Essentials: The Science & Process of Healing from Grief

I'm Andrew Hubertman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine.

Today we are going to discuss how we conceptualize grief, both at an emotional and at a logical level.

“I'm going to teach you about the neuroscience and the psychology of grief and incredible findings that have been made in just a few key laboratories that point to the fact that we essentially map our experience of people in three dimensions.”

Just give you a little hint of what those dimensions are. They relate to space where people are, time when people are. I'll explain what that means. And a dimension called closeness. And how those three dimensions of space, time and closeness are what establish very close bonds with people.

And are what require remapping reorganization within our emotional framework and our logical framework when we lose somebody for whatever reason.

The important thing to point out is that grief is a process. Like any biological or psychological event, it has a beginning, a middle and an end. And I do believe that being able to orient in terms of where you are in that process can be immensely beneficial. Not just for predicting how long it's going to last, but in order to conceptualize the person or animal that you lost in a way that allows you to best preserve their memory while maintaining your own functional capacity in life. Along those lines, I want to point out that grief and depression, while they can feel quite similar in certain ways.

And have overlapping symptomology, loss of appetite, challenges, sleeping, crying in the middle of the day for no apparent reason, et cetera, they are distinctly different processes.

“As we wait into this important topic, I'd like to emphasize some of the common myths and misunderstandings about grief.”

Some of the myths of misunderstanding arrive from the beautiful work of Elizabeth Kubler Ross, a psychologist who wrote the famous book on death and dying. The different stages of grief, very quickly, are denial, anger, bargaining, depression, and acceptance. But unfortunately, those five stages were sort of taken to be gospel for a long time, and we now know based on neuroimaging, based on more in-depth psychological evaluation,

and, frankly, more researchers and clinicians moving into this area and observing that while much of what Kubler Ross described does hold true, it's not always the case.

How do I know this? Well, I know this because brain imaging studies involving what's called functional magnetic resonance imaging, FMRI, in which you can evaluate which brain areas are more active than others, according to blood flow, which correlates with neurolectivity and so forth. Teach us that the brain areas that are associated with motivation and craving and pursuit are some of the primary brain areas and circuits that are activated in states of grief. We understand also on the basis of brain imaging studies that, in order to understand grief, we have to understand how attachments are represented in our brain.

“And it turns out that both attachments and the breaking of attachments in healthy ways are governed by three important what we call dimensions.”

The three dimensions of relating to someone or an animal or a thing are space, time, and closeness. And in order to illustrate each one and how they work together to support relationships and their involvement in the grieving process, I'm going to tell you about an experiment. The experiment involves putting people into a brain scanner that allows the researcher to evaluate brain activity in different areas. In fact, can look in a very non bias way, not make any predictions about which brain areas are going to be involved and the experiment is the following. The person, which is say the research subject, first sees images of things that reside at different distances from one another.

So in one case, it's a beach or a parking lot with bowling balls set at different distances from one another. Their brain is imaged, and as their brain is imaged, they see different pictures of different scenes, the beach, the parking lot, et cetera, bowling balls spaced in different ways close together far apart regularly spaced non regularly spaced. When one does this sort of experiment, you see a lot of brain areas activated, not surprisingly the visual cortex, the area the brain that is responsible for creating visual perceptions.

But also a brain area that seems uniquely tuned to the distance between you and the objects will refer to that measure that dimension as we call it as proximity. Then subjects listen to tones. Those tones also are spaced from one another, so it could be something as simple as my hand meeting the table to up that I'm having to be sitting in front of.

But as they evaluate different types of sounds and patterns of sounds, for instance.

“They can start to parse brain areas that seem uniquely tuned to the spacing of sounds independent of what sounds are coming in.”

That is, it becomes active, specifically in response to changes in the spacing between sounds. Much in the same way as they could identify brain regions that were only activated when there were changes in the distance between objects such as the bowling balls that I used in the previous example. And then the subjects saw a different set of images. The images that they saw were of people and of faces and some of the images that they saw were of people's faces right up close and other images were of people at a distance where you could see the whole body of the person.

Now, they also varied the emotional relationship to those people. That is, they were able to get photographs from these research subjects' lives. So they could show them pictures of, for instance, their sister or some random person off the street. They could show them pictures of a parent or of a neighbor or of a celebrity that's well known or of somebody that they didn't know at all. So they were able to vary both the position of the person closer far. And they were able to vary the emotional distance to the person, which is this dimension that I'm referring to as closeness, which is not physical closeness, but how attached or how well you know somebody. Now, this may be sounding like a somewhat complicated experiment, but the takeaway from this experiment is exquisitely simple and exquisitely important. The result was that in all three conditions.

Changes in the physical spacing of these objects, changes in the temporal. That is the time spacing of these sounds and changes in the emotional distance between the subject and different people.

The same brain area was uniquely activated. And that brain area, it turns out, is a brain area called the inferior parietal lobule. The inferior parietal lobule. Now, you don't need to know where the inferior parietal lobule is.

“In fact, you don't even need to know the name of this brain area. What you do need to know, however, if you want to understand grief and how to move through grief, is that your map of people is not a map of emotional closeness per se.”

It is a map of emotional closeness, what we call attachment, that is interwoven, that is braided in in a very intimate way with your map of where they are in physical space and where they are in time. When you saw them last, when you're likely to see them again, and if you were to want to see them, how much time it would take to reach them or for them to reach you. Now, earlier I said that one of the key functions of our nervous system is to be able to make predictions. And so it's somewhat obvious, but nonetheless important to state and restate, that one of the most powerful aspects of our attachments to people, animals and things, is our ability to predict what it would take to see them again and when we are going to see them again.

Now, all of this sounds like a bunch of neuropsycho-babel parsing of the obvious. I'd encourage you to suspend that belief for the moment, because if you understand that all relationships are mapped in the brain and body through these three dimensions, space, time and closeness or proximity of space, proximity in time and proximity of attachment, how close or rich or bonded you are to someone.

“Well, if you can understand that, then it almost becomes obvious, or at least it becomes intuitive as to why after the loss of somebody in particular a death or the loss of an animal, this map has to be reordered. Why?”

Because if we are attached to someone or an animal at a deep level, it is almost always on the basis of a lot of what we call episodic experience, a lot of episodic memories, memories of things that happened. Like memories are literally the conscious recollection of your experience of somebody or an animal or a thing. And within that memory, you have an understanding of what has happened with them in association to you, what's going on with them, where it happened, when it happened, when somebody has taken away from us for whatever reason.

Grief is the process of uncoupling, unbraiding and untangling that relationship between where people are in space, in time, and our attachment to them. This is very, very hard to do, and for some people, it's almost impossible to do at least at the outset of grief.

“When we have a rich catalog of experiences with somebody or of them, that memory bank is not just flushed out the moment that we learn that they're no longer with us.”

What happens is the brain continues to make these predictions that they will be in a certain place, or a certain time, right, that they'll be in a certain time zone, or they'll walk in the door any moment. All of those predictions still hold. The neural activity continues. We call this reverberatory activity. That explains the yearning for and the desire to interact, and yet it's just beyond our reach, because once they're gone, our brain still functions in a way. These neural circuits still function in a way that put us into an action state of seeking them, looking for them in the same location, expecting them to contact us at whatever frequency that we were used to hearing from them, or that we could reach out to them and reliably get a response.

It is immensely disorienting, in other words, to maintain a close attachment, and at the same time to not be able to make predictions about where that person and more thing is in space and time.

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“For instance, if you've lost somebody or an animal or even a thing that was vitally important to you,”

it should make perfect sense to you as to why you keep looking for that person. Those expectations, those predictions that the brain is making are entirely normal. Because they are based on that deep catalog of episodic memory that you maintain about that person. Again, it's simply an activation of this map that involves closeness, space, and time. Not surprisingly then, the reordering of that map that's required in order to move through the grieving process is going to involve some remapping.

“Psychologists and neuroscientists generally agree that the best way to approach moving through grief is actually to remap these dimensions while maintaining the close sense of attachment to the person.”

By not in any way trying to undermine the intensity of the attachment or how important it was to you. So we'll now talk about how that process works and the different entry points, as they're called, to engaging in that process. These are tools gleaned from the research psychology, the clinical psychology, and the neuroscience literature. One involves the acknowledgment and really the understanding that you don't want to disengage or dismantle your real attachment to someone in animal or a thing. That's a real thing and there is actually no adaptive reason to try and persuade yourself or numb yourself or somehow avoid the thinking of just how much they meant to you.

What is important, however, is that you make some effort to shift your mindset and your understanding of that person in a way that holds in mind that, yes, indeed, the attachment is very real, and in some cases is very, very intense, but is now going to be uncoupled from the other two dimensions of the map, namely space and time.

But you are consciously going to try and prevent yourself from thinking about a couple of categories of things. First of all, you want to actively try and disengage from any attempt to engage in what's called counterfactual thinking, the what ifs.

“What if I called them a day earlier? What if they had taken a different route home? What if I had taken a different route home?”

These counterfactual modes of thinking are an infinite landscape of possibility, and they are very, very closely tied to guilt.

So as an infinite space, it's a very precarious one, and it will not allow you to uncouple that intense emotional attachment that I'm telling you is actually vital to hold on to from that catalog of episodic memory that you've established. In fact, it's going to strengthen those bonds. So in this dedicated five or ten or 30, whatever period of time you can tolerate and maintain focus. The idea is to think about your attachment in a rich way, and to perhaps even experience that in your brain and body.

This tool, if you will, of dedicated blocks of time for really spending some effort, and it isn't either effort to access the emotional connection while starting to uncouple the other nodes of the map.

“As it were, is something that is hard, but in terms of the options one has in order to deal with grief, it is indeed the most adaptive way to go about it.”

Now I'd like to consider why two people, both who are intensely attached to a person that is no longer there, can experience the grief of the loss of that person in such different ways.

We don't really know how other people feel. There's no clear way of knowing that the expression someone else has or whether not they're crying or not or their body language really represents how they feel inside. So that is important to keep in mind. Nonetheless, there does seem to be a sort of a split among people, and indeed among animals as well, even within a species, in terms of how intensely they feel the yearning aspect of grief. It appears based on a number of different lines of evidence that that relates to this molecule that some of you have probably heard of, which is oxytocin.

“Oxytocin is a hormone/peptide, a peptide just means a protein, generally a small protein, and a hormone is generally something that functions at numerous locations in the body to impact numerous organs and areas of the brain.”

Oxytocin has a variety of roles in the brain and body. It's involved in milk, let down during lactation. It's involved in parabonding, both in males and females.

It's involved in bonding of parent to child and indeed between romantic partners, et cetera, et cetera. Let's talk about some of the animal models that inform us about the potential roles of oxytocin in the grieving process. There's a species of animal called the Prairie Vol, and believe it or not, the Prairie Vol has been studied fairly extensively by neuroscience and psychology researchers. Prairie Vols are one species of animal, but depending on where they live, you find that some prairie Vols are monogamous, that is, they mate with the same prairie Vol for life.

They raise bitters of little prairie Vols, and other prairie Vols generally that live in different locations in the wild are non-monogamous, sometimes called polygamous. The neurochemical and circuit basis for this monogamy versus non-monogamy, quite interesting. However, in the context of grief and attachment, the prairie Vols have taught us a lot, and they've taught us a lot through the following experiment. Take two prairie Vols that are coupled up, so these would be monogamous prairie Vols, that have established a couple of them.

I guess you would call that a Prairie Voldom anyway. Put them in a case together, they mate together, they raise young together, and then you separate them. You literally put a physical barrier between the two of them, and you can evaluate how strongly one prairie Vol will work to get access to the other prairie Vols. And what you observe is that the monogamous prairie Vols will work very hard to get back to their mate, but the non-monogamous prairie Vols will not work as hard to access a prairie Vol partner.

This turns out to be interesting when you start to explore the patterns of so-called oxytocin receptors in the brain. To make a long story short and to also bridge to the human literature, it turns out that the monogamous prairie Vols have far more oxytocin receptors in this brain area that I mentioned earlier, the nucleus accumbens.

So in other words, non-monogamous prairie Vols seem to have less yearning for attachment overall, at least to a single individual prairie Vol.

And when we look at the human literature in terms of oxytocin receptor expression and brain imaging experiments and so on, but you find is the same, that people that experience intense grief and a deep yearning and a motivation to reconnect with the person animal or thing that is lost.

“In many cases, have heightened levels of oxytocin specifically, or I should say oxytocin receptors to be exact, specifically within the brain regions associated with craving and pursuit.”

So for those of you that find yourself in this kind of stuck mode, this persistence of trying to reach into the past or wishful thinking, this counterfactual thinking, the yearning, the desire and the impulsivity that leaning in at a almost reflexive way to try and access that person again, to text them, to want to hear from them, could.

And I have to highlight, could reflect the fact that you just so happen to have more oxytocin receptors or maybe more oxytocin overall in this brain area that's associated with motivation and pursuit.

Does not necessarily mean that you are more capable of attachment than people who move through grief more quickly. And I should say that people move through grief at different rates, even if two people lost the same person or same animal, people move through this at different rates. And some of that is no doubt psychological, but some of it no doubt is also neurochemical and biological. I'd like to take a quick break and acknowledge one of our sponsors element elements is an electrolyte drink that has everything you need and nothing you don't.

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But as is the case with so many interesting scientific findings, often when there's a negative result, there's a more interesting result nested in that negative outcome. And this is the case in a particular paper I'll share with you now. This is a paper published in the journal Biological Psychology. And again, the title is posed as a question, which is emotional disclosure for whom a study of vagal tone in bereavement. What this study explored was whether or not written disclosure of the emotional connection to somebody that was lost would be effective as a way for people to move through the grieving process.

The study also explored the so-called vagus nerve. The vagus nerve is an extensive nerve pathway that is bi-directional between brain and body. So brain to body and body to brain. The way to think about it in terms of what we're going to talk about now is heart rate and heart rate variability. The vagus nerve is generally associated with parasympathetic functions and has the capacity to slow down our heart rate.

This is what we call an increased vagal tone. Now in this study what they did is they had people, and I should say it was 35 participants, go through a writing exercise for a period of weeks.

“One group was in the so-called written disclosure group. What they did is they, on day one, they would write about what happened when a loved one died.”

And indeed they used people who had experienced real loss. And so they were asked to talk about and write about their deepest emotions and thoughts about it. Memories of their loved one, very intense stuff. If you think about it, if they're in the immediate period of having lost someone, then they actually were asked to write a letter to the person that they lost.

The other group was a so-called control group where they were simply told to write about how they used their time.

So in emotionally kind of empty writing exercise, if you will, they described what they were doing today after they woke up, etc.

“No have the emotional content and so on. What I didn't tell you thus far is why they had them do this exercise at all.”

They had them do this exercise because many of the effective practices for moving through grief involved, as I mentioned earlier, getting close to, and actually deliberately experiencing the attachment that one has to that person that was lost, not distracting oneself, not getting into this counterfactual thinking, the what if, what if, but rather thinking about it, in this case, writing about the real attachment.

And so the initial idea was if people write about this attachment that they're going to experience this attachment and that will serve them in some or many ways in terms of moving through grief.

And that wasn't what they found. They found no difference between the two groups. Until they explored who had higher vagal tone, who had a greater degree of so-called respiratory sinus A-rhythmia. In other words, who was able to modulate their state using their breathing and their body? And what they discovered was that a subset of individuals who had a high degree of vagal tone seemed to get more benefit from this writing type exercise.

“So this is one study, and I would consider it fairly preliminary with 35 subjects. Although, you know, it's a study unto itself, and I think it quite nice one.”

And it really set the stage for a number of other studies that followed from this group and other groups that really point to the fact that yes indeed, accessing the states of emotionality by writing or thinking about somebody is quite powerful in terms of engaging the bodily states and the mind states associated with the attachment. That is very beneficial for moving through grief. That is very beneficial for sensing the attachment. And now it makes perfect sense as to why some people would benefit from that sort of practice more than others, because some people are able to access more real somatic feelings of attachment by writing about the attachment or by thinking about it than others.

Because again, what this paper really points to and set off a number of other investigations related to is that for those that can really feel the relationship between breathing heart rate, what we call vagal tone. Well, those people are going to be in a better position to move through grief, not because they are disengaging from the feelings of attachment, but because they are better able to access those feelings of attachment. So what this relates to of course is that tripartite map, that three part map that we talked about earlier, that representation of space where things are, where the person is, where their belongings are, where their car is, where their bicycle is, time when you were expecting to see them on a regular basis, when they would call, when they would come home from work, etc.

And that third node, or that third dimension of attachment, which is literally attachment and closeness. Now I'd like to take a moment and consider some of the tools that you can access that support healthy transitioning through grief. These are tools distinct from that neural map that space time closeness attachment map that we're talking about before. Rather, it's important to remind ourselves that everything exists in a context of our baseline physiology. And I'm certainly not going to be the first or the last to tell you that everything in life, learning relationships with people that are still around.

Our health in every way immune system, et cetera, function far better when we're sleeping really well, and when we are generally awake during the daytime and asleep at night. There's a particular feature to our diurnal and diurnal meaning the opposite of nocturnal, our diurnal pattern of the release of a hormone called cortisol. It's linked to our increase in temperature rhythms and can further increase our temperature, which leads to waking and so on. The typical pattern of cortisol in a healthy individual and we really can't say physically and emotionally healthy individual is that cortisol is going to be somewhat high right around waking.

And then it will drop gradually such that by about 4 p.m. in the afternoon, which is actually when body temperature tends to start to drop as well.

Cortisol tends to be very low and then remains low in a healthy individual such that at 9 p.m. it's very low and throughout the night as we sleep it's very low. There's a very interesting paper exploring the relationship between cortisol rhythms and grieving in particular complicated versus non complicated grieving, again complicated grieving being the form of grieving that reflects a immense challenge of people moving through the grieving process such that it really needs to be dealt with right.

Again grieving is healthy but complicated grieving is a prolonged grieving and has other dimensions as well hence the name complicated the title of this paper is diurnal cortisol in complicated and non complicated grief slope differences across the day. And the figure to orient to in this paper if you do decide to check it out is figure one which beautifully shows right should say very clearly shows that when you compare the cortisol levels between people experiencing complicated grieving versus non complicated grieving what you find is the 4 p.m.

And 9 p.m. cortisol levels are significantly higher than they are in the non complicated grieving group.

This raises a very interesting idea we arrive at a scenario where it makes very good sense to think about modulating that is controlling the foundation of your life in a way that establishes cortisol rhythms and sleep patterns and patterns of autonomic arousal and kind of calming release that position you to navigate the grief process in the best possible way.

“If you are somebody who is heading into grief or is challenged with grief getting adequate sleep at night and establishing as normal a pattern of cortisol as possible is going to be very important.”

And there is a very simple straightforward way to do this and I apologize to the listeners of this podcast and advance if I sound like a repeating record but the most powerful way to do this is to view sunlight very close to waking it does not have to be right at sunrise but when you get up in the morning if the sun is in doubt. Please turn on as many bright lights as possible in your environment why do I say this thing about sunlight over and over and over again well having an early day cortisol peak and a very low cortisol level late in the day 4 p.m.

“9 p.m. is immensely beneficial it reflects a properly regulated autonomic nervous system it means being alert during the day and your ability to sleep at night is quite tightly correlated to this viewing of sunlight in the morning.”

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So what are the tools that we can think about using in terms of healthy adaptive moving through grief trying to avoid complicated grief and prolonged grief grief disorders clearly it's a value to dedicate some period of time perhaps every day perhaps every other day depending on your capacity and schedule. These could be periods of time ranging anywhere from five to 45 minutes maybe longer these blocks of time would be. Appropriately described as rational grieving rational grieving is a clear acceptance of the new reality that the person animal or thing no longer exists in the same space time dimensionality that we knew them before and yet holding on to an anchoring to the attachment that we had.

Those sorts of expectations are maladaptive they do not serve as well.

“The second aspect of this is to understand that the nude of the map the component of the neural map that you're anchoring to is a very real component of you these are literally cells that represent the depth of attachment.”

We talked a moment ago about the importance of accessing quality sleep on a regular basis. They're again a rich array of tools to do that in the mastering sleep episode and again highlighting the importance of sleep for not just emotion regulation and autonomic control which is so vital but also for making sure that neural plasticity takes place because again neural plasticies a two part process there's the triggering of the plasticity which. In case of the things we're talking about today will be naturally activated by the practice of a dedicated focusing on the attachment feeling the attachment to the person maybe even writing about the attachment to the person as was described in that previous study.

Also just the plasticity is triggered by the mere loss of that person the intensity of that experience but neural plasticity the literal rewiring of connections occurs during deep sleep and in what I call non sleep deep rest or NSDR and you can find NSDR scripts these are short behavioral protocols that you do for 10 to 30 minutes at some point throughout the day maybe even multiple times today that have been shown to accelerate neural plasticity.

“Coming up such a practice can be very useful and understand that it involves some cognitive work we have to hold on to the attachment and imagine and feel as much as we can the attachment.”

While also being extremely rationally grounded and trying to not try to hold on to the past.

Trying to not anticipate the person walking in the room this is very hard because when we think about the attachment the attachment tends to drag with it. We talk about preparing ourselves for grief we can prepare ourselves to grieve more adaptively by regulating the level of catacolamines in particular up and effort and tool such as the one found in our mastering stress episode and tools of the short that we talked about today.

Using that vagal tone by actively building up the relationship between exhales and slowing down of the heart rate so called respiratory sinus A rhythm.

Those things can be very useful tools and of course I want to restate again it is often important to access the trained professional psychologists or psychiatrists or both or bereavement grief or all of the above in order to get the proper support for grieving.

“I think that the tools that we've talked about today would be not only compatible but would be complementary to the sorts of approaches that they take.”

And I would encourage you to not lean away from but rather to lean into the building of those episodic memories to build up a richer and richer set of experiences and emotional attachments. And while the process of grieving is in direct relation to how close we are attached to people there are ways to move through it and of course it is the depth of our attachments and the number and the depth of meaning of experiences that we share with others and with animals that makes life so rich and worth living.

Thank you for being willing to explore this rather complicated and sometimes extremely challenging thing that we call grief from the perspective or through the lens of neuroscience and psychology and last but certainly not least. Thank you for your interest in science.