Jennifer Levin
Hi everyone and welcome to Untethered: Healing the pain from a sudden death. I am Dr. Jennifer Levin, and I specialize in traumatic death and helping individuals through the struggles, pain, trauma, and chaos of an unexpected death. Today’s podcast is the first in our new format. Moving forward, I plan to interview professionals who work in the field of sudden or unexpected death and individuals who have experienced losses themselves. In today’s interview, we have both. Dr. Rynearson, is a semi-retired clinical psychiatrist and researcher from Seattle Washington where he founded the section of psychiatry at the Mason Clinic. In addition to full-time clinical practice, he has served on the clinical faculty of the University of Washington as a Clinical Professor of Psychiatry. For over 20 years, Dr Rynearson has maintained a particular clinical and research focus on the effects of violent death on family members and has been published in clinical papers, book chapters and three books, Retelling Violent Death and Violent Death: Resilience, Intervention Beyond the Crisis and the Restorative Nature of Ongoing Connections with the deceased. He has delivered numerous national and international training on the management of the clinical effects of violent death and with grant support founded the non-profit organization the Violent Death Bereavement Society (www.vdbs.org), establishing an informative network for service providers, teachers and researchers of traumatic grief after violent death. He also developed a collaborative training program for Israeli and Palestinian clinicians in supporting members of their communities with traumatic grief associated with violent death. Currently Dr. Rynearson is spear heading a grief companioning program for individuals who have experienced a violent death, to receive no cost support to help guide them through their grief journey Finally, Dr Rynearson lives in Puget Sound and enjoys hiking and spending time with his family. I want to say – that I am proud to be a volunteer in Dr. Rynearson’s Companioning program and have had the absolute pleasure to get to know, work beside and learn from him. Welcome. Dr. Rynearson. I am so pleased to have you here today. And I think the first question I would like to ask you is how did you get into the field of sudden and unexpected loss?
Dr. Rynearson
Well, first of all, it's very unusual that a psychiatrist has been involved in this whole area of grief, I think in part because grief as I see it is more of an adjustment, a right of passage than it is a psychiatric disorder. So it's an adjustment I've always been interested in, because that's been my primary interest in psychiatry going back 60 years ago, when I began my began my training in that era Adjustment and psychodynamics was really emphasized in the in the training. We certainly were neuro biologically based in psychiatry in the 60s and 70s. But we also spend a lot of time getting to know patients and getting to know what their stories were and what sort of situational factors had impacted. And I was always much more interested in that aspect of psychiatry than I was in terms of diagnosing a disorder in the 60s and 70s. There were about half as many psychiatric diagnoses as there are now. Or too many as I see it. So I had early on a particular interest in listening. I started off my training, my graduate training in neurology for six months and then switched back into psychiatry. Because I enjoyed listening to people's stories. That's what I found most riveting and then helping them to enlarge and deepen that story so that they could somehow change themselves within it. And of course, there are lots of models to help with that in terms of psychotherapy, but my experience with grief therapy. Well, that was not an important part of our, of my training in it at any rate and there was very little research that had gone on in the 60s and 70s when I was training, there was of course, Kubler Ross model which was popularized in the 60s that I think was very useful, but very misleading in terms of grief occurring and the specific stages, and of course, I know about Freud's seminal study on pathologic grief which I think still holds a lot of water, a very helpful model. And then they really the first study of grief after unnatural dying was in the coconut grove fire Lindemann in 1943. That was also turned into a monumental sort of study that's always quoted. And maybe I can talk a bit more about about that about Alexandra Adler, who was at another hospital in Boston, she was Alfred Adler's daughter. And she had completed a much better study than Lindemann did. Lindemann was very psychoanalytic, and she was not. So she focused much more on the trauma of the dying, than she did on the dying, the death itself. And what got me I think, intrigued in this whole array of traumatic grief was a personal experience, which I'd be glad to talk about. You want me to get into that at this time? It was after my training in the early 70s, that I moved to Seattle to start a section of psychiatry at a sort of the Mayo Clinic of the Pacific Northwest, it was then where nearly 100 of us, specialists on the staff. And I wanted to practice in a place where I could still be a doctor. But I also had a shared appointment at the University of Washington in the Department of Psychiatry, because of my interest in teaching, so I had a lot of residents who were working with me as well, at that point. And shortly after Julie and I arrived in Seattle in 1972, with our two preschool kids, we decided to have a third child and Julie went through a very, very significant postpartum depression, I pretty much had to work, cut back work half time to take care of Julie and now three kids. Wendy, our infant daughter, who tragically died a month after she was born from an intracranial hemorrhage. And a week later, when this was layered on Julie's postpartum depression that she was seeing a psychiatrist and on medication, she killed herself. So where before I'd been a pathic clinician who knew a bit about grief and emphasized and reinforced the importance of time and working through dynamically these major kind of changes, I found myself going through, becoming much more of a participant observer than than a psychiatrist. And I think what got me interested in traumatic grief was experiences that I was having that did not fit with the models that I was familiar with. Sure, I think that would be very helpful to our listeners. There are basically two stories that go on after any kind of grief. One is the story of the relationship. And the other is the story of the dying itself. And they both have to be retold. And obviously the story of a violent, sudden, unnatural dying is very different than the story of a natural dying. If Julie had died from, oh, if she had died from leukemia, that's something that could have been announced. And it is something I would have understood as a form of dying that was external to her, external in the sense that we were going to have an opportunity to adjust to it. But the dying itself was internal and biologic and it was no one's fault. And it was astigmatized. And that's something that we anticipate dying from eventually is some sort of biologic death, either from cancer, or stroke, or vascular problem or just senescence just wearing out. So I found myself going through vivid flashbacks of what she had experienced as she was dying. It was surreal, because I couldn't be there. This was an imaginal replay of what she was thinking, what she was feeling, how I might have intervened, there was no role for me and that unnatural dying. And that's one of the things that differentiates it from natural dying. If she had died from leukemia, I would have had time to have understood what was going on in terms of the dying itself, we would have had opportunity to prepare ourselves and our children. Her friends and relatives, could've ringed around her, we could have gone through a natural dying story that would have had some sort of role in me, for me in the dying story. But there was no role when she committed suicide because I was not about to go along with that. There was something so pathologic going on with with Julie and the way that she died, that it was traumatic. And it occurred as a visual flashback I was having panic attacks in the middle of the night when I would dream about it. It was a story I couldn't tolerate starting because I knew how it would end. And I think for for me and the vast majority of family members after there's been a violent death, this begins to subside spontaneously within the first several months. And it doesn't require any sort of formal intervention. I never went through any sort of formal intervention. I think that that's not because of my strength. I think it was also a part of that can be contributed, attributed to my rather privileged background and not having any sort of significant psychiatric problem before this. But the other thing was, at that time in my life, I didn't have time to consider myself. I didn't need therapy, I needed a plan. I needed some practical way to survive this. And we call it psychologic first aid now. And I found that my major source of resilience were my kids. I had to be strong for them, I had to take care of my kids, make sure they were going to be alright. How old were they at the time? Five and three. And so we spent a lot of time together. And we spent as much time as the children needed to talk about Julie. And I certainly brought it up fairly frequently. But obviously the three year old and the five year old handled it in much different ways. My three year old handled it quite magically. So I wrote I initially began serving as a volunteer for a lot of the support groups in Seattle, where I was where I had some connections, and then I got interested in the importance of screening people before they got into any sort of support group and I've really enjoyed group therapy ever since my my training and in the 60s and 70s we used group therapy for everything there were a lot more active sort of groups going on then at least in terms of training. So I thought it was really important that people be carefully screened to make sure that they had mastered enough of the traumatic story of the dying that they wouldn't get up and run out of the group because they couldn't tolerate other people's trauma stories because they were having a hard time managing their own flashbacks. So it's really important, I thought to stabilize people after a violent death, to the trauma of the dying before we began working on their grief reaction, so that that was something that began to occur to me because of my personal experience. And then beginning to apply some of those insights into developing a short term focus manualized intervention, group intervention that we first wrote the manual in around 2000. So a little over 20 years ago. And it's been one of the one of the few manualized interventions for traumatic grief. And recently, we've done pre, we have prepost measures on over 300 subjects that have gone through the intervention so that we've sort of entered the kingdom of the evidence based on the last four or five years. But my work prior to that has been much more anecdotal and based on some of my insights, and working with people over over time,
Jennifer Levin
You said that group work is magical. Can you talk a little bit more about that?
Dr. Rynearson
It's very different, I think, than, at several different levels, than individual work, it's, it's difficult to set up a group after traumatic grief because I think you have to be in a large enough community and have developed a sector that reinforces this, this clinical interest, so people are calling in, and asking for a rather specialized group, group is individual, different than individual therapy, I think because rather than the relationship being dyadic, between the therapist and the patient, it's much richer than that. If the group is running well, and they aren't interrupting one another, and everybody has time not only to detail their own story and their own feelings, and their own progress, but they have an opportunity to help each other. And I think that that's an important resource for resilience is that not only is your story being processed in a natural sort of format, I mean, this has gone on for 1000s of years after there's been any kind of death, and particularly a violent death. It's people getting together and needing talk about it over and over again, not everyone, there's some people that want to get through it or need to get through it in a much more stoic way. And that's not to be challenged. Over time seems to to be restorative for a lot of people. George Bonanno's work with natural dying at Columbia is really highlighted. Only about half of people go through a very significant interval of distress after there's been a natural death, I think it's probably higher than that after a violent death so I think, group gets you out of that dyadic frame into something that offers a lot more opportunity, not only in telling, but in helping. And of course, the other thing that I emphasize, which is particularly fascinating to me about grief, is that once you begin getting engaged in with someone and their grief, it's not just two of you in the conversation, there are at least three, the people that died, the person who died, sometimes people, so whatever setting you're in, this person begins to appear to some extent, to some extent, their memories and the importance of including the voice of that person and in some way, and of course, theirs. This has gone on for many, many years a lot of techniques to empty chair sort of technique. Bob Neimeyer writes about this prolifically lots of different ways of including the presence of the person, that has died. I'm so glad you brought that up, I often feel like I develop a relationship with the individual who's died through the therapeutic process, I feel like I get to know them. And there's often a sadness that I didn't get to meet the individual because of the way that they're described by their loved one. And I feel very connected to that person, I get to see videos and pictures and artifacts, and I, I really feel like I get to know them. And I'm glad you really, you mentioned that.
Jennifer Levin
How did your personal story your personal experience change you both as a clinician or motivate you as a researcher?
Dr. Rynearson
Well, I think it may be much more tolerant for ambiguity. I think if someone is handicapped as a therapist, if they're setting out with some sort of a rigid model or protocol when they're trying to help, and guide someone through a story of, of death, or of a violent death I never know what to, to expect. And maybe that's because I've been doing this for over 50 years, and I'm I'm much more I'm much more comfortable with the unexpected, and with the capacity to be surprised, and also what I call a vigilance for novelty. Trying to find something new and different in a story, and different sort of approach as person is telling it so that you don't get completely absorbed in in the way that they're processing things. Also, I think it has made me much more respectful of psychodynamic work than neurobiology, there is no pill for grief. There have been a couple of rigorous well controlled, prospective studies that have been done most recently by Kathy Shear, and four or five other people with over 200 family members who had lost someone through a suicide, a very carefully designed study where they gave medication and compared that with active psychotherapy compared with just plain support, where people were coming in once a week, and being checked on by somebody that wasn't really doing active therapy and what, what was established was that pills don't work, they have no effect on the grief itself. It helps with depression, helps with anxiety and those sorts of disorders. So that's something that's been confirmed recently. And I think it's an important confirmation because there's a distressing number of people that are on antidepressants that come in to see us when there's really no indication for their being on them. And it's, it's sometimes a real task to get them to be able to stop taking it. I don't think the medication interferes with the therapy. But I think it's clinical negligence for people with grief reactions to me, started by their primary physician on antidepressants and not go through some sort of psychotherapy.
Jennifer Levin
Let me ask you, looking back over your career. You're semi-retired now. Correct?
Dr. Rynearson
Yes, ma'am.
Jennifer Levin
Looking back over your career, what would you say are some of your greatest accomplishments in your work?
Dr. Rynearson
Well, it's hard for me, it's hard for me to say I, I can tell you what I, the way I started and what I was hoping for. I began getting funding in 1993, from the Department of Justice, through VOCA (Victims of Crime Advocates) you know, that's implemented through all 50 states through a different agency in each state. And I went out to give a talk at the Department of Justice headquarters to show them how I've been using their money since 1993. They gave me a promising practice Award, which allowed me to bring clinicians in from other sites across the United States for five years. And I had a four day training program and we bring in teams from New York and San Diego, Houston and almost every major a lot of major cities, and I was focused on some of my psychiatric friends who were dealing with trauma, to bring in their clinicians to teach them our intervention to see whether or not it could be replicated. Interestingly, it's the academic centers that I encouraged to come in and get trained and propagate. The intervention didn't, weren't nearly as productive as the clinicians who were already engaged. And often women, and often social workers, rather than psychiatrists, or PhD psychologists, like it's it's rare that psychiatrists are even doing this sort of work. So that shaped and shaded a lot of the hopes that I had. The other project that I got very enthused about was an international project where they, you know, University of Washington Department of Psychiatry and also the Middle Eastern Studies group at the University of Washington got very interested in what I was doing, and began sending me over the Middle East to train clinicians. in the Middle East, I wasn't doing direct clinical work, but I was working with I spent almost two weeks in Gaza. And I also spent time in Jordan and in Lebanon, and in Syria and Israel trying to actually through the university, we were able to, to translate our manualized intervention into Arabic and Hebrew so that they had access to the manual before he even went over for the training. So I had hoped to, to work out some sort of an ongoing project after those five years, where they would be using the intervention that had been translated into their own language. And of course, there are huge cultural differences between what we're doing here in the United States and what goes on in a Muslim country. I learned a lot, but a lot of what I set up has fragmented, I think, because of what's gone on in that part of the world. But I'm still in touch with several of the clinicians that are running our groups.
Jennifer Levin
That's amazing. If I can ask you one final question. Most of my listeners have recently experienced a sudden death. What type of advice having, having been through this yourself? Would you give to somebody who has a long road of healing ahead of them?
Dr. Rynearson
Well, one of the first things that I would want to reassure them about is don't be in a hurry. I think the best prospective study that's been done on violent death was done by Shirley Murphy. Here at the University of Washington School of Nursing, she had an NMH grant. She studied over 200 parents who had lost a child to a violent death in Oregon and in Washington, and it was a naturalistic community based study, these were not people asking for help. And she got a very high rate of people that were willing to go along with the, with the study, I think it was a bit over 60%. And what she established as she's followed this cohort, for five years, what she established on the basis of a standardized measure that she sort of constructed was that within the first year, there was a dramatic decrease in the level of distress with mothers and fathers. Fathers more than mothers in terms of the decrease in distress. But that level of distress never really changes. Even in five years, a third of the mothers that have lost a child to a violent death, still report a traumatic sort of aftermath when they're asked directly about it. Does that mean that they have PTSD? No, I don't think so. Shirley thought so. Shirley Murphy, the author. I think that's normative. I mean, this was a, based on a population of people that weren't asking for help. And they weren't disabled at five years by their traumatic aftermath, it's when they were asked directly about the dying that they still had a lot of trauma associated with. So this isn't anything that anybody gets over quickly. And that should not be the objective and, and some people are able to coast out of this much more quickly than others. But I think mothers are particularly vulnerable, when there's been a death of a child violently. In part, I think, because of the level of attachment which began even before the child was born in terms of all of the nonverbal imaginal sort of attachment that was going on more than imaginal once there was quickening. And all that goes on, I think, presumably more with mothers than with with fathers in terms of the feeding, the proximity, the cleaning all of the nonverbal source of engagement, that that's going on that makes the whole issue of safety and proximity, much more central, I think, for mothers or can be, that is for fathers. I think whenever a child leaves home, no matter the age of the child, if the mother gets worried about the child, even at age 50, or 60, I'm talking about the child. It's still upsetting.
Jennifer Levin
So don't be in a hurry. I know I have also a lot of people who've lost spouses, but in terms of general loss, sudden death all together, don't be in a hurry. What else would you tell them?
Dr. Rynearson
I think there have to be definite indications for getting therapy. And if you've decided you want therapy, the importance of investigating who is going to be appropriate to help you. Particularly if there's been a violent death, I think it's important to see somebody that knows something about what I've tried to structure for you in terms of the the separateness of the violent dying story from the story of the of the living, and the importance of being able to stabilize yourself to begin managing the violent dying story in a more restorative way, that before you get into the grief. And sometimes if you've seen a grief therapist that's not familiar with this therapy, they immediately want you to begin getting engaged in the grief therapy of letting go of the memories of the person not to surrender them entirely. But to talk more about the relationship with when really what you need to talk about if you're having flashbacks and dreams and panic attacks, is work that is directed at that unfinished story. I think companioning is important as well. I think a support group for for violent dying is supportive, because people are able to get it into a context where they're able to talk about something that that's so sometimes so horrific and so helpless, that it's only people that have been through it themselves that can quietly listen but resonate what they've been through to respect it to, to make it real, because what they what they've gone through is so surreal. So I think having the opportunity of talking with others, others outside the family, sometimes the family can no longer tolerate period about what's going on. They need somebody outside. So I think I think this group is lucky to have someone like you who I'm sure knows people in the community that would be appropriate. But I think you need to really be somewhat disabled by flashbacks, and by dreams and by every single day feeling despair over this and not being able to summon anything positive, around which you can begin reaching out again to reconnect with living. I think that's when, when therapy should be considered and not necessarily in the first several weeks, I think people particularly after violent death are so preoccupied with all it needs to be done that it takes all our energy just to get through the investigation and sometimes the trial and it's only four to six months after a violent death that people are in a position where they can begin summoning what they need personally. So it's always different.
Jennifer Levin
Absolutely. Well, I cannot thank you enough for your time today and your expertise and guidance. And I really appreciate you sharing your personal story. I think it always is so helpful to an audience when they are able to hear the personal story behind any health professional, who has really gone through something traumatic that has influenced the work that they have done. So thank you again for your time. And with that, we are going to end our interview. In today’s interview with Dr. Rynearson we learned both about his personal history with sudden death and the diverse projects and activities that he has conducted to advance knowledge and treatment for individuals who he describes as having experienced a “violent death” which includes homicide, suicide or accidents.” Dr. Rynearson talked about some of his major accomplishments as a physiatrist and a researcher, how his personal experience with sudden death changed him as a clinician and shared his advice for listeners who are living in the aftermath of a sudden loss. My next podcast will be on Wednesday, October 26th and I will be talking with Dolores Cruz who is going to share her story with us. Dolores’s son Eric died over 5 years ago in a car accident. Dolores has worked hard in her grief and is now a vital part of the healing experience for many people parents who are grieving the death of a child. I hope you join can us. Thank you so much for joining today’s episode of Untethered Healing the Pain After a Sudden Death. For help with a sudden and unexpected loss, sign up for my free mini course, where I will teach you about the 3 Truths About Living With A Sudden and Unexpected Loss. Please visit www.fromgrieftogrowth.com to sign up.
