The Interview with Dena Moistoso

How to Manage Grief, Death, Dying and Suicide

“Grief is another form of Love”

to contact Dena Moitoso you can email her  at denamoitoso@erbgood.com

On a Personal Note:

I first met Dena when she gave a workshop about grief, trauma and death,  I was so impressed by the knowledge, stories and strategies she shared in that workshop that I knew needed to interview her for this podcast.  What I loved the most was that she is such an eloquent speaker and teacher.  She is a remarkable story teller and each story has real staying power in the lessons we learned.

I also did this interview as I know of several friends that are grieving the loss of someone they love. Also, this is an area that is not taught in medical education much at all. The approach is difficult and the conversations can be hard. Dena makes it easier.

The interview was so rich with great content and information that I made it a two-part series.

When you listen to Dena speak you'll discover how she makes a very heavy subject (death, suicide and grieving) very understandable and hopeful. That's not easy to do.  You'll hear the care she has in her voice and how warm she is in her descriptions. She's like the Aunt who always knows how to make you feel comfortable.

 

I know you'll enjoy listening to her speak and I am very lucky to have discovered a new friend. Please enjoy the knowledge she shares in this interview.

Lalit Chawla

Dena Moitoso is a registered psychotherapist and holds a master’s degree in Psychology with a specialization in traumatic bereavement. For over 20 years, Dena has provided individual and family counselling to those grieving the loss of a loved. She is a founding member of the Waterloo Region Suicide Prevention Council (WRSPC) and the local chapter for Bereaved Families of Ontario.  In addition to her own private practice, Dena is the professional consultant for WRSPC, and she presents on many workshops related to bereavement throughout the province.

It is Dena’s personal experience with loss which compliments her knowledge and understanding of the challenges of grief.

 

Dena Moitoso M.Sc., Psych.  CRPO, OACCPP

Registered Psychotherapist

"Grief is another form of Love"

In Part 1 of the interview, Dena talks about a car accident that led to a tragic personal loss and how that led her to become a grief counsellor. I also get a little personal about the loss of my mother, who died from metastatic breast cancer at 52 and the confusion I had around that.

 

Deena has so many tools and strategies and helping people understand all about grief, post-traumatic stress, suicide and t how to navigate the emotions and behaviours around those topics.

 

In this first episode, she shares the whys and hows to help people who have lost someone. We talk about:

 

- How men and women grieve differently and how that affects their relationships.  

- We talk about the whole task of grieving

- A brief history of how people grieved

- Tools to help overcome the loss of a loved one

- How to behave around someone who lost a child

- The dance between joy and suffering

- Tools and strategies on how to manage grief and get back to living

- How different age groups deal with death, from children, adolescents, adults and the elderly

- How our hormonal levels change in grief and stress

- How our sleep is affected and the exercise to remedy the overactive mind

- How grief affects our breathing and how to easily overcome it.

In Part 2,

I talk with Dena about an uncomfortable but important subject-

Suicide,Traumatic Bereavement and PTSD.

 

Dena breaks down some misconceptions and shares how to help people understand grief, post-traumatic stress, suicide and navigating the emotions around those issues. 

 

In this episode:

 

- Dena goes into further detail about brain physiology and how different areas of our brain remembers or stores information. How we learn certain environmental cues such as being afraid of the dark, for example.

- She uncovers how our brain processes trauma, violence and death. 

 

 -The important dos and don’ts when counselling or consoling a person or family who has lost a loved one, including the language, we use around death and suicide.

 

- She’s very helpful in clarifying survivors' thoughts and feelings after a loved one dies from suicide.

- The questions they have “what could I have done?” and how to reword it.

- The important question family members can ask after a person has died from suicide.

- How to do Grief work and the role of support groups-when and if a person should join one and the hazards of doing it too      quickly to overcome traumatic events.

- She clarifies some details regarding the choices individuals make when a person dies from suicide.

- The language to use when there is a traumatic death.

 

- Why we need to talk and decompress in our lives and how that behaviour helps in times of bereavement.

- She explains why hope is important in our lives

 

If you have ever suffered from a personal loss or you know someone who has you will find both these episodes incredibly helpful.

The Interview

Lalit: (00:00)

Dena, I am so excited to have you here today and thank you for doing this.

 

Dena: (00:11)

My pleasure.

 

Lalit (00:12)

Now I wanted to ask you, you are a grief counselor. How did you get into that? Because I don't think that is something that a person decides to become, "hey, I'll be a grief counselor." I was wondering if you could share with me how you, got into this profession.

 

Dena: (00:31)

Yeah, no, you're, so right. In fact, very uncommon to find somebody who specializes specifically on grief. Most agencies have a broad range of approaches to, the counseling experience. I think my story is a little bit unique. In my previous life I used to be a special ed teacher working with developmentally delayed children. So my role was a resource teacher because I would work with families and so on. And so it was, a wonderful career. And then one day, on a Saturday morning as I was driving home from the market with my kids, and then somebody went through a stop sign and crashed into our car and it was a catastrophic experience where my three year old daughter did not survive. And it completely shattered my world. So I knew that I was no longer a teacher. I didn't even know who I was. And so as I healed from my injuries and continued to ask the question, what is this life all about and who am I now? This was in the late eighties.

 

So I, I failed to find the answers, so I decided to become a student of myself and, went back to school and took a lot of sociology courses,physiology courses and writing courses . I started off with a writing course, so that I could find some critical feedback to what I was feeding to, and what I was feeling, without the intent of ever becoming a grief counselor, but rather with the intent of trying to figure out who I was in the, in through that process, as I developed more and more confidence, Istarted up a bereaved, support group for parents grieving a child and that was exactly what I needed at that time to be with other parents. And later after that the funeral home that gave us space to meet asked me if i would like to work for them. And as I was continuing to study myself, I found myself leaning towards the courses that gave me the answers and then a little longer on in the story i turned out to become a grief counselor.

Dena with her eldest grand daughter Milli

Lalit: (03:16)

Well I took your workshop and I learned so much in that one day. It was amazing that the science and research, it was clear you knew your material and it was very impressive to me. Umm, I'm sorry about your loss of your three year old daughter. That is probably the most feared thing I think any parent would have to lose a child. I don't want to dwell on this too much but where you injured from the accident?

 

Dena: (04:04)

Well, my injuries were catastrophic, I was the one who wasn't supposed to survive, and you also have to think that this was back in 1988. The diagnostic tools we're not as sophisticated as they are today. So my three year old's brain bleed went undetected and so she to came to a head injury, within 48 hours of the accident

 

Lalit: (04:37)

Now for you to process all that, one thing we hear people talk about grieving, mourning and bereavement. Are they the same thing or how could you define that better?

Dena: (04:51)

I must admit that it's actually the work of Dr. Alan Wolfelt. He has drawn our attention to language as a way to kind of guide us through this process.I'll give credit to him for reminding us that morning really is the outward expression of this profound feeling of hurt and loss and brokenness. And often we'll see that in that initial period. So those first four seasons of the year where there are so many firsts that people experience. And so there's this outward demonstration of that pain. And what happens is that over the course of time, that outward expression becomes internalized and that's what we began to call the grieving process. it's a more personal, intimate experience of integrating this loss.

 

Then you have the word the bereavement is the state of being bereft.I always appreciate the root words.The German root word for bereavement is to be robbed. And so this is how we have these three terms that again, can help to guide us, right? Uh, there is a bereavement process that a family goes through, and within that they will go through a mourning phase where there will outward demonstrations and they will be cues for us to respond to. And then as the people enter into the grieving process, it's about recognizing that they're figuring out how to walk with this. and it may not be obvious to other people because they start to go grocery shopping and they start to do their laundry but make no mistake, they're grieving on the inside.

John with his Wife Jill

Lalit: (06:56)

I think I remember you talking about the traditional versus contemporary grief theory. Could you remind me about that?

 

Dena: (07:12)

Most people could almost sing the five stages of grief, that are set out by Elizabeth Kubler Ross. So it was in 1969 that she was doing significant research on the dying process. And within that she came up with the five stages of the dying process. Now, at that time, there really wasn't a lot written about grief aside from, Freud's, 1931 kind of submission of the melancholy phase, we really didn't know what to do with, bereavement. And people started to recognize, denial, anger, bargaining, depression, acceptance.

 

They,then go 'hey I go through all of those things when I'm grieving". And so then people adopted those stages as guideposts you could even call them. So that was the beginning of a conversation and it really took off because to be fair, I think we all like to kind of think about nice tidy formulas that have a beginning and an end that kind of created that. Also the impression I think that led to was that grief is kind of somewhat orderly that it, it does have a beginning in that it does have an end. So, you know, that's kind of the song that everybody started to sing. And I'll be honest, I know that there are still some courses at university levels in which they're still teaching grief from a five stage perspective.

 

I know that Elizabeth Kubler Ross never really intended it to be that she's written books since then to kind of let help people understand that. But, it's hard to undo something that people have adopted. to get to the point in terms of the traditional perspective, it was highly influenced by that stage model. And the suggestion was that there are things that we have to go through. There are steps that we have to go through, but ultimately we come to an end and that is pretty much the traditional perspective on grief. It also occurred during a time in which, after World War II, there were many people in this country, in our neighbourhoods who were grieving multiple people. And, because there were major casualties in those wars, it was hopeful to feel like, "so we're going to get to the end of this"and so that's part of why we adopted this feeling is because you know, we'll get over it, we'll get past it. Life is for the living and just do that work, follow these steps and you'll get to the other side of it.

 

It is like an academic perspective because the soldiers in the trenches, the people who are grieving, the people who are walking through this. Are like "I thought I went through the anger stage a month ago"? Why am I angry again? They started to realize that they are doing something wrong or I have to keep my mouth shut because people will tell me I'm doing something wrong. The traditional perspective was, scripted, but it wasn't a very humanistic, you could say. So then gradually as we get to the contemporary approach degree for it is about realizing, okay, grief is not tidy. It's actually rather messy and it doesn't have an end because love doesn't have an end. so it was many of the contemporary writers that started to talk about continuing bonds. For me I'm a big fan of, Thomas Attic who wrote a book, that tells us about the heart of grief. he really inspired us to consider the relationship that continues when a person has died. And, so the momentum was about continuing bonds and honouring the relationship and honouring the legacy of those who have passed. it's about recognizing that we have the capacity to live with loss.

 

Lalit: (11:54)

Did he say, I have learned grief is another form of love?

 

Dena: (12:01)

Yeah

 

Lalit: (12:03)

And I always thought that was so nicely put. I learned that grief is another form of love. And, when my mom, she died at age 52 from breast cancer I was a young man, in my twenties. And I remember it was a very confusing time for me. I was in medical school, and I think for awhile, if I were, to be honest, I was confused about what grief really meant. And then when I heard that expression, grief is another form of love. It changes grief. Otherwise it can be very heavy on the heart. So I thought that was very useful. Now, the one thing that you really pointed out that really struck me in the workshop was that men and women grieve differently. And I can totally, uh, I certainly understand what it's like. I know what I did. Yeah, can you talk to that? How do they grieve differently?

 

Dena: (13:21)

Yeah, well, men and women are different, right? Our physiology is different we're just different and so it makes sense that at some level we have to accept the fact that there are different styles in terms of how to manage emotions. Now, having said this, it's not an absolute right because there are plenty of men who have feminized qualities and there are plenty of women who have masculine qualities. So if we, but for the sake of this conversation, if we can just kind of use those terms, male and female, masculine and feminine. Feminine Energy. And then find where the, that people fit in within that spectrum. Right? But essentially, masculine grief tends to be instrumental. So by that it's referred to that many men are action oriented. They're not necessarily the talkers. They're not necessarily the processors, the thinkers, they're more the action oriented, uh, style.

 

Lalit: (16:15)

Well, I find that's where there can be a lot of conflict between men and women, you know in their in a relationship. There has been a loss of say- one or the others, partner, by that I mean a father figure, mother figure. The men that I've seen, they're like, "I don't know why is my wife, and why didn't she get on with it?" And, and I think there is that misconception about it, correct me if I'm wrong, but the timeline of grieving varies for people and how we do it.

 

Dena: (16:58)

Well, it, does. But in addition to that, there are other factors that you're highlighting one of them, particularly is if it's husband and wife and they're grieving your child or they're grieving for an elderly parent or a sibling. Husband and wives take turns". They can't both go into the pit at the same time. if you look at systems theory, if they both went into the pit, nothing would function.

And so without a contract, without stating it out loud, there's this natural turn taking where if one person is in the pit, the other one stands guard and they support. So, that's one of the elements that can be confusing, for couples. again, at the risk of being stereotypical, for many men, there's still a caveman component, a part of their personality, which is like -I'm here to fix, I'm here to protect, I'm here to help.- And when that partner is broken and they can't do anything to protect that or to kind of fix that, there's a frustration. And so that's part of the reason why some men have such a difficult time seeing their spouse suffer because they can't fix it. Whereas as you probably know, for many women, they can be in the hurt, they can be in the puddle and know that they don't have to fix it. But it's a natural instinct for men to want to try to fix it.

 

Lalit: (18:30)

What would a hurting female, want from her husband? What can she ask from her husband?

 

Dena: (18:42)

Just to be present, present in the pain. it's not, easy to see somebody suffering, but that's ultimately what would be the most helpful.

 

Lalit: (18:54)

But what about the reverse? Say, if the male figure, lost his parent, and he was to always be chopping the wood and, there has been a bit of a change, you know, more of a shutdown or closed down. And that that might cause, the female partner to feel frustrated and say, "you know, you need to talk to somebody or you need to get some help." They don't, does that happen?

 

Dena: (19:31)

It does. But again, those are assumptions that may not really fair again, because for some men it's not the narrative that gets them to a place of healing. I think about a couple that I worked with, in which, the husband would go into the garage every night for a year. He would go into the garage and spend hours there. And at the end of that year he was able to tell his wife, what I've been doing is carving an angel out of a stump of wood.

 

I was thinking about another gentleman. he was a university professor in both of his sons died at the same time. And, what he did is he was worked on this tapestry and for a year he would kind of go into his space and he would just work on his tapestry And He created this remarkably huge, long work of art. But within that tapestry model, he would embed elements about his sons. Right. So, and those are examples of how men may not need to find a narrative to work through their emotions, but rather find an activity that makes it feel meaningful It's a mindful activity. Many of these are, but it's meaningful and it's solitary.

 

Lalit: (21:37)

But what about a couple though? I mean, it may be hard for the female partner to watch the doing; I would assume that she could feel isolated in the, in that- " why don't you talk to me?" So sometimes are you saying that sometimes they don't need to talk?

 

Dena: (22:04)

Well, it's, it's really, I mean, every situation is unique, right? But I really look forward to the opportunity to meet with couples as soon as possible to give them some clarity on, what are some of the limitations of them being able to support one another. when it comes to family systems, they can be very supportive to one another, but they can't do their grief work together. Grief is highly contagious and that's why we do the turn-taking. That's why we have a tendency of wanting to protect the other person from our own deep sorrow. So couples really benefit from having support or back grief counselling separate from one another. Or they can come in and be together during the counselling sessions so that we can clarify these possible misconceptions and misunderstandings that they give each other the space that they need. Right, we're talking about that initial period. Then of course, as time goes by, if we're talking about maybe into the seventh, eighth month, there's a much greater level of tolerance for each other's pain and they can then begin to talk and to connect. But in the beginning, it's very difficult to tolerate the edginess of this hurt.

 

Lalit: (23:28)

So does that refer to the tasks theory you had talked about?

 

Dena: (23:33)

Yes. So I guess I'll go back to Elizabeth Kubler Ross and how she developed those five stages. Right. and as I said before, it was the start of a conversation that has continued and there's been lots and lots of work and effort in researching and getting a sense of what is grief and how do we help to support people through this. I tend to lean towards the work of William Wardon. H

 

He wrote a relatively insignificant looking book in 1982 and it was entitled, Counseling for the Grieved Individuals, within that he framed these tasks and now it all, it resonated for me when I thought of the word task because when I think of a task, I think about something that you do over and over and over again until you master it, right? And so then he highlighted the four tasks of grief.

 

The first task, and of course they don't go in order, but just for the sake of our order, - the first task is coming to terms with the reality that this has happened. And at first glance, that seems pretty obvious because people, of course, were present at the funeral. They know that this has happened cognitively. however, it feels like there's a long distance between the brain and the heart. And so it's not denial, but a very strong sense of disbelief. So the task of grief is to approach the reality of what has happened in a gentle way, repeatedly until it's integrated.

 

So when I, again thinking about this originally, I used to think, wow, you know, remember the time when a person had experienced a loss, there would be like a committee of well-meaning people who would go to their house, clear the closets, clear all the shoes, get rid of all the triggers that would remind them of their loved one because they were trying to spare them from facing those realities. It was well intentioned, but what William Wardon is teaching us is that we have to approach those realities in a gentle way, but we have to face those realities and it's called grief work.

 

So we're not always working at it. So like part of the theory around grief is that we have to also take a break from it. But when you're doing grief work, it's about opening that photo album. It's about opening that closet and touching those clothes. It's about recognizing that now you have to do the blue box. It's all of those reality checks that help us to master it. The second task is experiencing and expressing the emotions that you feel, which again, at first glance it feels like I cry when I have to cry, but we live in a society that is uncomfortable with emotions and so it doesn't take long before bereaved individual discovers that it's not always safe to express. And so William Wardon reminds us, we have to find those safe places to express, to be true to ourselves. The third task, making adjustments to the environment that reflect the current reality. That's a mouthful. But ultimately it's about change and it's about realizing that nothing is the same. And so even though we try to keep things the same at first because you know, sameness is familiarity and familiarity is comfort. But over the course of time, it just doesn't fit. It's like a round peg and a square hole.

 

Dena: (27:22)

Nobody's gonna use those shoes at the front door. The slippers that were left beside the bed are going to gain dust. And you might even find that people start to avoid looking at it after a while. And so William Warden really is teaching us, we just have to make some adjustments so that it doesn't trick our brain and that it continues to reinforce task number one, which is coming to terms with the reality. So I think about a woman that I worked with and her husband was an avid gardener, had his gardening boots at the back. And those were precious to her. When she would come in, she would see those gardening boots and they would remind her of her husband. But as time goes by, she noticed that she was avoiding the backroom because looking at the boots was painful. And so after some discussion, part of meeting the task work was the result of coming up with an idea to fill them up with dirt, put some plants seed in there and make them phases in the backyard. so you can see there's a change. But now when she looks at those boots, it doesn't trick the mind into thinking, is he here? Is this just all a nightmare? It's just an honouring of what they stood for.

 

Lalit: (28:45)

That's a lovely way to remember.

 

Dena: (28:51)

People have become really creative at that. I think about the industry that's emerging. Like people are making beautiful memorial quilts out of t-shirts that their loved ones would wear or they're commissioning somebody to create a teddy bear out of the sweaters that their loved one had. And it's just about transforming something so that you don't have to get rid of everything. You just have to kind of make some adjustments so that you keep the things that make you feel linked to that kind of ongoing relationship. And, and those linking objects can be really meaningful. Oh.

 

Lalit: (29:28)

You know, for years, I did not have a picture of my mother, because it was too painful to look at her. I literally had to forget because I felt I couldn't do the work, I couldn't carry on, it just, it was very difficult. And it's only, you know, in the last few years I have a picture of her in my home office. And so, had I known some of those tools, I mean I don't think I have anything physical that, but just having that picture just really helps me honour her and remember her

 

Dena: (30:23)

Yeah. Well, and I think it's natural, Because if initially you look at a picture and it provokes tremendous pain, of course, you would avoid that pain. but I guess what we're talking about with regards to this task work is realizing that part of this journey involves intentional approach towards in which is painful and it's what we call grief work so that we can begin to integrate the experience of loss with our life. Because pictures are incredibly precious, aren't they? And, and if we interpret that initial surge of pain to be bad, there's a huge consequence because by putting away the memories, we put away the love and there is a fracture in us if we have to do that. So even though at first it's very painful, the outcome is the opposite of that because you actually feel connected. So I hear what you're saying. As you look at her picture now, it brings you joy. It brings you comfort. It took you a while to get there. And so it would have been helpful if you'd had known it so that it wouldn't have been so long a distance. But you do what you do. Right.

 

Lalit: (31:41)

The thing is, I don't know if I talked much about her after she had passed. It was also a busy time. I was in medical school trying to (survive), it was perfect for the masculine energy cause it's, I had to, do, do, do, ... you know, ignore, ignore, ignore. And so that was good to get the job done, so to speak. But only later, you know, I was able, I talk about, and think about her and I talk to my daughter about her and show her pictures and tell her "if your grandmother was here, she'd be doing a craft with you. She loved craft just as much as you do. I think that's where you get your love of craft from is from her. " So it does, honour that. I think, you had talked about this at the workshop for instance if a parent has lost a child and they walk into a room, other people who know that they've lost a child, and they feel guilty or they feel reserved to talk about their child playing baseball and things like that.

 

Dena: (33:09)

So there's a silence, right? sometimes what happens is that people's grief is disenfranchised for that level of protection. So the component with regards to disenfranchised grief is that the less that it's acknowledged, the more profound your grief reaction is.

 

Lalit: (33:30)

So it's better to talk about, what your child did, even though they lost their child.

 

Dena: (33:41)

 yeah,

 

Lalit: (33:43)

Because I think there would be a hesitancy, if I talk about my son or my daughter, it might make her or him feel bad. But you're saying that's not the case.

 

Dena: (33:54)

Well, you know, I sometimes have very well meaning people ask me this question like I don't want to talk it out about it because for fear that they're not thinking about it or that I'm going to trigger them, I always have to remind people, oh, they're thinking about it. You never have to worry about it. Yeah. It may not be here. It might be over to the side. But that's always present because we are the sum of all of those who have touched us. And so when somebody who has really shaped who we've become, when they pass away, they remain with us in a different way. At first, it's filled with pain, but as time goes by, it continues to be a reference point. So when I hear you talking about how you speak with your daughter, she knows her grandmother and she never met her. And isn't that what we want? We want to kind of maintain a level of legacy that carries that person's love and spirit forward. We have the capacity for that. It's not like we don't have room for anybody else in our lives. If we carry them in our hearts, I often say we've been able to kind of keep all of us alive. Why can't we keep our loved ones alive? Right.

 

Lalit: (35:18)

Well, yeah. You know, I remember one thing you said, we can have joy and suffering - you can hold both at the same time. Because you can't be in pain and grief and suffering all that time, and it doesn't mean that you don't love them, and it also doesn't mean that you can't have joy either.

 

Dena: (35:45)

Yeah. So, you know, this language has existed in our society forever. In fact, when you read the writings of Kahil Gibran, which is dating to the 1923's, joy in sorrow is all over his poetry, So I think that sometimes with our modernism, we oversimplify our complexity. And say you either have to be one or the other. The one thing that is, pardon the Expression Gospel for me is the understanding that we can coexist with both joy and sorrow. And here's the other caveat. One doesn't cancel out the other, they just coexist.

 

Lalit: (36:33)

Well, I would think that sometimes, people may feel guilty to have joy even if there's been some loss. And if they do have moments of laughter or joy that they may not want other people to see it because they may be misinterpreted.

 

Dena: (37:00)

Yes. And so it's a real struggle for bereaved individuals who have been so bereft so broken and then all of a sudden they find themselves in a different situation and they're laughing at a joke for the first time. And those cheek muscles haven't been used that way. So you actually feel that and led and followed by a sense of, "Is this okay? Should I be able to laugh when I am so broken?" I'd like to suggest that kind of guilt actually just comes from the ego determining what you're feeling is different. And you know how it is. The ego doesn't like anything different. So if it's different, it's got to be wrong. So it's an easy translation. We can easily talk to people about kind of recognizing where these impulses and where these feelings come from the right. I must admit I missed one piece in the William Wardon task theory that I think is really important.

Dena: (38:02)

We haven't talked about number four and number four is taking the energy that it takes to grieve and placing it back into living. In other words, it's about reinvesting in life and, that's work because you don't always feel like you want to invest in life. In fact, most bereaved individuals are angry at life, but part of the grief work, the task is to force yourself at times, give yourself permission at times to invest in life. And that happens in so many different ways. When I'm working with clients and I'm talking to them, some people really do appreciate the theoretical frameworks. That's how they function. So when I'm able to offer these theoretical frameworks, I'm able to say you're already completing task number four because you're here, right? But they could also just be going for a haircut. That's an investment in life. So it's really about helping to see in baby steps, ways in which they can immerse themselves and living again rather than just existing.

 

Lalit: (39:17)

The one thing as a parent, and I assume parents think about it, how do people, how do they look at death differently? I, know I was concerned when my father when he died at 77 and my daughter, she was about five. I didn't know how to explain that or what she would think. So children, teens, adults, elderly people, how do they experience it?

 

Dena: (39:55)

It's, it's incredibly important to recognize that even though it's one tiny word that we're talking about, it's so complex and grief is very developmental. So it really depends on, age and stage of where you are in your life age in terms of cognitive growth, and development in terms of, being able to understand abstract concepts, development meaning where you are in your life cycle that will allow for this grieving, this grief work to take place. So we know that children under the age of 13, 14 will have different developmental stages that will help them to understand death under the age of five or six. They cannot understand the permanence of death. It's abstract. it is like how we don't teach children Algebra because they can't understand Algebra at that age. And so, therefore, the same principle applies with progressed to death. They will hear the words, they will echo the words that are being told to them, but they will then a week later say, well, when is he coming back?

 

Dena: (41:21)

Or well, why can't we just go to heaven and see them? These are all abstract concepts. And children, again struggle with the permanence of things at that age and their primary need is to have consistency and, a sense of predictability in their environment. And that's not happening because likely the adults around are brokenhearted. so they lack consistency and they lack predictability because everything's in flux. And so children, demonstrate emotional distress over those things more so than the loss of the loved one because they always expect them to come back. So then we go up to the ages of eight, nine more so around nine, ten and what happens is that they begin to understand the permanence of death, but they also start to kind of look at death as a bad thing. And that something bad happens when people die.

 

Dena: (42:29)

So this is where people or children can begin to have nightmares because they start to generalize that bad thing. And this is where the boogie monster kind of comes in, It's not uncommon for kids to say, well, it was because I didn't eat my spaghetti that daddy died. Or if I'd had not broken that toy, daddy would be here. So it's not uncommon for kids to try to make sense of how something so bad can happen. And they often over-identify with themselves. and then we go into the next developmental cycle, which is the adolescent period and the adolescent period. Whereas, you know, sometimes they get a bad rap, but teenagers are highly spiritual. They're looking for the meaning of life. They're, trying to make sense of life and what happens around them.

 

Dena: (43:19)

So they're deeply feeling people when a tragedy happens, and particularly if, it's within their peers, they're deeply the raft by that loss because they're trying to make sense of what's going on in the world. then you go onto emerging adults where part of their function is to kind of, you know, figure out who they are, what their level of industry is. Can they form intimate relationships? If a death occurs, then it compromises their ability to trust that there is a world out there that they can trust in that, that relationships can remain, that people don't just die. So it has implications in how they invest in life and then you go into the adult age. And, and for us adults, we, cause we're, you know, primarily done developing psychologically, we know who we are. We have our sense of industry, we've got relationships. So the grieving process has more latitude. People have a tendency of grieving more intensely in their adult years because there isn't anything else standing in the way. Right.

 

Dena: (44:36)

Last cycle, is the senior years now they tend to be a little bit more compromised and being able to express emotion because their bodies are compromised. And so to feel intense emotion, and that is risky because it can elevate the heart rate, it can elevate your blood pressure and the stuff that they're doing that it's like our system seems to regulate the emotional output. Not Uncommon for me to hear people saying things like, it doesn't seem to affect grandma. I don't know. My grandma's not reacting. I thought grandma would be much more upset. I don't think psychologically that grandma can get there because it would compromise her survival.

 

Lalit: (45:19)

Do you think that happens at a subconscious level?

 

Dena: (45:22)

Yes. It's our internal gauge, right? It's our psychology that kind of determines. Much like, as I say in young adults, they have the ability and children to compartmentalize. So effectively that when they're playing hockey, they're just nothing else playing hockey and when they're grieving, they're grieving. So it's not, they're not kind of consciously compartmentalizing. It's their psychology that is able to separate these aspects so that it doesn't compromise their development. Interesting way.

Lalit: (46:01)

Yeah. Well, what about the crisis reaction? You know, once when there's a loss, there's phase that, a person goes through in the first 24 to 48 hours and then, you know, that's the reactive phase and then you can you remind me about that?

 

Lalit: (46:20)

 

Dena: (46:21)

Yeah. Well, you know, again, we talk about grief as a small word, but there's just so many things. when people experience a loss, depending on the nature of the death it will then result in what level of crisis that person's going to be in. You can almost say that we interchange trauma and crisis here because really it's the stress hormones that we're, we're speaking of. If it's a sudden and unexpected violent death, there will be a high level of crisis trauma reaction, right? If it's a loss that has been as a result of a palliative care situation where there has been some anticipation that that person is going to die, there is going to be a low level of crisis and trauma, but there's still going to be crisis and trauma.

 

Dena: (47:21)

Many people will tell you, "even though I knew it was happening when they took their last breath, I couldn't believe it." So we're never really fully prepared. We think we are, but when the time comes, it provokes that crisis, So again, think of that on a spectrum, if you will. There is a high degree in a low degree, what we can tell you is that, in the first 48 hours or so, people will have, these stress hormones pumping through their veins, the cortisol and the adrenaline, and it serves them well because they're able to put one foot in front of the next, it dampens their emotions ever so slightly so that they can figure out who on the list they want to call. within 24 hours, they're essentially entering into a financial arrangement with some funeral home, which is big. but because of this stress hormone, component, it is dampening the surge of acute emotions, making them actually pretty competent and able to put together the most remarkable memorial services. Think about the number of times we've gone to a funeral and it has been so meaningful and families only have three days to do that.

 

Lalit: (48:58)

I've always been amazed by that, how is that possible?

 

Dena: (48:59)

Yeah, and it is because they've got those cortisol levels and the adrenaline levels. And so those, those actually create a level of competence that, and again, I think we've evolved into using these systems, in our society anyways because I can certainly tell you that there are many other societies in which there's a huge demonstration of emotion right off the bat. But perhaps within that society, the norms of accommodated that and our society, we need to be in control in order to honour our loved ones legacy.

 

Dena: (49:42)

And it appears we can do that, which is pretty remarkable. So then what happens is that over the course of weeks, days and weeks, those cortisol levels reduce as, so your adrenals start to neutralize. And as they do, then emotions begin to become more and more permanent and more acute. And so it takes a good six to eight weeks for your adrenals to neutralize, again, think about that on a spectrum, If it's a violent, sudden death, we're looking more like eight weeks out, eight to 10 weeks out. so the acute period of grieving is actually somewhere between two to about six to seven months. And that is so contrary to what most people expect, Most people expect grief to occur almost on a linear level. Kind of like if you break a bone, heal calcifies slowly. With grief, it's a bit backwards in that you feel numb, you feel dissociated, you feel disconnected for the first couple of months, and then you begin to feel the impact and the permanency of that loss in those months after.

 

Dena: (51:14)

And so it's an acute period because it is during this period that fewer casseroles are arriving, fewer phone calls are coming in. Now that blue box does definitely has to be filled. I can't put it off anymore. And the reality of our person's absence begins to manifest in so many different ways.

 

Lalit: (51:38)

Now when you say blue box what do you mean by that?

 

Dena: (51:42)

I'm talking about the ordinary tasks of housework. Many people speak of that because oftentimes it's the partner that had that job. You know, when you're in a relationship, you divide and conquer and you've quickly find out there are tasks that you've never done that now you have to do.

Lalit: (52:07)

Yes one thing that was, is very helpful to know about is about how our sleep is affected. Would you go through the different cycles? I really liked the analogy of, the file folder and how we can use that technique to make it easier. I've actually used that also with journaling. I've told patients about that, how to decompress. Could you recap that for the listeners? the whole sleep cycle, how it happens, what happens in that time? Why do we stay awake, etcetera?

 

Dena: (52:52)

Yeah of course. It is actually one of the first things that I try to, educate clients that I serve, is on the sleep cycle. and again, it's not that hard to understand, but I don't think that we have done a very good job of, of getting to know how sleep works. So, first of all, it's understanding that we sleep in cycles, 90 minutes cycles and after 90 minutes or within those 90 minutes, we go through different levels - we enter into restorative sleep and then we enter into rem sleep and rem sleep. The first rem sleep is only about 15, 10, 15 minutes long. Then we go into another 90-minute cycle with restorative sleep in there and then the next rem sleep doubling to maybe 20, 25 minutes and so on throughout the night. This is what we do. Our REM sleep increases, but we have these increments, these cycles.

 

Dena: (53:55)

Once people understand that, then they begin to master their own kind of sleeplessness by understanding what wakes them up. So most common for people who are newly bereaved, I can almost finish the sentence for them because this is so common, they say, I go to sleep at 11 and then I wake up, it's like one 1-2am o'clock every night and they're trying to figure out what they can do? They say I've gone to my doctor to tell them about this. I have been given sleeping pills and I can get to sleep. I just can't stay asleep. And that's a telltale mark of high levels of adrenalin. So Your adrenaline levels are so pumped that people are not able to get to sleep. But once your adrenals are neutralized, that's not the problem. The problem is the overload of the brain.

 

Dena: (54:55)

Many of the readers/listeners probably know but we have learned so much more about what happens in our sleep. We now know what happens in REM sleep and it is the brain sorting through the day's information and then consolidating it with existing information. So I literally think about our brain like a computer and all the file folders and the files. And so this happening, but because this loss is so new that it is like the brain doesn't even know what file folder to put it in because there's no reference, during REM sleep, as the brain reviews the day's occurrences, it's looking for a way to consolidate. But given the fact that there has been so much happening in that person's life, I basically imagine it as that there is a firework of activity that actually jolts people into the awake state in the second REM sleep. And it falls in line with the, with regards to the timing.

 

Dena: (55:58)

So again, if I'm able to teach this to clients, then they're able to go, okay, so there's a reason for that. Step number one, people just need to know there's a reason for this. And then the second step is to say, now if we're making the assumption that you are awoken because there's an overload, what if we help the brain unload some of that organization before you go to bed so that it lessens the pressure during that second rem sleep. So when I counsel people to do is to get a sheet of paper, not a pretty journal, but a sheet of paper and to literally write down their whole days, events in detail. I woke up at this time, I did this and then I did this and I can't believe I ran into this person. And then I saw this on the commercial and then I saw this on the radio. Every single thing that they can think of to write and write and write point form. It doesn't have to make sense. Just write the whole day as much as you can remember. And then take that piece of paper, rip it up into little pieces, throw in the garbage and say they're done with that day.

 

Lalit: (57:07)

And that lightens the cognitive load.

 

Dena: (57:11)

My experience with most people takes a good three days of them doing that and then they start to regulate their sleep.

 

Lalit: (57:21)

So at least three days of that technique. I've shared that technique with people who just have trouble sleeping in general. They say their brain is too full, they just keep thinking about too many things. And, they have found that has helped. So we must just be processing all the little things that are maybe, not hugely important through the day, but, and we're still processing

 

Dena: (57:52)

Because the caution here, it's not necessarily to provoke emotion at the end of the day because then that will create another set of variables. It's really about mechanically reviewing the day, dumping it on that paper, ripping it up. Because that's very symbolic. Saying my day is done, doing some rituals around calming down and getting ready for bed and allowing then for your brain to kind of do the rest of the work that you didn't do.

 

Lalit: (58:21)

So you would write every like I brushed my teeth,...

 

Dena: (58:24)

Whatever comes to your mind. Absolutely. and then again, ripping it and, and making that a ritual for completion. I think the reason that I notice a three day phenomena in terms of it being becoming more consistent is that we also have to tend to the circadian rhythm and the fact that if you've had bad sleep habits, whereby that becomes a part of a pattern where the brain now just kind of naturally wakes up. Whether or not it's REM sleep, it takes a while to undo that, but it's good to hear that, some of your patients have recognized that like almost right from the top that it starts to help them.

 

Lalit: (59:08)

Well, even if there is no loss, it's just a way of, decompressing. And I think that's part of a good nighttime ritual is decompressing.

 

Dena: (59:19)

So I'm wondering like, do you find that it helps to, understand why, like in terms of the sleep cycles that, sleep education, that sleep hygiene,

 

Lalit: (59:32)

I don't know if everybody  (patients) really wants to understands the why of it, because when you go into REM, non REM may be complicated. I remember it's even complicated when I was studying it in medical school. So just trying to remember that. But I find most people are generally saying, "okay, just tell me what to do." And if that works, I'll give it a try. And, I have told my patients to stick with it for at least five days. Don't, put any judgment. It's not like regular journaling where you're trying to process your feelings or anything. It's just very boring and basic kind of stuff. And then I used the, example like you said that, your brain is trying to file these things away and you just have more, and more stuff to file

 

Dena: (01:00:31)

So that's giving them an explanation in terms of that's the function of REM and the fact that they have these REM cycles. I just, find that if we're able to find the words that makes sense for people, then they become much more intentional about this commitment to help themselves. It's that same kind of principle.most people, and I hear this often people will say, "yeah, I'm always being told to go for a walk. I don't want to go for a walk. What's the point in going for a walk? I don't have any interest in going for a walk," but if I'm talking about the benefits of a walk by saying, you know what, people who are in distress are lazy breathers. We don't breathe well when we're in distress. The one thing that is a, for sure, you cannot walk without breathing. So when you go for a walk, one of the benefits is that it forces you to breathe well. And when people understand that there's a higher motive they realize there is, an actual reason why this would be beneficial, and they're more likely to engage because now they have intent.

 

Lalit: (01:01:41)

Yeah, that makes sense. Walking is one of the best meditative exercises as well because it forces you to breathe. You're out in nature. So I'm a big fan of walking. Anybody who lives in my neighbourhood knows that I'm always walking and I'll walk for at least 5-10 minutes because it just relaxes me. It does something, and I think it probably just comes down to breathing.

 

Dena: (01:02:11)

So breathing is the bilateral movements, So when we're doing bilateral movements, we're stimulating both the left and the right hemisphere. it's scientific, but it's very accessible. People are like, sponges when it comes to, okay, I can do this, You know, the same thing goes where like hydration, how important it is to drink plenty of water. But if we don't explain why then they might just push it to the side and forget about it. But if people understand well, stress is a huge dehydrator. Think about the number of times you've had to kind of do public speaking and just everything dries up. So this is the most stressful time in your life and your body just needs to be quenched, so no less than a litre of water a day.

 

Lalit: (01:03:02)

Well, I say the average person should drink three to four litres of water per day. And every coffee, tea, alcohol or juice you drink, you have to drink another glass of water. I'm a big proponent of hydration.

 

Dena: (01:03:22)

Our brain is the tissue that needs that hydration, right? So if we don't do that, then how can we problem solve, our way out of an emotional experience when our brain is deprived of both oxygen and hydration?

 

Lalit: (01:03:38)

Right? it's ironic in that in the time of a loss, that's when more than ever, that's when we need to be doing the right habits. We need to be eating properly, trying to sleep better and walk and to try to process that. But that's often the time when people lose weight because they're not eating and probably it is the thing that they need to do more.

 

Dena: (01:04:11)

I think that's where we have made such great strides in this area of grief and bereavement is understanding it's not just an emotional experience. It's a deeply physical experience. And, and although we can not fix the wound in people's hearts, we can give them tools to help carry that brokenness. And so some of these basic teachings are tangible. They are doable for people and it's going to help them to be able to carry their sorrow.

 

Lalit: (01:04:50)

I'm all about tools and strategies and things that you can use. I think as a clinician and as individuals, the more we know how we can help ourselves and in different times and different circumstances. So if you can't help yourself if you don't have any knowledge of what's gonna work. We may think "let's do this", but that's, not helpful at all. 

 

Dena: (01:05:23)

Yes, so that it's very empowering for people who feel very broken and helpless. And if you say, okay, your homework is going to drink water, you're going to go for a walk, That's easy to do. Pay attention to your breath. I think that's easy to do, right? and that's something easily of the clinician can do. Yes. They may refer somebody to for counselling, but if I can give you one suggestion or two suggestions, walk and drink water and make sure you eat enough is easy to do

 

Lalit: (01:06:09)

What are some factors that inhibit healing like, or grief?

                                                                 END of PART 1

                                          BEGINING of PART 2

 

Dena: (01:06:20)
Well, I think that, sometimes people say, "you know, this was a, a bad time to experience this" as though as there's ever a good time, but, there is some truth to that because if a tragedy occurs during your time in which a person is already experiencing major health issues, it's really compromises their ability to cope. If a tragedy occurs,where there has been family rifts or a disconnect from their community that can really compromise their ability to grieve. So there certainly can be things that impedes a person and I'm not even talking about the nature of the death. So for instance, if it's a death that's been stigmatized, then, that can really impede a person's ability to grieve well when they don't have the community support. So there's a number of factors that can influence a person's ability to grieve well.

Dena: (01:07:35)
You know, the one thing I found very helpful was when you talked about how the Amyglada and the Hippocampus, much easier to say, the Thalamus and Prefrontal Cortex - can you walk through that again because that's very good information. How our brain is thinking and processing everything.

Dena: (01:08:11)
Right and again, we're talking about situations. It has a higher degree of trauma attached to the loss. So again, using that spectrum idea where it's been more unexpected, where there's been a prolonged sense of crisis, whether it's been a violent death, then we refer to it as a traumatic bereavement. Traumatic bereavement, again, is much more physical because of the element of trauma associated with it. And way that I've, explained it to people is that, so we process all of our information via our five senses and our five senses inform us of our reality. And so as we experience a particular event, those five senses are filtered through the hippocampus. And the hippocampus then determines is this a familiar experience or is this a new experience? And if it's a new experience, it will communicate with this membrane that is in our brain called the Amygdala.

Dena: (01:09:37)
And I have my fingers because I always think of it, it looks at, it's in the shape of an almond. It's about the same size of an almond. So it's a very small membrane that's in our brain that is there to respond to the hippocampus's version of this is new information- "we've never been here before. I have never been in an ambulance before. I have never walked into a house where there is danger. " You know, so all of those variables that you're sensorial has filtered out. Now the Amygdala is called to action and say what we're experiencing is dangerous. So therefore the Amygdala communicates with the adrenals that sit on top of the kidneys and say "Mayday, Mayday!We have a situation we are unfamiliar with." And so that's what really propels those stress hormones we've been talking about. That's where the adrenaline and the cortisol are now filtered through.

Dena: (01:10:37)
And the Amygdala then assesses there's danger in terms of being able to dose people for a prolonged period of time or a short amount of time. So, if we're driving down the highway and it's a slippery road and we think we're going to lose control of the car, the Amygdala gets ready to doses with cortisol and adrenaline. But then we miss it. And if everything's okay, the Amygdala knows how to restore it. But if we get a knock on the door at two o'clock in the morning by a police officer, and this is totally unfamiliar, the amygdala is ready and posed to keep us vertical and logical. So therefore it douses us with higher amounts of cortisol and adrenaline. And then what happens is that there's another part. So the hypothalamus now starts to kind of bring these components together and what it does, the part of your brain that says, so when it's two o'clock in the morning, when it's dark, when I hear a bang on the door, when I see a police badge, these all mean high level of danger.

Dena: (01:11:56)
It's incorporated the information from the Amygdala and the Hippocampus and the Hypothalamus, and then it stores it in our Cortex, which is the prefrontal cortex. And I always liked these kind of word plays. So cortex comes from the Greek term for bark and the bark around the tree is where all the nutrients for the tree is. And so our cortex holds all of the vital information that we need right away. And that's part of the reason with all of this kind of mapping that people will continue to be very highly reactive to those triggers that the Amygdala and the hippocampus have deemed as dangerous because it's now locked into our cortex. And every time you see the dark coming, it informs the Amygdala. It's dark again. This must be dangerous. Or if you hear an ambulance siren, the cortex has locked that information saying the siren is dangerous.

Dena: (01:13:14)
And so that's what we call triggers, right? That's where the triggers come from and unless we're able to recognize, what's happening, we'll continue to keep reinforcing the Amygdala and the Amygdala is going to continue to think, "I'm pretty sure dark as danger." And this is where you hear people saying they can't go into a dark house or they fear the dark. They have to have their nightlight on. Kids will often experience a trauma and associate the dark if the trauma happened in the dark and begin to fear the dark. And of course the risk is that if we don't correct that, it becomes embedded much deeper into the brain. So again, I actually map these things out for people so that they can see. And I think the benefit in being able to map it out is to be able to look at this experience objectively, to step outside of yourself and say, "oh, it's my wiring. That's what it is. Okay. Because I know that ambulance is not for me. Why am I feeling the sweats? Why am I feeling like it's all happening again? Because it's embedded."

Dena: (01:14:37)
I want to kind of change gears a little bit to a topic that is probably very hard and maybe people aren't always comfortable talking about, and that topic is suicide. You know, if we look at Canada, there's about 4,000 people who die of suicide a year in Ontario. 1000 people die of suicide.and usually it's in the ages of 45 to 55; which is the highest age group of suicide. It's the second leading cause of death in youth secondary to accidents being the first. And I believe that even though the rate of suicide is increasing as well. In America,47,000 people a year commit suicide, 1.4 million attempts. There's a financial cost. It costs the US government to about $69 billion to deal with suicide and self injury. So, it's a loss of life and potential. In medicine, this is just some statistics from the American side, 300 doctors a year commit suicide in America. That is a very surprising to me and women physicians are more likely to commit suicide compared to male physicians. So, do you want to start off with anything? I didn't know that there's no question, it's just a bunch of statistics, but what is your experience with suicide and how did you get into that work?

 

Dena: (01:16:46)
Well, so the American Association for Suicide Prevention is a very large body, and they, have done a very good job of gathering statistics and, doing tremendous amount of research. So we do rely on the American association a great deal for information. So thanks for bringing that. One of the things that they have done also is challenged us with our language. It was in, 2006 that the American Association for Suicide Prevention, , declared that, the language around suicide is - when a person dies, they die by suicide, but they don't commit suicide. And it's about changing our approach, to language because here in Canada it was illegal until 1972 so it was a crime,within many religious sectors, a suicide as a sin. And so that's where that language came from. Commit, right. And, of course the more that we understand the complexities of this issue, the more we understand it is the world's largest public health issue.

Dena: (01:18:12)
So that's declared by the World Health Organization.But we know that it is a combination of both psychological and biological factors that lead to suicide. And so we were eliminating 'commit' because it kind of creates an end, perpetuates that stigma that something was deviant about that person. And we're replacing it with the same language that we use when we say somebody dies of cancer, somebody died of suicide. So that's one of the things that the American association has done is to kind of make that declaration and it's penetrating.

Dena: (01:18:48)
Yes, we never say the person committed cancer. The person committed a heart attack. Yeah that is important language.

Dena: (01:18:58)
The other thing that they did that I feel very passionate about is they talked about the element of choice and how people kind of often say, "well it's, it was their choice." They chose to die.And somehow that disenfranchises that person's struggle and the family's grief.

Dena: (01:19:18)
Andso their perspective is that, suicide is the result of a person's perception that there is no other choice. It's not about a choice, but their perception that there is no other choice. And it really speaks to the fact that people who are struggling with suicidality literally see their world from a very small perspective. In other words, their choices seem to have been eliminated. They live in a very narrow field. It's language that we have often used in the past. Like they weren't themselves, you know, they were in a tunnel. I think there's truth to those things. They were not themselves. People who grieve, those who have died of suicide are grieving for two people, the one that they knew and the one that they didn't know. So it's a complicated grief process. But they were also accurate in saying that people feel like they're in a tunnel because that's part of this diseased brain process is that their field of perception is incredibly narrow and they're not able to problem solve their way out of such a narrow field.

Dena: (01:20:30)
So it's not a choice, but rather the perception that there was no other choice.

Lalit: (01:20:34)
And the language you talk about -" I wish I had done something." I think people say I wish I would have vs. I should have.

Dena: (01:20:50)
That's one of the things, you know, the guilt that we feel when somebody that we care about is suffering is all due to our relationship and we take ownership for those who we care about. Right. And so in the advent of a sudden and unexpected death that results from suicide, inevitably people go to, "what should I have done? "What could I have done? " There is a preoccupation with the situation, the circumstances that led up to the tragedy. And we're always taking responsibility for that because of course we care about the person. So there's a lot of should or could or would us and they are so punishing.

Dena: (01:21:31)
And so there's no question that many bereaved individuals breathe by suicide. We'll find out so much more information in the aftermath, right? Is some families don't even know that their loved one had been suffering. And so it's not until after the death that we start to kind of peel back the layers and realize, "oh, these were indicators" or okay, there is some evidence of a struggle that they were experiencing- and so important because in peeling back the layers and looking at what that person might have been experiencing reinforces that this is a complex situation. It's not just because that person failed their test. It's not just because that person lost their home. It's because of a multitude of things. Because you and I both know there are people living under bridges and they're not taking their own lives. It is not because of the stress of things, right?

Dena: (01:22:41)
It's a much more complicated process. So it's important to let families know of this complexity. But in sharing this information now they're left with- "well, I should have known or if I were to have done this or if I were to have done that." So the Compassionate languages, can you replace the word should with the word wish. Can you look back at those now? Memories that now have much more sense to them and say, "I wish I knew then what I know now. I wish I would have done something if I didn't known about it." It's a compassionate way to talk about regret. And rather than the self punishing language of it was my fault, I should have done more.

Lalit: (01:23:36)
There was one prospective study, which showed that 23% of Interns had suicidal thoughts, but among those interns who completed four sessions of web based cognitive therapy, 50% of them had less suicidal ideation just by doing that type of work. One of the challenges in the world of medicine is that physicians, and I'm sure also with other allied health care professionals, is that there's a stigma about talking about depression and anxiety and I think certainly that opened up more.

Dena: (01:24:29)
Do you have what it takes?

Lalit: (01:24:31)
That's right.

Dena: (01:24:31)
Do you pushed through this program?

Lalit: (01:24:33)
That's right. Right.

Dena: (01:24:35)
So you never want to show your vulnerabilities. The same thing happens with first responders, right? It's fire police, ambulance say it's a, it's a huge issue with regards to both.

Lalit: (01:24:45)
And the Post traumatic stress of all that. I know in Ontario we've had, we've had some young potential doctors and there was some loss there. And, uh, that certainly has increased the awareness in medical schools as well. , I've forgotten just the statistics, but there's a high degree of students in medical school when they're studying and in residency that have depression in the whole process so...

Dena: (01:25:26)
Well, if I may say the other huge risk factors for medical students and people in such profession is the sleep deprivation, right? So if we don't restore our brain, if we don't kind of have that, those cycles, then we can form huge distortions in our thinking so it's two pronged grade. Like the, there can be a susceptibility that we now know has some genetic markers for suicidal depression. But in addition to that, it's the way that we live our lives that can also promote those levels of distress and sleeplessness is a huge one. If you talk to any, to most families, I shouldn't say any because there's always exceptions. But if you talk to most families who, whose loved ones have died of suicide, they're all able to recognize that yeah. For the last two to three nights, they didn't sleep at all.

Lalit: (01:26:22)
Yeah. Well, they use sleep deprivation as a form of torture and war. And certainly in medicine that's an issue. And the system is not set up in a way to allow physicians to sleep. We don't let airplane pilots, fly if they haven't had a certain amount of sleep. And we should certainly be cognizant of the people who are providing health care, making sure they get the right amount of sleep,

Dena: (01:27:00)
Even if it's 20 minute naps. It's enough to restore the brain ever so slightly,


 

Lalit: (01:27:05)
Ever so slightly. But you know, I'm a big proponent of setting up systems to get good quality sleep at a regular amount of time. You know, even if there are people who are doing the night shift and night work that we need to have systems in place, because you need to take care of people who are taking care of other people. Let's talk about, you know, trauma mastery and versus support groups. Is there a difference between when you should go into the support group and when you should deal with trauma and how you deal with that compared to what I think most people would think.

Dena: (01:27:56)
Yeah. So, so let me kind of do a quick one. So traumatic bereavement is an entirely different beast. I cite my Guru Dr. Teres Rando, who's a traumatologist from the states and she's done the bulk of the research when it comes to recognizing the unique aspect of traumatic bereavement. And here's the premise. It's not just the coexistence of trauma and grief, but it's the fact that trauma and grief are constantly interacting with one another and potentiating one another. And so when a person has a trigger, say the ambulance siren, it will elevate and trigger all of the physiology associated with that fear response followed immediately by "my loved one is really gone." So they go from this hyperarousal to the sinking feeling, and I call that emotional whiplash. Like they're always kind of, cause it can be the reverse, right? They can have this moment of yearning for their loved one to which then their brain wakes up and says, "and why is your loved one not here?" And they will recount the accident. So this kind of back and forth experience is exhausting and it's the hallmark of traumatic bereavement.

Dena: (01:29:17)
What happens with regards to grief work and support groups is that in order for people to benefit from those, they have to neutralize their trauma, right? So the first order of business is to master your trauma, is to understand what's going on in the brain. It's to hydrate, it's to exercise, it's to the journal, it's to reframe some of the triggers. It's to nail some of those, hyperarousal moments and be able to neutralize those. And then, and only then, are people able in a safe way to join a support group. Grief is highly contagious and trauma is even more contagious. So if a person goes into a group and they have not neutralized their trauma, they're still not sleeping well and they're still a trigger happy with all of the triggers in the environment, they are susceptible to being affected by the words that somebody else says inadvertently. They will start to kind of generalize and incorporate their experience into theirs, it gets just, it gets risky for them.

Dena: (01:30:37)
The support group question is really important because sometimes our access to counselling is two-pronged. If you have benefits and if you have finances you can access it. But if you don't, it can be a real challenge for families. So support groups generally speaking do not have a fee attached and they can be really helpful. And so sometimes clinicians are a little too quick to refer their clients to a support group because they can't afford counseling. But if they go into a support group where their trauma has not been neutralized, it's actually dangerous for them. And you're, you're talking about a traumatic death I'm talking about pretty much, yes. But again, trauma is on a spectrum. So it's about assessing because it could be that a person is highly traumatized because their parent has died after a two year battle with cancer. But what was that battle like? What did that person experience through that battle? How many results came back? Shockingly, how much of a decline and then a surge and the decline in the surge happened during those two years? So we can't make assumptions about a person's trauma until we have their story.

Lalit: (01:32:16)
Understandable. Yeah, we've covered so much ground today. I'm not even sure what the best way is to sum up, but what I'd liked about what you did in the workshops, the do's and the don'ts that's on my list? There are things that we should do is when we're talking with somebody, one was, listen and be present with them. And just be there. Another one was, talking and sharing and reminiscing about the individual that may have passed and speak their name and not skirting around the issue. What other Do's come to your mind?

Dena: (01:33:18)
It's, about being present. It's about taking a risk. Sometimes. "I don't know what to say, but I just want you to know that I'm here for you." Those kind of humbling and caring words are really important for people who are hurting.

Lalit: (01:33:36)
And I think that those are good words. Like, "I don't know what to say and I'm just here for you" because often we don't know what to say. And even if it's a tragic loss. A good friend of mine- There was a tragic, traumatic death actually and I was at the funeral and with his mother and I said, "I don't have any words to say." And she hugged me and she said: "there is nothing to say, you just being here is enough." I don't know whether it's a male thing, but you feel you have to say something but sometimes there is nothing to say.

Dena: (01:34:30)
That's right. And sometimes we're uncomfortable with quiet with silence, but sometimes silence speaks volumes.

Dena: (01:34:37)
It does. That's great. I know some of them, don't say "I know how you feel." Right? You said that's one thing to avoid, but say somebody lost their mother. I lost my mother wouldn't that apply there?

Dena: (01:35:06)
no, because you don't really know.

Lalit: (01:35:08)
Because it's different for everybody.

Dena: (01:35:10)
Absolutely.

Lalit: (01:35:11)
Yeah.

Dena: (01:35:11)
Absolutely. You know, when you have a shared loss experience, again it's, it's about this, knowing, this intuitive, knowing that tells you, okay, I think it's safe for me to say "you know what, I also experienced the loss of my mom and anytime you want to talk I am here for you "

Lalit: (01:35:31)
That a good finesse and the proper use of language. "I too have lost my mother if you ever,..." that's good. And the other don't was - don't change the subject in what context when you've said that?

Dena: (01:35:51)
Well and this is actually quite common. So bereaved individuals it doesn't take long for them to recognize that it's not always safe to open up because people are either dismissive or they feel uncomfortable. It takes an incredible amount of courage for them to share what they're feeling. If they get dismissed, it can feel like such a slap. Because it took so much courage to open up, to be honest, and then only to be met with either judgment or dismissal. The message then is, I must not speak of this. I must not talk about this. And so that's when things kind of can be complicated for people because the thing about talking ... so people say "what's the benefit in talking about it?" Well, that's what sets us apart from the rest of the animal kingdom? One of the principle things is our language. And it's interesting because we are all feeling and thinking beings and it is all of our thinking and feelings. The minute that we put them into words, it seems to organize them almost kind of like words become a code. Think about how often people feel comfort by reading a poem that speaks the words they've been thinking about. Think about what happens at the end of a very busy day. If you're talking to a friend and you just go nuts and you talk and talk and talk nothing has changed. No problems have been solved, but you feel better because you've organized the chaos. So words in grief are really important. The narrative is important because it actually helps to organize the chaos. It doesn't make things go away. Nothing is fixed. But the people, the person, feels validated and organized. That's it. So when we shut them down, we interrupt that ability to get to that place.

Lalit: (01:37:58)
And I, I remember another don't is-don't compare losses because it's so different and experiences are different as well. So, uh, this has been really fantastic and educational. I want the listeners to know a little bit more about you. What do you do when you're not counselling and do you have any hobbies?

Dena: (01:38:31)
I love to cook. Really. I just love to cook. I will get home like at 7:30 pm and I will cook something from scratch and eat like at9:30,p.

Lalit: (01:38:41)
Do you have any favourite dishes?

Dena: (01:38:44)
Just about everything. I don't like mushrooms, but yeah, I love to cook. That's probably where my happy place because it's a very mindful activity. I can't really think about anything else then because otherwise, I'll forget if I put salt in. So I, that's, that's my favourite thing to do. I really do also appreciate the outdoors, but also from that mindful perspective. In fact, one of my favourite winter activities is downhill skiing. And the reason that I like downhill skiing is cause I can't think of anything but how to get down that hill.

Lalit: (01:39:22)
That's very good. Do you, do you have a particular exercise routine that you do?

Dena: (01:39:28)
I like to say that I get to the gym more often than I do, but yes, I do try to get to the gym.But in the summertime it's about cycling and in the wintertime and we try to go skiing.

Lalit: (01:39:40)
Do you have a morning routine? Do you have a way to get yourself charged up for the day?

Dena: (01:39:46)
Not really, I'm not a very active morning person. I like to putz around and I listen to the news just to kind of get me informed of what's about to happen or has happened and tossed my half a Bagel. And after work I go.

Lalit: (01:40:03)
Well, what about at nighttime? Do have a nighttime ritual?

Dena: (01:40:06)
It's cooking. Yeah. My days are pretty tied up with regards to my schedule and stuff, but it's the weekends that I really look forward to. I have three grandchildren and I spend a lot of time with them. I love them.

Lalit: (01:40:25)
Do you have a, a life lesson or a favourite quote or words on a billboard or do you have anything that comes to mind?

Dena: (01:40:39)
It's interesting, obviously my angle, we've been talking about grief. I would love to see it on a billboard "Like Love Grief is a Lifetime Commitment.

Lalit: (01:40:52)
Like love. Grief is a life long commitment. That's where it's words to think of- that is great. Did you want to add anything else? Is there any final departing comments?

Dena: (01:41:12)
Possibly. What I would add to this is that I discovered this early on. The grieving process is a highly spiritual journey for people. We often talk about meaning in life and so on. When a person has been shattered by a loss, it's almost like that part of them has also been shattered. Any kind of value to life, any kind of oomph or any spring to their step and so, you know, they hear the words 'hope' and often they ask "what is there to hope for,?" Well hope is there in terms of hoping that you find meaning in life again. And the way to find meaning in life is kind of become more introspective is to kind of allow yourself to be vulnerable and to explore.

Dena: (01:42:10)
The introspective and complexities of life. So that I think ...I was quite surprised when I entered into this field; I never thought about. So I actually went back to school for a year and then to learn, you know, the psychology of religion and you know, personality and religion. Like why do we need to have that? Because we are spiritual beings. That's why and when we're shattered, part of the journey is about a search for meaning. And, and that's how people get to the other side of their brokenness is to be able to find things that are meaningful in their life and that somehow are connected to the legacy of their loved one.

Lalit: (01:42:54)
I think that's a perfect place to end, Dena. Thank you so much.

Dena: (01:43:00)
My pleasure.

Dena: (01:43:01)
Thank you. Now I normally ask if the audience wants to get ahold of you, can they?

Dena: (01:43:09)
Yeah, sure. Absolutely. Yeah. Probably email.

Dena: (01:43:30)
Denamoitoso@erbgood.com

Lalit: (01:43:46)
You've been splendid and I, I really enjoyed this. And thank you again for everything.

Dena: (01:44:00)
You're most welcome. My pleasure. 

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