S1 Episode 47: Dealing with Loss

The COVID-19 pandemic has caused unprecedented loss — of loved ones, of social interaction, and of our entire way of life. Dr. Richard Friedman, Professor of Clinical Psychiatry at Weill Cornell Medicine, explains why the anguish we feel is normal — and how specific coping strategies can help minimize the potential impact on brain health during periods of adversity. 

Dr. Philip Stieg: The COVID crisis has created an extraordinary amount of loss for people around the world. Loss of loved ones who have died, loss of connection with friends, family, loss of jobs, daily routines, dating and mating, and the ability to travel safely to name a few. And then there’s the deeper loss of things we took for granted the loss of a way of life, especially in large cities and a sense of control and safety. I’m very happy to have my colleague and frequent guest, Dr. Richard Friedman on the show to help us cope with these troubling issues that so many of us are experiencing. Richard is Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medicine. He’s also an Op Ed contributor to The New York Times. Richard, great to have you back.

Dr. Richard Friedman: Great to be here.

Dr. Stieg: I think all of us living in New York have appreciated how COVID-19 has temporarily and in some ways permanently changed life as we know it. And one of those major issues as we’ve seen in the hospital is how we as doctors and patient’s families deal with loss. The loss of life, the way of life, friendship, access, freedom mobility. What’s been your experience in helping manage some of the clinicians dealing with the process of loss. as they’ve been working in the hospital through the COVID crisis?

Dr. Friedman: Well one of the challenges is that while there is nothing new about death and loss to humankind, what’s different is that in a setting of a pandemic, the rituals that we have for dealing with loss have been affected. You can’t be with people who are loved ones who are sick because they are quarantined in the hospital. You are separated from the people you most want to be around and support who were ill and dying, and people are dying alone. So you have this terrible situation. It’s bad enough to lose those you love and be separated from them. But then not to be able to comfort them and to be with them when they’re sick and help them get better or be with them and help them die, is a terrible loss.

Dr. Stieg: How have you seen that manifest itself in the family member?

Dr. Friedman: They feel terribly anguished and grief stricken and guilty, as if, you know, it were within their power to fix the problem and to be there and they feel helpless. What can they do to relieve the suffering of somebody they care about if they’re being told they can’t go see them? So they feel helpless in a way that’s unique in a pandemic because normally, you know, when you’re facing loss, you try to deal with it by engaging all your friends and your social support. But you’re being told, “Hey, you have to stay away from people and you have to protect yourself and protect them.” It means you don’t have access to it. The coping strategies are basically limited.

Dr. Stieg: So it’s kind of a double whammy. You know you have the emotion about either the severe illness or the death of a loved one and your feelings about that but then also the pure fact that someone’s dying and critically ill and you can’t be there.

Dr. Friedman: Yes, exactly. Your normal rituals and coping strategies are, are not available to you.

Dr. Stieg: So you’re the psychiatrist extraordinaire, what do you recommend to people? What steps can they take to deal with this? It sounds to me almost overwhelming.

Dr. Friedman: It is overwhelming. And I think what you need in an extraordinary situation, like this is as much support as you can get from friends and loved ones. And that has to come. If you’re living at home with them, then obviously you’ve got them and you have access to them. But if you don’t, it’s going to have to come virtually by being on the phone with them, hearing their voice or seeing them through FaceTime or WhatsApp or Zoom, anything that you can do to have contact. It may not be as satisfying as being with them, but at least it’s something.

Dr. Stieg: I would suspect each culture has their own ritual for dealing with severe illness or death. How important are these rituals? And if we can’t go through them because of the COVID crisis what do we do to replace them?

Dr. Friedman: We have to create new ones. People are very inventive and we’ll improvise. And you know, I’m thinking of what happens in New York city when people had to stay inside and yet they felt an enormous appreciation for the medical communities work on COVID. What did they do at 7:00 PM? Everyone through their windows open and started banging on pots and pans in the entire city was still the, clanger a sound of people applauding the medical community for doing all they could to deal with crisis. That’s just an example of how social we are. And if you take away one ritual, we come up with another. So I don’t know the answer as to what will relieve all of this. I just know that we’re inventive and we will figure out ways to deal with it and come around.

Dr. Stieg: What is sounds to me what you are saying is that social interaction is a key component of coping and dealing with this stress. Correct?

Dr. Friedman: Yes, it’s the critical one. And even, even being out amongst strangers, and I’ve noticed that people are kinder to one another on the street asking, how are you? How’s your family complete strangers. I’ve observed this, I’ve done it myself.

Dr. Stieg: One of the things I was surprised at is that I don’t know whether a lot of people understand that the majority of our healthcare professionals were redeployed. And by that, I mean the department of neurosurgery virtually all of my nurse practitioners and all of my physician’s assistants, and 50% of my faculty were put into environments that they don’t deal with on a day to day basis, they were put in ICU in the emergency room. Caring for people with disease is extremely different than what they did on a daily basis. And one of the issues that they would come to me with is we’re trying to help them get through it.was, you know It’s so hard to work with somebody for so long, and then they end up dying because that isn’t part of their normal routine. Did you find professionals come to you with that issue?

Dr. Friedman: Yes. Actually, one of the things that I did along with colleagues was to act as a sort of emotional support to different departments in the hospital. And I discovered that many of them were used to treating patients and getting them out and seeing them go home. And here they were treating patients and seeing them die. It was a completely demoralizing experience because all the things that they were used to doing that work suddenly weren’t working because they had a new adversary, coronavirus, which for older people was deadly.

Dr. Stieg: And so the health care professional, as well as the associated family members both experienced this severe sense of loss.

Dr. Stieg: Do you have any suggestions for closure? I mean, how do you get beyond this without having lasting scars?

Dr. Friedman: Well, I think it’s a humbling experience where people actually have to recognize that their ability to, especially doctors who have enormous difficulty in seeing their patients die and their charges to get them well, not to see it as a failure, but actually to recognize that our power is limited and we can’t cure everyone and we can’t make everything better and it’s not necessarily a sign of failure. It’s a sign of how difficult the problem is. And I think you need the perspective that you do all that you can do and still recognize that you might fail. And it’s not so much whether you succeed, you succeed by doing the best you can with what you’ve got and it’s imperfect.

Dr. Stieg: So with the stripping away of these rituals and, or, an individual being put in a situation where they’re not normally exposed to death, is the process longer in terms of recovering? Is that something that you shouldn’t feel badly because it’s taking longer than you thought it would take to start feeling better?

Dr. Friedman: I think it takes as long as it needs to take, you can’t rush grief. It has its own course. It’s like a sawtooth pattern. You know, you go in and out of periods where you feel, okay. And then suddenly, you know, something and association will bring you right back and you experience a torrent of unhappiness and grief. So you have to allow it to follow its course.

Dr. Stieg: In addition to the grief that one experiences I’m presuming that there’s also a lot of internal anxiety associated with that process. Is that true?

Dr. Friedman: Well, I think people are anxious if they don’t get better right away. So whether it’s grief or anything else, people wonder, Oh my gosh, you know, something is wrong. I’m not better right away. I’m not over this. They’re not used to that. So I think they get anxious and you can help people by explaining there’s a normal process for grief, and it can take many months to get better.

Dr. Stieg: And I think that we live with the concern about a second wave for COVID, whether or not it comes, we still feel that this is going to be an ongoing problem in our life. That the impact of either loved ones dying or seeing patients die… What do you think is the best way we can tell our listeners to cope and deal with this. What should they do?

Dr. Friedman: Well, it’s a new normal now and we don’t do well with uncertainty. You know, you can get used to bad news or good news, but it’s very hard to get used to on certain news. Hey, you know, we don’t know when this will end. I would say it’s important to recognize. Yes, it’s true that it will go on for a while, but pandemics come and go and eventually we’ll have a vaccine or treatment or herd immunity and it will take a while. But in the interim, we have to adjust by this. It’s not that the adjustment is so awful it’s that people don’t know how long they have to do it for, or when it will end. And if you keep having intermittent periods where you loosen restrictions and then have to re tighten them, it drives people nuts because they suddenly feel like they’ve gotten out of jail and you turn around and say, “You know what? You have to go back in because we made a mistake and we opened up too soon.”

Dr. Stieg:  We know that exposure to changes in psychological environments will at some point in time facilitate the generation of new brain circuits and alterations in brain chemistry. Number one question is, how long does it take for that to occur? And, if we assume that it will occur if long enough, should we be thinking about giving people medications sooner to avoid that? So they don’t get new abnormal circuits?

Dr. Friedman: Well, we don’t know if you have a person with a known history of illness like depression, you might presumptively medicate them heading into a very big stress in the hopes that you will protect them against, you know, developing an episode of depression, but in the vague sense that you want to, do neuroprotection for people who are going to face adversity, there isn’t any evidence that we can yet do that, even though we know that chronic adversity is bad for your brain. The best thing that we can do is to lower stress by stress reduction techniques, like exercise, meditation, mindfulness, various forms of relaxation to give, give the person a break from the chronic and toxic stress. I think that’s the best thing.

Dr. Stieg: In my practice. I don’t think enough patients do that. You’re in psychiatry. I think you see more patients with emotional issues. Do you think that’s true that we, one of the things we as doctors need to really enforce is getting patients to get exercise, to do mindfulness training?

Dr. Friedman: Yes. I think, I think that this should be a core part of medical practice and that we should do it for everybody and offer it to everybody.

Dr. Stieg: What about the sense of loss of control that occurs during this COVID crisis? Both again in dying and in being sick, what advice do you have for people? I, I find that when I give somebody bad information about what they’ve got, one of the things I try to talk with them about, “Listen, you’re not going to control this.” So we have to come up with other mechanisms so you can come through it. What do you tell patients?

Dr. Friedman: Well, since my patients generally don’t have, you know, fatal illnesses, but have treatable illnesses, maybe not curable, but manageable illnesses. I say, you know, your worst fear that you’re not going to get better is wrong because you can get a lot better. Even if it means at some point in the future, there’s a risk of this thing coming back. So I want to help them focus on the things they can control, like the kinds of environments they’re in, the people they’re with, the experiences they have. So you want people to have a sense of agency. Even in the worst setting situations, people can choose the kinds of experiences they’re going to have, even if they can’t choose their fate ultimately, or what’s going to happen with the medical illness.

Dr. Stieg:  I also think that, you know, there’s the, the worry, and then the worry leads to a sense of anxiety. Or are they both happening in parallel?

Dr. Friedman: Worry, and anxiety are just normal signals to me when people are facing threat and I normalize them and I say, “Of course you feel like this. And it’s, it’s, it’s quite expected and normal. And if it gets to the point where it interferes with your function or you can’t tolerate it, we can do something to lower your anxiety.” Medically, let’s say or behaviorally.

Dr. Stieg: Has the COVID crisis affected our sense of resilience?

Dr. Friedman: It’s challenged it. I don’t think human nature has changed. And I don’t think it changed the fact that, you know, in any group of people, there’s a distribution of those who are a lot more resilient than those who are a lot less resilient. It’s just a huge challenge test and reveals what that distribution is.

Dr. Stieg: Do you think there are any exercises that one can perform to improve their sense of resilience or is it genetic? Is it cultural? What can we do to help ourselves with that?

Dr. Friedman: So, a lot. Actually you can recognize that adversity actually helps build resilience and it’s not necessarily a terrible thing. And then on the other side of it, you will be more resilient when you get through it. But the question is how to get through it. And that includes doing all the things that make you feel supported, meaning people — you know, your social connections, taking care of yourself and being in good, in as best medical health, as you can be and getting good sleep and exercise and nutrition. I mean, all of those things are part of, you know, dealing with stress and adversity and will help with the building of resilience.

Dr. Stieg: So the expression that what doesn’t kill you makes you stronger is okay, as long as you have insight and then start trying to do things that will help make you stronger.

Dr. Friedman: Yes, absolutely.

Dr. Stieg: Richard, thank you again for being with us today to talk about this extremely difficult and delicate topic. COVID has changed our lives, but I believe you have provided both me and all the listeners with hope and some strategies for how we can cope with the difficult times we’re in and will probably face in the future. Thank you again.

Dr. Friedman: My pleasure.