BONUS: Professor Katherine Shear on Prolonged Grief Disorder

2024-06-20 00:32:25

Twelve-year-old McKay Everett disappeared from his Texas home in September 1995. His father Carl returned from an Amway meeting to find the back door ajar and the telephone ringing. On the line, a woman with a raspy voice demanded $500,000. Over the next week, the FBI played a game of cat-and-mouse with the kidnappers, who used inside information to stay one step ahead of the investigation. Ultimately the FBI uncovered a series of crimes that started long before McKay was taken. Most shocking of all was the suspect. McKay had been betrayed by someone he trusted – a pillar of the community hiding a dark secret. But decades later, McKay’s mother, Paulette, still isn’t satisfied with the official story. She doesn’t think everyone involved has been brought to justice. Ransom: Season 1 - Position of Trust is a story of greed and betrayal and how one’s outward appearance can be dangerously deceiving.

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Speaker 2
[00:00.00 - 00:18.68]

This episode of Ransom is sponsored by BetterHelp. Do you want to make a change in your life? I think that most of us really do, we want to make good changes. Therapy can help empower you to make the changes you really want in your life, and to make them, more importantly, stick.

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Speaker 3
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Producer Ben Kubrick Here, to better understand the grief process, we reached out to Dr. Katherine Scheer. Dr. Scheer is a psychiatrist and a professor at Columbia University, whose recent research focuses on bereavement and grief. Especially what psychiatrists now call prolonged grief. Which is grief that doesn't get better on its own and interferes with daily life.

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Prolonged grief is especially common for relatives of homicide victims and people who die in violent ways. All right, here's our interview with Dr. Scheer.

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So I guess, just to start, what's your name, who do you work for, and what do you do?

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Speaker 1
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So, my name is Dr. Katherine Scheer, and I'm a professor of psychiatry at Columbia University, and I direct the Center for Prolonged Grief at the School of Social Work.

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Maybe kind of, even before we get to prolonged grief, can you talk about kind of like, what is grief in general, and how is it similar or dissimilar to depression?

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So the question of what is grief? is one that is, it's a really good question, and the answer to it is really that it's the response to loss. And the work that I've done has all been loss of a loved one. Bereavement is the loss of a loved one, but grief occurs after all kinds of losses.

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It's not only the loss of a person, and it's a simple definition, right? it's the response to loss. But it's a very complex, multifaceted, has a lot of different components to it. Grief does, and it changes over time, and it's really kind of unique to each relationship. But at the same time, there are commonalities in it.

[02:49.44 - 03:24.68]

And at its heart also is yearning and longing, and sort of very strong, persistent thoughts and memories of the person that we lose. So that's at its heart. But then we can also experience, we do experience a lot of sadness, and that's where it kind of intersects with depression. But also when we're grieving, we experience anxiety and anger and guilt, and sometimes even shame. We can really experience any and all of the painful emotions that we're capable of.

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And we even also during grief, will experience positive emotions as well. So it's quite complex, and it's also more intense than almost any emotional experience that we have in our lives. And so it's often confusing to people. Often, people ask the question, You know, am I grieving? right?

[03:43.76 - 04:07.76]

And really, the answer to that is there is no right way to grieve, there's no wrong way to grieve, but what we have to do is come to terms with a loss. We have to find a way to wrap our minds around it, to adapt to it. In other words, to reorganize our lives so that we can move forward in a meaningful way. In the context of a person that we love very much, not still being there.

[04:08.04 - 04:35.34]

The biggest difference between grief and depression is the yearning and longing that's at the center of grief and the preoccupying thoughts and memories. And then from there, everything that the person experiences that is similar to depression, when it's grief is really focused on the loss. So the sadness is not sadness in general, it's sadness around the loss. You know, if you ask the person, if this person were back tomorrow, how would you feel?

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They would say, Fine, that's all I need. Whereas in depression, people feel bad about themselves and the world, you know, it's a much more global, pervasive kind of mood change. Also, another important difference is that the depression really affects the ability to experience those positive emotions and grief. You know, we're not there a lot of the time, but we can experience those positive emotions.

[05:03.70 - 05:06.22]

So kind of neurobiologically, it's different in that way.

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Speaker 3
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Is it complicated in that grief could push someone into kind of like a depression in addition to their grief?

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Absolutely yes. So the loss of a loved one can also trigger a depression, an episode of major depression. And we've known that for a long time, and loss is very stressful, so it's a huge stress.

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And grief itself is stressful, because it's very intense, it's so intense that it kind of throws people. So people worry about their grief. In addition to worrying about the loss, they worry about the grief as well. And also the way that we think and feel in grief is often confusing.

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You know, we want to move forward in our own lives, but then we don't because we don't want to go forward without. The person who died would be an example of that. Or, you know, we feel like the emotional pain is almost unbearable, but then we don't want to lose it because we feel like we should be feeling emotional pain. And people feel disconnected very often from other people around, for example, C. ..s.

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Lewis wrote a lovely little monograph called A Grief Observed after his wife died. And he said he really, really wanted people around him right after she died. But he couldn't connect with them at all. He's English, so he said he felt like there was cotton wool between himself and these people.

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Anecdotally, you hear a lot of stories about parents who lose a child, kind of getting divorced or having relationship problems. Do you know anything about kind of the actual statistics, and can you talk to that?

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So the actual statistics do not support divorce, but I think it depends on how the couple is able to manage their relationship after the death of a child. If they understand and appreciate that they're going to grieve in different ways, that's very important that they not expect each other to grieve in the same way. And they're respectful of the way that their partner is grieving. And if they understand, too, that. Even though, maybe the partners were close and were often the supports for each other when stressful things happened in their life. In this situation, they're probably not the best person to be their primary support because they are grieving too. So parents likely have to turn to someone else as their primary support. If they do all of those things, I think that is helpful for the marriage.

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Yeah, but you're saying, statistically, there doesn't seem to actually be an effect from just the loss of a child.

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Right, right.

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Can you talk about just kind of some of the general symptoms that people experience in kind of the acute stages of a loss?

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Yes, in the acute stages of a loss, people experience intense yearning, longing, searching for the person who died. They might have even feelings that they can sense their presence. They often want to listen to the sound of their voice, look at pictures, of course, and sometimes even do things like smell their clothes. There was a suicide recently at Stanford that you may know about, it was a lot in the news.

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And the mother who was on the news was wearing her daughter's shirt, and she said the reason she was wearing it. And she said that any mother would know. This is that she could smell her daughter on the shirt, and that was very comforting to her, made her feel close. And that's a very typical thing that people don't always appreciate.

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I think it's again very natural.

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And people do experience anxiety about how they're going to move forward, what's going to happen in the future. About changes in relationships and changes in their sort of social identity. Often it's just a very, very intense emotional experience when someone close dies, and it can be hard to kind of even do ordinary daily life things.

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Like, some people have to put little sticky notes up, saying brush your teeth, take a shower, eat breakfast, things like that. There's a lot of data on hallucinating, the presence of the person, as well as actually sometimes actual visual hallucinations or auditory hallucinations, or even any kind of sensory hallucinations. Even hallucinating again, the smell of the person. One person told me once about their grandfather dying.

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They would hallucinate his cigar smoke for a long time afterwards. People, often, they very often have experiences of seeing something that seems like a sign they feel is a clear sign from their loved one. Someone recently told me about seeing a dead animal that they were convinced was related to someone who died. Butterflies, birds can be like that.

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Once lost someone who was a certain kind of airplane pilot, and when that kind of airplane flew by at a certain time of day. That they were convinced that this was a message.

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Speaker 3
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Can you talk about the kind of role of religion in grief?

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Speaker 1
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Well, religion plays a very big role in grief for anyone who is religious. People often get quite a lot of comfort from both the social aspects of religion and also the sort of beliefs, the religious beliefs. It can be a big comfort to people. However, it's also the case that many people who are religious have a period of time when they basically feel kind of disconnected from God. And from their religion, and from the people in their religious group.

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That's a very painful kind of feeling and they have to kind of work their way through that. Sometimes religion has expectations and beliefs about death and grief that don't fit with their own beliefs. In that case, religion can be not at all helpful. And also sometimes can be almost a risk factor because it's not supportive.

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Speaker 3
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Do you know if there's been work that's been done on kind of homicides specifically, and kind of how media coverage or the judicial system? Like having to go to trials and testify and things like that might impact bereavement and the grief process.

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Speaker 1
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Media coverage can be very painful for people, it can be very intrusive and very painful.

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But I'm not thinking of the actual research findings in this, if that's what you're looking for.

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Sure, yeah, I mean, I guess maybe if you just want to talk kind of more generally to that.

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Speaker 1
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Yeah, I mean, I think grieving is really a very personal, very private kind of experience. The media sometimes gets overenthusiastic about trying to get the actual story from the person, and that can be experienced as very difficult and intrusive for people. The other thing that is really important with homicides, basically with trials, is finding the person who's responsible and then getting them convicted. Is often very, very important to a family member. Or at least getting some kind of closure around the death of their loved ones. And so they're pretty preoccupied with that.

[13:11.74 - 13:24.20]

Until all of that is done, and that, of course, can take a very prolonged period of time. It often does so. People don't move through their grief while they're trying to cope with the homicide aspect.

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After a brief break, we'll be back with Dr. Scheer to talk about her research into prolonged grief.

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Speaker 3
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Dr. Scheer spoke with us about how she developed a treatment for prolonged grief and helped to get it recognized by the medical world.

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I was doing research in anxiety disorders, and a postdoctoral fellow who was interested in grief had identified this syndrome that we used to call complicated grief. We now call it prolonged grief disorder. And it wasn't responding to treatments for depression. This person was not a clinician herself, so she didn't really know very much about treatments. But she really wanted to interest someone who would want to take this on. And I don't know how she knew that was going to be me, but it was.

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So it was serendipitous in lots of ways, but once I started it, I was very, I found it very, very fascinating.

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How is the more medical world? How have they traditionally thought about grief?

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The medical world has traditionally thought about grief as a form of depression, and that's really how I started in. This was that people were thinking it was like depression. So it should respond to treatments for depression, and it just wasn't responding to those treatments. And then the work that we did further kind of confirmed that. Because we developed a treatment for people who had prolonged grief. But it's really not so different to have prolonged grief as to have any grief.

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And we compared it in some really, really rigorous studies to really good treatments for depression. And the grief treatment made a big difference in the grief, and the depression treatment made just a little bit of difference. It didn't make no difference.

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But yeah, and so kind of what goes into, you know, when does normal grief kind of cross over into what we call prolonged grief?

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I mean, from the point of view of what it looks like, it's persistent, pervasive, yearning, longing, and preoccupying thoughts and memories of the person who died. That's associated with other grief symptoms, like a persistent, strong feeling of disbelief, feelings of protest, that no, this shouldn't have happened. Trying to avoid any reminders that the person is gone in this way. That interferes with daily life, because the loss itself is so stressful, and grief is stressful. We have some natural early coping responses that are kind of helpful, like the avoidance can be helpful. The disbelief can be helpful in the beginning, because it kind of mitigates the intensity of the reaction in the very beginning.

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Can you explain kind of some of those terms or those behaviors? Yeah, right.

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So people want to avoid reminders that the person is gone, so that might mean they don't want to go back to places that they enjoyed with the person. It might be, you know, it might be a walk in the park, a certain park, it might be the place where the person worked, or just any number of physical places that are reminders. Sometimes it's places within the house.

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So people don't want to go into the room that the person lived in, or they don't want to go into their tool shed. Because any place that really reminds them of the person who died sort of activates their grief even more, and in the beginning, the grief is so activated. That if you do all these things, it just, you know, it would be almost unbearable. It just. It makes sense to try to kind of manage those emotions. But over time, if people are avoiding many, many things and for someone very close, often they're just. There are literally hundreds of places or people or activities that are reminders of this person. And so their life has to become very, very constricted on the one hand.

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On the other hand, it also deprives them of being able to connect with their memories of the person in a positive way, which is what most people do. So, most people don't end up, you know, in the long run, having a whole lot of things that they avoid. And when they do, it kind of interrupts the process of adapting to the loss. And also it's very natural when someone dies, especially if it's a sudden death. The person is now gone and you want them, and so you want to say no, you know, this shouldn't have happened.

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This is wrong, it's unfair. And you know, those are all things that are true. And the feeling of protest, the thoughts of protest, is a little bit comforting in the very beginning. But again, you can see that over time, it can get in the way of accepting the reality that the person is gone.

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And so if you can't accept that reality, then, paradoxically, by not accepting it over time, you end up kind of losing the person every day again. Because they're not there, and you haven't really accepted the fact that they're not there, so it actually ends up worse. Another example is people will very naturally start thinking of alternative scenarios after someone dies, that's another very natural thing.

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So that means, like, you know, let's say someone got hit by a car when they crossed the street. If only they hadn't crossed the street at that moment, you know, they could have crossed the street five minutes later, five minutes earlier.

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And do we know kind of? Are there known risk factors for prolonged grief?

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Well, this sudden, unexpected death in general is more difficult, it creates more opportunities for thinking about how things could have been different. It's more shocking and, you know, kind of creates the need to kind of process the shock part of it as well. So probably for both of those reasons, it makes it harder.

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And that increases the rates of prolonged grief disorder down the road. You know, death by what some people call unnatural causes. I think of them more as violent causes like suicide, homicide.

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Accidents, you know, natural disasters, things that come kind of out of the blue. That increases the rates of prolonged grief, probably doubles or triples it.

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What about for the person grieving? are there certain risk factors that might make them more likely to experience prolonged grief?

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So people who have a history of mood or anxiety disorders, or maybe any mental health challenges, it's generally harder again. It's a risk factor, not 100, but it's harder to manage all of the psychological challenges that come along with the loss.

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What about, you know? We talked about the type of death, what about the type of person lost?

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Right, what seems to be the case is that prolonged grief is actually more common after someone loses someone. Very, very close and very, very rewarding relationship, but it's often in the context of that being a very special relationship. So it might be that the person grew up in a family that wasn't very supportive, that didn't have really good supports. Or, you know, where there might have even been some trauma or abuse. And then they grow up and they find either a partner, or they might have a child that they're able to treat very differently than they were treated.

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And so the relationship they lost was very special, but often in a background not so great relationships. The loss of any young person is also a risk factor, so a child or even a young adult. And the circumstances of the death around, you know, so Covid, for example, where the person, you know, where we couldn't be with people who were dying, and the person died in, you know. Often in very, what seemed like very sad, exceptionally painful circumstances, and also where a bereaved person might feel, in some way, actually responsible. Maybe they were the ones that brought the infection into the house inadvertently, but they did it and then they survived and someone else in their family died.

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So those are risk factors.

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So what percentage of people who experience grief will end up having prolonged grief?

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So, on average, about seven to 10 after a natural death, and it's two to three times that after a death by violent means suicide, homicide, accident. The proportion of people who experience prolonged grief disorder is an estimate at this point because we haven't had actually diagnostic criteria to benchmark, so we're not quite there yet, but that's our estimate. Seven to 10 after a natural death, and let's say up to 20 to maybe even 30 after, let's say a child who dies by suicide or homicide or accident.

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And when did prolonged grief become an official diagnosis?

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Prolonged grief became an official diagnosis in the World Health Organization in the spring of 2019 and in the DSM in the fall of 2021.

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Speaker 3
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So that's brand new, basically.

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Brand new. It was a very good feeling when this condition was officially recognized by the DSM-5 in the United States. Because our work is focused on developing and testing a treatment, which we did successfully. It's a 16-session intervention and it's been highly efficacious for people. And most mental health professionals are unaware that this is even a condition, let alone that it can be treated.

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Speaker 3
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Yeah, so you're hoping that kind of now there will be greater awareness of this and more people will get treated for it.

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Yes.

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Speaker 3
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And do you know, is there any interplay with kind of relationship troubles and prolonged grief? like if one partner has prolonged grief, does that cause difficulties?

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It does cause difficulty anyone with prolonged grief. Generally, there are difficulties with everyone that they're close to in their life because people are trying to help them and it's not working. And so they get frustrated and they sort of either withdraw or they get kind of, you know, aggressive, harsh with the person. So yeah, there are often difficulties and the person can't connect with other people.

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They're like, C.

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S. Lewis In the beginning, they stay like that.

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Speaker 3
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Yeah, what advice would you give to someone you know who's experienced a serious loss?

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Speaker 1
[25:58.84 - 26:37.50]

I would say to not worry about what their grief is looking like. To allow themselves to experience what they are going to naturally experience and to treat themselves with a lot of self-compassion. And to know that we have natural, intrinsic adaptive capacity as humans. And that it's very likely that they will be able to move through this loss in ways that they can't really foresee. But kind of having faith in that and in themselves, and being as open as possible to support from other people is also really helpful.

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Speaker 3
[26:38.20 - 26:59.42]

You know, it's kind of interesting because you say, you know not to judge your own grieving process, and you know that you'll get through it. So it seems like there's a challenge then of, like, you know, when does someone then go and seek treatment? Or, you know, talk to someone to see if they might be experiencing this kind of more prolonged grief process?

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Speaker 1
[27:00.92 - 27:26.60]

Well, I think people should seek treatment whenever they feel like seeking treatment if they're not sure. You know, I mean, I'm saying, accept your grief for whatever way it shows itself, and be self-compassionate. But if you're having trouble with that, by all means get help. I mean, there's no reason not to get help in terms of prolonged grief disorder that we don't diagnose until the DSM says a year after the death.

[27:26.84 - 27:42.22]

So, but if you're feeling like you're just not moving forward at all after six months. If you feel like essentially like the person died yesterday, then go see someone. Go see a good grief therapist or mental health therapist, who knows what this is?

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Speaker 3
[27:42.22 - 27:50.62]

Yeah, what about do you have any advice for kind of people who are relating to someone going through the grieving process?

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Speaker 1
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I mean, most of what you can do is just kind of be there, to be present as much as possible and to kind of keep in check. Your own natural inclination to want to soothe them or comfort them by making it all better, because you can't make it all better. And you know, it's not a good idea to try to give them suggestions about what they can do to make it better, because that's often feels very unsupportive. So just being there to listen, to help, you know, with anything that they need help with. But to spend time with them and comfort them in that way by your presence.

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Speaker 3
[28:29.74 - 28:36.80]

And are there any kind of myths you often hear or misconceptions you want to correct about grieving?

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Speaker 1
[28:37.32 - 29:05.82]

Well, there's a still very prevalent idea that there are stages of grief and that you're supposed to go through the stages of denial. And then what is it? denial, anger, bargaining? So there really isn't any support for that. The one thing that people can get from it is that grief has a lot of different aspects to it, so it often has these different aspects.

[29:06.04 - 29:19.30]

But, you know, not everyone has a phase of denial, not everyone has anger, pretty much everyone has sadness. But they don't occur in stages. And it doesn't mean that something's wrong if you're not experiencing one or another.

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Our website RansomPodcast.

[29:36.16 - 29:58.38]

Com Ransom is researched and written by Ben Kebrick and hosted by M.e. Art Rascone. production and sound design by Ben Kebrick, Erin Mason and Trent Sell, who also did the mixing. Co-created by Austin Miller for Podcast One, executive producer Eli Dvorkin for Workhouse Media Executive producer Paul Anderson.

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And for KSL Podcasts executive producer Cheryl Worsley, Ransom is produced by KSL Podcasts in association with Podcast One and Workhouse Media.

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Speaker 3
[30:11.04 - 30:23.12]

Thanks for listening to this bonus episode of Ransom. If you're getting anything from this show, please share it with a friend. And if you haven't yet, subscribe to it on your favorite podcast app and leave a rating and review. Thanks.

2
Speaker 2
[30:23.44 - 30:42.24]

This episode of Ransom is sponsored by BetterHelp. Do you want to make a change in your life? I think that most of us really do, we want to make good changes. Therapy can help empower you to make the changes you really want in your life, and to make them, more importantly, stick.

[30:42.76 - 31:04.58]

You get rid of the bad, enter in the good, and all of that is helped with. therapy. Therapy teaches us skills that help us live a happier and a healthier life, so if you're thinking about therapy, BetterHelp is the way to go. It's entirely online, designed to be so convenient for you, it's flexible.

[31:05.16 - 31:27.60]

It suits your schedule because you can do it from anywhere, from your office, from your own bedroom. Take a moment here and visit Betterhelp..com Slash Ransom today to get 10 off your first month. That's BetterHelp. H-e-l-P dot com slash ransom. This episode of Ransom is sponsored by BetterHelp.

[31:27.60 - 31:48.82]

Do you want to make a change in your life? I think that most of us really do, we want to make good changes. Therapy can help empower you to make the changes you really want in your life, and to make them, more importantly, stick. You get rid of the bad, enter in the good, and all of that is helped with therapy.

[31:49.54 - 32:10.88]

Therapy teaches us skills that help us live a happier and a healthier life, so if you're thinking about therapy, BetterHelp is the way to go. It's entirely online, designed to be so convenient for you, it's flexible. It suits your schedule because you can do it from anywhere, from your office, from your own bedroom.

[32:11.58 - 32:13.80]

Take a moment here and visit BetterHelp.

[32:13.80 - 32:24.48]

Com Slash Ransom today to get 10 off your first month, That's betterhelp H-e-l-p dot com slash ransom.

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