Is grief an illness? When does “normal” grief become clinical? Columbia’s Dr. Katherine Shear shares insights from her groundbreaking research.

Question: Is grief a form of illness?

Dr. Katherine Shear: Right. So grief is the natural healing really response to the loss of something very important. In the work that I've done, it's really always been the death of someone very, very close. And I focus very narrowly on that kind of situation. Grief itself occurs if you lose other things as well. But if you want to talk about grief that occurs after you lose someone very close, grief itself is a very natural reaction. So is inflammation if you get cut, right – that's a very natural reaction. We don't think of natural grief as an illness, primarily because there's so much baggage associated with illness. But some very prominent thinkers and researchers have, in fact, said that we should consider grief similar to inflammation or you could say even an acute infection or something where you have a natural response that's a healing response essentially to some kind of an injury.

And certainly the loss of someone very close is a kind of an injury. I mean, so people that we're very, very close to are just so important in our everyday functioning in so many different ways. So when we lose them, lots of things are disrupted and we do have usually very, very powerful emotions and we become very preoccupied with thinking about the person who died, and really trying to grapple with coming to terms with that takes a lot of emotional and even physical energy. And so in that sense, you know you could say that it's like having the flu or something or maybe where your body has been exposed to something that's not usual and that you're having a natural healing response that's also very disruptive.

So we don't advocate – I wouldn't advocate medical treatment for grief, even though it is a very disruptive state, I think that it's interesting in that in the case of grief, there's not only an internal natural healing response, which I very much think there is, but there's also a social healing response. So, of course, when we know that someone has lost someone, we naturally – certainly if they're someone close to us, we're going to be there for them for quite awhile after the death occurs. But even if they're not that close, we'll often go to the funeral. We'll go and visit them a few times early in their homes, bring them food, take care of them in various ways, certainly not expect them to be taking care of us, even though we might be a guest in their house. All this is very natural. I mean, we don't really hardly need to be taught. I mean, people do it in all kinds of cultures and it's just something we do. And that is, I think, the best way for the healing process of grief to be helped along, not by medical treatment.

Of course, some people don't have that or down the line – or they may, for example, develop a depression, a really full-blown depression. Because grief is not depression; it's different from depression. And so if they do develop depression, they may benefit – they may really need to be treated. And certainly down the line, as I was saying, that down the line, they may kind of their grief healing process may not go the best way. It may get kind of sidetracked or derailed, in which case, we do then want to treat them.

Question: When does grief become clinical?

Dr. Katherine Shear: Right. So the way I'd like to describe it first is just sort of what we see and what people experience. And to do that, I'm going to back up for one minute because grief is a natural healing process, from our point of view. But it sort of never really completely ends after you lose someone very, very close. So what happens to it though is it evolves over time, right? So in the beginning, we call it acute grief because it's kind of very inflamed. And it's very dominant and it's a very intense reaction. And then over time, it progresses to a place where it's much more in the background. But it's still there.

So, for example, if the person that you went to visit that had the acute grief, if you went back and visited that person let's say five years later, and you said to them –first of all, you would not expect them to be preoccupied with the loss anymore, right? You would expect them to be themselves again. They wouldn't be crying all the time. They wouldn't be only thinking about the person who died. They'd be engaging with you on probably totally other topics. But then if you said to them, you know, "I was thinking about this person who died the other day and I was remembering some story," you wouldn't be surprised if they got kind of quiet and maybe even got a little teary at that point as you started to talk about this person that they loved very much who is gone. In fact, you'd be pretty shocked if they said, "Who is that? I don't think I remember that person." You wouldn't expect that at all. So that s the natural sort of trajectory, if you think about it, of loss and how upset that person will get five years from now. It's very variable. It really depends on who died and how close you really were to them and what's going on in your life otherwise and all kinds of things like that.

So what happens when you get complicated grief? And the answer to that is that instead of that natural process unfolding so that the thoughts and the memories kind of recede a little bit into the background, sometimes we think of this as begin to reside in your heart instead of center stage in your mind. Instead of that happening, the person actually gets kind of sidetracked in the mourning process, such that they start to kind of ruminate over something related to the death, very often some way that they think they could have prevented this death. So the person will start to think if only I'd gotten this person to the doctor sooner, they would have been diagnosed sooner, maybe they would have been able to be cured. Or sometimes it's focused on the medical profession. Why didn't the doctor misdiagnose this person? Or even sometimes even there are really medical errors and the person is very focused on that. Sometimes it's related to I can't manage without this person. The person – instead of thinking about kind of how they are going to manage, they get sidetracked by thinking I can't possibly manage, basically telling themselves that.

So the complications that derail grief include these kinds of repetitive, we call them ruminating kinds of thoughts. Or also there's a lot of pain, emotional pain, of course, in the acute grief process. And some people are kind of frightened of those emotions or even frightened of the thought of the person really being gone, and so they try to avoid it. So they try to avoid things that trigger the emotions and they try to avoid thinking about the person having gone or the person having died. And so that avoidance is also a complication. It becomes a complication because it interferes with the natural processing or their coming to terms with the death that has to go on in order for you to move into this kind of integrated grief state, which is the later one.

Recorded on November 3, 2009
Interviewed by Austin Allen