Prolonged Grief Disorder: Holly Prigerson

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are so fortunate to be joined by one of my former mentors who I’ve known for 20 years, Holly Prigerson, who is now Irving Sherwood Wright Professor of Geriatrics at Weill Cornell Medical School and Professor of Sociology and Medicine and Director of the Center for Research on End Of Life Care. She has conducted a number of landmark studies. There are any number of things we could talk to her about, coping with cancer, et cetera. We’re going to talk to her about prolonged grief disorder today. Welcome to the GeriPal podcast, Holly.

Holly: Oh, thank you, Alex, my star mentee. And it’s a pleasure to be here and to finally meet Eric.

Eric: Well, we got a lot to talk about. Before we jump in the topic, do you have a song request for Alex?

Holly: Yes, I do. My song request is Come On Up To The House by Tom Waits.

Alex: And why this song?

Holly: I like that it’s irreverent. I like that it’s about suffering. I don’t like that it’s suffering, but I like that it’s sort of a flippant view of suffering that we all go through, trials and tribulations, and try not to take yourself so seriously is sort of the message. And I even like a little dose of pragmatism when they say come down from the cross, we could use the wood. That line just kind of tickled me, so

Alex: Tom Waits has great lyrics. Here we go.

(singing)

Eric: Thank you, Alex.

Alex: Thank you.

Holly: I do have a question for you. Did you have to learn that this week?

Alex: I learned that yesterday.

Holly: Wow. Very good. Very good.

Alex: Fortunately that was much easier than some of the other songs that you were considering like Left and Right by what’s his name, Charlie?

Holly: Charlie Puth. Yeah, I love that song.

Alex: Right. Great song. When he does that with the people from BTS, it’s like everything’s on the left speaker and then everything’s on the right speaker.

Holly: Exactly. That’s why that song blew me away.

Eric: I don’t think you’ve done a BTS song, Alex.

Alex: No. I don’t know if you know this, but people do like to tweak me and they choose intentionally incredibly difficult songs for me.

Eric: That’s why I can never select Alex’s song. I would always choose…

Alex: Female diva singer song. Eric made me sing My Milkshake. [laughter]

Holly: Oh yeah.

Alex: and Brings Boys to the Yard. [laughter]

Eric: Dan Malach also loves to give you hard ones, Alex.

Alex: Yeah, he does. He does.

Eric: So we’re not going to be here talking about all of Alex’s songs, but we are here to talk about prolonged grief disorder. And Holly, we got a lot to cover. But I feel like before I can actually understand what prolong grief disorder is I feel like I have to have a better understanding of what grief is. And I’d love to hear from you how do you conceptualize grief?

Holly: So grief in a nutshell is wanting what you can’t have. The word bereavement means robbed. And so grief is that yearning and craving and pining for someone or something that you love and you’ve lost. It’s no longer there. And so you don’t know who you are without this person. You’ve miss them. You have these pangs of anger and bitterness like why them? So it’s a yearning and a craving and a loss of meaning and identity, bitterness, feeling stunned, shocked, disbelief over what happened. It’s a constellation of symptoms that really evoke a feeling of wanting that thing back because you feel like on many levels, you just need that thing to be your best you. So you feel like there’s this craving, that’s a yearning and craving and longing for something loved.

Eric: I was listening to radio and there was yesterday and there was a discussion about grief and music. And they were talking about how in some ways, grief is also, it’s an expression of love. It’s a different type of expression of love. We’re used to Valentine’s Day flowers. You have this person in front of you. But grief is that expression of different type of love.

Holly: You know, a lot of people have been saying that, and even some of my most respected colleagues, and I get why people say that because it just feels right. But the reason I’m not sure I agree with it is because it’s more like a wanting and a craving for something than an attachment. Is an attachment love? People who love someone are attached, but is attachment necessarily the same thing as love? That also would make it very difficult to pathologize it because we show people who have this really strong yearning for someone who’s no longer there. They want to die. They’re suicidal. Their life is over as they know it. And to call that love means it can never be a barrier to your happiness. It just makes it hard to think of and consider in those terms.

And so I guess you could say it’s a form of love, but it’s really about attachment and wanting something and seeing that thing as so essential to who you are and who you want to be. And if you want to call that love, that that’s your prerogative. But at extreme levels, that love can be pathological. Just like extreme levels of sadness or extreme levels of anxiety can reach really extreme levels where it’s normal and natural, but it’s problematic for adjust a healthy, adaptive adjustment.

Eric: So I often think about grief as you have this in some ways an adaptive response to something that was important to you. And it’s interesting because I think back to my own past grief reactions and sometimes there’s a yearning for the grief. There’s a yearning for this desire to feel something about something that you’ve loved so much in the past.

Holly: That is so insightful because I think people don’t get that or is that a lot of the fear that bereaved people have, who get stuck in grief, is they’re afraid they’re going to forget that person.

Eric: Yeah because and truth to your emotion may be the only thing you still have left of that person.

Holly: And they don’t want to give that up. That’s the love. That’s all the wonderful feelings that they had. And also it’s a little bit of an insult to one’s identity to feel like if this special person in your life can be forgotten, then you can be forgotten. It’s sort of this egotistical narcissistic concern you could say. But that’s an underlying fear that I think a lot of bereaved people have that I don’t know that many would acknowledge. It’s almost like in Israel there’s [inaudible 00:09:00], like never forget what happened with the Holocaust. People worry about forgetting. So they almost feel a need to enshrine or pay homage to this person to make sure that they won’t forget this person.

And we actually have developed some tools that help people do that so that they can compartmentalize and feel like they’re paying respects and maintaining a continuing bond is often a way people talk about it. But our living memory home is a way to both maintain that connection, because that’s the fear is that you’re going to lose this connection to this very special person. And you just feel like all of our humanities being minimized if you can just forget about this very special person in your life.

Eric: I guess it kind of goes on to-

Holly: It kind of jumps ahead to lots of ideas, but that was very insightful.

Eric: Occasionally I’ll have an insightful thought. Very occasionally.

Holly: All right. So then we can move on.

Eric: We can move on because that’s all I got here.

Holly: All right.

Eric: Well I guess the other question is when you have these grief reactions, you’re talking about specific things that we could potentially do. Is there a wrong or right way to grieve? Is there-

Holly: No, no there isn’t. And I think another narcissistic insult, however, is that there are not patterns to the way most people grieve. So in terms of controversy…

Eric: Yeah. So Homer Simpson, I always bring it up, Simpson’s episode, Homer goes through the five stages of grief in 10 seconds, one of my favorites. I’ll see if I can find a link and add it to the show notes here. So Kubler-Ross, right? Five stages of grief. I was taught this in med school. We had to memorize those. That wasn’t too long ago. That was ’98 when I started med school.

Holly: You wouldn’t think that that was one of the most controversial publications that we ever had. But it was because what we did did was not what people thought that we did. We took out the people who were stuck. So we wanted to answer that question. So in response to what you just asked-

Eric: Well, real quick, before you answer, what is the five stages of grief? Can you describe a little bit that for us?

Holly: Oh, you probably know it. It’s the acronym, DABDA, disbelief, anger, bargaining. Bargaining just so you know is more end of life before the death. So Kubler-Ross was really about people grieving their own death-

Alex: Their own death in advance, terminally ill people.

Holly: In advance. And so the bargaining part was that piece of if I stop smoking, will my lung cancer go away or that kind of bargaining. So that bargaining… It’s disbelief, anger, bargaining, depression, and then they call ultimately acceptance. But acceptance is a very, very high bar. We think it’s more of a reintegration and recognition that that’s how life goes.

Eric: And I think I actually got this question wrong in med school. I remember this. I said there are no stages of grief because I was wrong. Everybody-

Holly: If you were look on the internet, people even cite our gem publication that tested it. Because there are two ways of looking at the results that we got.

Eric: Yeah. So real quickly, what did you find in your study?

Holly: So just most bereavement experts, assuming we can call ourselves experts anyway, because everyone seems to think that they’re an expert in bereavement. That’s part of the challenge. They don’t like to say that everyone follows the same pattern. But that said, there are certain things with the stages of grief that are pretty much undeniable. The first is that disbelief, shock, numbness, initial response to the death of someone you love, the deer in the headlights reaction. It’s pretty hard to debate that most people don’t feel that way when they’re told that someone they love has died. Also that like a frog and boiling water, people get used to almost everything. People are resilient by and large and they adjust over time to anything even in a horrible, significant loss. So the real debate is those inner states that is there a systematic pattern.

And so when we tested it, we examined these indicators over time in people who were not stuck. And we found the exact sequence that was proposed, that DABDA sequence. And the likelihood that by chance that would happen was .008. So it wasn’t random that we found that exact pattern. So on average, does everyone go through those things? Does it mean that people can’t reexperience yearning at a later date? No. But are there these patterns? Yeah, of course there are these patterns.

Eric: I also got, and you can correct me if I’m wrong, when I think about Homer going through five stages. You’re in numbness, disbelief, then you go to yearning, then you go to anger, then you go to depression and then you’re finally accepting. And I got from your article, while the peaks follow this pattern, people feel a lot of different things where it just reminds me of the times I’ve grieved. It’s complicated, it’s messy. You feel a lot of things and you may feel a lot of things in the same day.

Holly: Oh absolutely. And we’ll probably get to this, I don’t know, but the initial analyses of prolonged grief disorder was I was with psychiatrists and a lot of them all thought that all the symptoms of distress were basically depression. So we did this factor analysis and we found out, no, these yearning, pining and longing are a separate cluster that loads differently than symptoms as being sad or blue about the loss or feeling anxious and anxiety cluster. So one of the things I say is that doesn’t mean that the yearning and the depression and the anxiety can’t co-occur. It’s like a fruit basket. In fact, in bereavement, they’re likely to all co-occur at the same time. The person who’s high on depression’s probably also going to be anxious. But what we’re saying is that the characteristics of this particular reaction are distinctive from the characteristics of a depressive reaction and or an anxiety reaction, which you might be experiencing these other feelings and emotions and behaviors too, but they’re distinct. It’s an orange versus an apple. They’re both fruit, but they’re different.

Eric: And then even five years later, you can all of a sudden have a anniversary or something that brings the grief back on, whether it be feelings of yearning, anger.

Holly: That’s totally normal and we don’t want to pathologize any of that. In fact with our assessments, we would avoid anniversary. We would assess people at the 13th month post-loss, not the 12 month, or not 24, 25, because that’s very well established. And I don’t know if you guys have experienced it. My mom died of COVID and last year was the anniversary. And that day I experienced it firsthand. I was just like pissed. I couldn’t concentrate. It’s almost this other unconscious level, like you know a year ago all these things happened and it really just brings it all back very intensely.

Eric: So if grief is one where you have these peaks. There’s a slow build up potentially as far as acceptance with these pings of grief, occasionally worse things of it with anniversaries or think triggers. How does that defer from is it complicated grief, prolonged grief disorder?

Holly: We’ve all agreed upon it being called prolonged grief disorder so we’re all talking about the same thing. And-

Eric: Is that the same as complicated grief?

Holly: They’re the same symptoms. They’re the same symptoms. And that also makes it more challenging for people to understand what the distinctions are because it’s really that yearning intense, yearning, pining, and searching for this person who’s died, which everyone does in the first few months post-loss. But what we found is so for example, we did an analysis where we got everyone who met criteria at six months at the time. And we wanted to know if you were to plot their grief severity over time compared to those who didn’t meet criteria, would everyone’s just decline over time? And would there be all these sort of false positives if you had picked them out too soon to say, “Oh, you just hadn’t given it enough time. These people are going to get better because everyone’s grief gets better over time.” No, it really doesn’t.

These people, you can pick them out at six months very reliably. And now to be conservative, it’s 12 months post-loss. These people are stuck. They were higher initially. They’re going to be higher later. Their levels of suicidality and suicidal thinking, risk of cancer, risk of dying of a broken heart, takotsubo syndrome, that all is significantly elevated in the very, very small subgroup. We say it’s about 4% of those who are bereaved, who are from community-based samples. So it’s different. These people, they feel like the rug has been taken out from under them and they’re not getting back their bearings.

Eric: Yeah. So let me ask you this. You’ve probably answered this a lot. I always have to look it up. It’s DSM-5. Now it’s in the DSM-5. If you can summarize what is prolonged grief disorder, what are the criteria?

Holly: The criteria are mostly yearning, pining, and so the death or loss of a significant other for starters. And we also wanted to start with death because could it be other losses? Honestly, yes. But we want to try to be as conservative as possible. Then it has to be at least a year. We did analyses that compared those who had a delayed reaction not high on those symptoms, and then after six months or after a year became high, compared to those initial people who were really high and it stayed high. And it didn’t really matter how they got to being high on those symptoms. But if they were high on those symptoms at six or 12 months post-loss, they were at risk of extremely bad outcomes, not very significant controlling for confounders controlling for depression, PTSDs. I mean, I’ll try not to talk too much about stats, but they were at risk.

So those symptoms were symptoms of yearning after 12 months post-loss and or preoccupation with thoughts of the deceased, but it’s really yearning. We actually did a bunch of analyses to determine how many of the remaining criterion C symptoms were necessary and we arrived at three of eight symptoms that included things like identity disturbance. You feel like you don’t know who you are anymore, where you fit in to the world. You feel disbelief. You feel a sense of meaninglessness. You feel extreme loneliness. You feel bitter and pangs of sorrow, emotional pain is how they they’ve phrased it. So I always wondered whether I’ve forgetting an important symptom, but it’s mostly meaninglessness, purposelessness, disbelief, yearning, loneliness, lack of purpose.

Eric: And then it has to be distressful, significantly distressful and or impairing your social occupational other important functioning.

Holly: Yes, so you did your homework and yes.

Eric: Yeah. I’m looking at it right now.

Holly: So when people say we’re pathologizing normal grief, these are people who are in this really extreme minority subgroup that it’s stayed that way for at least a year, and these symptoms in and of themselves are very distressing. They feel detached from others. The only person they felt they really could connect with is the dead. So they’re suicidal. So they have to have these distressing symptoms and they have to be significantly impaired by those symptoms. So by definition, their dysfunctional symptoms, this isn’t normal level grief.

Eric: And then you also address different cultures, religions have different norms around grief. How did you address that?

Holly: So actually, because we have this scale, we’ve assessed grief. There are thousands and thousands of study participants from Taiwan, from China, from Japan, from Australia, New Zealand. Almost everywhere in the globe, people have used the same standardized uniform and agreed upon metric to assess what grief is. There have been some studies, for example, there’s a Nepalis version where certain cultures have different words for some of these emotions. Some cultures don’t even have a word for grief. So you describe yearnings. We don’t have a word for that, or we don’t have words for bitterness, or the one that’s been really challenging has been emotional numbness. People get tripped up on what that means. And what we mean is like they’re physical numbness or they trip over that particular symptom, but it’s that sense of detachment from living people.

So we’ve validated with some modifications, it’s been very well validated through all these different cultures. So the cultural manifestations are more sort of manmade or person made imposed perspectives on what seems appropriate. Like in Indian culture, a wife was expected to annihilate herself in the funeral pyre. So culture imposes a lot of shoulds and woulds and coulds. But in terms of hardwired mammalian, I mean, it’s not just humans. There are elephants, there were whales. Apparently there was a few years ago in the Pacific Ocean whose baby died, or maybe the mother died and the baby was swimming around. Anyway, so mammals form attachments and that feeling of missing and wanting and needing that person is universal.

Eric: So would you say the emotional reaction tends to have a lot of similarities, but the outward expression, the mourning of grief of the thing you lost is more the thing that’s influenced by cultural norms.

Holly: Yeah. So mourning is more how people engage in mourning practices, whether Jewish people sit Shiva, those are mourning practices. But in terms of the emotional response to loss of something you love, I think animals feel it and humans feel it, and that’s universal.

Eric: So do you get a lot of pushback on it? Because there is a lot intense discussion, I guess we were talking about this before with the stages of grief, how individualized is there is no right way or wrong way. It really depends on the person. Do you get pushback on that?

Holly: I get pushback all the time. And what I struggle with is people, they’ll criticize what happened and fault it for lack of evidence when they just haven’t looked at the evidence. The evidence was overwhelming and that’s why the DSM committees were universally compelled to feel that it was time. Apparently there was more data supporting the distinctiveness and the need for this disorder than there had been for PTSD, for depression, for almost most of the other affective or anxiety related disorders in the DSM. And the reason is there’s highly specific criteria and we can identify who these people are. This disorder’s secondary to bereavement, is the single mental disorder, highest risk, for suicidal thoughts and behaviors of any other response, including PTSD and depression, which surprises a lot of psychiatrists. These people want to reunite.

So an example was last week, someone told me his sister was, it’s been like five years since her husband died, and when he was being buried, she started digging next to him. She wanted to join him. Her life was over. She wanted to be close to him. And I think what people don’t realize is people who are stuck in that state, they’re not highly functioning. They don’t want to go to work. They don’t want to interact with their family. They want to stay home and look at pictures and they just mourn the loss of the life that they loved and had and don’t want to go on. And they are at risk for a lot of physical and mental and social impairment. So it’s not that we are pathologizing. That’s a pathological response by definition.

Eric: So you’ve been building up the evidence for what decades now. And there is a lot of evidence. There’s clear risk factors for bad outcomes. Why do you think there is so much pushback for this in particular?

Holly: Because people say things like you said. So one of the criticisms is that it’s an insult to the dignity of a loving relationship. So that criticism really got me. Because it’s like first of all, how the heck would you ever know that? What does that even mean? So that’s what I don’t like when people are like it’s an insult to the dignity of a loving relationship, like really.

Eric: The pathologizing of grief is an insult, right?

Holly: If someone dies because they’re so bereft over the loss of someone they love that they don’t want to go on, is that an insult to that person? I think if anything, it might even show how devoted they were to that person. Anyway. I mean, that’s sort of a silly one to be honest because it’s a moot point. But what they’re getting at is that there’s a sense of stigma. I think they’ve claimed that I’ve been sort of been a tool of big pharma that I’m coming up with a new indication for people to throw drugs at.

And what bothers me about that is the way I got into this was the opposite. As a sociologist, among psychiatrists, and tricyclic antidepressants and interpersonal psychotherapy, which is the standard treatment for bereavement related depression, we’re working terrifically for that, but they weren’t touching these grief symptoms. So I get people who are coming to me saying nothing they worked has helped them. SSRIs don’t help them. Psychotherapy isn’t helping them. They want very specific targeted treatment for these particular symptoms.

Eric: Holly, I got a question. How much of it is we’ve all grieved? We’ve all experienced this normal, somewhat healthy, adaptive response, a loss that’s important to us. But few of us have had prolonged grief disorder. Few of us had that more pathological response. So we assume that everybody’s going to have that same response of us. And statements like I said that it’s an expression of love, how much do you think that’s playing a role?

Holly: I think you hit that on that head. Really, no seriously. That’s-

Eric: So I got two today. I got two smart statements, one dumb, two smart.

Holly: You did. So no, I think people feel like it’s an insult and it just seems like it’s medicalizing and stigmatizing what’s normal and it’s sort of yucking people’s yum in a way. And the challenge has been the criteria seems so easy to meet. Yearning for someone who you love, who’s to say who doesn’t do that? I challenge these people to meet the criteria. Because I hear from researchers who are like, “These criteria way too strict,” because no one’s meeting them. Because it’s really hard to be so stuck in your focus on what you’ve lost that you don’t want to and you can’t even engage in the here and now. So it’s just a different animal. And I think that people are confusing their feelings of grief with what this disorder is.

Alex: I want to ask a question about treatment, and that generally we don’t screen or assess for things that we don’t have treatments for because there are downsides to screening and instituting a whole health system wide policy of assessment. What are effective treatments? Or do we have any? What’s the landscape look like in terms of treatments for prolonged grief disorder?

Holly: So I think that the fact that the standard treatments for bereavement related depression were not working, that led people like Kathy Sheer to develop a very specific targeted treatment. It’s really an amalgam of a bunch of different approaches, largely cognitive behavioral therapy. But that specifically has proven effective. Richard Bryant in Australia has adapted different versions of it. There are many psychotherapies. And we even developed an online tool when I was at Dana Farber. I worked with Brett Litz who had developed a de-stress for combat vets who were suffering from PTSD and we adapted it for people who had lost a loved one to cancer. And that proved effective. That was a therapist assisted intervention, but it did produce depression, anxiety, symptoms of grief. So there are interventions, online interventions.

Because you can experience these symptoms before the death, actually, especially with dementia patients, so we’ve developed something we call empower for family surrogates in the ICU who are having these very, very dependent on this person. They can’t communicate and they’re in the ICU and they’re dying. And then they’re being sort of hounded to sign a DNR order. And we were asked by the critical care docs to come up with a psychological intervention to help them hear what was happening. So we target experiential avoidance and distress tolerance in the ICU. We have six 15 minute modules in the ICU to help with their grief. And we’ve shown it’s extremely helpful at reducing their grief and the numbness that get in the way of hearing what’s happening and making better decisions, which exacerbate problems and adjustment later on. So there are established pretty well published polls and approaches to address it therapeutically in terms of grief.

Alex: And for our listeners, just to distinguish what you’re just talking about, that wouldn’t be prolonged grief disorder. That would be another grief reaction in anticipation of their loved one’s death. It’s not 12 years after. It doesn’t meet the criteria.

Holly: It doesn’t meet the timing criteria, but one of the biggest risk factors for post-loss prolonged grief disorder is pre-loss prolonged grief levels. And we’ve examined this analytically. If you can reduce the amount of grief and help people adjust to the impending death, that reduces the amount. I mean, even in the stage theory paper, we showed that if they knew longer than six months before the death, that would lower the levels of grief intensity post-loss. So it does sort of seem like there is a certain amount of grief work that people do. In fact, people have even applied this to receiving targeted therapies for lung cancer. One reporter had asked me about people who had grieved their own death and didn’t want to try another round of something because they’d already gone through the stages they had said, and the just didn’t feel like doing that again. So you can have it before.

Alex: In pharmacological treatments, have there been any studies?

Holly: There have been very, very few. And for better or worse, we’ve proposed something that I think it tickles a lot of psychiatrists because it sounds kind of crazy. So there’s a little bit of a backstory. So I was in the psychiatry department at CMHC at Yale and every other treatment was naltrexone for smoking, for alcohol, for even behavioral things like gambling. And then I moved up to Boston and I mentioned to Susan Block, “Maybe it’s yearning,. It’s craving. It’s pining for someone. That sounds like an addiction.” And that’s where you can get into a lot of trouble. And it’s asking to being made up by these people to say now love is an addiction and all this stuff. But there have been studies of the nucleus accumbens activation in the brain when you’re shown pictures specifically of the person who died, but there’s not that reward that’s triggered when they show pictures of Oprah or someone else.

And so we’ve thought that if naltrexone helps reduce cravings for something you’re yearning and pining for, maybe that would free you up to explore relationships that you’re stuck looking at pictures. No, put that away. That’s not so rewarding anymore. Now that would free you. Because the thing about prolonged grief disorder that does distinguish it from depression, it’s very person specific. It’s really personal. It’s about that person. You think you need that person. So the idea would be to blunt the cravings for that loved one that was sparking all this longing. And I realized that I’m just asking for people to throw darts-

Eric: The great thing about social media and Twitter, everybody is very nice. [laughter]

Alex: That’s right. We all get along everywhere. Yeah.

Eric: Never a rude comment. So I don’t expect anything will occur.

Alex: That’s right. I have one more question along those lines. Has anyone tried ketamine? I’m just curious given its dissociative effects and anesthetic qualities.

Holly: No, but as long as it’s not contraindicated. A geriatrician was actually telling me that ketamine was given to someone who was bereaved and he died.

Alex: Oh.

Holly: I’m not the physician here. You guys are.

Alex: Right, right, right.

Holly: But maybe if an older widower has a heart condition, maybe you don’t use ketamine for their grief.

Alex: And the other thing that’s coming, being increasingly accepted in our culture and tested are psychedelics.

Holly: Absolutely. And I don’t know if you guys saw that, but Nicole Kidman, Nine Perfect Strangers, and that was about grief, yeah. So-

Eric: You must’ve loved that show, Holly, or you had strong opinions of it.

Holly: Yeah. Yeah. And then I was part of this panel where these guys who had been doing remarkable…talk about impressive data. That data were on showing how it was helpful for alcoholism. It was helpful for PTSDs. There is a physician that is trialing psilocybin out in I think in LA.

Alex: Great.

Eric: Well, Holly, love all of it. I’m assuming it was just an easy ride to get this into DSM-5.

Holly: Yeah.

Eric: Well, let me ask you this. I’m going to ask you a different question because we only have a couple minutes. If you had a magic wand, you can change one thing about what providers do around this topic of grief and prolonged grief disorder. What would you use that magic wand on?

Holly: I would ask them how they’re feeling and coping with their loss. The data actually taught me something because I was skeptical about this notion of experiential avoidance that you sort of have to go through it to get beyond it. And you never really fully get beyond it, but that grief is upsetting. There have been some debates about that resilient people don’t need to grieve. And there’ve been some arguments about that. And if you really love someone, then you will be grieving them. So there’s no way around it without really experiencing that loss and what that person meant to you, and that’s all normal and natural and healthy. It’s the people that can’t work their way through those feelings are the ones that are likely to be stuck, assuming that they had that really strong emotional bond. So I would ask clinicians to ask about how they’re feeling in response to the loss.

Eric: Well, Holly, I want to thank you. But before we end, how about we’ll turn it Alex for a little bit more of the song.

Alex: (singing)

Eric: Well, Holly, thank you very much for joining us on this podcast.

Holly: My pleasure.

Alex: Thank you, Holly.

Eric: And thank you Archstone Foundation for your continuing support and to all of our listeners.