Episode 44: Grief, Grieving and the End of Life

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Episode Summary:

The end of life is devastatingly hard, and difficult to navigate, for those grieving a loss, as well as the friends, family & colleagues of people grieving. We don’t know what to do, what not to do, or how to cope. Dr. Jennifer Levin, a traumatic grief counselor, talks us through understanding, coping with, and even growing with grief.

Guest:

Jennifer R. Levin, Ph.D., MPH, MFT.  Trauma and grief therapist, marriage and family counselor, with extensive experience in counseling and education on trauma, death and dying, bereavement, and loss.

During This Episode We Discuss:

  • There are different categories of grief experience: Natural, Traumatic, Anticipatory, Disenfranchised, Complicated, Prolonged, Delayed, Chronic, etc.
  • Everyone grieves differently. It varies within a grief category, within a family experiencing loss, and over time. This is so important to remember, to avoid judgment and hurt. The ‘stages of grief’ that you may be familiar with are not discussed in this episode—grief is more complex than the stages suggest.
  • There are many common themes in grieving, thus support groups provide critical communities. 
  • We cover how a dying or grieving person’s community can help them. And equally important, what NOT to do.
  • Organize your critical documents and affairs (see resources below), and clue someone in on where to find this information.  This is something grievers say they are very grateful for.

Quotes (Tweetables):

“…how an individual grieves is going to depend on their age; their cultural beliefs or practices; their religion; the relationship they have to a person who died; the intensity of the relationship; the history they’ve had of how many other people they’ve lost; their life stressors; their comfort with grief or with people who are sick; their personality.”

Dr. Levin

“ ….not everybody’s grief gets along and there are many different grieving styles that occur within the family.”

Dr. Levin

“…I say all the time to clients, ‘Grief has no timeline. It works on its own timeline.”

Dr. Levin

“…I always wanted to write a book—‘What to Do After all the Lasagna’s are All Gone’…”,  when “..the individual left grieving feels very alone, very isolated and has a difficult time re-entering the world.”

Dr. Levin


Episode Transcript:

Speaker 1 (00:00): 

The Original Guide to Men’s Health is moving to a monthly release schedule. We will be releasing new episode’s the first Wednesday of each month. We really appreciate you listening, and we hope you enjoy this episode.  

Speaker 2 (00:17): 

[inaudible] 

Dr. Pelman (00:18):

Whatever you do, whatever you enjoy, you need your health. Welcome to The Original Guide to Men’s Health, a podcast designed for men of all ages to learn about and access good health. This guide shares knowledge on how to be and stay healthy, maintenance and prevention strategies, along with reviews of conditions and issues affecting wellness are explored. Please join me, your host, Dr. Richard Pelman, as I interview renowned experts who will provide you with timely, relevant, and vital information so that you can embark on a journey towards better health.

Dr. Pelman (01:07):

On this episode of The Original Guide to Men’s Health, we’ll be reviewing grief, grieving, and end of life. You may be wondering why on a men’s health episode, we’re looking towards grief and grieving. But it is part of life, particularly in this pandemic where unexpected events happen suddenly. I think it’s reasonable for us to discuss these issues that are important and are part of the life cycle. To help guide us through this, we are going to be interviewing our guest, Dr. Jennifer Levin. Dr. Levin specializes in working with adolescents, teens, and adults experiencing traumatic grief and sudden loss. In 2000, Dr. Levin received her doctorate from UCLA School of Public Health. And in 2014, she earned her master’s in a clinical psychology program from Pepperdine University. She is a recognized fellow in thanatology, the study of death, dying and bereavement from the Association of Death Education and Counseling.

Dr. Pelman (02:13):

Professionally, Jennifer has served as the executive director of Hospice of Pasadena and has taught at several California universities. She provides continuing education, training, and consulting mobile grief services to schools, community-based organizations, experienced bereavement and loss. She is a licensed marriage and family therapist with a private practice in Pasadena, California, where she works with clients  living with chronic and terminal disease, bereavement, traumatic death, and post-traumatic growth. Dr. Levin, welcome. Thank you for taking the time to meet with us, and I know most people don’t like to preview the end of life or grief grieving. But as I’ve learned, it’s important for people to come prepared or be prepared or have resources. So take us through grief. First of all, a little bit of your experience of why it’s important to understand this issue, that one time or another will impact us all.

Dr. Levin (03:16):

Absolutely. Well, I just want to start off with a basic understanding of what grief is and grief is actually a natural response that we all grow through when we lose someone or something that we love. And in this case, we’re talking about someone who has died and it’s not a pathological response. It is like I said, it’s very natural and it’s not a problem that we need to fix. It’s nothing that’s wrong with us. And when we think about grief, we commonly focus on the emotional response that an individual goes through. But in reality, it’s so much more than that. There’s a huge physical component that goes through. And we also experience cognitive reactions, behavioral, social, cultural, spiritual, and a large existential component that’s all part of the grieving process as well.

Dr. Pelman (04:21):

So there are different types of grief that we as humans experience and categories are fairly varied and different. Do you want to just kind of go through the different categories that we might look at is the overall grief experience in the human condition? 

Dr. Levin (04:40):

Yeah.

Dr. Levin (04:41):

Most people think that all grief is the same and actually it’s not. A lot of it has to do with the way that an individual died. There’s what we tend to think of as natural grief. And this is often expected grief when somebody dies due to old age or the end stage of a disease such as cancer* or failing health. There’s something called anticipatory grief, and this is when you anticipate a death of a loved one. Someone you know who’s going to be coming to the end of their life in a short period of time, even as long as a year or longer than that sometimes. And with anticipatory grief, we have all of these micro losses that occur along the way. And so it’s just loss after loss, after loss and the person who is watching a loved one dies also begins to wonder during this time what their life is going to be like when they’re gone.

*Cancer: https://www.cancer.gov/about-cancer/understanding/what-is-cancer 

Dr. Levin (05:52):

So they’re anticipating the grieving process. There’s something called disenfranchised grief, and this can include not being given certain grieving rights by family members or even society who chooses not to recognize that you’re grieving a loss. Or you may be experiencing what we call an ambiguous loss, which is a loss in which you never seem to get answers to how a loved one died or the circumstances resulting in their death, which also makes it very difficult to grieve. There is grief such as complicated grief, prolonged grief, delayed grief, chronic grief, cumulative grief, and other forms of grief as well. Personally, I specialize in traumatic grief, which is one of those forms of complicated grief and where an individual experiences a sudden and unexpected loss often in a traumatic manner. And the griever is usually impacted by symptoms of trauma and grief at the same time, which can make the grieving process extremely difficult.

Dr. Pelman (07:12):

So as we view these different types of grief reactions, the behavior, and sort of the way that people will respond to you, or you respond to them may be different. For instance, as you talked about anticipatory grief, someone has a prognosis, a loved one that we all know will eventually end in death. So you have time to prepare versus the traumatic grief where it’s very short-lived and there isn’t that time. So there’s going to be a different interface in each of those. Do you want to go through a little bit with each of those of what actual grieving would look like? So, you know, people sort of have different approaches to this.

Dr. Levin (07:58):

Sure. Let’s say an individual has cancer and there’s the diagnosis, there’s the treatment. Well, it depends, you know, cancer is a different beast as well. There’s so many different types of cancer. You know many times there’s treatment and, you know, it looks like things may go well for a while. And then unfortunately with some types of cancer, that cancer comes back and there gets to be a point where there’s nothing else that can be done medically, end of life is going to occur from the disease. And an individual has time to spend with their family. And this is where anticipatory grief comes on, but they get weaker, they get sicker, they lose things. They lose the ability perhaps to walk or to eat, or to do certain things that they used to be able to do. But during that time, there’s time to maybe express wishes, to say goodbye, to see people and get things in order.

Dr. Levin (08:58):

And this can be very painful watching all of these changes occur, but at the same time it also gives, it gives the individual who’s dying the opportunity to get a lot accomplished. As I said, with the individuals that I work with, they may wake up on a Tuesday morning and I get into a car accident on their way to work. Or they may go out for a walk and have a heart problem and not come home from their walk. Or a suicide may occur during the day. And it’s very, very hard for family members and loved ones to, you know, see a person in the morning and then by the end of the day that they’re gone. So there’s disbelief, there’s numbness, there’s shock. There’s all of these different factors that come into play, not to say that those things don’t occur to a lesser extent in the other types of loss. Unfortunately in traumatic grief, many individuals may see the accident occur or the traumatic loss occur or may find their loved ones. And then there’s actual symptoms of trauma: hypervigilance, rumination of something they wish they hadn’t seen over and over, flashbacks. And there’s actual symptoms of trauma that occur as well that actually need to be addressed and resolved in addition to the actual grief or dealing with the loss of their loved one on top of the trauma.

Dr. Pelman (10:40):

So when we have a individual who has a sort of sudden event, and those that are left are totally unexpecting that to have occurred in their lives. When you encounter people who have been dealing with traumatic grief, what are some of the, well, first of all, unique features to that type of bereavement? And how can people, first of all, other family members, everybody’s affected differently, friends, acquaintances, coworkers help that person or those people?

Dr. Levin (11:21):

Well, let me start off. You said, “What are some of the unique features?” And again, this is like right afterwards in the beginning of the grieving process, one of the things that’s important to know is not only has their world been turned upside down. And again, this is for somebody who’s experienced the sudden and unexpected loss. But in the beginning, it no longer feels safe. Everything that they thought to be true of their world no longer exists. For example, I use the example of somebody going out for a walk. We expect that when a loved one goes out for a walk or goes in a car to drive and get groceries, but doesn’t get home. We expect that when people go out for a walk, they come home. We expect that when people go driving to go pick up groceries, they come home. And when those things don’t happen, the assumptions that we have about how the world works no longer hold.

Dr. Levin (12:22):

And so the world no longer feels like a safe place. So in the beginning, one of the most important things to do is to help an individual feel safe again in the world. And some of the things that can be helpful for that is re-establishing routine and structure, simple things like eating meals at a regular time, being surrounded by loved ones, daily routines. I know I just mentioned that really strong self care,  doing anything that establishes a little bit of normalcy at a time that is absolutely not normal whatsoever. But just doing things that make your world feel a little bit safe again. After a traumatic loss, you’re numb, you’re in shock. You’re, you know, in denial. Your body and your mind hasn’t caught up with what has just happened. And so having family and friends who are very supportive and understanding what you’re going through while your body is adjusting to this trauma at that time is very important while your mind is just catching up with what has happened. Having people who can help you just picking up the kids, getting some groceries, walking the dog, doing the tasks that all of a sudden you’re not able to do at that particular moment as you’re just trying to function, you know, just to eat, sleep, just do those basic things.

Dr. Pelman (13:59):

And for those who surround the individual who’s in this grief process or the family or, you know, close friends, coworkers who are all grieving, there are varied reactions from some people who just don’t deal with death very well and may turn away. So the family, the spouse, child, or coworker, or friend may wonder why somebody they know fairly well has just disappeared in their life. And there’s other people who are trying to be supportive and not unwelcome, but be a little more forceful than the person is ready for. So how do people gauge and what should people do? And how do we view those two extremes?

Dr. Levin (14:45):

Something that my clients probably struggle with immensely is reactions from family and friends. You know in our society we are so uncomfortable at large with the topic of death and dying. And we’re so uncomfortable being in the presence of others who are grieving. And so many times when our friends and families who are grieving need us the most, we’re so uncomfortable. We don’t know what to do. So we don’t do anything at all. So we do turn away. We don’t call because we don’t know what to say. When in fact people need us the most, they don’t need much from us. They need our presence. They don’t need us to fix anything because there’s absolutely nothing to be fixed. I think some of the things that my clients will say are the worst things that you could do are to say things like, you know, “He or she is in a better place,” or, “It was God’s plan.” Other comments such as, “If you need anything, just call me.”

 Dr. Levin (15:54):

Those are comments I hear over and over again as being so unhelpful. Comments or things that are very, very helpful are to drop off meals; come over and water the lawn;  pick up kids from school; just do things that need to be done. Because when people are grieving, they’re fatigued, they’re tired, they’re overwhelmed, they’re disoriented at times. And again, a lot of what I’m talking about is right in the beginning stages. And we can talk a little bit more about what long-term grief looks like, but often we’re out of sorts. And so having people just do things for us without having to ask is such a relief or such a welcome gift. I know one woman said, you know, everybody comes over and grieving during the pandemic has also been a very difficult thing for many people because of the social distancing, because of the isolation where normally we would congregate that hasn’t been such an opportunity for many people. But one woman talked about, you know, people came over, they fixed my fence, they mowed my lawn, they took the trash out, and just how helpful that was for her without having to come up with a list or having to ask people to do certain things. But just being there, being present, not having to let people know what you need. Cause like I said, a lot of times people who are really in the midst or the depths of grief don’t really know what that is.

Dr. Pelman (17:35):

So it would be something to sort of ask as not immediate family or very close friend, but you know, somebody you’re well acquainted with and I’m certain that many people feel they’re going to be too intrusive to come in and do many of those things, which would be welcomed. So how does somebody who’s not immediately within the nuclear family or absolutely so close that it’s not an issue approach somebody who’s grieving to find out where the boundaries are? What’s the easiest way for them to do that?

Dr. Levin (18:06):

That’s a great question. Usually closer member of the family will arrange a meal train or a will be organizing tasks that can be helped. So if you’re not in that inner circle, ask around and find out who is organizing it. Or, you know, Instacart or whatever, will deliver groceries or deliver food. I mean, if you can’t, you know, get in and do those real close things, there’s always things that you can just have delivered or sent or a note, things like that.

Dr. Pelman (18:45):

And then let’s look at the actual close nuclear family or very close friends, immediate relationships. We’ll take the person who is grieving to the point where they’re not functioning. And then the opposite, the person who continues on, goes to work, does all the things and doesn’t seem to have even stopped for a moment to ponder what happened. People will look at both of those and think they’re extremes, but we’re all different. So how do you address those two polar opposite types of approaches to grieving?

Dr. Levin (19:19):

So let’s talk a minute about what grieving actually looks like among different people. Grief is so unique. It’s such, I mean, it’s like a snowflake, no one will grieve alike. Everyone has different patterns. Everybody handles grief differently. There’s grieving styles across genders. Research by Kenneth Doka has shown that men are more likely to be instrumental. They like to grieve or it’s helpful for them to grieve doing tasks, instrumental tasks, doing things around the house, fixing things where women are more intuitive. They like to talk. They like to express their feelings. Of course, how an individual grieves is going to depend on their age;  their cultural beliefs or practices; their religion; the relationship they have to a person who died; the intensity of the relationship; the history they’ve had of how many other people they’ve lost; their life stressors; their comfort with grief or with people who are sick; their personality.

Dr. Levin (20:28):

So many different things. You use the example of someone who goes to work. Some people do not want to express their feelings. They unfortunately sweep it under the rug and they feel if they go to work, it’ll distract them. If they pretend everything is normal, then it didn’t happen or they’re going to be able to function better that way. Usually these are people who will experience what would be called delayed grief and maybe 2, 3, 4 years later, they may experience illness. They may experience a mental health struggle and it will come up and catch up with them later. Some people do become non-functional like you said. They may become extremely depressed. They may stay in bed. Many of my clients, especially with a traumatic loss, you know, if there has been a suicide, an overdose, a car accident where several family members have died, they do become non-functional.

Dr. Levin (21:35):

Luckily it usually lasts, you know, a period of anywhere three months to six months to nine months. Everyone is completely different. And hopefully there’s a lot of family support and love and care, and people who come and help with a lot of the daily functions to help somebody be able to get back on their feet. It’s just different for every single person. So grief is going to be very, very different. It’s very common to see people feeling overwhelmed, to have a lack of interest, to not want to go on with their life early on without the person that they loved. You see this so often when spousal loss, I mean, people who’ve been married 30, 40, 50, 60 years who’s grown up with a spouse and done everything with the person, their partner, all of a sudden doesn’t know how to exist without their loved one. Doesn’t know who they are.

Dr. Levin (22:36):

They’ve lost their identity. You see yearning and sadness and crying and loneliness. All of those things are very, very common. But one thing I share with clients is it’s not always going to be this way. It does get better over time. It doesn’t go away, but there’s a lot of tools that we work on in therapy and with social support and friends. So it does get better. We talked about, you know, it’s very common to feel like it’s difficult to fit in with friends. It’s a very known reality that there’s a tremendous amount of support, right? After a loved one dies. I always wanted to write a book, what to do after the lasagnas are all gone. You know, everybody crowds around and gives a tremendous amount of support after the funerals. But then life goes on. People get back to their normal routines.

Dr. Levin (23:42):

And the individual left grieving feels very alone, very isolated and has a difficult sometimes time reentering the world. Again, those who’ve been grieving during the last 18 months have been really struggling during COVID because it’s been very difficult to re-engage during the world, or into the world. And many times they feel that other people don’t understand what they’re going through. So grieving is very different, very unique for every single person. Individuals who are grieving are also faced with what we call triggers. Sometimes I call them grief attacks, or it’s a name often used throughout grief professionals. These can be sights and smells and sounds. Sometimes the dates are anniversaries or special events that come on without warning and just kind of hits you like a load of bricks or a wave. And you can be doing really well one moment. And then you’re just flooded with a grief emotion. And there are many ways that we help individuals cope with these memories or just bouts of extreme grief and sadness that are very normal, very natural, and just helping people work through those triggers that just bring up intense feelings of sadness that are all just part of the grieving experience. So I don’t know if that answers your question about how unique the grieving experience is. It’s probably one of the most unique experiences with many, many commonalities.

Dr. Pelman  (25:31):

So a number of things, obviously everyone is different and everybody’s reaction is different. When you mentioned an author, Kenneth, you say that again or spell it.

Dr. Levin (25:42):

His last name is D-O-K-A.

Dr. Pelman (25:45):

And he explores a lot of what we just reviewed?

Dr. Levin  (25:49):

He’s done a lot of research, but he was one of the first people who looked at gender differences in grieving.

Dr. Pelman (25:56):

So let’s, again, look at those polar opposites. The person who doesn’t seem least bit affected, you know, goes to the funeral, is at the gatherings, goes to work, comes back. If there’s family members, maybe they’re not that close. Maybe they are, or friends. What should they do, if anything?

Dr. Levin  (26:16):

You know, if someone’s not that affected, I would be very curious about the relationship they had with the individual who had died. You know, in terms of, you know, was it a parent that there was a falling out with 10, 15 years ago? I would hate to say, or be hard-pressed to say that somebody is not affected. It would just be whether or not they’re choosing to acknowledge it, or they’re just reentering their world right away as a way to distract themselves from what’s happened. Right.

Dr. Pelman (26:49):

Okay. Let’s say that they’re just choosing to not be affected and you know, said sometimes it comes back. Is it the place of somebody within the family to offer them the fact that perhaps they should get some counseling? And take the opposite, the person who seems so affected, they can’t get back on track. That person would be more obvious. The person people say, “Hey, counseling may be good for you.”

Dr. Levin (27:16):

Yeah, everybody does grieve differently. And a lot of times I’ll work with families. And one of the things that I will say is not everybody’s grief gets along and there’s many different grieving styles that occur within the family. And often family members don’t like to be judged by one another in terms of who’s grieving one way or another way are judged to be grieving right or wrong. Usually there’s a lot of critiques among family members as to whether or I’ve encountered many critiques among family members about whether one person is grieving an appropriate manner or another. But in reality, it’s unique for everybody.

Dr. Pelman (28:03):

Again, the person who is so withdrawn and not able to perhaps get to work, take care of themselves, get out, they seem to become isolated. That would seem very obvious. When friends or family or coworkers recognize this as an issue, how should they approach somebody?

Dr. Levin (28:22):

Just by, you know, noticing and say, you know, I noticed that you’re really struggling since so-and-so, you know, has died. Have you thought about joining a support group? Have you thought about talking to somebody? There’s also some wonderful books. A lot of religious organizations will offer support through a church or a synagogue or another religious institution. So a lot of different ways to get grief support there’s online programs and groups. A lot of the support groups nowadays are online due to COVID, but there’s, you know, in-person groups, there’s online groups, there’s in-person therapy, there’s online therapy, you know, or many people talking with their friends is sufficient. And then there’s the benefit of going to see a counselor. Going to see a counselor does not mean that you’re not handling your grief well. Some people just like to process the loss and the things that are associated with a loss, whereas other people will find they’re having significant problems in terms of parts of the relationship that were never worked through, or they’re having physical problems that have started stomach aches or headaches.

Dr. Levin  (29:53):

They’re not sleeping since a death has reoccurred. They’re having nightmares. They’re replaying situations that they saw in their head associated with the death. So people might engage in therapy for all sorts of reasons. I lead a spousal grief group and they find it participants will talk about how they find it, just so helpful to hear how other people are handling their loss. What are they doing about the loneliness? What are they doing about cleaning out closets and rituals around anniversaries and milestones? And so, it could just be a wonderful place to get support. So again, seeking support doesn’t mean that there’s anything wrong whatsoever. It could just be a wonderful resource or it could be an excellent avenue. If you are struggling with something specific related to your grief.

Dr. Pelman (30:58):

I know that many of the hospitals offer a group grieving opportunity for people to attend sessions. It doesn’t have to be immediate after somebody has passed away. It can be a year or two, even longer?

Dr. Levin (31:14):

Yes. I’ve had participants in groups five to 10 years afterwards, and I’ve had people, you know, reach out and call me the day it’s happened. And again, those are in more of the traumatic situations, but I say all the time to clients grief has no timeline. It works on its own timeline. And as soon as you set a timeline on grief is this as soon as it’s going to backfire on you.

Dr. Pelman (31:43):

And if we looked at the, I think it was anticipatory, we were talking about individuals who have a very poor prognosis that will at some point end in death. Tell me a little bit about, first of all, for that individual, the people who have received that very bad piece of news, go through some trauma right away. Everybody does. I mean, as a physician, we’ve had to talk to patients about a prognosis. Some are shorter than others, but what would you advise to the person who just received some bad news?

Dr. Levin (32:21):

There’s a lot going through somebody’s head who’s just received news like that. I spoke to a woman last week who thought she was doing well and was just told she had a three month prognosis, and she was incredibly overwhelmed and confused and angry and sad. And to be honest, all I could do at that point was just listen and give her the space to absorb everything that she heard. There wasn’t really anything I could tell her at that moment.

Dr. Pelman (33:01):

There seem to be stages in dying, obviously. And hospice situations are very well set up for that individual and the family to come to terms with sort of the end of life, that last turn of events that will lead to death. When I asked this question, I was thinking more in terms of, I just received the news, you know, reaching out for support. Obviously the physician, family, friends, some people would want to tell people, other people don’t like anybody knowing what’s happening. So again, we have polar opposite reactions cause we’re all different. So how do you, for that first part, that initial just got some bad news, how would you advise individuals? And then we’ll talk about the family and those around that individually.

Dr. Levin (33:50):

Yeah, absolutely. So first just give the individual some time to process what they heard. You know, what’s the first thing that comes to their mind, help them identify what are their biggest fears, the biggest concerns that they want to address in the amount of time. You know, I am a huge supporter of hospice. I think it’s an absolutely wonderful organization. I used to be a director of a hospice 20 years ago, and it’s something that I’m highly supportive of. And of course, you know, the goal of hospice is that everybody has a dignified death and a death without pain and able, it’s actually been a while since I’ve looked at the actual goals that hospice would say, so I apologize if I’m miscommunicating them. But you know, not everybody still reaches the acceptance and is okay or comes to terms with their death. Many people still die, unfortunately, feeling cheated and angry. But you know, to ask, you know, and actually I’ll be speaking with this woman later tonight, what is it that she wants to accomplish? What is it that’s important to her and what is it that she feels that she needs to do? And helping her in any way that I can accomplish those things, who does she want to talk to? What does she need to do to get her affairs in order? You know, just making those things happen to her so that she can not have the regrets. Is there anything that we can accomplish so that she doesn’t have the regrets that are there any regrets that we can eliminate?

Dr. Pelman (35:36):

And then for those that surround the individual,  you know, for the person who doesn’t wish to be isolated, yet many people don’t want to bother that person or intrude on somebody at this time. So what’s a general rule for people feeling comfortable about how far they can intrude or not intrude? Or, you know, how can they help? And, you know, again, we kind of started with this at the beginning, but now we’re in a very particular situation. Somebody who, you know, well enough mentions to you that they just were told they had X amount of time or a terminal diagnosis.

Dr. Levin (36:09):

Well, and again, I’m going to speak about this particular case. She has so little control of the remainder of her life. And so it’s going to be about what does she want with her friends and her family and how does she want help from them. And it’s not really going to be about what her family and friends can do for her. It’s what does she want from them. Because at the end of life, she’s lost all control over what’s going to happen to the remainder of her life. And so making sure she has as much control about the last decisions that she has available, while at the same point acknowledging that it’s so important that the people who love her have a chance to express how they feel. And if she does or does not want, you know, visitors or things like that, finding a way that’s acceptable for her to be able to receive their support. Whether it’s in a written way or a video or whatever, it’s all going to be about what she’s comfortable with and what’s okay for her.

Dr. Pelman (37:30):

So if say a friend, not somebody that they see all the time, but here’s from maybe one of the other family members that this is happening. What’s the safe way for them to approach this person? They may feel hesitant to do so. And yet still on the other side, if they don’t, after the person passes, feel some guilt that they didn’t. So, you know, it’s a human condition and kind of give some advice just in general. And of course we’re all different. So nobody holds you to absolutes.

Dr. Levin (37:59):

Yeah. And you know, you’re touching on such an important issue that I train my staff on because oftentimes there’s something called the Ring Theory*. And I wish I had it in front of me to show you. There was an article in the LA times about it. There’s a series of rings. So if you imagine a dart board. Okay, so the person who’s grieving or who’s dying is in the very middle. Okay. And according to the Ring Theory, you put comfort in and you dump out. So the person who is grieving or the person who’s dying is in the very middle and it all centers around their needs, and everybody else is external. So it’s all about what they want and what they need. So the friend who may or may not be that close, what they want or need is peripheral. It doesn’t matter as much as what the person in the middle wants or needs. And so they may have a need to express condolences, to express grief, sadness, or sorrow. They can only dump out their guilt or their sadness that they didn’t get to do that to people who were more peripheral than they are. They can’t dump in their sadness that they didn’t get an opportunity to do that. Does that make sense? 

*Ring Theory: https://www.latimes.com/opinion/op-ed/la-xpm-2013-apr-07-la-oe-0407-silk-ring-theory-20130407-story.html 

Dr. Pelman (39:35):

Yeah.

Dr. Pelman (39:36):

You know, I think for the individuals who were hesitant, you know, because maybe they’re close, but not there every day, but they heard this not from the individual. They want to approach individual, to be honest and say, I’m not good at this, but I do want to. Would that be acceptable?

Dr. Levin (39:53):

Yeah. I mean, but they need to talk to people and say, gosh, I feel really bad that I wasn’t able to do this. I’m not good at that. They need to talk to people on the outside of the circle, not to people on the inside who are more impacted by it. So they can write a note and send letters or condolences. But with their frustration about their inability that they didn’t get a chance to say goodbye or that they, you know, feel bad that, you know, they weren’t there for the person, that has to go out towards the outer part of the circle and not the inner part.

Dr. Pelman (40:38):

And, you know, while the person is still with us and they want to approach that person, can they take that approach? Yes.

Dr. Levin (40:45):

The person in the middle of the circle gets to do whatever they want.

Dr. Pelman (40:49):

So you want to approach the dying person and you know, your acquaintance? You can’t.

Dr. Levin (40:55):

Unless they give you permission

Dr. Pelman (40:58):

And how would you even? You know, they’re out and about and you run into them and you’ve heard.

Dr. Levin (41:05):

You know, hi, how are you? And if they say, “Fine. I’m doing great,” then you leave it at that. If they say, “Actually I’m not doing well, I have X, Y, and Z,” then you can go there because otherwise, you know, what happens is the person in the middle begins to take care of everybody else. And that’s what’s exhausting for the person in the middle.

Dr. Pelman (41:31):

And then, well, we have just the opportunity to explore not somebody who’s received a diagnosis, but just somebody who’s preparing their family for an event that may occur in a number of years or sooner based on age or just statistics. I was recently at a celebration of life for a friend who was in his mid to later eighties. And, you know, his family expressed two things. One is he had told his daughters that he was, and his grandchildren, that when he passed he had a great life. And they can be sad, but they shouldn’t feel that he was deprived of anything. And that was very helpful for them to just know that he had had that fulfilling life. The other was, he was very meticulous because his work required it and he had a book and he made sure they all knew where the notebook and it was organized book of accounts. You know, from financial to wishes, to desires, to property, to what to do. And obviously some of this runs into estate planning for those that can take care of the states and have the means to look after wills, but just to have a book where everything is organized with such relief to the family. So for those who are doing well, but eventualities it just seemed like a nice thing to do for those who remain.

Dr. Levin (43:03):

What a gift. You know, as I mentioned, I work with so many people who have dealt with an unexpected death and unfortunately some of them on the younger side, you know, thirties and forties and fifties, who never thought that this would happen so early. Who not only, you know, are dealing with the fact that their loved one unexpectedly died, but all of a sudden they have to figure out how to bury them, where to bury them. They have no idea whether it’s passwords to anything. There was no organization to anything. And it’s an absolute nightmare. It’s an absolute nightmare of paperwork, of bank accounts and it doesn’t end. And it is such, I hate to use the word “Burden,” but there’s no other way to put it on the person. You know, especially I had just a slew of men in their forties having heart attacks, you know, unexpected heart disease that nobody knew about.

Dr. Levin (44:03):

And, you know, women in their forties with young kids or, you know, kids in middle school, early high school, all of the sudden figuring, having to, you know, be single moms, all of a sudden having no idea how to find things out. And it was just the most stressful thing on them ever. And so I encourage everyone, everyone to get organized, no matter what age you are. I encourage everyone to complete forms such as an advanced directive*. I encourage everyone to have all of their passwords and whatever in a notebook. And speaking from personal experience, I not only is it hard to do these things, but it’s hard to be the receiver of this information. You know, my dad many times has showed me this is where all this information is. I don’t even want to hear that. And even though it’s all organized, I know where it is, but we don’t want to talk about it and we don’t want to receive it. But it is so important because life can turn on a dime. And so the individual you were talking about gave his family a true, true gift.

*Advance directives: https://medlineplus.gov/advancedirectives.html 

Dr. Pelman (45:19):

So Dr. Levin, what does healing from grief actually look like?

Dr. Levin (45:23):

So that’s a really great question. People ask all the time, am I ever gonna get over this? Or is my grief ever gonna go away? And in reality, no, we never really lose or, excuse me, we never fully recover from losing someone we truly loved. We never fully heal, but here’s what happens. The hole, literally people talk about a hole in their heart, things grow around the hole. The hole doesn’t necessarily get smaller, but instead lots of growth takes place. And there’s a couple of ways that I’ve heard this explained. One is commonly referred to as the Fried Egg Theory*. And if you think about an egg and if you put an egg in a pan and there’s the yolk. So if you look at the yolk as the grief, the yolk stays the same, but what happens is the white of the egg gets bigger and bigger and bigger.

*Fried Egg Theory of Grief: https://www.funeralguide.co.uk/help-resources/bereavement-support/the-grieving-process/tonkins-model-of-grief 

Dr. Levin (46:36):

And that is the growth that the occurs. So some days, you might feel like you’re closer to the yolk or you’re stuck in the yolk and the grief hurts really bad. But other days you are so lost in the growth, the white of the egg, which has grown so much, you’re super far away from the actual grief. And you forget that the pain is there. Another way I’ve seen this explained is like a ball in a jar. If you put a golf ball and a really small jar, the golf ball takes up the entire jar. But if you put it in a medium sized jar, the ball is still the same but the jar is bigger, and there’s more room and there’s more air. And if you put it in a huge jar, again, the ball is still the same, which represents the grief, but the jar is so much bigger. And there’s so much more room for expansion and growth that you sometimes don’t even notice that the ball is there

Dr. Pelman (47:53):

Is that happens spontaneously to some people?

Dr. Levin (47:57):

Nope. There are this whole thing and, you know, trainings on how to facilitate post traumatic growth and counseling, and how to facilitate growth. I mean, that’s the whole idea. And I mean, truly that’s my favorite part is to see people come in and say like, “I don’t want to live anymore. My life’s never going to be good again.” And then to see them go away, you know, 18 months later and talk about, you know, all the new opportunities in their life and the way they see the world differently. And, you know, that just takes place over time.

Dr. Pelman (48:31):

So some of the benefits to actually having counseling, to be in a group, to seek being with others, to have some guidance, is the ability to replace a small jar with a medium jar, to a large jar.

Dr. Levin (48:44):

And it’s just the reframing and seeing beauty in the world again. And, you know, we do a lot of gratitude work. And in terms of the work that I do with my clients who have experienced so much trauma, I rely on a lot of work that was talked about, or that has been studied by doctors Tedeschi and Calhoun in North Carolina. And they coined the term post-traumatic growth*. And this is a concept that’s actually been around for a really long time. But basically according to them, after someone has experienced a trauma and they experienced a huge drop in their life as a result of trauma, they can grow in a new way that not only do they go back up to the level in their life of where they were before the trauma, they actually exceed in their life, their wellbeing way above where the trauma occurs.

*Post-traumatic growth: https://www.apa.org/monitor/2016/11/growth-trauma 

Dr. Levin (49:52):

And often they experience growth in several new areas. And these areas or domains actually occur in their ability to develop deeper relationships; in their ability to try new things; increased inner strength in their ability to have a greater appreciation for life; or spiritual enhancement. So even though grief is perhaps one of the most painful things we will ever go through in our life, there are very positive things that can occur in terms of growth and healing. This is not exactly what I share with my clients when they come in to see me on the day or the first day. But it is something that I will say I find very fulfilling and helps me in the work that I do.

Dr. Pelman (50:56):

Yes. Well, we’d like to always wrap up episodes with resources and in your world, personally, you have a online program from grief to growth. And so it mentioned what you have is resources that you can think of, that we can also post for our listeners where they can find it on our website as well, but go through some resources for folks.

Dr. Levin (51:24):

Sure. So in terms of what I was just talking about for the advanced directives, AARP has a great spot on their website, AARP Advanced Directives,* and they have by state. They have the legal forms that you can download and complete your advanced directives, which is a form where you can assign a healthcare proxy to make medical decisions for you. There’s also a site called Five Wishes, which is a discussion in which you can talk about your end of life care wishes are with your family. And the discussion guide is at fivewishes.com**. When you do these forms, it’s super important that you give it to your family members and your healthcare providers so that can be part of your medical records. So that’s important. I developed a online course for individuals who are living with traumatic loss, and it can be found at my website, fromgrieftogrowth.com***, and at it’s under courses. And this is an online program. It has eight different modules where you can do it at your own pace and your own timeline. And again, this is geared specifically for individuals who have experienced a sudden and traumatic loss. And it’s a series of videos, growing tips and worksheets designed to help you work through some of the issues that we talked about today.

*AARP Advanced directives: https://www.aarp.org/caregiving/financial-legal/free-printable-advance-directives/ 

**Five Wishes: https://fivewishes.org/Home 

***From Grief to Growth: https://fromgrieftogrowth.com/ 

Dr Pelman (53:04):

And we have listeners around the states and around the world. Your religious affiliation minister, rabbi, the clergy pastor certainly have resources to help and hospitals nearby also have those resources. 

Dr Levin

Absolutely. 

Dr Pelman

Well, Dr. Jennifer Levin, thank you for joining us in a topic that is uncomfortable for many, many people, but is something that if we do think about and perhaps can help those who we wouldn’t be able to speak with because of our discomfort. Maybe this episode will give us some insight as to how to approach folks when we’ve been hesitant and for family members, some resources and some opportunities, so truly appreciated. And thank you. 

Dr Levin

It’s my pleasure. 

This completes another episode of The Original Guide to Men’s Health podcast. We wish to thank all guests who volunteered their time and knowledge. The information presented is the opinion of the speakers. The show’s recordings are engineered and edited by Sean Fox. Episode titles and descriptions, as well as editing assistance, are provided by Dr. Kathleen O’Connor, PhD. Music for our show is San Juan Bell’s, written and performed by Dr. David Whiting. The podcast is sponsored and published by the Washington State Urology Society.  The Original Guide to Men’s Health is an original publication of the Washington State Urology Society. Reproduction and use without the express written consent of the society is prohibited. For more information about men’s health and previous episodes, as well as additional recommended resources, visit us online at https://theoriginalguidetomenshealth.org/ . This is Dr. Richard Pellman thanking you for listening, and reminding you to take care of yourself.

Dr Pelman (55:14):

Good news. The Original Guide to Men’s Health has just finished a brand new website, and you can find it online at the originalguidetomenshealth.com. Also the https://www.wsus.org/podcasts.html. Our website has podcast episodes, resources, links to our brand new social media accounts, which can also be found in the episode description.

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