. It does not allow for a
consideration of different individual and social
factors associated with the experience of the
loss of a close relation (Fulton and Gottesman,
1980; Evans, 1994; Fulton et al, 1996; 2003).
Although Lindemann’s conceptualisation can be
considered reductionist, the fact remains that it
has had, and continues to have, a significant
influence on how to conceive and mediate the
experience of grief and anticipatory grief
(Granek, 2010; Gross, 2016).
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The evolution of the concept by
Therese Rando
Therese Rando, psychologist, thanatologist and
author, has published and edited several
theoretical and practical works on grief and
anticipatory grief, a concept that she has
greatly helped to redefine over the years.
In her 1984 book, she defined anticipatory
grief as normal bereavement combined with a
grieving process that occurs before the death of
a loved one (Rando, 1984). In this definition,
bereavement is an event, or time, after a loss,
when grief is experienced and mourning occurs
(Stroebe et al, 2001). This definition largely
corresponded to the original concept proposed
by Lindemann. However, the author emphasised
the protective quality of an individual’s
experience of grief before the death, which
allows a person to be better prepared for the
death of their loved one, thereby reducing the
length and intensity of the grieving process
post-mortem, thus avoiding the development of
complicated grief (Rando, 1984).
From 1986 onwards, it is possible to observe
an evolution in Rando’s model of the concept
of anticipatory grief, which she renamed in
1988 as the process of anticipatory mourning.
Mourning is defined as the external, cultural
and social expression of grief (Rando, 1984;
Stroebe et al, 2001). Similarly to other authors
(Fulton and Gottesman, 1980; Siegel and
Weinstein, 1983), her new model questioned
the original conceptualisation of anticipatory
grief because of the linearity of the initially
suggested grieving process, and the lack of
recognition of the losses experienced during
the period surrounding the death. Thus, Rando
(1986; 1988; 2000) redefined anticipatory
mourning as a multidimensional process,
identifying six dimensions, initiated by the
expectation of loss, namely the diagnosis of a
terminal illness, that also includes recognition
of the many losses associated with the
progression of illness and the period
surrounding death.
Although she recognised the difference
between the experience of anticipatory
mourning and post-mortem mourning, Rando
(2000) continued to recognise anticipatory
mourning as a therapeutic and protective
experience that facilitates post-mortem
mourning. She also suggested that healthcare
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professionals, mainly psychologists and
psychiatrists, should intervene in this
anticipatory mourning process to reduce the
risk of complicated grief after the death of the
loved one.
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A conceptualisation influenced by
post-positivism
Although Rando did not specify her
philosophical basis, some contextual elements, as
well as the way in which she explained her vision
of anticipatory mourning, seem to correspond to
the epistemology of post-positivism.
The first piece of context comes from the
philosophical tendencies of the period during
which Rando proposed a revision of the concept
of anticipatory grief to anticipatory mourning.
During the 1970s, there was a tendency to
abandon positivist theories, particularly in the
social sciences (Risjord, 2010). In fact, the causal
links supported by positivist philosophy were
questioned by the philosophers of the time, who
began to perceive reality as complex and difficult
to access with certainty through human
observation alone (Risjord, 2010). Post-positivism
is therefore an epistemological posture that enters
the social science scene as an alternative to
positivist perspectives(Risjord, 2010).
In addition, clues in Rando’s writings allow us
to weave a link with post-positivism. Among
them, the author mentioned the difficulty of
observing the whole phenomenon of anticipatory
mourning. Indeed, she (Rando, 1986) supported
the existence of anticipatory mourning, but that
we can only observe a small part of it. This is
coherent with a falsificationist view of science
(Popper, 1968; Risjord, 2010). Post-positivism
proponents, such as Karl Popper, suggested that
theories can be observed as false, but can never
be officially confirmed (Risjord, 2010). Moreover,
in subsequent writings, Rando delved into the
many dimensions that may be involved in the
experience of anticipatory mourning (Rando,
1986; 2000). She suggested that the interaction
of these dimensions may, in a particular context,
be identified by healthcare professionals as
anticipatory mourning. This fits with a post-
positivist position, where theoretical hypotheses
are created and deductively tested in order to
explain phenomena (Popper, 1968; Risjord,
2010). Rando’s six dimensions of anticipatory
mourning and their interaction are an example of
a hypothesis generation and causal chain. Thus,
the importance that Rando (1986; 2000)
attached to the theoretical modelling of the
dimensions can be considered an attempt to
explain the phenomenon of anticipatory
mourning. She did not claim that this modelling
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is exact, but rather attempted to offer a coherent
explanation of the phenomenon. This way of
conceiving knowledge is also relevant to the
perspective of post-positivism where knowledge
is seen to be hypothetical and fallible (Risjord,
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2010). The difference between Lindemann’s and
Rando’s conceptualisations can be explained, in
part, by their different epistemological perspectives.
Nevertheless, these two visions share a similar
ontological basis and a desire to reflect the
phenomenon as faithfully as possible.
Criticisms of the concept
Several of the analysed papers from the field of
sociology offered a strong critique of the concept of
anticipatory grief (Siegel and Weinstein, 1983;
Fulton et al, 1996; Fulton, 2003). Some of these
critiques were judged as being purely semantic
(Clukey, 2002), but we believe they broadened the
discussion around the concept of anticipatory grief.
Among the main points made by these authors
is the use of the concept of anticipatory grief in a
clinical setting, and the lack of consideration for
social aspects surrounding the experience of
illness, death and bereavement. Indeed, since its
introduction by Lindemann, the concept of
anticipatory grief was rapidly and widely used by
health practitioners to explain the experience of
an approaching death. Some authors (Siegel and
Weinstein, 1983; Fulton et al, 1996) attributed this
clinical infatuation with the concept of
anticipatory grief to the importance accorded to
the biomedical model (Siegel and Weinstein, 1983;
Fulton et al, 1996). Others suggested that the
popularity of the concept could be related to its
protective quality, that is experiencing anticipatory
grief can prevent complications during
post-mortem grief (Siegel and Weinstein, 1983).
In the same vein, all of these authors (Siegel
and Weinstein, 1983; Fulton et al, 1996; Fulton,
2003) criticised the reductionist character of the
concept of anticipatory grief and the grieving
process affiliated with it. According to these
authors, the palliative phase of an illness, as well
as the period surrounding the death and
subsequent bereavement, are experiences that are
defined by social, cultural and spiritual
components that the general concept of
anticipatory grief does not explain. In an article on
the psychosocial aspects of anticipatory grief,
Fulton and Fulton (1971) explained that the grief
reactions experienced by a person are largely
characterised by the social and cultural context in
which they are situated. Thus, without disproving
the concept of anticipatory grief, the authors
suggested taking into consideration the social
consequences of grief experienced prior to a
death. In addition, Fulton and Gottesman (1980)
reported that the relationship a person has with
the dying person has an impact on the way they
understand and live the terminal illness and the
subsequent bereavement. According to them, the
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concept of anticipatory grief should be more
representative of the cultural, social and
relational dimensions constitutive of this period
of life. It is also in this sense that Fulton et al
(1996) explained that researchers interested in
the social phenomenon of grief, whether
anticipated or not, should move away from
positivist and realist philosophies in order to gain
a better understanding of the phenomenon.
A conceptualisation influenced by
social constructivism
From the criticisms raised about the lack of
consideration of the social and cultural aspects
of the concept of anticipatory grief, it is possible
to infer a posture of social constructivism.
Moreover, this epistemological stance has been
explicitly mentioned as being relevant to the
sociological analysis of the end-of-life
experience in two of the analysed articles
(Fulton et al, 1996; Fulton, 1999).
Rather than conceiving of knowledge as an
objective representation of reality, knowledge is
seen as being socially constructed from
experience (Berger and Luckmann, 2014).
Similarly to the two other philosophical
perspectives, social constructivist authors
(Elder-Vass, 2012; Berger and Luckmann, 2014)
considered that there is a reality independent of
people, but stressed that we should be more
focused on the way in which the process of
building knowledge is influenced by the social
components of the world. Thus, social
constructivists place more emphasis on the
social aspect of knowledge development.
In this sense, without categorically denying
the possible presence of anticipatory grief, the
authors who have offered a critique of the
concept (Siegel and Weinstein, 1983; Fulton et
al, 1996; Fulton, 2003) have underlined the
importance of considering the bi-directional
influence of social and cultural components in
understanding anticipatory grief. This way of
viewing the complexity and dynamism of
experience leads to a significant fracture with
the deterministic vision of Lindemann’s
anticipatory grief.
How these conceptualisations
influence research
Following the critical analysis of these three
conceptualisations of anticipatory grief, the
second objective of this article remains to
determine the impact of these different
conceptualisations on research and subsequently
on professional practice. Let’s start by emphasising
that the theoretical and conceptual perspectives of
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researchers for example, the concept of anticipatory
grief, influence the way in which they envisaged
the issues, objectives and research methodologies,
as well as the way they discussed the results
obtained. As mentioned earlier, authors’
disciplinary, theoretical and philosophical
affiliations are not always explicit in the writings
used as theoretical support in research, which
may, in part, explain the confusion around the
use of different conceptualisations of anticipatory
grief. Without claiming an exhaustive review of
all the empirical literature on the subject, it is
possible to notice a strong influence of post-
positivist and reductionist perspectives in
understanding the concept of anticipatory grief.
Indeed, anticipatory grief seems to be mainly
understood as a phenomenon common to all
end-of-life situations and, in some cases, an
objectifiable and measurable phenomenon.
Also, as mentioned by some authors (Fulton
and Gottesman, 1980; Fulton, 2003; Nielsen et
al, 2016), there is a confusion over terminology.
While reviewing the retrieved papers, the
following terms were sometimes used
interchangeably: anticipatory grief, warning of
loss, pre-death mourning, pre-bereavement and
anticipatory mourning process.
Similarly, the fact that anticipatory grief is
triggered by the announcement of the
approaching death seems to suppose that this
phenomenon is common to all end-of-life
situations, thus reflecting a lack of consideration
for the various individual, social and cultural
factors that can influence the experience leading
up to death. This commonality of the experience
is noticeable where the samples used in the
research vary according to age, gender,
relationship with the dying person and context of
the disease (Allard et al, 2016). For example,
some researchers have explored the concept of
anticipatory grief in elderly palliative care
patients (Cheng et al, 2010), others with
caregivers of people living with dementia
(Garand et al, 2012), while still others were
interested in the same concept in parents of
children with cerebral palsy (Al-Gamal, 2013;
Al-Gamal and Long, 2014). Moreover, some
authors (Johansson et al, 2013) have been
interested in comparing the experience of
anticipatory grief between caregivers of palliative
cancer patients and caregivers of people with
dementia. However, as mentioned by Blandin and
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Pepin (2017), the caregiver’s experience of a
person with dementia follows a particular
trajectory that is different from other illnesses
and thus refers to a unique process of grief that
could not be compared with anticipatory grief.
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Lindemann (1994) and Rando (1984; 1986;
2000) suggested that anticipatory grief is
characterised by a linear grieving process, a
process of detachment or readjustment
progressively moving towards the resolution of
grief. This linear view of grief before and after
death is also present in the empirical literature.
For example, the objectives in Gilliland (1992)
were to explore the impact of anticipatory grief
on post-mortem mourning. Moreover, it is with
this same objective and realistic vision of social
phenomena that tools have been developed to
help clinicians and researchers recognise and
measure anticipatory grief or its components,
such as depression or anxiety. Among these tools
are the Anticipatory grief scale (AGS) (Theut et
al, 1991; Holm et al, 2019), Preparatory grief in
advanced cancer patients (PGAC) (Mystakidou et
al, 2008; Vergo et al, 2017), Marwit Meuser
caregiver grief inventory (MM-CGI) (Marwit and
Meuser, 2002; 2005; Marwit et al, 2008),
Terminally ill grief or depression scale (TIGDS)
(Periyakoil et al, 2005), and Caregiver grief scale
(CGS)(Meichsner et al, 2016). However, it seems
relevant to question these writings, since the
desire to objectify the experience before death
risks favouring a reductionist vision. Moreover,
by reading the components of these tools, one
might question whether the experience of
anticipatory grief is not sometimes reduced to an
experience of depression or anxiety.
Conversely, some authors (Fasse et al, 2013;
Clukey, 2002; 2008; Bouchal et al, 2015) have
qualitatively explored the experience of anticipatory
grief and observed a more dynamic and complex
experience than their initial conception of the
phenomenon suggested. According to these authors,
the experience of anticipatory grief should be
understood as a transitional phenomenon that
possesses its own beginning, ending and dynamic.
Therefore, from this perspective of anticipatory grief
as a transition process instead of a grief process, it is
flawed to compare the experiences lived before and
after the death.
Continuing professional development: reflective questions
●
●What are the three conceptualisations of anticipatory grief defined in this article?
●
●How do you personally understand anticipatory grief?
© 2020 MA Healthcare Ltd
●
●Which conceptualisation fits best with your understanding of anticipatory grief?
●
●How could your professional practice could be influenced by the different conceptualisations of
anticipatory grief?
International Journal of Palliative Nursing 2020, Vol 26, No 2
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Key points
●●Our conceptualisation and understanding of anticipatory grief is
influenced by our disciplinary, theoretical and
philosophical perspectives
●●Influenced by logical positivism, Lindemann described anticipatory
grief as a list of reactions/symptoms
●●Influenced by post-positivism, Rando described anticipatory grief
as a complex and multidimensional phenomenon
●●Influenced by social constructivism, some authors described
anticipatory grief as a complex and and dynamic
social phenomenon
Directions for reflection
and conclusion
The purpose of this article is to show how
disciplinary, historical and contextual factors, as
well as theoretical and philosophical perspectives,
not only influenced the ways in which
anticipatory grief was defined, but also how it
can influence the way researchers undertake their
research, and how readers can interpret the
results. Extrapolating this idea, we believe this
interpretation can also influence the care
provided to people at the end of life and their
families. Greater emphasis should be placed on
the clarification of these theoretical and
philosophical factors in scientific writings.
Thus, in full transparency, it seems appropriate
to clarify the position of the authors of this
article. Their posture is rooted in radical
constructivism, which indicates that the only
access to reality is through an individual’s own
experience (von Glasersfeld, 1984; 1996). This
experience is influenced by the social and
historical context as well as by individual
interpretation. Therefore, it is not because two
individuals have the same social context that they
have the same interpretation of an experience:
experiences are unique owing to their
multidimensionality, and also because these
dimensions are uniquely related and dynamic in
creating the phenomenon. Thus, the authors
argue that these conceptualisations of
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Research
anticipatory grief are not enough to understand
the complexity and uniqueness of the experiences
that may occur prior to the death of a loved one.
It is their view that it would be more relevant for
researchers to rely on a philosophical perspective
that underlies a pluralistic view of experiences in
order to broaden the understanding of this
period of life. IJPN
Conflict of interest: None
Acknowledgements: This work, based on a PhD
thesis, was supported by the Social Sciences and
Humanities Research Council (SSHRC) (grant
numbers 752-2015-1389), the MEES-Université
and the Faculty of Nursing at Université de
Montréal. The authors thank Traduction Dupont
for their translation of this article from French to
English, Charles Lespérance for his help in editing
the article, and Sylvie Gendron for her
constructive comments on the article.
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