Our brain pathways are designed to get us through life’s traumas, as painful and debilitating as they are. Neurologist Lisa Shulman, MD, joins us this week to talk about how to make sense of grief, how trauma interrupts the connection between the cognitive and emotional parts of the brain, and how the brain learns to consolidate traumatic experiences and allow us to move forward. Plus… humans are not the only creatures to feel grief – hear how other animals experience loss.
Phil Stieg: Hello. I’d like to welcome Dr. Lisa Shulman, director of the University of Maryland’s Movement Disorder Center and esteemed neurologist. In her recent book, “Before and After Loss”, she describes her journey through life after the death of her beloved husband and soulmate, Dr. William Weiner. She likens the effects of prolonged grief to that of post-traumatic stress disorder. Let’s learn how she dealt with changes in memory, sleep disorders, and behavior as she worked through her grief. And along the way, she gives us insights into dealing with severe emotional trauma in our lives. Lisa, welcome, and thank you for being with us today.
Lisa Shulman: Thank you for inviting me. Phil.
Phil Stieg: In your writing of the book, you clearly bare a lot of your soul in terms of how your husband’s death affected you emotionally. Was the purpose of the book — to serve as a therapeutic exercise for yourself, or more of a guidebook for others through the journey of grief?
Lisa Shulman: Well, I very much appreciate that particular question because we don’t know each other, and so you wouldn’t know that it was quite unfamiliar territory for me to bare my soul that way. And I didn’t go about from the start writing a book. I sort of stumbled into journaling as my most effective healing practice. And then there were series of events. I became interested in doing my own research into the field. I kind of felt if I could understand more about what was going on, that I could start to do better myself. That led to me having a strong belief that that would be helpful to others. And so I wrote this book in the form of a hybrid where the first couple of chapters is bearing my Soul, my own personal experience. And then the following chapters talked about brain function and how the brain is impacted by a serious emotional trauma.
Phil Stieg: Can you set the stage a little bit about what your grief and complicated grief episode was for us?
Lisa Shulman: Okay. I was simply preparing dinner one night and opened a recipe book to a recipe that Bill and I had enjoyed in the past. And to my complete surprise, I found on that page that Bill had scribbled a little note in the margin – a note that he had written in the first days after his diagnosis. A very hopeful message. I didn’t expect that. It took me by surprise. And the next thing I remember is that I was standing in my kitchen – oddly holding this large butcher’s knife. Well, obviously, I lost awareness for a period of time. And I was so disoriented that I actually didn’t know what I’d been doing. I had to reorient that I was standing in the kitchen. And then when I saw the recipe book in front of me on the counter and then saw, of course, Bill’s note again, I was able to put it together. I didn’t know how much time had gone by, but whatever time it was, I was completely disoriented when I came back. I might not have noticed it even happened, to be honest, because once I saw what I was about to do, oh, I was going to do this recipe. I’m going to start cutting my vegetables again. I might have just glossed right over it.
But then I just paused for a moment, and I thought, wait a second, I lost some time. And as a neurologist, we call that altered mental status. So at that moment in time, I was very fortunate that I caught an event, an experience that had been happening periodically, but I’d never caught before. Later on I found out that it was an episode of dissociation. Dissociation is a period of time where you’re detached from reality. And it’s kind of like your brain understands that that very emotional input, that emotional stimuli is too much for you. And it’s kind of like an escape hatch where the brain just unplugs and goes, “you’re not ready for that stuff yet” . That’s exactly what had happened. And if not for that experience in that moment of realization that even a year and a half after my husband’s death, my brain was doing something it had never done before, something unique that caused me to do the research and write the book.
Phil Stieg: I’m sure many of our listeners are curious about how you differentiate between sadness and depression and grief.
Lisa Shulman: That’s an important question because they’re oftentimes confused and they are quite different. They’re quite different in their symptoms and they’re quite different in the experience, and they’re even different in their treatment. Actually depression is kind of like, if you can think of it kind of like a negative experience where you’re hollowed out. And loss and grief is somewhat more tormenting, actually. When it comes to the actual treatment of the two, it’s very interesting that many people think that antidepressants would be helpful for both depression and grief. However, many studies show that antidepressants are helpful for the depressive symptoms, but not the grief or emotional trauma itself. So that’s an important difference in terms of understanding how we have to manage grief and loss.
Phil Stieg: You described a number of symptoms that you experienced after Bill’s death, such as the isolation and dissociation. What are the common characteristics of complicated grief? So people who might be experiencing it right now and listening could say, AHA, that’s what I’ve got.
Lisa Shulman: It’s very difficult to have insight into our own emotional life, actually. It’s a common thing, for example, for people to be unaware that they’re depressed. They may be less aware than we think that they are anxious or apathetic. And in the same way, when you’re actually going through grief and loss, one of the most interesting things is the way the brain manages a serious emotional trauma, is that the whole system is designed to maintain good function. That’s the idea. The idea behind the evolutionary development of these pathways to manage emotional trauma is, in fact, to help us survive it, which, of course, makes a lot of sense. Stay alive. Exactly. That means that if, God forbid, you walk out of your office tonight and you see a horrifying car accident and you are even involved in one, you aren’t paralyzed by it. You’re able to get up and perhaps help others who need help in the moment. It’s because we remain functional.
When you’re in the midst of it, you’re surprisingly functional. You’re doing your daily routines; you go to work. It’s not as if things are just falling apart. You go to supermarkets, whatever. However, it takes a bit of insight to see how things have changed. And among those things, is the summoning of various defense mechanisms. Again, the brain. I know I’m a neurologist, but the brain is brilliant in its design in terms of having all these built-in mechanisms to defend us and keep us functional. And what are some of those things? Well, all the defense mechanisms we learned back in school, whether you’re talking about denial, repression, dissociation, all of that comes to bear such that one can maintain your daily function. So, in terms of complicated grief, number one, it’s not easy, not always easy to realize that you are suffering from that.
Phil Stieg: Do you think that for a period of time early on in grief, that emotional avoidance is a good thing until you get to that point where you can understand it as the positive that it was in your life?
Lisa Shulman: In the book, I mentioned a concept of immersion and distraction. And that concept kind of connects with your question because what it says is we can’t live in a world of angst all the time. We have to have very thoughtful, deliberate modes of reconnecting those cognitive and emotional memories, also deliberately making time for refreshment and rejuvenation. And sometimes the world doesn’t allow that. Many people always think about we all think about when we see somebody who has lost a loved one or gone through a terrible time, what’s the right thing to say? And one of the problems is that it happens to me. I’m sure it happens to everybody. You see somebody and it just jumps right up to your mind and you say, oh, how are you? I’ve been thinking about you. I’m so sorry. And so forth. Well, think about what it’s like for somebody who’s recently gone through a terrible time going back to work and hearing that 100 times out of that day.
Phil Stieg: It wears on you.
Lisa Shulman: It certainly does. So how is a person going to find rejuvenation instead? What they need is from us – space.
Phil Stieg: You highlight three principles of healing, and the first being the subconscious conscious integration. What do you mean by that?
Lisa Shulman: The subconscious conscious integration refers to the deliberate work to reconnect the cognitive skills and our emotional memories. When important memories that you need to recapture in order to heal and have a full understanding of your experience have been suppressed. The question is, how am I going to get back in touch with that stuff? The areas that helped me do that were journaling, and not only journaling my thoughts, but also keeping a dream Journal
Well, somebody once asked me, how did you get involved in journaling for this purpose? Without thinking, the first thought that came to mind was desperation. You know, that you can be in such a dark place that you have to find a release to unburden yourself and to try to make sense of an experience. And I want to make sure that anybody listening understands that if you’re not somebody who can get that from journaling, then for some people, all types of creative practices can do this for people. It could be paintings, it could be photography, it could be dance, music. In fact, being out in nature for some people, hiking, all of these things can give you that space to relax and start to heal.
Phil Stieg: But it’s also consolidating your memories, too. Right? What I took away from your book is the combination of journaling and also journaling about your dreams allowed you to consolidate and get into the third component of healing, which was opening of your mind and new possibilities.
Lisa Shulman: You know I think there are many people who sort of recoil from the idea after a loss of thinking about any positive consequences of it. And life is filled with losses of all types. And it’s an important pivot to make to be open to new opportunities and possibilities. You may not have wanted to be left on your own, but left on your own there are things that open up that you’re going to have to do and you may choose to do based on that.
Narrator: Grief may be very personal, and each person’s experience of grief is unique. But the experience of grief is not uniquely human.
In her book “How Animals Grieve”, Anthropologist Barbara King, argues that “We humans don’t own love or grief – these emotions are widespread in other animals.”
Evidence of grief has been reported in many other mammals, and even some birds. Jane Goodall has observed it in Chimpanzees. They who may withdraw from their social group, lose their appetite, and have difficulty sleeping following the loss of a parent or off-spring.
SFX: Whale song
Dolphin and whale mothers have been known to spend days attending to the body of a dead calf, refusing to eat and abandoning the company of the rest of their pod. Marine mammal researcher Dr. Joan Gonzalvo theorized that since social animals are able to form strong emotional bonds – it takes time for their brains to adjust to the loss of that bond. Or, as one writer put it – “Grief” is the price we pay for “Love”.
Perhaps the most striking examples of animal grief are seen in elephants.
Veteran wildlife filmmakers Vicky Stone and Mark Deeble spent four years following a matriarch elephant and her family.
Mark recalls a vivid moment…
Mark Deeble: We’ve been following a family of elephants and the smallest calf was obviously seeing in a bad way. It was a desperate time for them because the drought was coming on. The matriarch was trying to get the family to water and the female and the small baby were holding up the herd. It was getting weaker and weaker by the day. We knew the inevitable would happen. It got stuck in mud and the effort of it trying to get itself out of the mud was just too much – it literally died there and then. It had a heart attack.
The female, she just stood there and didn’t move for perhaps 30 or 40 seconds. And then she let out this incredible shriek and knelt down and plunged her tusks into the ground. The rest of the family had gone on ahead of her but then when they heard this, they came running back.
The matriarch led the others back and she came in. And when she came, the mother just calmed down immediately. And she came forward and she tried to lift the baby out of the mud with her tusks and she wasn’t able to do it. This unfolded over a period of about 40, 45 minutes. And then at the end, she turned around and led them all away.
The last one to leave was the calf’s mother. It was as if she couldn’t bear to turn it back on her, because she actually walked backwards away from the calf. I just kept the camera running, she left the frame walking backwards, as if that was a last glimpse she was going to get to her calf.
Looking at elephants, it’s easy to be sort of anthropomorphic about them. I feel that what I saw was genuine grief. I was convinced that the feelings I saw were very real and I think that elephants show them in just the same way as we do.
Closing theme music
Phil Stieg: In your book, you compare complicated grief to PTSD and chronic traumatic encephalopathy. What are the changes are going on in the brain that makes Grief similar to PTSD or concussion?
Lisa Shulman: What’s going on in the brain following a serious emotional trauma is a very significant remodeling and rewiring of the neural connections with some paring down of some of the circuits and enriching of other circuits. This results in areas of the brain involved in handling trauma and threats to survival is our primitive brain, our limbic system, our amygdala. Those areas are strengthened when we’re going through times of emotional trauma and the interconnections that are so important with the advanced brain, the cerebral cortex, those become weakened. so that there becomes an imbalance where, as you might predict that the person becomes more hypervigilant, more anxious, more fearful, because all of those circuits have been strengthened and our advanced, logical, coherent brain is less able to bear down to the situation. So there is a profound change which has been measured by many scientists now in terms of actually the volumes of the brain in those areas and certainly the neural interconnections.
And most importantly, I want to point out that when you talk about PTSD, say we’re talking about mild traumatic brain injury, post concussive syndrome after concussions. In many of those cases, there’s actually no physical injury that can be shown on an MRI after a sports injury, for example. But yet we accept that as being a form of a physical injury. So that is part of the reason why I put out there that I think we should think about emotional traumatic brain injury in a similar fashion.
Phil Stieg: I think it’s important in the book you have a table that goes through the brain areas activated during grieving. And if you look at the list, it’s basically the entire brain. And so it’s kind of interesting to think that grieving is a process that appears to be somewhat dependent upon the interconnectedness of the entire brain. But focusing on recovery you talk about recovery constitutes the reconnecting of the emotional and cognitive components of the brain. How does that occur?
Lisa Shulman: Well, it goes back to the previous discussion about how a weakened connection has been set up between the primitive brain and our more advanced cognitive brain. What is the most obvious thing that’s going to be required? We want to go back to the baseline state where those interconnections were enriched, because I think that’s exactly what’s going on, Phil, in complicated grief or prolonged grief, that you maintain this imbalance and you’re unable to summon a more logical, coherent approach to your problems because you know what’s happened? A lot of the cognitive memories, the difficult traces of your cognitive memories have been suppressed in your subconscious, and you can’t actually recall some things because they’re so emotionally troubling to you. So that’s not going to happen overnight. Instead, it’s going to be finding ways that enable each individual to slowly get back in touch with those difficult memories and make them part of your life story.
Phil Stieg: And in relation to the dreams that people have during grieving, are there typical topics such that if somebody listening is experiencing dreams, they might say, AHA, that’s me.
Lisa Shulman: There are and I think it’s an incredible fascination. For one thing, when people have gone through an emotionally traumatic event, not all, but many have more frequent and more vivid dreams than normal. There are studies that have looked at the types of dreams that people have after emotional trauma and after loss. And there are certain themes. The one that appears in my book most frequently are dreams about traveling and journeys where journeys are disrupted by all sorts of mishaps and bad events. Another very common scenario after loss is when the individual who died returns in the dream and, in fact, oftentimes says that they’re doing okay. So there are these archetypes, if you will, of dreams. And when I first read that, I thought, Gee, how can I understand that? That’s crazy. But then when you think about it, Phil, our brains are all wired the same way. It’s not like we all have unique brains. We don’t like to think of it that way. But the fact is we have a lot more similarities than differences. And it’s maybe not at all surprising that we have similar types of dreams.
Phil Stieg: I was impressed with the statistics that you quoted in your book that grief is really common. About 15 million Americans at any given time are experiencing grief, and within that, 10 to 20% of them have profound, complicated grief.
Lisa Shulman: Of course, there’s going to be a lot of loss and a lot of grief in the world, of course there’s going to be that. And I feel ever more strongly that we shouldn’t pigeonhole the bereavement the loss of a loved one as something that is unique to other forms of losses in life. There is no unique area of our brain that handles bereavement as opposed to, for example, if you receive a new diagnosis yourself, if you experience physical or emotional abuse, anything that would be in the form of trauma is going to be handled in the very same way with the very same circuitry that we’ve been talking about here. I think that in general, we need to be thinking that all of these things are going to be common in our lives.
Phil Stieg: Do you have any advice for someone who is dealing with loss?
Lisa Shulman: I think that it starts with accepting being forgiving of oneself for maybe not having done everything exactly right. Going through a serious illness or a serious emotional traumatic event is a wrenching experience for people you’re not at your best. And I’m sure we know as physicians; we watch people going through these things, right. But then we have to start thinking about what are going to be the unique types of opportunities that are going to foster healing for each one of us. You know, for some people, it’s going to be that they have a lot of faith, faith-based practices for them is going to be just what they need. So it’s very, very individualized. And I wouldn’t take it for granted that if this worked for your best friend, it’s going to work for you. And then eventually where one wants to go is that you want to move to a place where you can honor the person who’s lost and find comfort through that.
Phil Stieg: The final question then is I want to be a loving person. How do I support someone who is grieving? I got the point in your book where you said snap out of it probably isn’t the right response. So how can I be an empathic, supportive, emotional individual with somebody with complicated grief?
Lisa Shulman: It’s a really important question, Phil. I think that what we want to do is show a person that we want to be with them and we want to be with them in the way that’s best for them. And that might be, let’s go for a walk. That might be, let’s come to my house for dinner. I’m going to make something I know you like, and we don’t have to talk about any of this stuff unless you want to.
Phil Stieg: So you offer things. So if you said no to the walk, no to the dinner, you keep coming back. And eventually the griever will say, I’m ready for that. I’m finally ready to come out.
Lisa Shulman: That’s a good point. That the person going through hard times might not be ready for that. Might think they aren’t able to handle it yet. And oftentimes we might think that we did our duty, we tried our best. But instead, the fact that you come back shows acceptance, and that’s what they need.
Phil Stieg: Dr. Lisa Shulman, thank you so much for spending this time with us. I think you’ve clarified that grieving and prolonged grieving is a difficult process for us as individuals to recognize. I think it’s equally important for the listeners to understand that there is help and for those of us that are around individuals that are grieving that it requires empathy, persistence and not focusing on the individual’s grieving process. Just be a friend. Lisa, thank you so much for being with us.
Lisa Shulman: And thank you so much for having me today.