Archive for 2016

Do Unemotional Grievers Need Counseling?

Some people appear unaffected by grief. Their life quickly returns to normal and they don’t seem to be upset following a death. Many well-meaning people, including therapists, might interpret this as repressed grief. These caring people fear that there will be a significant cost (substance abuse, withdrawal from others, disconnection from themselves, etc.) to avoiding emotions. Many times there can be, but sometimes this concern is misguided. Consider a few more factors before you tell a seemingly unaffected person to seek out grief counseling:

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  • How did they adapt to past losses? Past behavior is one of the best predictors of future behavior. If they previously experienced a major death or loss of relationship, consider how that went. If well, they will likely benefit from following the same steps (i.e. exercising regularly, talking about it vs. not talking about it, etc.). If it went poorly, they will likely benefit from trying something new like counseling.
  • How emotionally expressive are they normally? People who are typically unemotional will likely continue to appear unemotional, even in the face of catastrophe. Sometimes appearing unemotional is, and has always been, a maladaptive coping mechanism for a sensitive person who has never learned how to communicate their feelings (this person is likely to benefit from counseling). But don’t forget to imagine that it might just be their normal, well-adjusted temperament to be unemotional.  It does not have to be an indication that something is wrong.
  • Do they want to go to grief counseling? This question isn’t always so obvious. Have you asked? Can you respect their autonomy if the answer is no? Careful: forcing or guilt-tripping someone into counseling can actually make them get worse. Can you be patient if they don’t want to talk about it? How about providing some education about the impact of complicated grief (see my other post) if they aren’t sure?

Want some expert help assessing whether you, or someone you care about, would benefit from grief counseling? Give me a call at 720-515-9427 and let’s sort it out.

The Stages of Grief Myth

Pop psychology can be harmful.  The way most of us understand the “five stages of grief” (denial, anger, bargaining, depression, & acceptance) is a great example. A few cautions:

  • Elizabeth Kubler-Ross, who developed it, was not studying the experience of grieving loved ones but rather the experience of dying people themselves. Therefore, it’s relevance to grieving family members and caregivers is, at best, limited.
  • She repeatedly stated that people might not go through all the stages and that they are not linear (i.e. one stage does not neatly follow the next).
  • The stages may be most useful as a list of common grief experiences. Recent research replaced bargaining with yearning (intense longing to reconnect with the dead person) and found yearning to be the most dominant negative grief experience many people have.  This list, though, is anything but complete.  Grieving people experience a wide range of physical, cognitive, and emotional consequences.


At the end of her own life, Kubler-Ross summarized the myths born out of her model.  She wrote:

“The stages have evolved since their introduction, and they have been very misunderstood over the past three decades. They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grief is as individual as our lives.”

When Facing Death, Words Can Do a Lot.

In this podcast, Dr. Ira Byock highlights the importance of healing old relational wounds.  I am excited to share this because many of the people I see for grief counseling would be in far less pain today had they had the opportunity to have these sorts of conversations with their loved ones.  While still very possible, it's much harder to reconcile old wounds when the other person is no longer here.  Should you have the opportunity now, consider your future grief and don't wait.


Dr. Byock advises four statements that can guide these conversations.  I think they can also be a useful way of understanding about what grieving people need to reconcile before they can move forward following a death.

  • Please forgive me
  • I forgive you
  • Thank you
  • I love you

Listen to this fantastic podcast, or give me a call 720-515-9427 if you would like help mending or clarifying your relationships before you or a loved one dies.

Can Hospice Care Actually Lengthen Life?

The typical debate about hospice care vs. aggressive medical treatment is one of quality vs. quantity.  Hospice care emphasizes symptom management and emotional support, ideally leading patients and families to have a higher quality of life.  Aggressive medical treatment emphasizes curing or stalling an illness, ideally leading patients and families to have more quantity of life.  Research shows, though, that's not always the case.

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This preliminary study examined these ideas and found that hospice was not associated with shorter survival.  In fact, for some illnesses (CHF, lung cancer, and pancreatic cancer) hospice enrollment was actually associated with longer survival. Perhaps the conventional wisdom associating hospice with quality while aggressive treatment is associated with quantity is too limited of a view?  There may be cases where hospice care can increase both the quality and quantity of a patients life.

Furthermore, this (false?) dichotomy between quality or quantity at the end of life disregards a little known, and important, third option I will write about at another time: palliative care.

The Importance of Planning

We’re bad at talking about death. And yet, whether or not it’s conscious, most people have fairly specific wishes for how they want to die.

  • Some prefer to die at home surrounded by family members whereas others prefer to die in a hospital to reduce the burden family members might feel
  • Some prefer to know that their doctors will fight aggressively to the very end whereas others prefer more emphasis on the quality of their life once they have come to terms with what might be a low chance of recovery
  • Some prefer making specific plans around finances or what a memorial service might look like whereas others might be less concerned with specifics than having their values considered when decisions are made

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The most important step, though, is to have the conversation because the alternative can be disastrous. When people don’t talk about end of life wishes, patients often get what they don’t want and family members often end up burdened with the worst consequences. A well-intending family member might have no idea whether or not his or her loved one would have wanted to be put on a ventilator, or even worse, know when a ventilator should be turned off. They might feel guilty for the decision they do make; they might regret not having clarified things much earlier; And I’ve seen time and time again that not having these conversations can disrupt a family member’s grieving process, causing unnecessary harm for months or years following the death.

Many people prefer not to talk about death secretly hoping that if they ignore it, it will go away. Others imagine that these conversations can wait. But I’ve learned a simple mantra over and over again from my, sometimes intensely suffering, clients: Don’t wait. Find a way to at least begin talking about the most important conversation most of us never have.

Looking for places to start? I can be a resource, or you may want to start with these fantastic websites:

Complicated Grief: Definition, Impact, & Risk Factors

In the wake of a death, people experience grief. They may feel sad, lonely, or low on energy. They may feel disconnected from others and think frequently about the person who has died. This can go on for months or even years, but as long as the intensity of their symptoms decreases over time, their experience is most likely healthy and normal. The trouble occurs when time alone does not heal; in some cases these acute symptoms morph into a persistent condition called complicated grief. People experiencing complicated grief get "stuck." That is, they are unable to effectively move on with their lives.

In spite of affecting ten to twenty percent of people who experience a significant loss, complicated grief is a little known mental health condition. This is all the more surprising when its impact is understood: People who develop complicated grief tend to be debilitated by it. They may look severely depressed or traumatized. They may have difficulty connecting to others or keeping a job and are at greater risk for developing a substance use disorder.


Someone with complicated grief can benefit from psychotherapy. Also someone who appears high risk for developing complicated grief in the future can benefit from psychotherapy as a means of prevention, even before the death. Psychological risk factors for complicated grief include: already having a significant history of close people dying, a history of coping through suppression (i.e., trying to force stressful thoughts out of your mind rather than facing them), having a significant mental health history, or simply being very close to the person who died (e.g., the loving spouse). If you or someone you care about might be at risk for, or is already showing signs of complicated grief, speaking with a trained mental health provider could be of real help.

Learn more about preventing and treating complicated grief by contacting Dr. Altschuh at 720-515-9427 or visit