Speaking of Psychology - How grieving changes the brain, with Mary-Frances O’Connor, PhD

Episode Date: March 30, 2022

Few of us will make it through life without losing someone we love. Mary-Frances O’Connor, PhD, of the University of Arizona, discusses howneuroscience can help us to better understand grief and resilience after loss, why grief is different from depression, effective therapy for grief, whether it’s possible to experience grief over the death of a celebrity, and how to support people when they are grieving. Links Mary-Frances O’Connor, PhD Speaking of Psychology Homepage Learn more about your ad choices. Visit megaphone.fm/adchoices

Few of us will make it through life without losing someone we love. Grief, it's been said, is the cost of love. The yearning and sadness we feel after someone dies is the price we sometimes pay for the close relationships that we treasure. Some people are resilient after loss, able to cope with their acute grief and eventually adjust to life without their loved one. Others, meanwhile, find themselves unable to do so. Over the past two decades, researchers have begun using the tools

of modern neuroscience to better understand why that is, and more broadly to understand what happens to our brains and bodies during the grieving process and how best to help people mourning the death of a loved one. So what makes someone more or less resilient in the face of loss? How is grieving related to depression, and how is it different? What happens to our brains when we are grieving? Is there effective therapy for grief? Is it possible to experience actual grief over the death of a celebrity, and how is that grief different from grief over the loss of a loved one? How can we best support people when they are grieving? Welcome to speaking of psychology, the flagship podcast of the American Psychological Association that examines the

links between psychological science and everyday life. I'm Kim Mills. Our guest today is Dr. Mary Francis O'Connor, an associate professor of psychology at the University of Arizona, where she studies grief and grieving. She uses methods including brain imaging and studying immune system responses to investigate how grieving affects us both psychologically and physiologically. She is an expert in complicated grief, a clinical condition in which people don't adjust to acute feelings of grief. In addition to her many scientific publications, she is author of the recent book, The Grieving Brain, the Surprising Science of How We Learn from Love and Loss. Thank you for joining us today, Dr. O'Connor.

It's so good to be here. Thanks. One of the points that you make in your book is that grieving is actually a form of learning. Can you explain what that means? I don't think most people think of grieving in that way. This has really come about from years now of studying grief and grieving and reading a lot of studies about what happens when we experience the death of a loved one. And it really has struck me that grieving can be thought of of. form of learning. This is, you know, in a few different ways we can think of it. One is that after we

experience something as difficult as, you know, our one and only passing away, we really have to figure out, how do I live in the world now? What does it mean to retire when, you know, this person that I've been going to do this with for decades is no longer going to do that with me? So part of it is learning to be in the world as a person who carries this absence with them. But even at a smaller level, you can think about all the tiny little habits that we have to change. This is that feeling of, you know, the experience of picking up the phone to call them because something has happened. And then, of course, realizing that we can't call them. So all those little habits and predictions that we have to learn in a new way. Let's talk about the difference between grief and grieving since we're going to be

using those terms a lot as we talk. And you've made the point that they're not interchangeable terms. I found it to be helpful in a scientific way to distinguish between grief and grieving. And then as I did that, came to find that other people found it useful as well. So grief really is that feeling that you have, the sort of intensity that. that just overwhelms you and that sort of momentary experience. Grieving, on the other hand, is the way that grief changes over time without ever actually going away. So, for example, the first hundred times you get knocked off your feeling by that feeling

of grief, that wave of grief, the 101st time, it may be just as awful. But it may also be familiar so that now you may have some ways to comfort yourself or you may know how to reach out to someone in that moment. So even though the feeling hasn't necessarily changed, our relationship to the feeling changes over time. And the reason that people have found this to be useful, I think, is if we expect that we're not going to feel grief in the future, that somehow it's going to be over, then we'll be. be disappointed if years later, even decades later, we come across something and suddenly we get all teared up and have that wave of grief. That doesn't mean that we've done anything wrong in our grieving process. It just means that in that moment, we're aware of the loss of something really important. What is the relationship between grief and depression? And can a

person grieve without being depressed? The heart of grieving really is. around yearning, yearning for that person to be back or for things to be back the way they were before. And we know now from both diagnostic clinical science, but also brain imaging work, that grief and depression are not the same thing. So we can have both grief and we can have depression just in the same way you could have depression and anxiety, say, for example. But you can have one without the other. In depression, the feelings are usually more global. So while I may feel awful that my loved one isn't here anymore, with depression I will probably

feel awful about a lot of things. I'll feel guilty about things I've done in the past and worried about the way I'm, you know, interacting with people at work and also concerned about the things that I've never fulfilled in my life that I should have done. You know, depression tends to be quite global. Grieving really focuses on that loved one. It's really about I need this person to be back. I can't make it without this person with me. And so is a slightly different experience. You wrote in your new book about how losing a loved one can feel like losing a part of yourself. And you tied that in with the work of Arthur Aaron, who is another psychologist who was recently on this podcast.

Can you talk about that connection? Why do we experience loss this way? Well, to think about what happens when we lose a loved one? You have to first recognize that the brain encodes a bond when you fall in love with your spouse or with your child. the brain encodes this bond. Essentially, it creates a we, not just a you and a me, but it creates a we of overlapping experience. And because of that then, when a loved one is no longer there, we actually experience it as part of us as missing, right? So at a very neural and coded level, our representation of the we has a hole in it. It's not just the metaphorical way, perhaps, that we describe feeling like there's a hole in our heart. And so with that, then,

we come to understand differently, perhaps, and can consider things like phantom limb syndrome, right, where people who have had an arm or part of a leg amputated, they sometimes experience itching or pain in that absent limb. And we know it's because the brain has not rewired its representation of the body. And so we're actually experiencing sensations in the brain that aren't related to peripheral nerves. I think that we're coming to discover, the way that we gets encoded might mean that we continue to expect to have both parts of we as we function in the world and then experience it as a great loss, as a missing, as an absence, when they're not there with us. And so is there a kind of rewiring then that happens in the

brain after we lose someone? There is. And some of what we know about, this is actually from the work of Zoe Donaldson at the University of Colorado Boulder. She studies voles, these little rodents who mate for life. And because they mate for life, it gives us an opportunity to really investigate from a neuroscience perspective, what happens then if a mate goes missing in this vole couple? And what we know is that there is extensive change in the brain when the body. bond is originally formed. There are changes to the way the proteins are folded in the nucleus accumbens of the brain, this little part of the reward network in the brain. And then when time

passes, there are these neurons that are devoted to firing when we approach a mate, right? And as the bond grows stronger, we have more and more of these neurons, just signifying how important it is that this function of seeking out our maid and spending time with them get so much resources of the brain. And then upon separation, we see all the physiological changes that happen, the stress hormones that increase like cortisol or corticosterone in animals. And we see dopamine and oxytose really trying to motivate us to find them again. And over time, then, there are neurocestrone. and transcriptional changes that happen in the brain as the voles try to understand what has

happened and the analogy then to humans, although we have an additional two pounds of brain, so it's more complex certainly than for vols. But nonetheless, I think we're seeing how the brain has to really update and change, and that that's partly a mechanical process, and all of that takes time. So much of your work is on what's called complicated grief. What's the difference between complicated grief and just everyday grief? Yeah, I like the term complicated grief, but I have to be honest with the listeners. The term that's been chosen by the DSM, the diagnostic and statistical manual is prolonged grief disorder, and that's been recently adopted, actually, within the last

year. The reason that I like the term complicated grief, and really researchers are looking at the same phenomena when they, almost the same phenomenon when they use both terms, but complicated grief to me reminds me that we're talking about complications. So here's an analogy that may help. If you break a bone, we don't actually do something to knit those cells back together, right? That's a natural healing process that happens, although we might do something to support that process. So we may wear a cast, for example, to give it support or use crutches, right, to give a little extra resources.

And that's a natural process unless sometimes we have complications where there's a an infection in the area that's trying to heal, or perhaps there's a secondary break in the bone. And under those circumstances, it can be very helpful for intervention to go in and help get that bone back on its typical healing trajectory. So the analogy then is that I think grief is a natural response to loss. It just, it is what our brain, our mind, our body does in reality. action. And the vast majority of us are quite resilient. We know from the work of George Bonano that the vast majority of us will find a way to sort of restore this meaningful life, find a way to, you know, continue loving our grandkids and getting dinner on the table and getting out to the

grocery store, all those things. The difficulty comes when we can get derailed in that process. and prolonged grief disorder and the interventions that have been developed to treat prolonged grief disorder really focus on trying to build new skills in a person who's been derailed in their natural grieving process and by enabling them to use these new skills to get back on that healing trajectory. So intervention is not designed to get them to stop grieving. That's not, that's not the idea, but rather to take care of ways they've become derailed, particular thoughts they're having, behaviors they're engaged in that are not helping as they're trying courageously to move forward. And by intervening in this way, we know now some of the terrific work by Kathy Shear at Columbia

University, we know now that we can intervene effectively for folks who've had prolonged grief disorder for a decade, they still benefit from this type of psychotherapy. And is it just directing people to think differently? Is it like cognitive behavioral therapy? Are you given exercises to kind of keep you from ruminating? I mean, what are you trying to do with the person who has this disorder? There are a few different aspects to it in prolonged grief disorder treatment that she has developed. It's a manualized therapy. And it includes, a number of things. One of them is really focusing on the loss. Many of us, even when we talk about how awful grief feels, that's still different than focusing on what happened at the moment of death

or when we realized the finality that this person just wasn't coming back. For many people, they need more exposure to those memories to really understand what happened and how they understand the experience. So they'll do types of what we might recognize as exposure therapy, where clients will talk about it and have that recorded and then listen to it, while developing skills of how do I move into the feeling of grief and then out of it again, developing new skills around emotion regulation, developing skills around acceptance. But other things as well, the other aspect isn't just focusing on the loss, but focusing, as I say, on restoring what is life like for you now.

And many people, because grief is so painful, have come to avoid situations or reminders or people associated with their deceased loved one. And the trouble with avoidance is it tends to spread, right? So we start avoiding a small number of things, and then we start to avoid more and more things that remind us of these painful grief feelings. From the perspective of the brain, if we're going to learn what life is like now,

and we're going to learn what makes sense for us, what can be meaningful, we have to engage in new experiences. That's how the brain learns. And so the therapy helps to come up with possibilities, things that you might be avoiding, and also things that you might try now. And by giving people the support and encouragement,

sometimes even permission to engage in new behaviors, their brain does learn that life is full of many possibilities. And the final piece is really working, with the support system of the person who's grieving so that they understand what this person is going through and that they can provide that sort of courageous support and also, you know, not back away from the intensity of the grieving person's feelings. So when many people think of grieving, what comes to mind is Elizabeth Kubler-Ross's five stages of grief, right? Denial, anger, bargaining, depression, and then, finally,

acceptance. But you've written that these stages aren't an accurate picture of how people grieve. So how did the five stages become the standard of how we think of grieving? And is there any part of that model that you believe makes sense? Well, this is a great example, I think, of how making the distinction between grief and grieving can be so useful. So I have just enormous misrespect for Dr. Elizabeth Kubler-Ross, who's a psychiatrist working in the 1960s, a woman in her field when there were not many women in her field. And she did what any good scientist does when they are working with a phenomena. She described, right? So she had this revolutionary idea that we could talk to terminally ill people, that we could ask them what their experience was like.

And then she trained other medical residents and chaplains and social workers and psychologists and doctors, to also talk with terminally ill people and find out what their grief was like. And this was then also applied to bereave people as well. So she described grief in a very accurate way. Anger is a part of grief, isn't it? And depression is often a part of the feelings of grief. What makes it difficult, and we know now from some of the more recent work by Jason Holland and Bob B. Meyer, who looked at the trajectory of grieving over time. So the difference between just

what the moment felt like the anger, say, for example, someone is expressing, compared to how that anger might change if you interviewed the same person multiple times across a year or a couple of years of their life. And so what we know now is that there isn't a linear, process. We don't do all of depression and then we get to all of acceptance, but rather, over time, research suggests that yearning declines and that acceptance increases, but that this doesn't happen in a stair step kind of way. Rather, we know, for example, that at anniversaries or at the holidays, people tend to have a resurgence of grief. And that doesn't mean that their grieving trajectory isn't still going in the right direction, it just means that these are moments where people

are aware of their grief. So if we use it as a description, I think that that works well. If we use it as a prescription for how to grieve, I think it often doesn't fit people's experience, and it doesn't mean their experiences is wrong in any way. We recently had another episode with psychologist Dr. Pauline Boss, who was an expert on what she termed ambiguous loss. That is loss where a loved one is physically absent, but there's no body, like a prisoner of war, or where a person is physically present, but mentally absent, as in dementia. Do our brains process ambiguous losses differently than they do a more clear-cut loss like an actual death? It's such important work, and I think people really resonate

with this idea of ambiguous loss because it is so challenging. So as I described before, even in a very clear-cut case where we were there when the person died, we already are dealing with sort of these two streams of information that are in conflict with each other. So on the one hand, we have the memory of being at the bedside of knowing that this person has died. And on the other hand, because of this bond that we formed, the way that we encode attachment is that this person will always be here for me and I will always be here for them. And we don't actually have to be in someone's presence in order for us to have that attachment of belief, right?

You wouldn't be able to send your kids to school every day if you didn't, you know, know, know deeply at the end of the day we'll all be back. So they're going to come back. Exactly, that they're all going to be back at home at night. And so that attachment belief really doesn't rely on the presence of the person. Well, even in a clear-cut case of grieving, these two things conflict initially, don't they? We have a memory on the one hand, and on the other hand, this is an everlasting relationship. And the solution is just to go find them if they're not in our presence.

So that, I think, causes a lot of disorientation and is part of why it takes so long to grieve. Now, if you add on top of all that difficulty and uncertainty, where you don't have memories of that person, of seeing their body at a funeral, of having a graveside to go to, then it makes the grieving even more complex, even more discerpt, even more discerable. orienting or potentially takes even longer. So while I think that we experience the feelings of grief, just as we would in a case of clear-cut death, there are all these additional layers that then come along with it. It's a little bit related in a sense that when people grieve about a celebrity who died, someone they greatly admired. It's not a physical loss in the same way because you didn't have an actual relationship with the person other than the one you had in your mind. And you've termed this parisocial grief.

How is it that we can feel intensity of grief with someone like that, a celebrity, someone we admired who has passed away? This is a fascinating phenomenon, isn't it? We see when someone who's a famous actor or a musician dies, just this outpouring of grief often. And it seems almost incomprehensible. How are these individuals who did not know this person so moved that they, would come to a place and leave flowers and like candles. And you even just hear people describe or perhaps have felt yourself that pang that really sticks with you when a celebrity or an actor or a musician has died.

And I think it relates to exactly what you were saying, while there's no official relationship that could be pointed to from the outside. And certainly we know that person doesn't know us. On the other hand, many of those art forms, they provide us a way to access some of our inner emotions. Think about the way musicians will write lyrics and we think, oh my goodness, how could they know that about me? Right? That really describes exactly how I feel. And I think that is a kind of bonding that happens.

And often these relationships, I'll call them, these connections to actors and musicians happen at times in our life where we really are trying to find the words for how we feel inside. So that time that we have spent binge watching an actor or spent time, you know, listening over and over and over again to music, I think in a sense that is a kind of bonding. And therefore, that parasycial grief means that we lose a person who really understood the way we see the world. And we often associate that with a particular time in our life, right? So if a musician dies that I listen to, you know, all through college, I feel a little piece of my college self has gone as well that I'll never have again, you know? Yeah, yeah, we're very nostalgic. Yeah, I can understand that loss. So I've heard you say in some interviews that grief or bereavement is a health disparity.

What do you mean by that? Well, we don't often think of it that way, but we know that mortality is, of course, different in different communities. So rates of mortality really became clear during the COVID pandemic how different it was affecting minorityized communities. black, indigenous, and people of color. And so we forget then that the result of that is that bereavement is also a health disparity. So even just taking the example of COVID, we know that black American children were over twice as likely to experience the death of a caregiver compared to white American children. And for American Indian children, it was more than four times more likely to experience the death of a caregiver. And so if you think about health equity, then, if we talk about grieving at a public health level,

at a social, cultural level, then it's important for us to have resources applied in a way that allows us all to process our grieving in a healthy way. And that may mean putting more resources in some places than others to bring everyone to the same level of having opportunities to grieve and experience support. I think it's an important policy aspect to consider how are we applying grief education in schools? How are we offering counseling? What kinds of, you know, even apps might we create that are culturally informed so that people who are in different communities can find what they need in order to grieve in a healthy way. People often find it hard to know what to do, to support someone who is grieving.

What are the right words to say, the right kind of support to provide? And is that something you can look at, for example, when you're doing brain research so that you know what is making people feel better? This is quite difficult. being with a person who is grieving, there's an intensity that is quite difficult to sit with. People are having some of the worst experiences of their life. They will describe it that way often, and often quite unexpected as well. So we very frequently don't know what grief will feel like until we've walked through that door. And so the difficulty is, that especially in our culture, I think our goal often when we are trying to provide support

for a grieving person, the goal we have in mind is to cheer them up, right? We don't want them to feel this intense grief. Well, let's think about that for a second from the perspective of a grieving person. So for a grieving person, they're often having this unexpected experience that's really intense, like the emotion dial just got turned way up. And, now they're sitting with someone who's trying to help them to get into a different state than they are in, right? It's trying to cheer them up. I think for many grieving people, that feels even more alienating.

I'm already having a difficult time experiencing what I am experiencing. And now there's sort of a disconnect if I'm supposed to act as though I feel okay or as though what you're saying has made everything okay in the world again. And so I think our goal, perhaps, isn't so much to cheer them up, but to simply be with them. What is it that they're learning about what life is like now? What is it that they're learning about how grief feels? Are we able to just be with them? And to let them know that we will be with them however long and whatever shape this takes. And, you know, I'll be perfectly honest. I've, I've worked with a lot of grieving people. I feel comfortable when people cry uncontrollably. And I still say things that I think,

oh my gosh, that sounded so insensitive, you know. And so I try to just say to people, look, I don't know why I said that. I'm sorry. You know, that probably didn't sound. That didn't make any sense to you. I'd rather just find out what will be useful to you. Do you want to just go for a drive and not talk at all? Do you want to just pretend this hasn't happened and, you know, go to the movies? Or do you want to talk about it and tell me when it's like a friend recently, a part of my circle of friends, he had experienced the death of his mom. And he sort of blew up and, you know, anger after this thing we had all been at together. And our friends were sort of like, what's wrong with him, you know? And I said, guys, he just,

lost someone a couple months ago. Everything is a little on edge for him. And, you know, just giving him a little extra TLC and a little extra benefit of the doubt goes a long way. So what are you researching now? What are the next questions that you want to answer? Well, one of the things that the distinction between grief and grieving has led to, is an understanding that much of our neuroimaging work studies grief. It studies that moment. So in the scanner, bereaved people have brought us photos often of the deceased person. And we can scan those so that in the neuroimaging scanner, they're looking at a photo of their loved one on goggles

and comparing that, say, to looking at a photo of a stranger. So, you know, we have some ways to elicit this grief for stress. response moment. But what we don't have many studies of yet is what changes over time? If we were to scan the same person multiple times across the first year or two of their grieving experience, we might see some things that change. Now, there are a few studies like this, but very few. And I think that would help us to understand more about what a typical trajectory looks like, perhaps what it looks like when people don't have that increase in acceptance and decrease in yearning. So that's one of the methods I think we have to look forward to to to understand more.

Well, Dr. O'Connor, thank you for joining me today. This has been really interesting and I hope it will be helpful to our listeners. Thank you. Thank you so much. Thanks for bringing this important conversation to folks. You can find previous episodes of Speaking of Psychology on our website at www.combeingof Psychology.org or on Apple, Stitcher, or wherever you get your podcasts. And if you're listening on Apple, please leave us a review.

If you have comments or ideas for future podcasts, you can email us at speakingof psychology at APA.org. Speaking of psychology is produced by Lee Weinerman. Our sound editor is Chris Condiom. Thank you for listening for the American Psychology. Association. I'm Kim Mills.