‘You can’t really study grief without studying love’

You describe grieving as 'ultimately a type of learning'. Can you outline how an understanding of the brain informs this approach?
It is across many years of investigation, and many research projects of my own and others, that I have come to see framing 'grieving as a form of learning' captures many aspects of this process. At its most broad, bereaved people have to learn how to live in the world while carrying the absence of their one-and-only with them. That learning, to restore a meaningful life, is one aspect. 

At a more basic level, bereaved people have to relearn every small habit that incorporated the 'we', beyond just 'you' and 'me'. So, every time you cook a meal and don't have to automatically consider your child's food preferences, or every time you reach for the phone to call your mom with the news of the day – each of these is the learning to nottake into account the other person on this earthly plane. 

We see lots of activity in the posterior cingulate cortex (PCC) when we do neuroimaging studies of grief, a region involved in self-referential memory, and learning requires updating how the hundreds and thousands of days of predictions from our self-referential memory no longer applies in the here and now. 

Most people who have been bereaved might recognise your distinction between grief, 'the intense emotion that crashes over you like a wave', and grieving, as a process with a trajectory rather than a moment. Do you see that distinction adequately considered in bereavement science itself?
Making this distinction came from designing studies to investigate grief – and recognising that when we are eliciting that wave of emotion in the scanner, by showing participants photos they have brought us of their deceased loved one, the data from how the brain elicits grief is not the same as how the brain changes over time with adaptation to the loss. This would require several scans on the same person, to observe the trajectory of changes in that feeling. Very few of these studies exist in the neuroscience of grief, although we have some excellent studies looking at how the psychological experience changes over time, such as George Bonanno's work with the Changing Lives of Older Couples (CLOC) study. 

I think the surprise to me was realising that this distinction isn't just helpful in doing scientific work, but for people who might believe they won't feel grief again, that someday this will be 'over'. It doesn't matter how long it has been since the death, when you become aware of the loss of something so important, you will feel that momentary wave of grief. But that doesn't mean it won't also change over time, become more familiar, more manageable, or even the source of great compassion for others –even though it will never go away.

You write of 'yearning' being at the heart of grief, and the brain needing to update its virtual map of the person you have lost. Does this suggest that immersing yourself in the person and the hard fact that they have gone is better way to grieve than avoidance?
I'm a big fan of having a big toolkit of coping strategies. I believe that avoidance has its place – if you need to just pretend nothing has happened, and cheer for your son's football game for 45 minutes – that's a great moment to choose avoidance. Coping strategies work best when they are appropriate for the moment at hand. In addition, grieving is very stressful for the body and the mind, so denial can give you a break for a while. But if that is the only strategy we keep reaching for in the toolkit, it is likely that we won't learn how to manage our waves of grief, we won't come to understand how this new life we are forced into really works, how to connect with the living loved ones around us. We may also need to spend time crying on the shoulder of a dear friend, a friend who can really listen to us without judgement. And we might need to do some 'instrumental coping' – finding someone who can show us how to fix the toilet or how to cook an egg. We might need to pray, or vent our anger, or take a trip back to our childhood home. These are all coping strategies that enable us to manage the fact that we are now a person who might be overtaken by grief at any time, and who understand the irrefutable mortality that we've come to know through the death of someone close. 

The neuroscientific approach presumably has implications beyond grieving. For example, you write that 'the ephemeral sense of closeness… exists in physical, tangible hardware of our brain'. 
You can't really study grief without studying love. There has to be something that is 'lost', and that means there has to be a bond before the bond can be broken by death. The neurobiology of attachment has taught us a great deal about how that bond is physically encoded in the brain. We know that the process of bonding, falling in love with our partner or our child, is part and parcel of a huge change in neurochemicals like oxytocin and dopamine, that encode this as our one-and-only, and motivates us to seek them out and spend time with them, taking comfort in their presence and offering our unconditional caring. An aspect of that bond is in the nucleus accumbens, part of the reward network of the brain. But it is also in the overlapping representation of self and other that occurs in medial prefrontal cortex (mPFC) of the brain.

Perhaps the most common bit of advice given to bereaved people is 'give it time'. Is this trajectory of grieving actually reflected in brain imaging work?
As I mentioned, we don't have many neuroimaging studies of grieving to date, or that change over time. But we know from excellent clinical science that yearning tends to decrease over time, while acceptance tends to increase. This is not a line from A to B, however, as many ups and downs in our emotions occur over this period of adaptation. We know from careful research that the anniversary of the death, holidays, and birthdays tend to temporarily increase our grief, our yearning, and sadness. This doesn't mean that the trajectory is still moving toward a more manageable place, it is a temporary awareness of the loss again, and will recede like the tide. 

In normalising the grief reaction, do you get to the point where you believe there is no 'right' or 'wrong' way to grieve? You also point out that the Kubler-Ross model has been wrongly taken as a 'prescription for how to grieve', rather than a description.
I believe that there are as many different ways to grieve as there are ways to love – which makes sense, since they are closely related processes. Most of us find that marriage, for example, is very different than we expected, and this is usually true with grieving as well. Everyone I know has a very different marriage, with different emotions, different ways to approach problems, different rituals and interpretations of events. Yet, they are all still marriage. So, scientists look for patterns across these very different expressions of grief. Dr Elisabeth Kübler-Ross was a brilliant scientist, using the best technology at the time in psychiatry – the clinical interview. She had the revolutionary idea of actually talking to terminally ill patients, and accurately described their experiences of grief, which were then applied to grief of bereaved people as well. But research since the 1960's has shown that although she gave us an accurate description of grief, of moments in time, that grieving does not occur in a linear way through these stages. Much longer studies – by Holland and Neimeyer, for example – have shown that we go back and forth, with more and less acceptance over time. The trouble is that many people think 'the five stages' is a prescription for grieving, and feel like there is something wrong with them if they don't experience anger, for example. 

You describe Complicated Grief Treatment, revisiting intense and overwhelming emotions again and again. Is that suitable for everyone? 
Complicated Grief Treatment, now called Prolonged Grief Disorder Treatment, includes teaching clients a number of different skills, including understanding grief, managing emotions, seeing a promising future, strengthening relationships, narrating the story of the death, learning to live with reminders, and connecting with memories of the person who died. This is done because for some people, the support of their living loved ones does not enable them to get past the 'stuck points' that are quite natural in grieving, but persist longer in some people than others. So, if a year after the death of a loved one, a person is flexibly able to move into and out of those waves of grief, is able to find connection with their friends and family, and able to find moments of enjoyment in the day, then they do not need intervention. Remember that grief never goes away, but we can find ways to still have a good life, however we define that personally, even after devastating loss.

It also helps to know that people can both have major depression and also prolonged grief. But careful research has shown us that they are distinct, and that evidence-based, grief-focused psychotherapy is a better treatment than therapy for depression. These randomised clinical trials, funded by NIH, also showed that anti-depressants do not help the feelings of yearning we see in prolonged grief disorder, although they may help symptoms of depression, if those are present. It's one example of how this type of careful diagnostic science can help us to see what doesn't help, as well as what does.

I love that you include the Serenity Prayer. Sometimes I think that encapsulates all of Psychology, or at least all of therapy…
I couldn't agree more!

You also include a C.S. Lewis quote from the book he wrote after the death of his wife: 'No one ever told me that grief felt so like fear.' What do you see as the great unspoken of death?
The neuroscientist, Jaak Panksepp, actually labeled the neuroanatomical system as the PANIC/GRIEF system, which I think is a little bit brilliant. Think of losing your child in a grocery store – the panic that we feel in that moment is extended in some ways, throughout grieving.

What remains to understand, for you and all the other great bereavement researchers you mention?
Umm… how long do you have to discuss this? In all seriousness, we really are in the infancy of our scientific understanding of grief and grieving, and the role of the brain and the body in this painful experience. We need many more people who understand grief and grieving – as researchers, as clinicians and doctors, and even as neighbours and friends and family. The more we know in general, the higher the floor from which future great researchers can take us further to deeper understanding. 

In terms of writing the book, you weave three characters throughout – the brain, science, and yourself as a trusted guide with your own experiences of loss. Do those characters define how you approached the whole process? Do you think it's a good approach for any author writing about Psychology?
Well, I think it can be difficult to study a phenomenon with which you have little experience. My grieving experience has been very different from other people's – for example, I have never had prolonged grief disorder, after the death of my mother at 26, or after the death of my father. I did experience depression, and so I felt more attuned to the difference between them, perhaps. But thinking of framing the information as three characters is more a method of an author, an artist, I suppose. I wanted to find a way to convey the knowledge we have from grief research, and make it useful for those who could apply it to their own lives. The realm of the author is framing, interpreting, and telling stories in ways that are accessible and interesting. I hope I've been able to do that. 

-        The Grieving Brain: The Surprising Science of How we Learn from Love and Loss is published by HarperOne.    

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