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Welcome to "The 7 Domains of Women's Health." I'm Dr. Kirtly Jones, the host of "The 7 Domains." Our continuing topic today is grieving, the intellectual domain. What do we know about the grieving process across time, and people, and cultures? All of us have our own experience grieving. You just cannot have walked on this earth for very long without having lost something or someone you love.

So today in The Scope Virtual Studio, we have an expert to help us think about what we think we know about grieving. is a PhD and licensed clinical social worker. She's the director of , a Hope and Comfort in Grief Program at the Ï㽶ÊÓƵ of Utah, and she teaches at the College of Nursing.

Dr. Jones: Thanks for joining us, Dr. Supiano. Can I call you Kathie?

Dr. Supiano: Yes, please do. Thank you.

Dr. Jones: This will be the Kathie and Kirtly show, if you're ready.

Dr. Supiano: I'm ready.

Dr. Jones: Okay. I have a question, in that how did you come to your work on grieving? You had so many options in life.

Dr. Supiano: Well, thank you for asking. I would say I came by this honestly in that I started my career as a geriatric social worker working in a nursing home in Wisconsin several decades ago. It was a setting that had, of course, a lot of death, and a lot of dying, and supporting our residents as they were dying, and supporting their families.

I'd worked in geriatrics for decades, and then when I came to the Ï㽶ÊÓƵ of Utah, I was able to join a wonderful team and start the palliative care team at Ï㽶ÊÓƵ Hospital. And I was the first social worker there. And of course, that brings you very close to death frequently, almost on a daily basis.

In that, my social work responsibility was much more than the symptoms of the patient, but care of the family. And so knowing that that care at bedside has a lot of impact on the grief that follows, that's really where my clinical interest morphed into as much a teaching and a research interest in the area of grief.

And then when the opportunity came to become the Director of Caring Connections, it just felt, Kirtly, like the natural evolution of my career. And it's really where I've landed and where I find really the most professional satisfaction right now. Assisting grieving people in having a solid remembrance and an ability to deal with the thoughts, and feelings, and emotions that need to be dealt with so that they can have productive, satisfying lives and still carry a memory of the person who they've lost with them.

Dr. Jones: That's a wonderful evolution of a life's career, I'd say. It almost makes me tearful to think how rich and engaged it's been and how much you've learned.

I remember many years ago when I was in medical school, I was young, and we were taught that grieving followed certain patterns, the five stages of grieving that had been presented by Kubler-Ross back then. And it was comforting for those of us who were so naive. I mean, we were 22, 23. We were naive in the world of people and emotions, and we didn't have your experience. It was comforting to me that you could package grieving into a few compartments.

Now, I'd had my own experience with grief, and I had packaged it by putting it away. I had to put it away for a while. So I was comfortable in that there was a cookie-cutter approach to grieving. And I was looking at my own grieving, and I said, "Okay, I think I'm done." Now, of course I was nowhere near done.

But can you talk about those Kubler-Ross stages that we were taught years ago?

Dr. Supiano: Well, I can echo that because I was taught the very same thing in my graduate education. And we thankfully know a lot more now. I commend Dr. Elisabeth Kubler-Ross, who was a pioneer in this area, and really got us to a place as a society where we started talking about death and dying.

And her work and the five stages were really established in the context of the dying person's awareness. They just sort of oozed out into the griever's awareness.

As you articulated, people aren't that tidy. People can't fit themselves into little boxes. People are messy, which is really the fun of working with them. And grief is actually messy. I would actually argue that grief is supposed to be messy. It's supposed to be a turmoil. It's supposed to turn your world upside down. It should be impactful.

And of course, there's a continuum of how it's impactful. Some people are affected and some people are deeply afflicted.

But with respect to the five stages, there's been a considerable amount of scientific evidence that has said that this is not a valid framework for understanding grieving, in that grief is not linear.

I know you've spoken about emotions earlier, but in grief, there are all sorts of emotions: guilt, anger, sorrow, deep, deep sorrow, sometimes relief, sometimes happiness with recollections that we're loving. So all sorts of feelings can happen and the human brain is just not that compartmentalized.

What resonates with people is those kind of five items in grief actually do happen for a lot of people, though some people never have a molecule of denial, and some people have no anger at all.

I'm really careful that we don't confuse the idea of sorrow and depression. Those are different things, but I do think it's important that we recognize that people actually spiral around emotions a lot, and they can for years.

The reason the stage model can actually be hurtful is it tells people there's a prescribed one way to grieve, which is always a flawed approach. And it also suggests to people that if they don't do it in a tidy fashion, somehow they're not grieving well or properly.

I have many people who call our office and say, "I'm a bad griever. I thought I was done with anger before and I saw the person who harmed my family member earlier."

You can imagine a family in a legal proceeding where a person has died having to go to court, and of course there, again, they're flooded with feelings, particularly anger like the first day. And they say, "Oh, I thought I was done with anger. There must be something wrong with me."

So I think it's absolutely essential, especially in the intellectual domain, but certainly in the affective domain as well, that we normalize that all sorts of chaotic feelings and all sorts of chaotic thoughts are part of grief.

The good news, and I just think this is wonderful news, is that the human brain has an innate capacity to do this work. Now, for some people, it's smoother and speedier. For some people, it's longer and much more complicated. But the brain has a way of doing this. The body has a way of doing this. Our social constructs, our spiritual selves, we all have a capacity to grieve.

One of the ways we actually help grieving people is to first give them that hope, and then secondly, acknowledge that. Professionally we call that normalizing. But for the public, that's as courteous as saying something like, "Well, given what you've lost, it makes perfect sense to me that you feel that way." Even just that gift gets people off that stage road that kind of goes to nowhere.

So I'm glad you asked the question about stages because, first of all, they're not supported by scientific research, and number two, we think that construct actually can be harmful to some people.

Dr. Jones: Well, I really love the way you said that sorrow is not depression, or sorrow and depression are different things, because sorrow is a lovely, lovely word. It's certainly an emotional word, and it's a deep, powerful word, but it's a beautiful word personally. Depression is something as a clinician, I think, "Oh, that needs to be dealt with and you have to get therapy and maybe drugs," but sorrow is the stuff of poetry and human experience.

Dr. Supiano: You're exactly right. So Shakespeare even gave grief therapist the quote of a practice when he said, "Give sorrow words. The grief that doesn't speak bids the overfraught heart break." So sorrow is that space of experiencing the magnitude of the loss.

And so sorrow and grief are actually not problems to be solved. Whereas I'm a clinician, you're a clinician, depression is a problem to be solved and we can solve it, or we can at least manage it.

Now, that said, there are grieving people who, if their grief is not validated and they don't have a space to process it, if their grief is disenfranchised or ignored, or they're told to stuff it, they can develop depression at the clinical diagnosable level.

Then, of course, we do know that people who had depression before the death happens are going to have a much harder time with grief.

The solution to both of those situations is at the very start to give space for that sorrow, to offer a container for that sorrow so the person can express it in a way that's safe and in a way that's supported and allows them to process.

So I don't like the language of "move on." I certainly don't like the language of "get over it," because we know this is quite variable with different people. But long before people ever get to me as a grief therapist, they benefit from having many generous, thoughtful listening people in their lives that don't tell them what to feel or tell them what to think, but allow them to share what they're actually experiencing, even if it's unpleasant to hear.

Dr. Jones: Well, I remember hearing, and then of course experiencing, for all of us who have something to grieve over, it pulls up once you've lived long enough other grieving processes.

Dr. Supiano:Absolutely.

Dr. Jones:Every sorrow recapitulates the last sorrow in some way. It's just when you feel that way, it reminds you when you lost your grandfather, or you lost your daddy, or you lost your beloved dog. You have to relive the whole thing all over again.

Dr. Supiano: There's a benefit to that, as well as a challenge. So, first of all, all our griefs are connected. And of course, the longer you live the more accumulated losses you have, and that's normal. And at the same time, your social orbit can shrink in late life. My advice is to have friends of all generations. But that orbit can shrink and you have fewer people to support you, or you lose the person who would be supporting you. So I think that happens.

The good thing is, and you probably have had the same privilege I have had to know some extraordinarily resilient and wise people. These are people who grieve all along the way. They don't stuff it. They don't ignore it. They manage their griefs as they come, and they learn. And one of the things they learn is just what you said, that every loss is also unique.

So people will say something like, "Well, gosh, when my grandmother died, I felt ready for it. Yeah, I miss her, but that didn't prepare me at all for my son dying." Well, actually, they're very different griefs. The experience is very different, but that first grief actually did prepare you for this now tragic loss of a child because if your family helped you with grief of grandma, you learned you could talk about grief and you learned it was okay to cry.

Even though you don't feel like, "Now I'm an expert griever," if you really think about it, how we manage the earlier grief either equips us for the next grief or it undermines us for the next grief.

So I think what's really important, not even professionally, but as human-to-human care, as we're supporting grieving people, it's to give them that space so they can process it. Bidden or unbidden, spoken or unspoken, grief has to be addressed. And if we don't address it, it's just going to pop open or rupture with either another event or another loss or the next crisis that happens in our lives.

So it's kind of like mental health maintenance or health maintenance. You just kind of have to keep up with it over the course of a lifespan. The job loss, the marriage loss, the healthcare changes, when people are able to look at them realistically in the setting of good information, good support, all the self-care that we know is essential, and wellness, people can actually allow the natural processes of grieving to unspool and they'll manage.

Dr. Jones: As I think about sorrow, it is so wrapped up with love. For me, the good part of grieving is the recognition of how much I loved that person. If you look at the wheel of emotions, the primary emotions and secondary emotions, I think that love and grieving are so entwined and one calls up the other.

Even if someone hasn't died, the very thought of someone you love dying makes you vulnerable. So I think love makes you vulnerable and grieving makes you vulnerable, but they both add to resilience. They both make you resilient to life.

Dr. Supiano: Of course they do, Kirtly. Just think the opposite of that, to say, "I won't allow myself to love because I won't allow myself to be hurt." Well, then you turn into kind of like a hard-boiled egg actually.

Yes, love and grief are vulnerable, both of them evidence vulnerability, and they are tied together. With love, however, and sorrow, I think it's also important to recognize that people grieve what they never got.

So when, let's say, the brother who tormented you all your life dies, you may be grieving the brother you really thought you should have had, but he wasn't. I think sorrow is all of that. And then it's the question, "Will I, in the face of this much pain, allow myself to be vulnerable?"

Again, thinking of sorrow now, the way we can help people sort of remain appropriately vulnerable, and I don't mean vulnerable to harm, but I mean vulnerable to being human, is if we offer them support, if we offer them compassion, then instead of turning their grief into bitterness, they can actually turn their grief into gratitude.

Just like you said, it makes me realize how much I loved that person. Well, of course, you still miss that person desperately, but now instead of that being like stabbing pain, that's now this warm remembrance.

That doesn't happen right away, of course. But with time, that's what we want to have happen. Not a "put him on a pedestal" remembrance, but this realistic appraisal of that relationship and being able to hold that person in your heart and go through your life informed by the relationship you had with that person.

You mentioned the grandmother. Well, my grandmother was a profound influence in my life. She's been dead for decades, but I still have fond recollections. Of my parents, it's not uncommon for me most days to say, "Well, gosh, what would my dad advise me to do here?" Those are warm remembrances that help me navigate the age that I am at now.

Dr. Jones: That's a powerful way of framing the educational process, offering up what you know to the people that you are meeting with, that this is a process that grows in a positive way, not just in a negative way, when they're ready to hear it.

Dr. Supiano: In a supportive, guided atmosphere, this comes organically out of the griever. You talked about stage theory as not an explanatory model, but a model that is explanatory, and one of the many well-substantiated theories of grief, is called meaning making.

Let's just say you had a very close family member die by suicide. At the start of that death, your immediate grief, no one would be able to make sense of that death, to make meaning of that death. But over time, grievers actually do this.

That's not to say I understand the cause of death, or I understand why on this day at this time this person decided or elected or ended up feeling there was no other choice but to take their life. I want to be careful with the language there because we don't want to attribute intention when we don't know that there's intention in the case of a suicide death.

But over time, a grieving person, as they're making meaning of the death, would just say something like, "I may never figure out why this happened, but I recognize now that many people in the world are suffering and many people are suffering the same sort of loss that I'm suffering.

"At first I thought I was alone, and now I know other people have lost family members, and I know other people have lost them to suicide. I'm comforted in my time in a support group where I'm with other people who understand this loss, and we learn from each other and we grow in guidance from our facilitator, and these things are very important."

So we wouldn't expect that sort of experience early on in a grief process, but what I'm trying to convey is that this is what the brain, not just our brain-brain, but our spirit too, wants to do. It wants to make sense of it. It wants to be able to come to terms with it.

As I say, grief is a lot like stubbing your toe on the bed in the middle of the night when you're trying to get up, because you just feel it again and again. But over time, you kind of learn to navigate, right? And people can do this.

So when people say grief is stuck . . . and it can be, and we can talk about what that really means in terms of the kind of care people need. But people are only able to do the loss. There's a stuckness there.

Or we also know other people that just get busy and they get that new life going, and they never give themselves the time to reflect on the magnitude of the loss. Those people don't do well.

It's more painful to do both and to move back and forth. But you'll notice I'm moving my hand back and forth, and that's when we say grief is moving, grief is working, grief is doing what it's supposed to do.

Dr. Jones: That's very helpful to me as I try to understand the many ways that people in the world deal with loss and watching them go back and forth and being amazed at those who are resilient after multiple losses.

Everyone listening can use this conversation to think a little more deeply about the grief process. And I want to thank you very much, Kathie, Dr. Supiano, for helping us with this.

This rounds out the intellectual domain of The 7 Domains of Grieving. And if you're interested in more, just keep looking for us in "The 7 Domains of Women's Health" and the grieving podcasts wherever you get your podcasts, or at womens7.com.

We hope your hearts can be full of love as you come to think of what you have lost in the past. Thank you very much.