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Ask a Doc: Grieving

In our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, Dr. Matthew Iwaniec answers questions about grieving.

Matthew Iwaniec, PsyD, is no stranger to difficult emotions. As a specialist in assessing and treating the emotional distress associated with chronic and acute physical illness, he has also seen first-hand the pain that comes with loss. He says that a frequent challenge for people who are grieving in our society is that, “We tend to see painful or complex emotions as bad, and we judge those feelings harshly.”

Attempting to suppress or reject the “bad” emotions associated with grief can backfire, leading to extended periods of anger, depression, and detachment sometimes referred to as complicated grief. Conversely, learning to accept and experience a full range of emotions, without necessarily labeling them as “good” or “bad,” can help us to make meaning out of loss and improve our well-being. A good starting point, whether one is actively grieving or not, is to gain a better understanding of grief and its mechanisms.

Grief: What it is …and isn’t

Matthew Iwaniec, PsyD, Allegheny Health Network

Matthew Iwaniec, PsyD, Allegheny Health Network

Aaron Bomba: How do you define grief?

Dr. Matthew Iwaniec: Grief is the psychological response to a loss, such as the death of a loved one. It’s a mix of emotions, thoughts, behaviors, and physiological changes that impact both the social and spiritual aspects of a person’s life.

Something that helps is to conceptualize or picture loss as a physical injury, and grief as the process of healing from that injury. It’s one of the most difficult things people will ever go through in their lives, but it’s very natural. Grief is not an illness.

Biologically, our emotions are experienced through what’s called the limbic system, a collection of areas in the brain that work together to generate and express emotion. Then, that emotion is regulated by our frontal lobes.

Aaron Bomba: I’ve often heard grief talked about as occurring in stages. Can you speak to that?

Dr. Matthew Iwaniec: There are many complexities and subtleties with grieving, and some “stage” models get used in ways that oversimplify it.

It is helpful to understand two broad phases of grief: acute and integrated. First, there is acute grief, which is what you experience in the early stages after a loss. This is associated with very intense emotions. Then, there’s integrated grief, which occurs after some amount of time has passed, and some of the intensity of those emotions has decreased. The feelings of loss are still there, but you are beginning to accept them.

If someone can’t seem to move out of the acute phase and into the integrated phase, we call that complicated grief, and it should be treated by a mental health professional. Grief should evolve over time. That doesn’t mean it goes away, but if, for example, one year after a loss, you feel exactly the same as you felt one week after it happened, that can be an indication of complicated grief.

People sometimes describe grief as a rollercoaster of emotions, because the process involves some of the lowest lows and highest highs. Strong feelings can include yearning, longing, sorrow, anxiety, fear, guilt, shame, anger, and also positive emotions like pride, happiness, and gratitude. The complexity of grief can be part of what makes it so painful to go through, and hard for others to understand.

Aaron Bomba: What kinds of guidance do you give to people to help them deal with grief?

Dr. Matthew Iwaniec: There’s never an easy answer, or just one approach that will work for everyone. But I do emphasize to people that their grief is very normal. People get into trouble when they believe — maybe based on their upbringing or just society’s influence — that grief is somehow abnormal or offensive. That can cause them to suppress how they feel. Our culture loves to avoid pain, but suffering is inevitable. Leaning into it is usually the healthiest way to proceed.

Having a framework for grief can be helpful, too. It’s important for people to know what to expect, and that there can be a mix of emotions that will come and go throughout their day, triggered by different reminders.

Lastly, I tell people not to judge themselves. Feeling incompetent — maybe like you can’t complete simple tasks or you’re lacking purpose — is very common with acute grief, as is a lack of interest in your normal routine, brain fog, confusion, attention and memory problems, and difficulty planning ahead. Changes in sleep and appetite are normal as well.

Understanding grief as a process

Aaron Bomba: Might you actually say that grief is “good”?

Dr. Matthew Iwaniec: People don’t think of it that way because it is so painful, and we tend to categorize painful experiences as “bad,” but yes, grief is good because it’s necessary. The process helps us work through loss and get back to a life of meaning and connection.

I also like to think about it this way: grief is, in some ways, the flipside of love. It’s the form that love takes whenever we lose someone. Your grief means you have loved and are connected with someone who has impacted your life in some way. It’s a positive thing, even if it doesn’t feel like it at the time.

However, as I mentioned, if your grief doesn’t transition from acute to integrated, it can cause problems.

Aaron Bomba: What are the signs that someone might need extra help processing, or that they might be stuck in what you called complicated grief?

Dr. Matthew Iwaniec: One sign would be excessive avoidance. As you go through the grieving process, you eventually need to get back to a sense of normality and routine, but that can be painful. Common examples of avoidance or suppression might be avoiding a gravesite, or staying away from things you used to do with the person you lost. Maybe you used to go to baseball games together, and now you avoid baseball altogether. Widespread avoidance will ultimately increase negative emotions over time, and prolong your grief.

On the other end of that spectrum would be excessive attempts to be near or feel close to the person you lost. One example might be someone who has lost a child spending all day in that child’s room, going through toys, clothing, and belongings. In and of itself that isn’t necessarily bad, especially early on, but it could be negative if you stop engaging in other areas of your life because you’re spending all of your time trying to feel a closeness to the person you’ve lost.

Another sign that someone might need extra help is that they’re fixated on the most distressing elements of the loss. Grief is particularly difficult if the death was unexpected or sudden. For instance, homicide and suicide scenarios can lead to complicated grief. If someone seems highly focused on the suffering the other person experienced, it might be a sign that they need help.

Playing the “if only” game is also a cry for help. It’s normal to question things like, “If only this had or hadn’t happened,” but if you’re stuck on these scenarios and cannot accept what has happened, consider that a red flag.

Helping loved ones who are grieving

Dr. Iwaniec points out that the grieving process varies and there’s no one “fix” to help someone who is grieving, but a good starting point is to be present and empathetic.

Dr. Iwaniec points out that the grieving process varies and there’s no one “fix” to help someone who is grieving, but a good starting point is to be present and empathetic.

Aaron Bomba: If someone we care about is experiencing grief, how can we help?

Dr. Matthew Iwaniec: There is no one-size-fits-all method of dealing with grief, but it’s a good rule of thumb to lead with empathy and sensitivity — simple gestures to be physically and emotionally present. It’s also important to understand that grief is different for everyone. Your experience of it will not be the same as someone else’s, meaning coping mechanisms that may have worked for you or others may not work for the person you want to help.

Also, keep in mind that people experience, and express, emotions differently. Emotions are mediated by genetics, the environment we grow up in, beliefs, and other factors. Some people feel emotions more intensely, or express them more openly, than others do.

To be most effective, you should encourage honest communication. Don’t make assumptions about how they feel. To start off, sit down and ask them how they’re doing in an open-ended way. Ask how they’re coping, or how they’re dealing with the loss. That allows them to respond however they’d like. They may say “fine” or not even want to talk at all, which tells you this might not be the right time or place to talk. General flexibility is important, and just saying something like, “I’m here to talk if you need me” can show support.

One thing I think that’s important is to be mindful of differences in religion, faith practices, and personal spirituality. These things may be extremely important or comforting to some, and less so to others.

Some things that are generally not helpful to the grieving process are statements like: “they’re in a better place,” “they’re in heaven now,” or “at least they’re not suffering anymore.” As a general rule, “at least” statements aren’t good because they can invalidate the person’s grief. While well-intended, they’re not always well-received. Remember, it’s not about you, so don’t talk too much about your own grieving process or beliefs or offer advice unless the person asks for it.

It can also be good for people experiencing grief to participate in some sort of ritual or service. If it’s appropriate for them, maybe go to a funeral or a viewing. It doesn’t necessarily need to be religious, just something to mark the loss and recognize the enormity of their grief.

Aaron Bomba: Is there anything else you’d like to express to readers?

Dr. Matthew Iwaniec: Grief is a difficult subject because it comes with so much variability. It’s hard to tell people what to do or what not to do because there’s no one answer. An important caveat to offering advice or help is recognizing that grief varies and evolves over time. That means that dealing with someone one week after they experience a loss and six months to a year after experiencing it will be very different.

There’s also no proper time frame for being “over” a loss, and grief isn’t something to be “solved.” It needs to be worked through — which can be difficult for caregivers and loved ones, because we want to fix things. But sometimes the most you can do is offer a shoulder and an ear.

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