Interview with George Bonanno on Bereavement

[David Baxter PhD]

An Interview with George Bonanno, Ph.D., on Bereavement
David Van Nuys, Ph.D.
Mar 15th 2010

Dr. Bonanno describes lessons learned from his 30 year research career studying bereavement (grief in response to the death of a significant other). His findings debunk many grief myths that are widely held, including the notion that grief is always a drawn out process, and that it proceeds as a predictable series of stages. In reality, many people get over their losses fairly quickly. Rather than stages, the typical experience is more like periods of sadness that gradually get less intense. It is also the case that people normally experience intense happy emotions during bereavement as well as sad ones, moving back and forth between the two, with both emotions tending to be intensely felt but brief in duration. The more that people smile early on during bereavement, the faster they tend to recover their equilibrium. In many ways distraction and avoidance end up being better ways of managing intense grief than involved grief-focused conversations. Distressed people can become sensitized by such conversations and end up having a worse outcome than they otherwise would. Involved grief-focused discussion can be useful as a componant of psychotherapy for people displaying complicated (non-remitting) grief. Formal therapy is generally not indicated for normal grief. However, it can very useful for grieving people to have the opportunity to talk with an understanding and caring family member or friend if they desire it.

David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show we'll be talking with my guest, Dr. George A. Bonanno, about findings from the new science of bereavement. George A. Bonanno, Ph.D., is a professor of clinical psychology and chair of the Department of Counseling and Clinical Psychology at Teachers College, Columbia, University. He received his Ph.D. from Yale University in 1991.

His research and scholarly interests have centered on the question of how human beings cope with loss, trauma, and other forms of extreme adversity, with an emphasis on resilience and the salutary role of personality, positive emotion, and emotion regulatory processes.

Professor Bonanno's recent empirical and theoretical work has focused on defining and documenting resilience in the face of loss or potential traumatic events, including the death of a loved one, terrorist attack, bio-epidemic, traumatic injury, and life-threatening medical procedures, and on identifying the range of psychological and contextual variables that predict both the psychopathological and resilient outcomes.

His research has been featured in the New York Times, Science, the Wall Street Journal, and the Washington Post, and he's appeared on CNN and 20/20. Professor Bonanno co-edited the book Emotion: Current Issues and Future Directions and recently authored The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss.

David: Dr. George Bonanno, welcome to Wise Counsel.

George Bonanno: Thank you, David. Nice to be here.

David: And I appreciate the opportunity to speak with you. I've been reading your 2009 book, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss, and, I must say, I've been learning a lot. For example, I don't think I even knew that there was "a new science of bereavement." How does one scientifically study bereavement?

George Bonanno: Well, really, that's a wonderful question. We study bereavement the way we study almost any other phenomenon, and the reason that I use the phrase "the new science of bereavement," because there was remarkably little scientific attention to the phenomenon up until only about 20 years ago, which is really an interesting point in and of itself - why, for whatever reason, that we, as a culture, the scientific culture, was so late in coming to this phenomenon. But, really, the methods that we use are really just the same methods you would use to study any other phenomenon.

David: Well, were you the first person to begin to study it scientifically, or were there others before you?

George Bonanno: I think I was one of the first people. My colleagues, Camille Wortman and Roxane Silver, in the late '80s, had done some studies, and they had published a paper in 1989, called The Myths of Coping with Loss, in which they had argued that there were these clear assumptions about bereavement that had almost no scientific data behind them.

So they really got the ball rolling with a few of their own studies and with making this broad statement about the lack of evidence. They also, at that time, initiated one of the first real, long-term prospective studies about bereavement. It took a number of years for that to really get going. You know, it takes a long time to do that kind of research.

And there were a few other people, of course, doing research. Wolfgang and Margaret Stroebe in Europe were doing, really, some of the first really solid studies. Sid Zisook, in University of California San Diego, was doing some research, and there were, of course, other people. I'm probably slighting people by not remembering all the names.

David: Okay.

George Bonanno: There were a few people out there doing it.

David: Yes. Well, a lot of us avoid anything related, topics related to death and dying. How did you get into this particular specialty? And you've stayed with it, now, for 30 years. How did that happen?

George Bonanno: Well, that's an interesting story, in a way, and I admit that I was somewhat adverse to the idea, myself. I had finished my Ph.D. in clinical psychology, and I was really trained in a kind of experimental clinical research. But I felt there was something quite not right in what I was doing. It wasn't quite hitting the mark for me, so I was looking around to do something else, and I was offered an opportunity by Mardi Horowitz at the University of California San Francisco to run a bereavement study. And Mardi really was a pioneer in the study of trauma, and he had some funding to do a bereavement project, and I think he was interested in a lot of different things at that time, so he wanted someone to head up that project, and he made the offer to me because we had met each other before.

It was a very appealing offer because I had, essentially, carte blanche to do what I would with the research, but I was wondering about, did I want to get involved in such an? it seemed almost morbid to me at the time, the study of this grieving phenomenon.

And as I began to learn about the phenomenon, then I was quite struck by the fact that, coming in a way from the outside, I was quite struck by the fact that the literature seemed really out of date. The way people were doing the research, or whatever research there was, and the conclusions they were coming to just didn't seem to jibe with the rest of psychology as I knew it. So that piqued my curiosity and my interest.

And I went out to San Francisco with the intention to stay for three years and to start this project. But we tried all kinds of wonderfully adventurous things that had never been tried before, and it was so interesting and so exciting to really learn, in a sense for the first time, some new things about this subject. And as I delved into it, I began to realize this is an intense emotional phenomenon that almost everybody goes through, and often more than once in the course of their lives, and yet we knew so little about it. So that, to me, became very exciting, and it's remained a tremendous interest of mine, probably, for the rest of my career.

David: Yes, I guess it is exciting to be on the frontiers of research and to realize that there's room to make an original and significant contribution. And certainly, just in the process of reading your book, it cleared up a bunch of misconceptions and mythology that I had just taken in unquestioningly, so I found it an exciting book to be reading.

So, as you began to study bereavement, you discovered that most of us have rather unquestioningly accepted a lot of mistaken assumptions about the grieving process. So take us through those myths that start with Freud and then continue through Helena Deutsch, Bowlby, and finally Elizabeth K?bler-Ross.

George Bonanno: Yes, well, if I may, let me take you back one little bit further, in that one of the first things we did is we began? Well, one of the myths was really that grieving? Well, actually, this does go back in time, that the myth that grief for everybody is a long drawn-out, very elaborate process akin to work.

I think to be fair, I wouldn't necessarily pin this on Freud. Freud did propose the idea that mourning was work, or what's come to be known as the grief work hypothesis. However, Freud was very cautious and remarkably so. When I've read his original papers, I was quite struck by the fact that he was very clear in stating these are speculative ideas. I don't have any evidence for this, but I'm just assuming that grief is like this. And he was really focusing on depression in the paper Mourning and Melancholia, and it speculated about bereavement. It was really Freud's followers that took the idea, in a sense, and ran with it in a, I think, unscholarly way.

So the idea that grief is a long drawn-out process that everybody has to go through - and we're talking months and months of this suffering until you work it through - we first saw very little evidence for that, because I think most of the research and most of what was written about bereavement at that time had come from mental health professionals, therapists, etc., or people doing research in psychiatric contexts where they had clinical populations. So, what I mean by that is they were working with people who were doing very, very poorly, often seeking help. And so that got generalized as the norm.

So, in our research, one of the things we did, we invited anyone and everyone who had lost a loved one within a certain window of time - I believe we did three to five months in the first study, so three to five months after a loss - anyone and everyone who had lost a loved one, and we focused on the loss of a spouse in that study. We invited them to come to our interview rooms and to participate in some experimental tasks, and we followed them over time.

And from that first study, we've done this now many other times, and we consistently find that there's a wide range of reactions, that some people suffer just enormously and for a long period of time. Some people suffer in a less pronounced way, but for a period of time as well, and then gradually recover. But most people, typically, struggle for a period of time, few days, a few weeks, and then they get back to their lives, and they continue to function. They may not resolve the loss; they may not fully put aside the pain, but they're able to continue functioning. And we've come to call those people "resilient." So, we call that response resilient as a way of marking that and distinguish it from the other responses.

So this, right off the bat, we see that, okay, here are these wide ranging differences, and most people actually deal with grief in a fairly proscribed and limited way, and this did not jibe at all with this notion of grief work.

David: A lot of us in the therapeutic community have been influenced by Elizabeth K?bler-Ross and her five stages of grieving. And I take it that you found that, by and large, that was not taking place.

George Bonanno: Yes, that is true. And interestingly enough, when I first began to work on this book, the book was really a decision on my part to bring this research to a broader audience. We'd been doing it now for about 20 years, and I realized it's really time that this information gets to a broader audience because it's not in the general public.

So, when I first began to put the book together, I honestly didn't give much thought at all to the K?bler-Ross idea of stages because it had been a long time since we even thought about it, because there was just no evidence at all that this had any relevance to the grieving process. It was only when I began to talk with publishers and to talk with people in the book publishing world, that I realized that that's not at all the case for most people, and that most people would be expecting some notion of stages. So, it was then that we began to write about it a little bit. But, essentially, we've never seen anything remotely like that in our research.

What you see is fairly, I think, monotonic is probably the best word. People go through this sort of oscillation period where they go in and out of states of deep sadness, and that gradually lessens, and they move on. One of my colleagues, Toni Bisconti and her colleagues, describe this as a pendulum of friction. There's a sense of being up and down a lot, or in and out - however we should describe it - of going in and out of this state of deep sadness and deep distress. And that just gradually reduces. It swings. The oscillations of that pendulum gradually reduce until the person finds equilibrium again.

That's pretty much what we see in many people. And then, of course, there are people who fail to recover and really struggle for a long period of time, but those people also pretty much stay in these long states. We don't see anything remotely like a progression through different experiences that predicts recovery.

David: Yes. Well, before we leave K?bler-Ross altogether, one of the interesting things that you pointed out was that her ideas about denial and anger and the elements of those five stages really came out of her work with people who were dying rather than people who were grieving for somebody who had died.

George Bonanno: Yes, that's right. And, in fact, I have no idea if those stages even are applicable to the process of confronting one's own death.

David: Well, I was wondering that, based on your research. I was hoping you would know the answer to that.

George Bonanno: No, I don't. Well, I think the simple reason is that there isn't much research. I think, probably, that's a topic that it will be quite a while before we get around to facing. There's a little tiny bit of research on the subject, but I would imagine that most people who are nearing the end of their lives are not terribly interested in talking with researchers, although they might, for the sake of posterity, of describing their experience. But, as far as I know at present, there really isn't much research.

But, in any case, K?bler-Ross had formulated the idea of those stages, not based on data that I know of, but based on her experience working with dying patients and then, later in her career, had reiterated them as also the stages that people go through when they lose a loved one.

David: And, somehow, that just really took hold and has pretty much permeated our culture. And one of the unfortunate spinoffs of myths about grief work is that some people end up getting judged as "not doing it right."

George Bonanno: Yes, absolutely. I just can't even count any more the number of people that have contacted me over the years. If my work's been in the media in any way, I often get phone calls and now emails and letters saying thank you very much for saying that it's okay to get over a loss quickly, it's okay to do other things, because everybody in my life is harassing me to get in touch with my hidden grief and such things like that. So, what it's done is it's kind of implied that there is a standard grieving process that everybody should go through, and if they're not doing that, they're in big trouble. And that's really not the case at all.

So, I think people have clung to this stage idea because there's something comforting about it, and in a way, it offers a predictable sequence. But I think, really, whatever gain people get from that is very much counter set and probably obviated by the fact that it can be very harmful to assume that everybody should go through the same process.

David: Yes, it brings to mind a situation that I was involved with in a professional organization that I belong to, not psychology related, market research. And somebody experienced? one of the administrators in this organization discovered a death and didn't show much grief in the organization. And people who were not psychologists were making all sorts of psychological attributions about this fellow and how dysfunctional he was because he "wasn't dealing with the situation." And I was more cautious about that, I'm happy to say, and I feel confirmed by what you say here.

I was happily surprised to discover that you've done a number of studies with Dacher Keltner. I interviewed him on my other podcast series because I've been interested in positive psychology in my other series called ShrinkRapRadio. And I also attended a day-long CEU session he gave on health and happiness. You describe him really well in the book. My impression of him, too, was that he was a surfer guy, and he's not. But he's definitely one of my new heroes. Perhaps you can tell us about some of the work the two of you've done together.

George Bonanno: Oh, that would be a pleasure because Dacher Keltner is one of the most interesting and probing minds I've ever encountered and a wonderful human being, too. When I first began to do the bereavement research, I met Dacher in San Francisco, and he, at the time, was a post-doc with Paul Ekman, and Dacher has since gone on to do wonderful things in the emotion world and expanded the horizons of that world into the domains of happiness and affirming lifestyle endeavors, etc.

What we did initially, which was quite fascinating, actually, we were videotaping bereaved people. We'd asked bereaved people to come to UCSF, up to Langley Porter, to the Psychiatric Institute, and to tell us about their loss. And we did all kinds of structured, diagnostic things. And we'd also always include open-ended interviews, where we would tell people, "I'm going to allow you to talk now for a few minutes, and whatever you say is okay, but really tell me what this is like for you." And we videotaped that and coded it, and we found that, even though these people were talking about their loss just within a few months of its occurrence, that most people were showing signs of laughter and smiling and positive emotion.

There is a way to code positive emotion that's fascinating. It goes back to the 19th century. It was developed by Duchenne de Boulogne. I'm sorry; Paul Ekman had developed it in relation to Duchenne de Boulogne's work. Duchenne de Boulogne was interested in muscular dystrophy and people who could not control their facial muscles, so he had taken photos of people with giving them mild electric shocks to the face. And what would happen is they contracted various muscles of the face for seconds, and he could photograph them. So, he took a series of photographs of the face which had enormous impact on Charles Darwin, and Darwin used a lot of Duchenne de Boulogne's photos in his first book on facial emotion, The Expression of Emotion in Man and Animals.

And somewhere along the course of that, researchers began to notice that the smile, the contraction of these round muscles around the eyes, the orbicularis oculum muscles, which Paul Ekman identified in the '70s and called the Duchenne smile, so when we have a positive experience, we can smile very easily. All of us can smile or laugh, and we, in fact, smile and laugh many, many times during the day.

But most of the time when we smile, they're really polite gestures. We're smiling to show that we mean well or that we're benign. Spontaneous smiles and laughs are less frequent, although they are frequent as well. But when we laugh spontaneously or smile spontaneously and it's a genuine positive feeling, we have a relatively involuntary contraction of those round muscles around the eyes. We do the smile of the eyes, and we can see this in videotapes, and it's a very reliable and robust phenomenon.

So, what we saw, what Dacher Keltner and I saw in these tapes early on, was that most bereaved people were making these genuine smiles with their eyes or genuine laughter with this eye smile as well, the Duchenne smile, even early on after a loss. We looked to the literature to see what we could make of that, and to our great surprise, there was almost no mention in the literature of any kinds of positive emotions during bereavement. If it was mentioned, it was almost always mentioned as a sign of denial. There's something wrong if a person is smiling after the loss of a loved one, yet here we were seeing that most people smile and laugh when we videotape them and code the eye muscles.

So we looked at that further and, of course, we found that not only did most people smile and laugh, but the more that people did that, the more intense and the more frequent were their smiles and laughs with the eyes, the better off they would be down the road, the quicker they would recover, the fewer symptoms they would have over time, and the more quickly they would return to a normal level of functioning.

David: Just so that our listeners aren't painting the wrong picture in their minds, what you describe is a kind of oscillation as they're talking about their loss, that they might be remembering some of the good times, and that might evoke a smile or some laughter. Then they might oscillate back down into sadness and then come back up again with another memory or some other philosophical reflection that brings a smile to their?

George Bonanno: Yes, absolutely. You're absolutely correct in describing that. So, really, the dominant emotion, the dominant experience, is sadness and there are also some other emotions, and there's anger, sometimes contempt or shame, where people are having all kinds of memories and difficult experiences.

While they're having those experiences though, one of the most interesting about this is that our emotional reactions are designed to be relatively ephemeral. They're like little bursts, little episodes, of emotion, and that's how we're wired and it's very effective. So with sadness, sadness turns our attention in. It turns our attention inward and allows us to reflect and withdraw from the world a little bit, and that's why we're sad during bereavement, is we're sad because we've lost something. We slow down a little bit. Our heart rate slows down. We tune out the world a little bit, and we're really stunned and, in essence, sitting there with that sense of "this person, that I am so - that is so important in my life, is gone, and I need to, in a way, recalibrate, restructure, my life. I need to think of the world with this person not in the world. I can still remember them. I can still think about them, but they're not going to be there." And that's a painful experience. But we really need to turn in and reflect, but we don't do that for very long, and then our attention comes back outward again.

And there are good evolutionary reasons for that, because it would be quite dangerous, I think, in our ancestral past to be lost inwardly. We'd be quite vulnerable that way. So we come back out of that state, and we can engage the world again in a less emotional way, and it's at that time that we can sometimes even have extremely positive expressions, positive experiences. We engage with people and laugh with them, and we connect with them.

The other thing about laughter that's quite remarkable - laughter and smiling, these Duchenne expressions I'm describing - is that they are very appealing to other people, and there's a kind of contagion that happens with laughter and smiling that makes other people feel better, and it's a way, in a sense, that we have of really connecting with someone and rewarding them for staying with us. And then, that also is a very brief experience, and then, in a sense, we turn back inward to again explore and again reflect on what has happened to us.

So rather than this elaborate, steady state of months of deep sadness, it's really much more of an in and out kind of an oscillatory state, and this sadness is punctuated at times by positive states and smiling, laughter and connection to other people.

 

[David Baxter PhD]

Re: Interview with George Bonanno, Ph.D., on Bereavement

David: That's really fascinating. And you mentioned earlier that you hear from people how freed they feel hearing about the acceptability and the frequency of positive feelings that are mixed in with the sadness, and you can count me in that number. After my mother's funeral, my sister and I went to the movies, and I've always felt a little shy about disclosing the fact that my… But my mother loved going to the movies and so do my sister and I, and somehow that's just what we wanted to do. It felt like the right thing to soothe our grief at that time, but imagine, some people would have thought that we were in denial and that it was a shameful thing to do.

George Bonanno: Yes, yes. That's exactly right. In fact, I typically try to stay away from giving people advice about grieving and what not, but one of the things I will say to most people is do what feels right to you. If you feel like you just want a break for a few seconds, take the break. If you want to go off somewhere quiet and engage in deep reflection and really let yourself feel the pain of loss, do that, but at the same time don't feel shy about also giving yourself a break and going out and relaxing a little bit too. You know, it may be just a few seconds. It may be a half an hour, whatever you feel you need. We do need to get those feelings off our minds at times. Yes, absolutely.

David: Now, I have the impression that you've identified, broadly speaking, three groups of people, the largest being people who show a lot of resilience and bounce back rather quickly with smaller oscillations between sadness and feeling more or less normal. And then a middle group, and somewhat smaller group of people, who experience a more prolonged and heightened period of sadness, but then come back down to normal. And then a third group which, maybe, is the smallest of all I'm hoping, who experience what we might call extreme grief, and they really peak very high in terms of their sadness and have difficulty coming down, if ever at all. Is that right?

George Bonanno: That is right, yes, and the third group you mentioned, we call those the "chronic" group because they, for a long period of time, they struggle. They're usually around 10, maybe 15%, so it's something along the lines of one in every 10 people, which is, actually, quite a few, but it is the smallest group.

David: Okay. Well, starting with that first group, actually, at the more resilient ones, you have a whole chapter on resilience. And I know there's been a lot of research on that topic of resilience. What do we know about resilience? What does research tell us about it, and is it something that can be developed or increased?

George Bonanno: Well, that's a very interesting question. It's a question that is getting a lot of attention these days. I'm a little bit skeptical about whether or not we can increase resilience, but I can tell you a few reasons why. Some of the research that I've described, where we followed people over time and mapped out these different trajectories, we have done that same thing in the context of other more traumatic events.

So we had a sample of people who had been in the World Trade Center on September 11, or right near the World Trade Center on September 11, and we followed those people, recruited those people and followed them over a number of years. And they were incredibly generous with their time and energy to talk with us in our studies. We have done some research on the SARS epidemic in Hong Kong. We recently did some research on people who had been brought to a level one trauma center for a serious accident, a traumatic injury, and required emergency surgery. We have looked at people with breast cancer surgery and all other kinds of bereavement samples as well.

So, we've looked at this across a number of highly aversive life events, and we almost always find around 50%, 60%, of people faced with these events will be resilient. And by that, I mean they will, for the most part, be able to continue functioning pretty well almost soon after the event. So, the big question, of course, has become who are those people and how can we make other people more resilient or not.

So, as you might imagine, because that's a relatively new research area and there were a lot of misconceptions about traumatic events as well, in the trauma world it was assumed that only exceptionally healthy people could be resilient in the face of extreme adversity. And, of course, we found that not to be true. If so many people are resilient, that means it's a common phenomenon. But if it's a common phenomenon, then it's not just super-copers, super-healthy people, who will be resilient. It's really anybody out there in the normal world. Everyday people are resilient.

So why are they resilient? Well, we've found… Well, first of all, if we can reason a little bit of this out, if lots of people are resilient, there are going to be lots of different stories there. There are going to be lots of different factors that people have, so there isn't going to be one or two, or even three or four, main factors. There are going to be lots of different reasons why people are resilient.

And what we've begun to uncover in our research, this broader research, is that there, in fact, are a whole host of factors that can make people resilient, or help people to be resilient in the face of adversity. And none of these factors by themselves is sufficient, so it's really a question of do the more factors, the more resilient factors one has in one's life, the better off one will be, or the better one will be able to withstand difficulties?

So, some of these things are, say, social support, which, when I say social support, what I mean is having a network of friends or people that you can talk to or count on to help you out. Having financial resources helps. Keeping the stress down in your life also helps. A lot of stress or long-term stress generally wears us out. Being able to laugh and have positive emotion is another one of the things I've mention already that can be a resilience factor. So, there's a whole host of these factors that we've been gradually uncovering that are likely to make people more resilient.

Now, whether we can make people or improve their resilience, that's a tricky question, and I've been pondering that a lot lately. The military is doing some things where they're trying to make soldiers more resilient, and I mention it. I was a little bit suspicious about it or a little bit wary about it. And the reason I'm a little bit wary about it is because if, say, 60% of the population - and I think the military's probably the same - say roughly 60%, we'll just use that as an assumption, 60% of the population are going to be resilient anyway when something bad happens, they're going to be able to cope well, what happens, then, when we try to give those people a resilience training? Is it possible we'd make them less resilient?

There has been a whole host of examples of this kind of thing. There've been attempts to decrease eating disorders in the California public schools, and those interventions ended up increasing eating disorders. Now, I'm speaking from memory here on some of these studies, so I may not get all of this exactly right, but the eating disorders one was interesting because what they ended up doing was telling students who had never thought about eating disorders that having an eating disorder was an option they might consider.

And it really can backfire. There's a whole literature on this - things like bicycle helmets. Bicycle helmets do prevent injuries. However, bicycle helmets have tended to increase bicycle accidents. There is also literature on safety belts. Safety belts also prevent injuries, but they can increase accidents. People who drive sports utility vehicles tend to get into more accidents because they tend to feel that they're safer.

So, the question is, really, if we go around teaching people, doing things we think will make people more resilient, it's possible that we might actually make people less resilient.

David: That's really fascinating. That had not occurred to me. I had heard about that attempt in the military. I think I saw that there's a series on PBS that's running right now, "This Emotional Life," and they mention it in that third episode, which is all about happiness.

George Bonanno: Yes. So, I would hope that that would not be the case, but these things can be a little bit tricky. It was only recently that we finally slowed down doing something called Critical Incident Stress Debriefing. When a really horrible thing happened, mental health professionals would tend to flood in an area and offer everybody a very brief intervention, maybe a one hour intervention called Critical Incident Stress Debriefing. Now, it was assumed that that would be relatively harmless and would actually help some people, and it looks on paper like it is. But, in fact, the data show that when we do those kinds of things, not only is it typically not effective, it does actually harm people.

One of the studies that I talk about in the book, which is one of the studies I'm most struck by, was done in England with a sample of people who were in motor vehicle accidents, people who were hospitalized from motor vehicle accidents. Now, that's a pretty serious event. It's a scary event to be in a motor vehicle accident. It's serious enough to mean an emergency hospitalization, so it's a scary thing that happens.

And what the researchers did is they, within two days, within 48 hours of hospitalization, they visited as many of those people as they could, and they randomly either offered them, I think, just a simple chat - I don't remember exactly what the control condition was - or a one hour debriefing. And the debriefing, again, seemed harmless enough. All they did was have them review systematically what they had just gone through and to describe their reactions to each step of the event. So, they had them describe the accident and how they felt at each step. So, what happened here? What was going on in your mind? What did you feel? What happened now? What was going to on in your mind? What did you feel, etc.

Then, if I'm remembering this correctly, they told them a little bit about what trauma reactions are and suggested that they express their feelings as much as they can to loved ones afterwards, and that they would also… that their general physician would be notified that they'd been in this research study. That was all they did. It took about an hour. So kind of a little chat about what you'd just gone through, with a mental health professional, and then they left.

Well, it turns out that three years later, the people that received that debriefing were much worse off than anybody else in the study. So then, one of the common concerns in this area is, well, what we need to do is find the people who are most distressed, who are really doing poorly, and target those people right away. But these researchers did that, and what they found was, among the people who are most distressed, if they just left them alone, if they gave the control condition, most of them got better. If they didn't, if they got this one hour debriefing, they were still worse three years later. And they were worse in, literally, every aspect that they had measured. They not only had more distress, they were less likely to report enjoying being in a vehicle again. They had more physical pain, just all kinds of ways in which they were suffering more, all as a result of this simple one hour debriefing.

David: That is remarkable.

George Bonanno: Right.

David: And one of the things I had wanted to ask you about and that I think you're talking about now, I was going to ask if there was any overlap or relation between PTSD and grief, and I'm thinking of people who lose friends or loved ones in a tragedy such as an earthquake, as has just happened in Haiti, or a flood or war or terror attack. Does that complicate the grieving picture when it's combined with…?

George Bonanno: Well, not really, actually. It's led to some real clarity, actually, in fact, because the research on trauma and PTSD really came first, and I think that's one of the reasons why we began to study bereavement. Because the research, starting around 1980, research really took off in the study of trauma, and eventually people began to think about bereavement as a related event.

So, initially, what we were finding was that when people were exposed… when a loved one died in a particularly violent or disturbing way, that then tended to produce in the survivors both depression and PTSD, or trauma reactions. So they had a mix of depressive grief and trauma reactions. And trauma reactions, you know, are essentially reiterating or remembering intrusive recollections of a horrific event, and I think what people do is they play over and over and over the images that they have, whether real or imagined, of what happened to their loved ones.

Now, what that's led to is the development of a new diagnostic category for grief reactions. People are calling it a number of different things because it's not yet established - either complicated grief, or prolonged grief, or traumatic grief - but it's a mix of some trauma-like symptoms and some depressive symptoms, and it really is the marker of prolonged and unresolving grief reactions. So it really does tend to incorporate this traumatic piece, this traumatic bit, of these very painful images that are unbidden and intrude on our awareness, as well as the other hallmark symptom is something called yearning, which is this unremitting desire for the person to have the person back, not global, but really focused on that person. So it does seem to be a combination of these.

And we'd actually done some research early on. It seems to be my function in this field to be the dubious critic, but early on, I had been very skeptical about the necessity of that diagnostic category. But we did some research doing an analysis called "incremental validity," where we basically say, okay, if we measure depression and measure trauma reactions in people, do we need anything more? Does a traumatic grief or a complicated grief measurement or assessment, does that tell us anything more incrementally?

And, in fact, it did. So we found that we were able to develop a more fine-tuned understanding of what the particularly painful and prolonged grief reactions look like. And I think that's really important because it will allow us to offer treatment in a much more focused way.

David: What about loss through suicide? Would that fall into that category?

George Bonanno: I think it definitely would. There isn't as much known about grief reactions after suicide, I think largely because it's relatively infrequent, and that's a good thing because, from what we see so far, losing a loved one to suicide is extremely painful and extremely difficult. And you can just imagine what people go through, because the healthiest reaction, typically, is to put it out of one's mind as best one can. It's impossible to do that for losses, usually, so we have some sadness and the kind of deep reflection that we oscillate in and out of, as I described before.

But with suicide, it's very hard to stop thinking about the event because it's so easy to engage in counterfactual thinking, these kind of "what if" statements - if I'd only done this; if I'd only seen the sign; if I'd only not allowed him to go on that trip. And people find themselves really struggling with that kind of thing, because suicide is such a tragic ending for somebody. So I think suicide is probably one of the worst things one can deal with, yes, as a survivor.

David: Now, what about people in that group of extreme grief reaction where it's extreme and it's prolonged? Is psychotherapy of some sort the recommended response to that? And, if so, do we know… are there particular forms of psychotherapeutic intervention that are more effective than others?

George Bonanno: Well, that's a great question. I think, in fact, that we're making great strides in that regard. A couple colleagues have done really wonderful work. And the history of that is really that it… initially, grief treatments were offered to almost anybody, and there was an assumption, because everybody had to go through this painful, elaborate process, that almost anybody could benefit from treatment. So there was generic assumption, I think a very wrong-headed assumption, that grief and just the simple fact that somebody was bereaved was condition enough for them to be in treatment.

And the results of that kind of assumption were that when people did what's called the meta-analysis, which is an assessment of a whole body of research, they consistently were finding that the grief treatments were not effective. And that's partially because people who don't need treatment are not going to be very good therapy patients and so, possibly, not likely to get better, or perhaps even get worse.

It was more recently, as we've begun to identify, really, what a prolonged refraction looks like, that we've been able to develop more focused treatments, treatments specifically for that type of difficulty. And I think as now we've really begun to clarify this prolonged grief or complicated grief category, exactly what it looks like - and we're still working on that, of course - but as that's developed, so have treatments specifically designed to target those difficulties

One of my colleagues here at Columbia, Kathy Shear, has been pioneering a form of treatment, and another colleague in Holland, Paul Boelen, has also developed an approach. And there are probably other people developing approaches now, as well, because it's becoming clear that this is a necessity.

David: Just briefly, what would be the thumbnail sketch of those approaches?

George Bonanno: Well, right now, I think they're probably broader than they should be because no one's exactly sure yet what the crucial components are, so Kathy Shear's approach, which has produced good results, is kind of a kitchen sink approach. It's got lots of different component in it. It has definitely focusing on the death event, on the loss itself, and how people reacted to it, and getting them to really talk about it, almost like an exposure treatment for PTSD, where they sit in the comfort of the therapy office, in the safety of the therapy office, and revisit the death event itself.

Paul Boelen's treatment, in Holland, also has a component like this, where he has people talk in detail about what the death was like, because he argues you often find that there's some kernel of misunderstanding there that the person's clinging to, that's really eating at them. I talk about it in my book about an example of a woman who couldn't have children with her husband, and she got it into her head that that was the reason he'd died. If she'd been able to have children he wouldn't have died, and she had developed this whole cascading set of ideas that were quite far from the truth.

There's another story, that I heard from Kathy Shear, of a man who his father was quite elderly and was beginning to be a bit senile and unable to take care of himself. And the night before he died, he went to visit him, and his father was being particularly difficult with him, and he said, "You know, I just don't know how much longer I can take this." And the next day, he went to his father's house, and his father had gone out in the backyard and froze to death.

And he had assumed that his father went out, essentially, in great anguish and either committed suicide or just cried himself to tears and froze to death, when probably, either because he was beginning to be a bit senile and delirious, he either didn't quite know what he was doing, or he slipped, or something like that. But this man had fixated on the idea that it was because he had said these harsh things on the day before that that's why he died.

So these treatments will… part of them, I think, are to get at this kind of erroneous beliefs. There's a cognitive component to it. One of the other components that people have talked about is, really, just getting people back out in the world again, getting active again. The treatments usually… most people are talking about not doing any kind of treatment for at least six months, maybe a year, after the loss, before there's a real clear sense of the person not getting better.

So, if we say even the most conservative's about six months, at that point, six months of deep anguish and pain can really take their toll on a person. There's a downward spiral that gets out of hand, and the person is really not functioning. They're probably barely functioning at work; they're probably not going out; they're probably sitting with a lot of anguish all day long, and that's exhausting and debilitating. Often that's accompanied by health problems because our immune systems really can only take so much, and our immune systems begin to fail.

David: Well, also, we're learning a lot about the plasticity of the brain and there's the possibility that some kind of a negative pattern is metaphorically getting burned into the brain, I would think.

George Bonanno: Well, that makes sense. So there's something called behavioral activation, which is just simply getting somebody up and out, and there's quite a bit of promise in doing that with bereaved people who have reached this chronic state.

Another thing that we've seen in the work is that often, but not exclusively, we see that the people that tend to have these exceptionally painful and drawn out grief reactions tend to have been a little bit too dependent on the person they lost, either behaviorally for their daily activities, or psychologically dependent. And that means, when the person's gone, they're going to feel quite helpless. So there's a sense of helping the person develop new relationships or new activities and getting them, again, out into engage in the world a bit more.

David: Yes. Have you studied the role of religious or spiritual beliefs or, for example, belief in some kind of afterlife, in people's ability to cope with loss?

George Bonanno: We've tried to get at that a little bit. I find it a very difficult phenomenon to study because the way people think about existential questions - religion, God, the afterlife - these are profound questions and touch profound aspects of human functioning. And they don't lend themselves real well to simple questionnaire-type research. We haven't done the deep probing interviews that probably are required.

In the book, I talk quite a bit about people having a continued connection with loved ones after death, and that's been a little bit mystifying. We found that, often, it's negative when people have this sense of the continued presence. It's often negative, but it's also often positive, and like just about everything else with bereavement, there's a wild range of variability here. So some people, if we ask them about such experiences, they'll say that they really don't have anything remotely like that ever in their experience, and other people will immediately lighten up and talk about those experiences. It's very personal, I think.

But one of the things that's interesting about bereavement is that, most of the time, we go through our daily lives not thinking too much about mortality or our place in the universe. It's really a fascinating question if you… I do this by going down the street to the Museum of Natural History in New York and the Hayden Planetarium, and I can watch a movie that shows us in New York and then pans out until we see the United States, and then pans out further till we see the globe and see the earth in space, and then pans out further till you realize the earth is just a speck in a larger system, and pans out further and further and further, until you realize we're just a speck in a gigantic, unfathomable universe.

Most of us don't think about that too much as we go try to catch the bus or something like that. And, in fact, the whole idea of what life is and death is and why we're here and what possibly our place in the universe is, these are gigantic questions, and we sometimes reserve the thought about those questions for religious services and things like that, or moments of reflection. But most of the time, we keep ourselves pretty busy. We watch television; we play or we sit at computers; we listen to iPods, etc.

When we lose a loved, though, one of the things I think that's fascinating about bereavement is it most definitely begs those questions. It most definitely asks us to think about life and death and what happens when we die. And either that catches people very much unawares, or it offers people, I think, sometimes an extremely powerful vehicle to embrace those questions.

And I'm increasingly interested in that side of it. We haven't done a lot of research on it, but I'm very interested in that side of it, that, in a way, you could call that the positive side of bereavement, is that it does get us in touch with something larger than ourselves.

David: Well, as we begin to wind down here, I think so many of us struggle with how to support someone else, a friend or a family member, who's suffered a loss. Do you have any advice for us on how to be with a person at such a time?

George Bonanno: Well, okay. I had mentioned earlier that I tend not to give too much advice, and I do try with this one a little bit, this question. I think probably allowing that person the space to tell you what they need is really a good idea. People often report that they don't want to hear platitudes, and we want to offer words of condolence or something, and there's the standard phrases, of course - I'm sorry for your loss, etc. - that everybody understands is well intentioned. But then, often, we find ourselves trying to say something to make the person feel better, like, "You'll be okay," or "Gosh, it's terrible," or "I know how you feel." And most bereaved people report that they don't really particularly enjoy hearing those things - "Nobody can know how I feel," "It's not going to be okay, how would you know?" etc.

And one of the hallmarks of emotional reactions is that, when we're feeling emotions, they're very, very strong and powerful. When we're feeling emotions, they don't feel like they're going to go away, which is partially why they work. So when we feel angry, it feels like anger is all-consuming. When we feel sad, it doesn't feel like tomorrow I won't feel said. It feels pretty much like I'm going to feel this way the rest of my life.

So, I would suggest staying away from saying such things unless it feels right, but I find it's really important to give people lots of room to let me know what they want, to let us know what they want. And given that I do this research, often I'm with people who lose loved ones, and I think there's a little bit of an expectation that I'm going to say something or do something, but I find that, really, people will tell you what they want.

So sometimes I'm with someone, both as a researcher, but really as a human being. I'm maybe with someone who lost a loved one, and I don't mention it. I think it's important to be sensitive when you're with that person, so not to be engaged in rip-roarious jokes and humor that might be inappropriate, but really letting the person talk about it if they want to, or not talk about it if they don't want to. Or talk about something else, or maybe the person wants to be quiet and reflecting, and they want you there. Or maybe they want to be alone. You can ask sometimes people if they'd rather be alone or etc.

I like to tell the story of a colleague of mine, a wonderful human being named Lisa Capps, who I was doing some research with about 10 years ago. She was a linguist, and we were doing a study of narrative from the Reef people. She was only, I think, 33 years old at the time, and she learned that she had cancer, and she died within about six months of that time. She had two children, a husband, and she just really was a remarkably wonderful human being. It was a shock to everybody when she died.

We were working on a paper. The paper got a good review in a scholarly journal, and they said, if you revise this paper and do some things, we'll probably publish it. So Lisa said to me, "I'd like to keep working with you on that paper," even though she knew she didn't have long to live. "I don't want to talk about my cancer. I want, with my relationship with you, I want it to be that we work on this paper." And that was quite a lesson in [inaudible]. And so she was saying, "I want to feel like I still can function in the world and have something to contribute, until I can't," and that if we talk about our cancer, it's going to take that away from her. So that was really quite a powerful lesson.

David: Yes, well, this is such fascinating and important work that you're doing, and Dr. George Bonanno, thanks so much for being my guest today on Wise Counsel.

George Bonanno: Thank you for the interview. I very much enjoyed it. You're very good at this. It was a great interview.

David: I hope you found this conversation with Dr. George Bonanno as informative and fascinating as I did. His book, The Other Side of Sadness, is written in such a way that it will appeal to both a professional and lay audience alike. There's a lot of information in it that I think is important for us all to incorporate into our thinking about bereavement and loss.

You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.

If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at Shrink Rap Radio Psychology Interviews: Exploring brain, body, mind, spirit, intuition, leadership, research, psychotherapy and more! ? All the psychology you need to know and just enough to make you dangerous. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.

Dr. Bonanno's book, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss is available at Amazon.com