How Should We Be Talking About Grief?

In the wake of a loss, how do we reconcile the Five Stages of Grief with feelings that shift day to day? In this episode of Health Science Radio, licensed professional counselor and assistant professor of psychiatry Mandy Doria walks through some common misconceptions about grief, loss and healing. 

Content warning: death and dying. 

Transcript

Matt Hastings:

Welcome to Health Science Radio – a podcast from the University of Colorado Anschutz Medical Campus. 

A content warning at the top: the topic of this episode is grief and loss, so we will be discussing death and dying.  

In 1859, the naturalist, author and philosopher Henry David Thoreau wrote of loss in his journal: 

I perceive that we partially die ourselves through sympathy at the death of each of our friends or near relatives. 

Each such experience is an assault on our vital force. 

It becomes a source of wonder that they who have lost so many friends still live. 

After long watching around the sick-bed of a friend, we, too, partially give up the ghost with him, and are the less to be identified with this state of things. 

Helping us dig into the complexities around these topics is Mandy Doria – a licensed professional counselor and assistant professor in the Department of Psychiatry at the University of Colorado School of Medicine.

Doria works with patients to reframe how we examine and discuss grief to normalize the feelings around grief that are simultaneously both intensely personal while being part of the larger, shared human experience. 

Matt Hastings:

Okay. So, Mandy, how would we define grief?

Mandy Doria:

This is a great question, not only for our conversation, but for our society too. So most of us define grief in the traditional sense of loss:  losing a loved one to whether that's to a sudden illness or a traumatic death. But really, grief is a sense of change in our life. Grief can be anything from a job loss to moving, to political and social unrest, or even relationships changing. There's a lot that's going on in our world, and so there's a lot to grieve. There's a lot of that emotion to go around. And typically, anyone you ask about the most impactful time in their life, it likely is going to have something to do with grief or some big significant change in their life.

Matt Hastings:

Is it part of it too, that it's the human mind trying to categorize something that may feel too big, too unknowable, to try and process and categorize that experience?

Mandy Doria:

Sure, yeah. We're always trying to understand the human experience, and when we try to put something in a box, usually we do that in order to define it so that we can control it, and then react to it, and deal with it, right? We want to deal with our grief and move on, and be able to know how to do that. But it's not that simple, right? It can’t always be put in a box, and there's a lot more existential depth to these experiences that we have as humans.

Matt Hastings:

It's connected to, in what we consider traditionally as a positive experience. There's a positive connotation to joy, and to happiness, and to love. So there's a thought that the inverse of that must be inherently negative. And so do you think that that drags down the concept of how we talk about grief?

Mandy Doria:

Yes. I do think people are afraid to maybe, not only address their own grief because it is a painful process and can be difficult, but it's also hard for us to address grief with each other in society and talk about it and leave space for our grief stories. Typically, I hear a lot from other people when I'm working with patients who are dealing with traumatic loss, "How do you hear these stories? Isn't it so depressing? I don't know how you do it," but it's not just about the difficult experiences, right?

There's often a lot of room for connection and love and joy in this kind of work and in the discussions about grief that we can have. I really believe that to grieve is to have loved. You can't really feel loss or pain without having loved and lived your life. So validating that, "This is a part of the whole experience," and maybe not, like you said, polarizing grief as a negative thing, but as a common normal thing that we all go through in some way, shape, or form.

Matt Hastings:

Yeah. And so given the fact that it's such a universal experience and so intensely personal at the same time, the previous attempts to try to talk about grief from an academic perspective – I think a lot of folks' concept of that really adheres back to the five stages. Just so people are kind of clear on them and what we're talking about, do you mind running through the original five stages that were outlined in the 1960's, right?

Mandy Doria:

Yeah. It was actually, I believe 1969, Elisabeth Kübler-Ross came out with her book, On Death and Dying, and she carved out these stages initially for healthcare workers to understand how their terminally ill patients were feeling. So it was a set of characteristics, and feelings, and thoughts that went along with knowing that someone might die. 

And those stages are denial, anger, bargaining, depression and acceptance. A lot of people like to criticize these stages because that's not really the order that emotions always go through, so she did come out with this book to address some of those questions and criticisms in 1974, to remind us that these are not prescriptive.

We don't have to go in this order. We can bounce around from minute to minute, hour to hour, day to day. It's more of a scaffolding, dynamic process of what we might experience, not necessarily in a linear fashion.  

Matt Hastings:

Right. And then, with  that too, she also amended it to say that it wasn't just for those healthcare workers and it could be experienced on the individual level, right?

Mandy Doria:

Yes. So once you lose someone, these are stages of grief that you might go through, and so then, she and David Kessler combined their work together to come out with their book, On Grief and Grieving, to kind of address what that is like for the grieving individual to face.

Matt Hastings:

Where does the academic literature around defining these as set categories, or how we talk about the process of grieving? Where is the literature on that right now?

Mandy Doria:

We still use these five stages of grief to be conversation starters with our patients to address how they're feeling, and we talk about how this is a contiguous process. There is nothing that needs to stop and start at any point, and that there is no timeline for grief. 

There are a lot of other models out there that people like to use, which we don't have time to get into, but the most recent adaptation of this model was David Kessler's work on adding a sixth stage of grief, saying that we don't need to stop at acceptance. In fact, most people don't want to accept this loss, and that didn't feel right to move forward with that stage. So he came out with the sixth stage that he and Elisabeth worked on together, called Finding Meaning. It was more about honoring and marking that loss, and what it meant in order to engage with how to move forward in your life so that you don't have to leave it behind. You take it with you, but in a meaningful way, and try to integrate that into your practice.

So when we're thinking about the literature now, there's a lot of room for some work on this because it is a complicated process, but I do find that this stage helps me work with my patients in conversations of how they would like to integrate this loss into their life.

Matt Hastings:

It's a good place to start to have those conversations.

Mandy Doria:

Yes. And just like we can't put people in a box, we also can't put interventions in a box. So really, I think the ability to connect with people and their story and be present with them in their pain is what we find to be the most helpful. And  helping people navigate some of these stages to normalize them and name them. Sometimes when we name them, we can validate them. David Kessler says, "You cannot heal what you cannot feel," so just really encouraging those feelings to come up, and then processing them.

Matt Hastings:

And it seems too, that having  meaning be a final one that's added onto this current framework, this current way of understanding and thinking about it, meaning really sets it apart from the other five in that it's intensely personal. It is what your definition and what your personal definition is of finding meaning, entering this new stage of your life with this grief and how you carry it, and interface with it, and interact with it. So could you talk a little bit about why it's so important from both thinking about it from that framework, but also just in general, why it's so important to personalize grief?

Mandy Doria:

Yeah, this is a great point, because no two people are going to grieve the same, even if they went through a very similar experience. Grief is almost like a fingerprint, right? We all hold these unique experiences in our life. 

So we don't want to force these stages to go through any type of process, even with finding meaning. Someone will do that as they're ready, but we could invite different ways to make meaning through encouraging people to make time in their grief, maybe carving out some time in their day for that and how they would like to honor their loved one or honor this loss that they've experienced in their life, whatever that is, and however that looks to the individual.

Some other ways that we can think about what it means to us is through journaling and expressing our thoughts out on the paper and really try to identify what we're thinking and what we're feeling and getting it out on the paper to identify how we're doing and possibly what we might need. And then asking for what we need in those situations. Which sometimes is really hard to do, and we don't always know what we need, but giving yourself a chance to ask for what you need when you can. 

I think any way of expression is helpful, just thinking of ways to mobilize those emotions and put them into thought or action. For example, a lot of suicide loss survivors might join a suicide prevention organization or go on an Annual Walk to remember their loved one, is one example of finding meaning.

Matt Hastings:

So it seems like it's a lot of community or creative arts, finding ways of expression that really are a good outlet and a good way to channel those feelings in some way, right?

Mandy Doria:

Yeah. Yeah, channeling them, and also letting yourself have really bad days when you have them. It doesn't always look as external, right? Sometimes it's okay to feel sad and be in that sadness and pain, and then considering who you feel safe to talk about that with, or like you said, express that with.

Matt Hastings:

So it seems like that is something that maybe folks might not inherently know, that it's okay to have a bad day, it is okay to not be at 100% , and that portion of it, I think, gets left out. So I think when we were talking about that, what things are we missing? Do you think there needs to be more grief education, and what would it encompass as a subject area, I guess, for folks to take a class in?

Mandy Doria: 

Yeah. That's a great point. I want to answer your question, and something else just came up as you were talking about that. In reflecting on the things that make us upset, I think it can really point us to the why, right?

"Why is this bothering me so much?" Oftentime, it's based on our values and what we value, right? When we lose a spouse or a child, no wonder why it's so painful, because we value that connection and relationship and support as human beings, and those are the closest people to us and how painful that is to go through – validating that for yourself if, "Of course, I'm upset because I care about this thing, and this is why it's been hard for me." 

So grief education can look like anything from, if you are a grieving individual or even supporting a grieving individual, seeking, like you said, online courses in grief, to learn more about that process or joining a support group in your local community.

There's a lot of grief counseling centers that offer support groups for those things as well to kind of normalize the process. I think the best education we can provide is normalizing it, like this podcast, talking more about grief as a part of the human experience, and not being afraid to lean into hard conversations, and be there for people who are grieving or going through something tough. 

Most people don't know what to say, so then, they don't say anything at all, and then there's this elephant in the room. Saying nothing is often worse than saying something that you might not feel great about. Unless you're sitting there to listen, unless you're sitting there and the person asks you to be present with them and just listen and say nothing. So just remember, we all make mistakes, and part of grief education is experimentation and trying to say something and ask someone how they're doing and be present with their story. 

I think finally recognizing helpful versus unhelpful things to say to someone grieving. For example, we don't want to point people in directions of what they should do. "Have you read this book? Did you do this? Have you prayed? Have you done this?," because that can often leave someone isolated in their feelings and not feel like what they're feeling is valid, because we want to fix and make people feel better. We also don't want to judge them for how they're feeling, like, "It's been a year. You should be fine by now."

We want to stay away from phrases like that, and trying to not justify someone's death or loss. So, for example, "They're in a better place," or, "Aren't you relieved? This was such a long journey." That can really, again, make someone actually feel more isolated than cared for, even though it may come from a good place. So, yeah.

Matt Hastings:

That's great.

Mandy Doria:

Yeah.

Matt Hastings:

Thank you. I think one of the things that commonly you hear people say, "I'm sorry." Do you think that's helpful?

Mandy Doria:

Yes, and, "What are you following up with?" There's nothing wrong with these phrases that have been culturally part of our practice of grieving. And if we don't have a way of grieving in community, I think that's also tough, which I think we're going to get to in this conversation, but maybe following up with, "And I'd like to support you, I'm going to drop off a meal on Thursday." 

I think we ask people what they need too much, and they often don't know what they need, so do what you think they might need, right? Offer practical help, show up, call, follow up. A lot of times, traditionally, when someone's grieving due to the loss of a loved one, a lot of people show up initially, and then the weeks and months thereafter are actually the hardest once everyone goes away, so I would just say it's more helpful to show up with your presence however you can.

Matt Hastings:

Are there other parts of expanding grief education a little bit that people may not really have a concept of: we're  talking about worsening mental health issues or prolonged grief. I wonder if you could speak a little bit about what people are missing when we talk about that.

Mandy Doria:

Yeah. So stepping away from the conversation of non-pathologizing grief is hard to do because we want to make sure that we're offering a lot of time and care and space for people to have really hard days and dark feelings and empty thoughts, right? But there is a difference between grief and depression. Sometimes grief can trigger past mental health issues like depression, and sometimes it can bring on a depressive episode. 

These two cross over a lot and if you are concerned about yourself or a loved one, for example, having thoughts of suicide with a plan, or feeling hopeless and depressed and detached from your supports and wanting to isolate more than is normal, you may be experiencing more signs of depression, and you may want to talk to your mental health provider or a primary care physician. 

But that is different than a longing to be with the deceased loved one that is different than feeling down and being tearful throughout the day, right? And so when it comes to prolonged grief disorder, that is a newer diagnosis in the most revised version of the DSM or the Diagnostic and Statistical Manual, which points to 12 months as a marker. So people have to have experienced these symptoms most days, every day for at least a month, and the loss has to be at least 12 months ago.

Those symptoms are really because our brains get caught in a negative feedback loop. When we ruminate about our loved one, it mimics the brain's response of the reward system in the brain, sort of, like in an addictive pattern. And so when we think about our loved one, it almost feels like we're connecting with them, even though we're actually not. That can leave people a little bit trapped in a negative feedback loop, and this is sometimes where we see prolonged grief disorder or complex grief, otherwise known as complex grief.

Matt Hastings: 

Yeah, and that seems like it straddles a difficult place between different concepts of: we need time, we need space to feel to heal, and work through this process. But also, it has a prolonged grief disorder on the other side. It's 12 months of this, and so working through this, is it really behoove people to work with a mental health provider to kind of separate out the two and figure out what shape their grief is taking?

Mandy Doria:

Yeah. I think, just in order to kind of bring up some of those difficult emotions maybe that haven't been fully processed. Also to address possible changes in identity, self-worth, the way that you view the world, the way that you interact with other people or your work. Because, typically, that diagnosis comes with impairment in different areas of your life, relationships, work, school, et cetera, hobbies.

Matt Hastings:

Changing topics: you mentioned at the top that grief can go beyond losing a person, and it can result in a change in role, a change in society, in community. I wonder if you could talk a little bit about Past the Pandemic and some of the things that you saw in the wake of the COVID-19 pandemic, and how that change and large sense of grief – on a community, on a state, on a national, on a global scale, impacted conceptions of grief and how we feel that in U.S. society today.

Mandy Doria:

Yeah. This is a great question and probably worth a whole other conversation because we know how the COVID-19 pandemic changed so much for so many of us.

Matt Hastings:

Yeah.

Mandy Doria:

Pretty much everyone was affected in some way, shape or form. Whether that was their job role changing or having task inundation, having to show up way more than other people that you knew in your community, such as healthcare workers and frontline workers, all the way to a breakdown in social relationships, when we weren't really feeling safe to be around one another. 

So thinking about the level of grief and collective trauma that we faced in light of the COVID-19 pandemic was massive. Yeah, stages of grief, talk about stages of grief, all the things that we went through emotionally. Our program, Past the Pandemic, specifically supported healthcare workers in the work that they were doing with the communities that they were serving, and addressing and validating some of the common themes of grief and loss that they experienced. 

We found that this was a helpful lesson and session to keep in our program year after year, because grief needs to be witnessed in order to heal from it. So many healthcare workers went through so much, and it was never named for them about what that meant and how it changed them, or their perception of their work, or their perception of the world. By naming that, that really took some of the difficulty of moving forward in their jobs to be able to acknowledge the impact of the pandemic and how that had on them.

And so from anywhere, from a healthcare worker to a construction worker, it really impacted all of us, a stay-at-home mom. I mean, it impacted that person having to go from one job to multiple jobs of teacher, babysitter, and all of these things. So I think it changed the way that we perceive social connections, and it changed the way that we felt a sense of efficacy in our work. 

Which brings me to the final point, this loss of community. So much of our social well-being and mental well-being has to do with how we exist in community, whether that's talking to the grocery store clerk on your way out or connecting with your local barista at the coffee shop, or finding recreational centers that you belong to, church and faith-based groups. And a lot of these spaces, which are referred to in the literature as third places, really were shut down and continue to.

I think neighborhoods continue to struggle with not having as many spaces like this. So when we think about third places and the loss of that, I encourage us to now think about, "What are our spaces outside of work and outside of home?" And for some of us, work and home collapsed into the same space, and so we don't really even have always that notion of going to work or going into the office, or whatever type of job we have as much with hybrid or virtual work schedules. So with that loss of social connection, it's even more important that we find third places in spaces and communities  that we feel safe with and that we can connect with. So, yeah, the pandemic brought along waves of grief that are very complex and have been studied in the literature and still are being looked at.

Matt Hastings:

Do you think – along with the pandemic meeting, ongoing trends that have kind of been fostered in U.S. society for a while with: when you go through an experience of loss, and there's a tacit pressure to feel normal, to get back to work, to carry on, to keep doing it – it seems that that seems a little pervasive culturally within the U.S. So do you think that that trend of: dust yourself off, get back up, and get back at it, that meeting a complete change and a collapse of third places,  and sometimes down into one place through the pandemic, really sort of supercharged a lot of the issues that people have on feeling and expressing grief in society? Because it doesn't seem like there would be a community for a person who even might be going through an individual loss. Do you think that those two were connected and create a little bit of a challenge for people in U.S. society currently today?

Mandy Doria:

I love that parallel, and I think it's really interesting to think about. 

Yes, I think that we tend to be hard on ourselves with how we're coping and healing, and we need to move forward. We get those messages all the way from growing up and what our family may have taught us, or what society teaches us. 

Also, yeah, through the pandemic. I don't know many workplaces that maybe take on new hires now and give the history of the last five years of their company with what they've been through, and to name the state of their team and where it's at, and name what people might be experiencing as they come into this work setting, right? We don't really slow down enough to kind of acknowledge what's happened here, and how those dynamics may have shifted, how roles may have shifted, more expectations in certain ways.

I think the biggest marker of where people felt safe in their workplace typically tends to be transparency from your employer and clear expectations, and being able to communicate that and ask for what you need, even if you don't know if you can give it to them, or ask for what your employees need, even if you can't give it to them. 

So that does kind of fit along with this, a reverse capitalist culture where we always have to be on the go, and completing, and doing, and fixing, and healing. Yeah, I think that's a great parallel and could be tied to a lot of the undertones of what we might expect a grieving person to do and what healing might look like, getting back to work, and coming out with friends, and being okay, and having a smile, and being able to laugh, and are you making room for acknowledging the pain and the suffering that you've been through to be able to understand how that's impacted you and your sense of being?

Matt Hastings:

Yeah. That seems probably the most important point to take away from this conversation, is that, holding those two combined, those two feelings combined at the same time, you're able to go out, be with friends, and feel a sense of kinship and community with people that are close to you. B ut also still realize that that loss, whatever form or shape that it took, is still part of you. Do you think that that's the case? Do you think that’s the case?

Mandy Doria:

Yeah. I like that a lot. I think when you think about the most impactful experiences you've had, it might be helpful to ask yourself, "How has this changed me? How do I feel about it now? What do I want to make of this moving forward?," and that that doesn't have to be super concrete, acknowledging that grief may come up in different waves or unexpected moments that could trigger.

And I encourage you to maybe pause and acknowledge what you're actually feeling in that moment. Because that's where healing happens –  when we stop and acknowledge what that impact really is, and it doesn't have to look pretty.

Matt Hastings:

Yeah.

Mandy Doria:

Yeah. It often looks messy and complex, and maybe results in ... I don't know, ice cream out with a friend and telling your story, or journaling alone and feeling isolated sometimes, but then, what do you come back to, and what brings you meaning, and what brings you value in your life?

Matt Hastings:

But acknowledging that complexity seems to be the, not the final step, but probably the next step or the first step in a journey, and understanding your personal grief and how it has taken shape in your life.

Mandy Doria:

Yeah. I really want to make a plug and validate that grief really is love, right? And so there's this quote that I like. I'm going to read it to you if that's okay.

Matt Hastings:

Sure. Yeah, please.

Mandy Doria:

"Grief, I've learned, is really just love. It's all the love you want to give, but cannot. All of that unspent love gathers in the corners of your eyes, the lump in your throat, and the hollow part of your chest. Grief is just love with no place to go." I like that quote.

And what I'll add to that is that you can translate that love into what brings you meaning now. Acknowledging and being mindful that, "I can hold space for my sorrow, and my pain, and my trauma, and my grief, and also welcome joy, and love, and connection.” Not only because that's what feels good and makes me a happy individual in society, but because that's what we need as humans, right?

Matt Hastings:

Yeah.

Mandy Doria:

We need to leave space for both. Some would argue that the more room you have for suffering, the more room you have for grief, the more room you will have for joy.

Matt Hastings:

That's great. Well, Mandy, thank you so much for joining us.

Mandy Doria:

Yeah.

Matt Hastings:

I really appreciate it. This was a great conversation.

Mandy Doria:

Yeah, thanks for having it with me. And really nice to address some of these really difficult, complex topics. If anyone else wants to chat about it, I'd be happy to do so.

Matt Hastings:

Appreciate it. Thank you.

Mandy Doria:

Yeah.