Psychiatry & Psychotherapy Podcast - The Process of Grief

Episode Date: July 4, 2019

Grief is the multifaceted response—emotional, behavioral, social—to a loss or major life adjustment (like a divorce, loss of a job, etc.). Bereavement is the process of grieving specific to the loss of affection or bond to a person or animal (Parkes & Prigerson, 2013; Shear, Ghesquiere & Glickman, 2013; Shear, 2015). Some of the signs and symptoms of grief are: -somatic symptoms (e.g. choking or tightness in the throat, abdominal pain or feeling of emptiness, chest pain) -physiological changes (e.g. increased heart rate and blood pressure, increased cortisol levels) -sleep disruption and changes in mood (e.g. dysphoria, anxiety, depression, anger) (Buckley et al., 2012; Lindemann, 1944; O'Connor, Wellisch, Stanton, Olmstead & Irwin, 2012; Shear & Skritskaya, 2012; Shear, 2015; Zisook & Kendler, 2007) Medical and psychiatric complications can also arise due to grief and include: -An increased risk for myocardial infarction -Takotsubo cardiomyopathy (Broken Heart Syndrome) -The development of mood, anxiety and substance-use disorders (Cheng & Kounis, 2012; Keyes et al., 2014; Mostofsky et al., 2012; Shear, 2015). Acute grief begins after a person has learned of the passing of a loved one (Shear, 2015). During acute grief, a person may experience immense sadness, yearning for the deceased, and persistent thoughts of the decreased (Maciejewski, Zhang, Block & Prigerson, 2007; Shear, 2015). Auditory and visual hallucinations are benign hallucinations commonly found in acute grief and involve the person seeing, talking to or hearing the voice of the deceased (Grimby, 1993). By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram:dr.davidpuder Twitter:@DavidPuder Facebook: DrDavidPuder Youtube channel Maris Loeffler Instagram: @agatetherapy

Hello and welcome to the psychiatry and psychotherapy podcast, with over 32,000 mental health professionals listening in every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. So welcome to the podcast. I am here with Maris Leffler. She is an MFT, an expert in grief. She works in the Sacramento, California area. And we have connection. on Instagram, and so we're going to do an episode on grief. And I hope in this episode, you get a little bit of practical information on how to sit with someone with grief and hopefully how to process your own stuff that comes up in dealing with other people's grief and maybe

also some insight into how to process your own grief, if you haven't done that completely in areas of your life. So Maris, welcome to the show. Thank you for having me. Appreciate it. All right. So tell me a little bit about how you got interested in grief. It's actually kind of a roundabout story. I wasn't sure what my clinical focus would be when I was going to graduate school. And it's kind of a lottery when you're looking for a placement as a trainee. I was in the Bay Area at the time going to St. Mary's. And I got placed at the Contra Costa Crisis Center, where you work solely with bereaved individuals and families and couples. And at the time, I was a little bit worried, what am I getting myself into? Only grief work, would this be really heavy?

But it was such a great group of other therapists. And my supervisor was really warm and accepting. and so I could grow these skills and I fell in love with the work. And I found it to be something that was really rewarding because these people really wanted help. And they had something concrete that they were working through and on. And there were phases to treatment. And so I fell into it and surprisingly was not burned out or worried about the emotional side effects of it. Wow. So it sounds like you had an amazing supervisor.

And one of the themes of things that I try to encourage people in this podcast is to get good supervision and to have good supervisors. I'm just curious, like, what were some of the things that you really appreciated about the supervisor? In our first intake interview, she said, I really want to make you feel safe to be open about basically your failures or things that you felt went poorly. And I want you to be able to share those things with me and not worry that you'll be punished or put down or faulted for those things. And it was a really safe nurturing environment. I had individual supervision with her as well as group supervision. And I was the only trainee pregraduate status clinician there was with other interns and then my supervisor who was licensed. And I felt really welcomed by that group.

Yeah, that sounds like an amazing. amazing sort of opportunity to be mentored by her. Okay, so what are some of the things that were taught to you at that time that have really stuck and become like part of how you do therapy? I think it's really about the foundation first that I got at St. Mary's, which was Rosary and Person-Centered, which just simply believes that we are all primed and growing naturally towards a state of self-actualization. And we have the tools and we're capable of getting there.

We just need the right settings and environment and support sometimes. And sometimes we lose track. And therapy was really a way to meet a person where they are and genuinely and authentically join with them and using empathy and unconditional positive regard to just help them find how to move forward and find their truth. And in the program at St. Mary's, we did a lot of trainings the first year. It was every other Saturday about eight or nine hours where we would practice the Rosarian model and sit across from our classmates.

And we learned how to sort information that clients would say into what they called mailboxes. And they were eight of them. And so you could really reflect back to the client, the different types of information they're giving. And to show them that you're attuned with. them and that was the foundation it's like I'm totally here with you this is your truth this is what you're feeling what you're facing these are your challenges this is what you can't figure out here's where you'd like to go here's where you're stuck and so forth so that was already priming me to work with people who were in these situations facing grief

and bereavement and then after that it was reading a lot a lot of different specific grief because I did spousal loss and parental loss and partner loss when I was a trainee. I didn't do any child loss or suicide loss. I was, you know, stepped into the grief work more gently, so to speak, so I could get my ropes and sit with it and see how it would affect me. Because like I said, I didn't know if it would come home with me. And I think everybody would kind of question that stepping into any clinical setting for the first time.

Yeah, I appreciate one, the method of practicing with, you know, another colleague across and you're learning, you're putting those skills to just not just, you know, it's not just a theoretical concept, but we're actually practicing it. I like that. And then also just continuing to learn, but then stepping into it slowly because some of those losses are, yeah, so much, there's so much more complex, you know. suicides and the family are some of the most devastating ones and child loss is just really, really tough. So yeah, since doing that work, how has that changed you as a person?

I think I've become more solid in my confidence and being able to sit with clients in their truth and in their various traumas and pains and relationship to their grief. And I've learned a lot from my clients. And like you said, it's a constant journey of still learning. And that's one of the reasons why I was drawn to be a therapist is that we get to learn forever because things are always changing new research is coming out. It's very exciting. And I get to work with people who have all kinds of different stories and challenges and wisdom to share. And it's a synergetic exchange every time I sit with a client. So I guess with the grief work component specifically,

I've learned how resilient people are. And a major theme is also you have no idea what somebody is carrying all the time just out in the world. You come across somebody and they could look and present totally normal, but you have no idea. Yeah, and we just had a guy. I run a treatment program that it starts five days a week and then it goes three days a week

and it's for people with medical and psychiatric issues, kind of the inner in between. And we had a patient who, after about one month of being in the program, finally it comes out. Like, this is the grief. And, you know, it's like with patients like that, you know, like, there's got to be more. You know, I got to find something.

There's something else that, like, we just haven't figured out or we don't understand or is this just genetic or biological? You know, these are the questions that ask myself as I as I see patients. And then, you know, some of that grief is just so deep in there in the trauma, you know, and some of the trauma is just like there's so much shame around it. Mm-hmm. So does that bring up any associations for you or any thoughts? Yeah, absolutely.

I think that grief is an interwoven experience into life on very, very, various levels. We have grief, not just of people that have passed or loss of attachment relationships, but also maybe the loss of a job or a relationship or, you know, maybe somebody's been diagnosed with some kind of chronic illness and a grief of the life that they wanted to live. Grief is a process that is in almost every person's journey, especially in therapy. I mean, we see it all the time. It's a part of what they're facing anytime somebody is sad or is struggling to accept something. There's elements of the grief process present. So really, therapists are equipped to work with grief. They just don't recognize sometimes that that's

really what's the driving force behind their struggles. Yeah. So do you see, this is a good question, and I think we should be really explicit about this. Like you've had pretty, advanced grief therapy. You've, you know, done this program and then you've been able to practice it for a number of years. Do you think that in general, most therapists are prepared well to do grief work? And if not, what else do they need to know or learn to be able to do this type of work? The research says that 50% of therapists don't feel equipped to deal with grief in clinical settings and that they weren't given the proper education, how much weight I put into that research. research in my own conclusion, I'm not sure. I think that we all have thresholds to hold the

space for different kinds of things, whether that's somebody's loss or somebody's trauma, depression, anxiety, and parts of that are the countertransference and our own unresolved stuff. I think that as human beings, like I said before, we all have our own losses and have been through grief, been through bereavement, whether it's a pet or a grandparent or something more difficult, like loss of a child. We've all been through some kind of loss. And that is one of the ways that we can call on our own pain and our own journey to inform our treatment. And you know how I believe that kind of transference in this setting can be helpful. It's, you know, we can use our own grief experience to sit,

with where the client is, whether that's in denial or shock or bargaining, depression, anger, or moving towards acceptance. So I think the long answer is we are, for the most part, all capable unless we have unresolved grief responses that we need to address in our own therapy, our own healing journeys. And the education is out there. There's all kinds of books, all kinds of articles. And if that is an interest clinically for somebody, it's very doable, very attainable. I think I also may be a little bit biased because I got all this structured training and only did grief and bereavement work for that first year and then also as an intern or now associates were called. I did a lot of victims of crime work, which victims of trauma often grieve the loss of safety or the sense of safety in the world and the loss is associated with whatever the crime was that was committed against them. and then also I had a supervisor who specializes in traumatic loss,

who I got a lot of really good structured, supportive supervision by. So I don't know if my answer is accurate or not. That's a hard judgment call. You know, I tend to think that people go into this work, from the ones that I've met, often have some insecurities. and I think that that's a good thing to be sort of humble with struggling with imposter syndrome a little bit. So when I hear the 50% don't feel equipped to do the grief work, I almost think like, okay, is that like, is that more because the people that go into this

tend to be, you know, higher feelers, tend to maybe have a little bit more imposter syndrome, be a little bit less narcissistic, you know, and that's where my mind. mind goes, but we're going to spend the rest of the time kind of diving into what might be some things that might help people feel more confident in doing grief work. So do you clinically differentiate in your mind between like acute grief versus chronic grief? I think it's more of an awareness of where the client is on their timeline. How long ago was the loss? What was the nature of the loss? What is the impetus? them coming into counseling? How was the consultation call? What, you know, was it a friend of the

family that said, you should go and talk to somebody or was it self-initiative? And those are more important questions to me that had formed treatment than acute grief, integrated grief, complicated grief. It's where is this person now? What do they need? What is the challenge? What was the loss? That's good. You said traumatic grief at one point. Do you differentiate, how do you differentiate that between other types of grief? Traumatic loss is, for example, an unexpected or tragic loss, car accident, suicide, murder, those types of things. Those are more traumatic, have been shown to be more traumatic in different ways

than chronic illness loss, dying about older age, you know, more expected loss. even though when you know somebody is going to pass, that's still monumentally difficult with respect to the grieving response. Okay. So sometimes on Instagram I'll post something like, you know, what do you guys want to hear? And they talked about adult attachment styles. So how does this help you or how does this influence your work with grief? What do you think about the different adult attachment styles?

I think they're relevant clinically to. be aware of, but for me, more so they're kind of filed away in the back of my mind when I'm sitting with a person unless some type of glaring pathology related to avoidant or anxious attachment is hindering the client from making progress, then I may try to, using Rosarian, and oftentimes that person may say, I don't know why I can't let go or I don't know why I can't acknowledge the depth of the relationship, something that would indicate avoidant or anxious tendencies, then I just meet them with empathy and reflect that back to them so that they can maybe make a statement that I want that to change or that doesn't work for me. But I'm not

in the back of my mind when somebody is talking about their grieving process. You know, oh, that's because you have anxious attachment or you should take an attachment style questionnaire. We need to know your attachment style. That's not been that prominent in the room for me personally. I'm obviously aware of it. I read about it a lot and understand it and wrote my thesis on the basis of attachment theory and I think it's fundamental to humanity and the attachment process is elicited when we go through grief. And so it's of course a part of the whole picture, but it's not something that is the forefront. Yeah. Yeah, I'm the same way. I've read a lot about it. I know the different types and how helpful is it to understand in the patient or how helpful is it for the patient

to understand about themselves? And that varies on the client. Do they benefit from psychoeducation or do they feel that it becomes dehumanized if it's all categorized with this psychobabble to them? And that's an intuitive sense of sitting with each client. You know, will this be valuable? Will this be a tool? Will this enable them to have some autonomy around the issue or not?

And that's really just a product of the relationship and varies. So just for our listeners, since you did do your thesis on this, how does avoidant attachment normally manifest in an adult? Well, an avoidant attachment style is postulated to develop after a caretaker of an infant. so that the adult when they were a baby would show signs of distress. So the infant is not comforted and learns that emotional expression won't be responded to. And so instead of expressing their emotions, they hold it in and they avoid seeking the attachment figure to have safety and that closeness. So if that were to directly show up as an adult, then you have somebody who's uncomfortable with intimacy and closeness and is fearful, although they long for connection and attachment.

It's difficult and it's very threatening to them. Yeah. So this is the kid in the Mary Ainsworth situation. When the kid is in the room and the mother walks back in. So the kid's been playing distressed while the mother's gone. The kid will pretend like nothing is wrong and go on playing. But the cortisol levels are higher. The kid's stressed out.

He's just, the kid has learned that the most adaptive thing for them to do is to not, you know, run to mother, to not cry because that doesn't get them their attachment needs met. Right. So maybe by being more avoidant, they actually can elicit from the parent. more good things. The problem may come later in life when these strategies are not effective

for them to gain connection in the way that they want to gain connection. So someone who's avoidant in the midst of grief may isolate more, may have a harder time expressing what their needs are. I don't know if anything else comes to your mind. Yeah, it's a little bit more difficult at times for people who may be avoidant to go deep into the therapeutic work and acknowledge vulnerable feelings around that relationship and potentially their dependency on that person. And I guess more so when a marital loss or spousal loss or partner loss, these things would show up in a more prominent way.

But yeah, it can be problematic compared to somebody who has more of a secure attachment prototype. Yeah, the other thing as a therapist is like someone who's more avoidant, you may not feel like this person is as invested. Or like, you know, you may kind of go like, what are they getting out of here? Sometimes the avoidant ones, to me, will be a little bit passive aggressive at times, like almost like pushing away. But they really want to be there. But at the same time, they push away. I don't know.

Maybe I'm mixing them up. I'm mixing them up. No, I think that you often find anxious attachment-style people drawn to avoidance because they'll seek the avoidant person and the avoidant person wants to be sought after. Like you say, they want that connection. They're just not sure how to show it, how to step in and join halfway with that person. And there's some kind of imago-type subconscious draw for the anxious person to fulfill the unmeltious. need by drawing the avoidant person in and succeeding in getting them to not abandon them or not leave because the anxious attachment person is hypervigilant about abandonment always on guard

for somebody to leave. Yeah, so the anxious attachment at one years old is the one that when the mother comes back into the room, they run to mother, they get angry, they may stay angry longer than the secure attachment. So the secure attachment will come back to the mother, cry, the mother will sue them, and they'll go back and want to play. The anxious attachment will come back to mother, and then they'll be upset at mother, and it'll be really hard for the mother to calm them down.

Yeah. And so in a similar way, like there may be, I'm thinking of loss in someone who's more prone to sort of an anxious type of relationship, you know, loss may be something that is very difficult for them. And they kind of would want to cling to or be angry, but then also want that closeness. I don't know if any other thoughts come to your mind. In terms of sitting with clients in an actual grief process, there's not a lot of correlation off the top of my head with the different attachment styles.

It's more of a working awareness in the back of my mind. Yeah. So what are some of the things that you have found helpful in your work with grief? What are the types of approaches that you use nowadays when someone comes in? I have to keep in mind what's bringing that person into the room and what do they need? And I think a large part of this comes from as therapists being clients ourselves at times. and what do we get out of going and sitting in the room with the therapist? And so I try to just keep an open, receptive, empathic stance with every person,

say it's a new client coming in for the loss of their parent. I just, I meet with them, I do an intake, what are your goals, what are your struggles, what do you want to get out of therapy? here's my approach, do you think will be a good fit? And then I really just let them unpack and let them express themselves in a space that's contained and confidential and to a person who is neutral and to who they feel that they can communicate these things safely. Because they they entrust in you that you have a knowledge base and an understanding to work with the problem or the grieving process and that's why they're paying for the service. That's why they find value

and coming for the most part. So I just feel like letting the client's truth speak in the first couple sessions and then in the back of my mind beginning to formulate my own ideas and using Rogarian leads throughout processing. I may say I'm noticing that it's really difficult for you to talk about the funeral or you seem to get really angry when you talk about how your brother is handling the situation and it's not confrontational. It's just leading the client to acknowledge dynamics that are happening and that unfolds and that just leads to where it goes and it's not so much a set of interventions unless, you know, it's very appropriate. And then I do have some tools and interventions and some psychoeducation that I use.

One thing that you said before when we were talking that, I really appreciated, which I would like you to talk a little bit more about, is how you really just allow the person coming in to talk about whatever an aspect of the grief that they feel like they need to talk about. If they feel like they need to talk about it more than once. If they feel like they need to talk about it 10, 20 times, you just let them go there. Do examples in your mind stick out where like after so many times it just something budged and finally they were able to make a breakthrough? How does that work?

What are your thoughts on that? Yeah. There are cases where maybe for six or eight months following a loss, somebody is in this heavy storm period of just I'm never going to feel better. I'm never going to feel happiness. And it's just rehashing and reviewing the events that led up to the passing of their loved one and sitting with them in that thick, dark place. And throughout that time, and six to eight months is just an arbitrary number for, you know, examples' sake. And then I do find over time that after a certain period passes and they have walked through their first,

their first Thanksgiving, their first Christmas, their first anniversary birthday, or whatever the significant days are in the first year after the person passes. And they begin to say, well, I feel a little bit lighter. I feel like I can go for an hour without thinking about it. or they start to make little comments about small reliefs. And those are when I see those budgets, as you say. And then you just really reflect that back to them and come from a strength-based approach

and say, you know, what would you say to yourself last year at this time? And would you have been able to take that in? And what would you say to somebody who is, you know, who's facing a similar loss? now and then they can go, wow, I am feeling better, or I have made a lot of progress and they can remember how they were in that period. And during that time, if they need to repetitively talk about the same things, it might be, you know, it's very complex and very variable because maybe they found the body. And then there's elements of trauma. You know, do we need to integrate the

traumatic experience with other types of therapy, whether it's EMDR, brain spotting, somatic experiencing. But people will need to talk about that and talk about it and talk about it and that's okay and that gets to be okay. And this is the place where that gets to be okay. And sometimes people come in and they express that it's a felt sense or a literal sense that they can't talk about it anymore in their families or with their friends because they're getting cues that they should be beyond it or they should have moved on by now. And then there's also people who come in and they see others around them doing this repetitious cycling around rehashing and rehearsing things and it's frustrating to them. And it's just every person is so different. And every person is a

different way of consolidating and understanding the feelings that come with the grief response. How do you think of if someone has like a lot of guilt towards themselves in the midst of the grief, does that change your approach? Not really. I just, I don't try to fix the guilt. I don't try to, because as a therapist, it's sometimes uncomfortable to sit with very deep shame and very deep guilt unless you've practiced sitting with it with the client because if a client is saying I feel guilty whether it's I feel guilty for not having spent more time or I feel guilty because they might feel responsible in some way for the person's passing. If I were to say, well, you shouldn't feel guilty or give some indication that, well, you just shouldn't feel that way, then that would be really

invalidating. And so I think it's important to allow the feelings to be real and to be expressed and to check myself and for therapists to be aware of the need to just comfort somebody and reflect back to them using their own words. You feel really guilty that you didn't spend more time with your mom. You feel really guilty you didn't call your mom back that day. She called you. That just gives them the space. to feel through that, to process through that. I like that. I like that a lot.

So it's like you don't, you're not afraid of the guilt. It's not like you want to stuff it down or fix it right away. What about anger? Like if they're having anger towards maybe the deceased or towards something about the situation, towards the family members, maybe how the family members interacted with them after the loss of their loved one? people oftentimes have difficulty acknowledging that they feel angry towards their loved one or the person who's passed away and in therapy after building trust and safety and rapport it's appropriate to give the client permission to feel anger to feel the negative emotions and what i say is in here we can put all the

felt sense of responsibility and duty to hold this person in a high regard and to love this person. Let's just take that and put it in our back pocket right now. And if you want to pull it out, it's there anytime. But in here, let's just put that in our back pocket and look at what was difficult. Can you tell me about when you felt neglected or when you felt unloved or those types of things and being allowed to look at them without the guilt, being given permission and normalizing that while you're grieving, you can also feel anger and you can also feel resentment. You said a little bit earlier that sometimes people will feel, especially when crimes have been done against them, this idea that the world is an unsafe place.

How do you work with them in that context? Well, I work with the body when it comes to trauma and this felt sense that the world. isn't safe anymore and it's just a question of how the traumatic experience manifests into whether it's hypervigilance avoidance nightmares and addressing those symptoms appropriately but you know people who face traumas and have either seen someone almost be killed or themselves fearing for their own life part of the psychological repercussions is that you don't feel safe in a world that may have felt safe before. And that gets to be their truth. And so we have to, in my opinion, take into account in therapy how the nervous system responds when we have a fight or

flight reaction to a traumatic event as well as how the mind and the psyche are suffering from that. So to answer your question, you know, approaches like somatic experiencing and using attachment theory and practice just in the room with me as an attachment figure of safety and brain spotting too, which is a body-based trauma therapy and also Rosarian, which as I said before just believes that everybody is on their own track towards developing to good, to wholeness. and they just need the right circumstances. That's good. If someone is feeling a lot of numbness, dissociation, is there like an approach that you have for dealing with those types of symptoms? I don't have a lot of experience with that. I haven't seen that, honestly, for the most part.

Because most people who come in are like, I need to talk. Oh, my God. I'm feeling all these things. I probably see a lot more of that because of the somatic patients that sort of end up in my program. So a lot, somatization a lot of the times is, they're a lot further from their emotions.

And so there's a process that we go through and helping them get in touch with their congruent emotional experience. Whereas, yeah, I agree that most of the outpatients that come to me are more probably in tune with that. The other thing is sometimes they have to get off of medications to get into a more congruent place. If they're on a bunch of benzos or sedating medications or opiates or marijuana, sometimes they need to get off those things to be able to get in touch with their emotional experience.

Yeah, and I also want to make a point to always, always, always ask the client to go get a physical and to have other types of evaluation, maybe from a psychiatrist or a physician to rule out any organic causes. It's, you know, therapy is not the end-all, be-all. and it's always important to get appropriate consultation. Yeah. Are there other things that are coming to your mind that you feel like are really important to say about grief and doing this work? Well, I was just thinking about how therapists may question their ability to sit with and process the grief with a client. And there's so many steps and events and triggers to walk with.

with, to walk through with the client, that it really isn't complex. It's really just about a human interaction and a safety and an empathy while they plan the funeral, while they are going to the cemetery on a certain frequency. They're going there every Sunday. How was it to go this time to the cemetery? Did you bring flowers? What did you feel? Did they mow the lawn? You know, these little things, if you can just allow them to talk about what appears to be minute, potentially, to an outsider, then you can do grief work. You know, it's, what was it like to pick out the casket or what was it like at the memorial? What is it like for you after the funeral is over?

What things remind you of that person? What brings you peace? Are you able to get out of bed? And also, you know, just the depression and the anxiety and the physical aftermath of everything. So we are all able to really do this work. It's not complex beyond our wildest dreams by any mean. It's a very human experience. Yeah, it's really good.

I like to keep it there and the simplicity of that. And hopefully this has been helpful if you're doubting your ability to degree for, work, we will give our little handout that we created and we'll put that on the website. And in the show notes, I will link Maris Leffler's Instagram. And that's a good place to connect with her. And, yeah, is there any other things you'd like to say before we conclude? Nope, I think that's good. All right.

Thanks so much for coming on. And I think this will help a lot of people. Thank you.