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We tend to associate grief with the death, but a number of other life events can trigger grief, too — from the end of a relationship to the loss of a job to financial hardships. Clinical psychologist Regina Josell, PsyD, explains the many emotions that come with grief and ideas to help you get through it.

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Grief: Strategies for Coping With Loss and Big Life Changes

Podcast Transcript

Nada Youssef:   Hi.  Thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio. And we're here with Dr. Regina Josell. Thank you so much for being here today.

Dr.  Josell:  Thank you for having me.

Nada Youssef:   Dr. Josell is a clinical psychologist in the department of psychiatry and psychology in Cleveland Clinic's Center for Behavioral Health. And today we're talking about grief. And please remember, this is for informational purposes only and it's not intended to replace your own physician's advice. So, let's talk about grief, it's a natural response, you know, it's accompanied with deep sadness and loneliness, but what is healthy grieving?

Dr.  Josell:  So, like you said, it's a natural response, it's a normal reaction to any kind of loss. And it can ... People experience it in different ways, but typically you're going to have a number of different intense emotions, sadness, sometimes anger, irritability, guilt. Some, all, of those. Depends on the person. But in addition to the emotional aspect there also are a number of physical, sometimes behavioral, cognitive symptoms. So, difficulty concentrating, difficulty making decisions. Loss of hope about the future, or confusion about what direction somebody's going to go in. Physical symptoms can be difficulty sleeping, loss of appetite with weight loss, sometimes people try to self-medicate, and so sometimes there's a problem, maybe a little bit alcohol or other drug use. So a constellation of symptoms.

Nada Youssef:   Yeah. So it sounds a lot, almost like depression, like maybe anxiety and depression.

Dr.  Josell:  Mm-hmm (affirmative).

Nada Youssef:   How can you tell the difference between depression and grieving?

Dr.  Josell:  It's a really good question, and the answer's kind of complicated. Because they can mimic each other quite a bit. With grief, depression tends to be what we call a stage. We'll get to more of that later. But depression is one stage of grief, that people can move in and out of. The sadness that goes along with that tends to be related to the loss. In major depression or other depressive disorders, usually that loss of interest in previous enjoyed activities or that dysthymic depressed moods, sadness, tearfulness, isn't necessarily stimulated by a particular loss. It's more pervasive. In major depression you might have feelings of worthlessness that don't necessarily go along with grief. And I think in major depression vs. grief, you're going to notice more functional impairment, so ... Over a more extended period of time. But grief can turn into depression, and so it's really important that grief gets addressed when somebody's experiencing it, so it doesn't turn into something worse.

Nada Youssef:   Thank you. So a lot of people think that grief is a result of death, but it could be a result of just unfortunate events, could it be like losing a pet, could it be a divorce, could it be anything like that?

Dr.  Josell:  Absolutely. Loss.

Nada Youssef:   Loss.

Dr.  Josell:  Some people will define it as any change in somebody's regular routine can trigger grief. But absolutely, divorce, the end of a relationship, loss of a pet, for sure, loss of a job, financial changes. You know? So bankruptcy, loss of a home, all of those can stimulate grief.

Nada Youssef:   Thank you. So is this something that comes and goes, or is grief a feeling that just like a blanket, that just stays with you until it's gone?

Dr.  Josell:  Oh no, it comes and goes. Yeah. And I think people who have experienced grief will really relate to that. You could be having a great day and you're driving in the car, and all of a sudden a song comes on the radio, and you're crying. And so, typically, it can come in waves, and it can come and go in intensity, and in the symptomatology that people experience, yeah.

Nada Youssef:   So you mentioned like a song in the car or something, so it's something that's triggering it, that reminds you of the emotion or, is that why?

Dr.  Josell:  It can be, but it doesn't have to be that. Absolutely, yeah.

Nada Youssef:   Okay. Great. So you mentioned stages of grief?

Dr.  Josell:  Mm-hmm (affirmative).

Nada Youssef:   Can we talk a little bit about that?

Dr.  Josell:  Sure. So, Elizabeth Kubler-Ross was a psychiatrist and a researcher, who really spent her life studying the dying process, and the aftereffects of death on survivors. And so, she developed a five stage protocol of death and dying. And so, that helps us kind of understand the process, but it's not all inclusive. And so, as we talk about these stages, I don't want to give the impression that everybody goes through these, that something's wrong if you don't. Some people don't go through all the stages. And it's not nice and sequential all the time. People can bop in and out of different stages. But there are basically five stages.

So the first one, denial, which is just kind of this difficulty comprehending the reality of it. And the way I have seen it with people is just, not always the reality of it, but the finality of it. You know? That this is really my life now. Like there has been this significant loss, and things are different, and they're not going back to the way that they were. And that takes a while to kind of wrap your head around it.

Nada Youssef:   Sure. Sure. So denial is the first step, what about something like anger?

Dr.  Josell:  Yes. So anger is another stage, if you will. And perfectly natural response. And the anger can be directed at a variety of sources. And it's not always rational. You know? So it could be directed at yourself, it could be directed at doctors, a hospital, it could directed at the deceased. They should have done this, they shouldn't have done that. I could be directed at God or a higher being. Sometimes just innocent bystanders, you know, the guy at the checkout line at the grocery store who looked at you funny. You know? It may get directed there. Yeah.

Nada Youssef:   Wow. Wow. So, thinking like, what ifs?

Dr.  Josell:  Yes.

Nada Youssef:   Is that something like, I know you had a word for it earlier, it's not regret, but what is it?

Dr.  Josell:  Bargaining.

Nada Youssef:   Bargaining. Can you explain that?

Dr.  Josell:  Yes. So bargaining is another stage. And we see this often in the process of dying. You know, thoughts like, okay, if you let me get better, I promise I'm going to go to church every week. Or, I promise I'll never going to ... You know, let my husband get better, and I'll never be angry with him again. You know? But it can take a form even after a loss, in the sense of, well, if we'd gone to a different doctor, maybe things would have turned out differently. If we hadn't gone on that vacation, and he wouldn't have contracted this disease, maybe things would turn out differently. If I'd gotten the electric collar for my dog a day earlier, maybe she wouldn't have run out into the street. So, that kind of ... I mean, there's some regret in there. But it's kind of this mental gymnastics that we're doing to try to undo something that we can't undo.

Nada Youssef:   So it also kind of sounds like a little bit of guilt, of I could have, I would have?

Dr.  Josell:  Sure.

Nada Youssef:   How do you deal with something like that, especially after someone maybe passes or something changes, you know, forever? How do you deal with that?

Dr.  Josell:  Sure. Well, guilt is a normal response shortly after we've lost somebody or experience a loss.

Nada Youssef:   Sure.

Dr.  Josell:  I think part of the way people deal with that is ... Well, two things. One is, you've got to feel the feelings. And I will say this about the entire process of grief. Trying to push away how we feel generally doesn't work. And often we'll have friends who will try to talk us out of our guilt, right? Which is very kind, very sympathetic. But I think for people to get through it, they have to feel heard. And that goes along with any of these emotions. So, I think people have to be able to think what they want to think, and then after it's been expressed, maybe do what we call cognitive restructuring. So start looking at the evidence, start to look at, okay, is this really how things went down? Is this really what I am responsible for? And sometimes that just happens pretty naturally. Yeah. Sometimes it needs a little nudge.

Nada Youssef:   Yeah. And then you mentioned depression, that's another level of it.

Dr.  Josell:  Absolutely.

Nada Youssef:   And once you're done with that, what is the final stage?

Dr.  Josell:  Well, acceptance.

Nada Youssef:   Acceptance? Okay.

Dr.  Josell:  Yeah. And so, acceptance is a sense of understanding that there is a finality to what has happened. Right? That this is your new reality. But also maintaining a hope for the future. And being able to experience like good memories of the past, and to be able to hold that with the sadness. The sadness, the loss, the emptiness, doesn't necessarily go away completely. If we've ever loved somebody, and we've lost them, or loved a way of life that we have, and we've lost that, there's going to be some sadness that's attacked to that, maybe forever. But, in acceptance, when we have kind of resolved our grief, we can hold the good memories with that. We can have memories and not send us into complete dysfunction, back crying in the bed every day.

Nada Youssef:   So, I can imagine there's not really a normal amount of time to grieve?

Dr.  Josell:  Correct.

Nada Youssef:   Normal, right?

Dr.  Josell:  Yes.

Nada Youssef:   So, but when is too long? When is it too long, and when is it time to see you or a specialist?

Dr.  Josell:  That's another good question. And again, it's kind of complicated. Uncomplicated grief can last for a year. Sometimes two. Excuse me. When we are grieving a loss, symptoms will vary, they will change in intensity, but for the first year or two you might experience a lot of those symptoms. Also I see for a lot of people that first year, sometimes they are so numb, and they're so busy dealing with like the business side of grief like, okay, I've got to do the bank accounts, or I've got to get rid of the newspaper, I've got to change the note on the car. You know? So they're so busy with the work that they don't always have an opportunity to feel. So sometimes there's a little bit of a delay. That doesn't mean you shouldn't get help, even if it's uncomplicated, and even if it's still normal. I say people should get help, a couple things. If you feel you're suffering, go talk to somebody.

One way that we get through grief is that we talk about it. And that can be with a friend, it could be with a family member. They're not always the best people to do that because they may be grieving as well. And that can be helpful, but sometimes it's not. So if somebody is suffering, go see somebody. If you are not functioning, right, if you are not, after a couple of weeks, I say, not returning to work, not ... And it doesn't have to be your best work, but are you up and out of bed and going? If you are not taking care of the kids, if you're not re-engaging in activities of daily living. If you're not doing your hygiene, showering every day or every other. If you're not doing chores. Things like that. So if you're functionally ... If there's a functional impairment, you're not doing your norm, probably should go talk to somebody. Yeah.

Nada Youssef:   So it sounds like the five stages that we talked about earlier of grieving, it sounds like if you're stuck on one of these levels, unless it's acceptance, that's when you should see someone?

Dr.  Josell:  Absolutely.

Nada Youssef:   Okay. That makes sense.

Dr.  Josell:  Yeah, absolutely.

Nada Youssef:   So, let's talk about what we can do to heal ourselves.

Dr.  Josell:  Absolutely.

Nada Youssef:   The things that we can do. I really like what you said about feeling your feelings. Because sometimes when they do that, some people disconnect from friends and family. And some people do the opposite, some people are distracted. What is the right balance?

Dr.  Josell:  Well, we get a lot of negative messages about grief, I think. And so, it really impedes people from being able to go through the process. You know, we're often told, don't cry, because it makes people uncomfortable, right? And people are, again, they're trying to be kind, but we get that message. And we often get it pretty young, don't cry. We get a message, go grieve in private. Which is not usually very healthy. And so, one of the best things that we can do is feel your feelings. If you feel like crying, cry. Crying's a manifestation of emotion. That's all it is. It can get detrimental. But when you're grieving, if you're sad, cry. Tell your story. I think that is one of the most important things. For grief to resolve, it needs to be witnessed. People need to know what we're going through, and I don't mean everybody. I once heard what I thought was a really great idea. Somebody had an idea, you know the little pins that people wear for like AIDS awareness, and breast cancer?

Nada Youssef:   Yes.

Dr.  Josell:  About if you are grieving that you should wear a pin. So people around you know, and just maybe are a little nicer to you. So, I tell people, tell your story. Find somebody who will listen. The first thing I do when someone comes to my office if they're grieving is, I want to hear what happened. I want to know about that relationship, if it was a relationship, that's the loss. I want to know the process of that person's illness or the accident. I want to know about their funeral. I want to know what they're doing now. Because there is healing in telling your story. So, funny note, my husband and I were in a ... We were driving to take our daughter to orientation. And our car literally blew up, like there was a fire.

Nada Youssef:   Wow.

Dr.  Josell:  We were all fine. But it was a little traumatic, and in hindsight, there was a loss. I mean, we lost this car, but it was also this loss of a sense of safety. And we got to where we were going, my mother came and rescued us, and we got there. And everywhere we ... So all our stuff was in the fire, so we had to go to Target and buy some things. Everywhere we went, we were telling people our story. We were telling people at the check out line, we were telling people everywhere we went, our car blew up.

Nada Youssef:   You found that it helped, to let it out?

Dr.  Josell:  It did.

Nada Youssef:   Yeah, yeah.

Dr.  Josell:  And it was funny, it was like in the process, didn't really realize what we were doing, and after the fact, my husband is also a psychologist, we're like, oh my God, we just like told everybody that every where we went. But it was, it was healing. So I tell people, tell your story. Share you're story. Feel your feelings. I think one thing that is really helpful for people is to get educated about the grieving process. Like I said, we tend to give people negative messages. Don't cry, grieve in private, bury your feelings, time will heal it. Time alone doesn't heal it.

So, I tell people, get educated about the process. The stages are not the end all be all, but they're, I think, they do give people a good understanding of what is normal. And when people understand, oh, okay. It's normal that I'm crying in the car, spontaneously. Oh, it's normal that I got two progress notes done today, when normally I can do thirty. That when they recognize what they're experiencing is normal, they feel less like a freak. And that is really healing. When people feel like, oh my gosh, something else is wrong with me. It makes the healing process much more difficult.

Nada Youssef:   So it sounds like grieving is normal. You are okay to get emotional outbursts in the car, anything that may be stirs up some memories, as long you're doing your everyday routine. You're able to go back to work, you're able to take care of your kids, and shower, and all that good stuff, right?

Dr.  Josell:  That is helpful. But you still might be suffering. The emotional aspect of it, some people are just like, they look like they're keeping it all together. And they are, but it's taking every bit of energy that they have. And so, it could still be a good idea to go talk to somebody. Yeah. Yeah.

Nada Youssef:   So, let's say I have a loved one that's going through maybe a death of family or a loved one for them, tell me what not to do. You know, what to do, maybe, and I'll see what they want, give the space, but what not to do.

Dr.  Josell:  Yeah. Don't minimize it. Yeah, don't minimize it. Just allow them to express themselves. Be supportive. Try to stay away from platitudes. You know, oh, they're in a better place. If the person grieving says that, absolutely, you want to agree with them. Yes. But, if they're not initiating it, I wouldn't initiate that. What it can do is it diminishes that person's experience of what they're going through. Don't say time heals all wounds. You can say things like, it'll get better. It'll get better. This is going to be hard right now, for sure, but ... So you can give encouragement without platitudes. Yeah.

Nada Youssef:   Sure. So, I am the grieving person. What should I not be doing? We talked about healing ourself, feeling our feelings, what I should not do to deal with my grief?

Dr.  Josell:  Well, you don't want to push it away completely. I mean, sometimes we just have to shelve it for an hour or two, and then we get home and we can let it out again. But try not to bury it. Don't pretend it's not happening. Don't ignore it. Don't overmedicate. Like don't self medicate, alcohol, food, other substances, can numb what we're feeling. All it does is postpone it. I know a lot of times people will go see their physician right after, you know, when they're grieving. And physicians, God love them, their instinct is, I want to help. Right? And so, here's some medication, this will help. That really makes me nervous. I don't like to medicate grief, because it's a natural process. And sometimes medications can help. If you're not sleeping for weeks, yes, give them something temporarily that might help with that. But I'm reluctant to heavily medicate grief, because normally it will resolve. Yeah.

Nada Youssef:   So when you're thinking about medicine, you're thinking about kind of needed a solution for sleep, or for the symptoms that come out of grieving?

Dr.  Josell:  Yes.

Nada Youssef:   Okay.

Dr.  Josell:  Short term. Yeah.

Nada Youssef:   Sure. Sure. And then lastly, I just want to talk about facts of grieving. So we said it is absolutely normal, and everyone grieves differently?

Dr.  Josell:  Correct.

Nada Youssef:   Someone can have their space, and it's okay.

Dr.  Josell:  Yeah.

Nada Youssef:   Someone wants to be in the middle of people, that's okay.

Dr.  Josell:  Absolutely. Absolutely. Yeah.

Nada Youssef:   And I like how you, again, you said feel your feelings. So the way out of grief is through it.

Dr.  Josell:  You feel it, yeah.

Nada Youssef:   And it's hard work, and it comes and goes. Right?

Dr.  Josell:  Correct. Correct.

Nada Youssef:   Anything else you wanted to add to this?

Dr.  Josell:  Just a couple other things that can help the person when they're going through it. Journaling can be really helpful. Because sometimes we don't have somebody that we can talk to. Or that we're comfortable with that. And so, some people either ... You can use it in a couple different ways. You can monitor your emotions. Because sometimes people feel like, oh my God, I'm still feeling this. But if they look back, they can see that it's getting less intense or it's getting less frequent, or they're having more good moments. Can journal about your feelings. Sometimes people will use it as a way to talk to the person that they lost. And that could be really healing. Take care of yourself. A lot of times when we're very sad, when we're angry, when we're in a bad place, we stop eating, we stop sleeping, we stop seeing our friends. Take care of yourself. Go back to the basics. Water, healthy food, exercise.

Exercise is one of the best things that we can do when we're experiencing any kind of intense emotion. It's great for anxiety, it's great for anger. You're angry, you get on a treadmill for 20 minutes and it will really significantly go down. And with depression, it'll increase endorphins, so it'll bring your mood up. Affirmations. Reminding yourself that this is a stage of life. That you're not going to live here forever. That things will get better, I think can be really helpful. Meditation. Guided imagery. Yoga. Those are all really good self-care activities that can help induce a sense of peace, and a sense of calm. And give people more of a sense of control back over their life. Because a lot of what people are experiencing with grief is that they've lost control. Things have changed, and often, no fault of their own, or unexpectedly. And so, when we do things that take care of ourselves, it gives us a sense of control again.

Nada Youssef:   Excellent. Thank you. Thank you so much. You were amazing.

Dr.  Josell:  You're welcome.

Nada Youssef:   Thank you. And thanks for all of our listeners who joined us today. We hope you enjoyed this podcast. For an appointment with Dr. Josell or another specialist in Cleveland Clinic's Center for Behavioral Health, please call 216=636-5860. Or you can visit ClevelandClinic.org/behavioralhealth. And to listen to more of our Health Essentials Podcasts from Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEpodcasts. And for more health tips, news, and information from Cleveland Clinic, make sure you're following us on social media, Facebook, Twitter, and Instagram, @ClevelandClinic, just one word. And thank you again for listening, we'll see you again next time. This concludes this Cleveland Clinic Health Essentials Podcast. Thank you for listening. Join us again soon.

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