Big Think Interview With Katherine Shear

Dr. Katherine Shear: My name is Dr. Katherine Shear. And I am Professor of Psychiatry at Columbia University School of Social Work and Columbia College of Physicians and Surgeons.

Question: What propelled you into psychiatry?

Dr. Katherine Shear: Well, I basically was always interested in human behavior. And I sort of thought about majoring in English, but then I had an interest in science, so somehow I ended up in medical school and psychiatry just drew me. And then my specialty is really psychotherapy research. And that, I got interested in because I was very interested in psychotherapy, but at the time that I trained to do it, it was not very well defined, psychotherapy, and it hadn't been tested. There was no scientific basis for it. And since I was very interested in science, I thought it would be – I just felt, again, sort of impelled to try to figure out what works and if it works and what works and how it works and things like that.

Question: Do you have firsthand experience with depression or grief?

Dr. Katherine Shear: Well, let's see. I've certainly had experience with grief in basically both of my parents died. And then also, I lost a cousin who I was quite close to when she was 39 and I think I was about in my early 30s at that point. So I learned different things from each of those experiences. What I learned from my cousin's death, which was very surprising to me, was that in a strange sort of way, after she died, I actually started to feel more comfortable with death, which, if you had asked me before that, I would have said the opposite would have happened. But something about, you know, I just started having these thoughts every once in awhile that because my cousin's name was Jackie and because Jackie was there, somehow it would be okay for me to be there, too, or for other people to be there. So that was something I think I brought with me over the years without really thinking that much about it until I got interested in grief.

And then when my parents died, that was a very different experience. And there I had the opportunity to – again, people I was very, very close to – and I was involved in their care at the end of their lives and I was with them at their bedside, both of them, when they died. So that gave me, you know, a different kind of insight into what it feels like to be in that situation. I think, in particular, even though both of them were quite ill but they time they died, the very strong since of disbelief that you have very initially right after someone dies. And also, as prepared in the sense as I was for their death, each of them, the emotions were very, very strong for a period of time after that.

Question: Do your patients' cases ever move you personally?

Dr. Katherine Shear: Well, of course, you know I am a psychotherapist. And by definition, I think I'm a person – and most of us are – who are very moved by the people that we work with. So I would say pretty much everyone that I've worked with has touched me emotionally. And it's a very good question because I think that is one of the ways that we learn about people and how to work with people, is that we are open emotionally to people in our work with them and so we learn emotionally about them. And you're right; far beyond anything that we could learn by collecting the reading skills that we do collect and some of the more I guess scientific research.

Question: What triggers a panic attack?

Dr. Katherine Shear: So what triggers a panic attack is – I'm hesitating because there's sort of two main models of this. I mean, one is that – I guess both of them center on the idea that everyone, you know, is capable of having a panic attack. If a tiger suddenly ran into the room, you would probably have a panic attack. And so that means that we have the brain circuitry to have a panic attack. And the idea is that the circuitry is meant to be triggered by actual immediate danger. And people who have clinical panic attacks have those attacks when there is no real danger. And so what we think is the trigger is more easily set off, so to speak.

Now, what sets it off? It can almost be like a loose wire. You can think of it as a loose wire in your fire alarm system or something. So sometimes it can just set off. But a lot of times, there's a lot of evidence that what triggers a panic attack is an actual bodily sensation of the sort that you have when you have anxiety. So if you think about adrenalin rush, you have heart palpitations; you get a little short of breath, you feel a little shaky, sweaty. Any of those kinds of feelings can trigger kind of what we call catastrophic misinterpretations on the part of the person who's prone to having panic attacks so that they're – what we know about such people is that they're more sensitive than the rest of us to the bodily sensations to start with.

So if you had, for example, panic attacks, you would be better able to tell me right now what your heart rate is, then I would be able to tell you. And so there's that sensitivity to start with and then something starts your heart racing. And that could be running up a flight of stairs. It could be drinking a cup of coffee. It could be getting mad at someone, you know, any of those kinds of things. Your heart starts to race and all the sudden, you sense that pretty early on when it starts to beat faster. And all the sudden, you are feeling – and your mind automatically thinks something terrible is happening – something very dangerous is happening within your body. You might think you're having a heart attack or a stroke or some such thing. And so that is frightening in itself, right? So then that triggers more fear, more bodily sensations in your continuing in that.

Question: How can you bring a panic attack under control?

Dr. Katherine Shear: Sure. I mean, I think that the treatments that we do that have been proven to be helpful for people center on kind of – it's almost like you have a phobia of your own bodily sensations. So you know how we work with phobias. If you were afraid of cats, someone who's afraid of cats, we'd put them in front of cats, right, so that they essentially learn that cats really aren’t that dangerous. And so we follow that same principal with panic attacks and we evoke bodily sensations. So we might have someone run in place in the office and their heart starts to race and they see that that's a normal reaction to running in place. And we're sort of there with them and helping them with that. And we basically desensitize them and teach them also what is behind a panic attack.

Question: Where does normal anxiety end and clinical anxiety begin?

Dr. Katherine Shear: Well, you know, that's a very good question because that's what we're grappling with right this minute in the new diagnostic system that's being – you know, every so often we rewrite the psychiatric diagnostic system. And so one of the big questions is should we be looking at anxiety and mood and other kinds of psychological problems on a dimensional scale like that. And if so, where's the cutoff? And so it's probably not just in one place. Now the scales that I've developed are ones that are focused very much so on diagnoses that we already make. And so there, the cutoff is basically determined by when we can diagnose panic disorder, for example. The Panic Disorder Severity Scale, we can say that – I can tell you a number. But, you know, there's a number that corresponds to the best kind of indicator that someone will have a diagnosis of panic disorders. So that's how we do that.

But it's absolutely true that there's a dimension – that these symptoms occur in a dimensional way such that certainly there's normal anxiety and there's normal panic, even. So panic's different from anxiety because panic is an immediate fear reaction, right? Whereas anxiety is more something we think is going to happen in the future. So panic occurs when you think, like I said before, if there's a tiger in the room or someone's pointing a gun at you. It's the future, but it's the immediate future, as opposed to I'm anxious about a test I'm going to have to take next week or something.

Question: Is grief a form of illness?

Dr. Katherine Shear: Right. So grief is the natural healing really response to the loss of something very important. In the work that I've done, it's really always been the death of someone very, very close. And I focus very narrowly on that kind of situation. Grief itself occurs if you lose other things as well. But if you want to talk about grief that occurs after you lose someone very close, grief itself is a very natural reaction. So is inflammation if you get cut, right – that's a very natural reaction. We don't think of natural grief as an illness, primarily because there's so much baggage associated with illness. But some very prominent thinkers and researchers have, in fact, said that we should consider grief similar to inflammation or you could say even an acute infection or something where you have a natural response that's a healing response essentially to some kind of an injury.

And certainly the loss of someone very close is a kind of an injury. I mean, so people that we're very, very close to are just so important in our everyday functioning in so many different ways. So when we lose them, lots of things are disrupted and we do have usually very, very powerful emotions and we become very preoccupied with thinking about the person who died, and really trying to grapple with coming to terms with that takes a lot of emotional and even physical energy. And so in that sense, you know you could say that it's like having the flu or something or maybe where your body has been exposed to something that's not usual and that you're having a natural healing response that's also very disruptive.

So we don't advocate – I wouldn't advocate medical treatment for grief, even though it is a very disruptive state, I think that it's interesting in that in the case of grief, there's not only an internal natural healing response, which I very much think there is, but there's also a social healing response. So, of course, when we know that someone has lost someone, we naturally – certainly if they're someone close to us, we're going to be there for them for quite awhile after the death occurs. But even if they're not that close, we'll often go to the funeral. We'll go and visit them a few times early in their homes, bring them food, take care of them in various ways, certainly not expect them to be taking care of us, even though we might be a guest in their house. All this is very natural. I mean, we don't really hardly need to be taught. I mean, people do it in all kinds of cultures and it's just something we do. And that is, I think, the best way for the healing process of grief to be helped along, not by medical treatment.

Of course, some people don't have that or down the line – or they may, for example, develop a depression, a really full-blown depression. Because grief is not depression; it's different from depression. And so if they do develop depression, they may benefit – they may really need to be treated. And certainly down the line, as I was saying, that down the line, they may kind of their grief healing process may not go the best way. It may get kind of sidetracked or derailed, in which case, we do then want to treat them.

Question: When does grief become clinical?

Dr. Katherine Shear: Right. So the way I'd like to describe it first is just sort of what we see and what people experience. And to do that, I'm going to back up for one minute because grief is a natural healing process, from our point of view. But it sort of never really completely ends after you lose someone very, very close. So what happens to it though is it evolves over time, right? So in the beginning, we call it acute grief because it's kind of very inflamed. And it's very dominant and it's a very intense reaction. And then over time, it progresses to a place where it's much more in the background. But it's still there.

So, for example, if the person that you went to visit that had the acute grief, if you went back and visited that person let's say five years later, and you said to them –first of all, you would not expect them to be preoccupied with the loss anymore, right? You would expect them to be themselves again. They wouldn't be crying all the time. They wouldn't be only thinking about the person who died. They'd be engaging with you on probably totally other topics. But then if you said to them, you know, "I was thinking about this person who died the other day and I was remembering some story," you wouldn't be surprised if they got kind of quiet and maybe even got a little teary at that point as you started to talk about this person that they loved very much who is gone. In fact, you'd be pretty shocked if they said, "Who is that? I don't think I remember that person." You wouldn't expect that at all. So that s the natural sort of trajectory, if you think about it, of loss and how upset that person will get five years from now. It's very variable. It really depends on who died and how close you really were to them and what's going on in your life otherwise and all kinds of things like that.

So what happens when you get complicated grief? And the answer to that is that instead of that natural process unfolding so that the thoughts and the memories kind of recede a little bit into the background, sometimes we think of this as begin to reside in your heart instead of center stage in your mind. Instead of that happening, the person actually gets kind of sidetracked in the mourning process, such that they start to kind of ruminate over something related to the death, very often some way that they think they could have prevented this death. So the person will start to think if only I'd gotten this person to the doctor sooner, they would have been diagnosed sooner, maybe they would have been able to be cured. Or sometimes it's focused on the medical profession. Why didn't the doctor misdiagnose this person? Or even sometimes even there are really medical errors and the person is very focused on that. Sometimes it's related to I can't manage without this person. The person – instead of thinking about kind of how they are going to manage, they get sidetracked by thinking I can't possibly manage, basically telling themselves that.

So the complications that derail grief include these kinds of repetitive, we call them ruminating kinds of thoughts. Or also there's a lot of pain, emotional pain, of course, in the acute grief process. And some people are kind of frightened of those emotions or even frightened of the thought of the person really being gone, and so they try to avoid it. So they try to avoid things that trigger the emotions and they try to avoid thinking about the person having gone or the person having died. And so that avoidance is also a complication. It becomes a complication because it interferes with the natural processing or their coming to terms with the death that has to go on in order for you to move into this kind of integrated grief state, which is the later one.

Question: How can someone move on from paralyzing grief?

Dr. Katherine Shear: I will say that we don't know too much about the brain in complicated grief, but we do have some hints that without really processing the loss, the brain remains in a state where there's a lot of activation of the rewards system in when the person is confronted with a reminder of the person who died. And that's more like what happens in a love relationship. So it's as though they just haven't moved beyond the acute grief state and they're still yearning and longing and wishing to – in a certain kind of way, it's kind of like the state you're in when you're falling in love. You know how you're always thinking about that person and wanting to be with them when you're not with them. So it's kind of like that, although there's some recognition there that the person isn't still there.

So it's kind of a great sadness and great yearning and longing that shows up in the brain, it looks like in the early studies. But we so far don't have a medication to really help that. We think that typical antidepressant medication helps a little. We don't know how much. In fact, we're just starting a brand new study to sort of see how much medication might help. But so far, it certainly isn't like a total answer. So you're saying, "Well what is the answer?" And it depends on when it is we're talking about. But if someone early on is having a lot of trouble and they can find someone in their life, someone that they are very close to who's still around and who's willing to kind of really talk to them a lot about what happened and be there for them, they need to try not to avoid what they're inclined to avoid. Now, someone who's going to develop complicated grief may not be able to do that on their own. So they may need to get professional help. But our work centers really very much on a psychotherapy approach to grief as opposed to a medication approach.

Question: What do you advise patients to gain from the grieving process? 

Dr. Katherine Shear: It's hard to give someone advice about this. I think to let the natural process be as much as possible, that is to say not to try to think about what they should be feeling or what they should be doing beyond the issue of avoidance. I mean I think because sometimes there's a natural avoidance and I do think it's a good idea to try not to do that. But other than that, to let that natural process unfold, I think actually poets and novelists and those kinds of people do a better job telling us what happens when you do that. And often what happens is a deepening of our humanity and our ability to love and our ability to be empathic with other people deepens through that process. But I wouldn't advise someone to get there because you either do or you don't. 

Question: Do people grieve in stages, as Kübler-Ross suggested?

Dr. Katherine Shear: Yeah. I mean, I think Kübler-Ross did an enormous service to medicine and to the world at large by drawing attention to the importance of basically reactions to dying and then to death itself. However, her insights or whatever – her ideas, I think, about what exactly happens have not turned out to be very helpful because they don't turn out to be very accurate. And so what I think about the trajectory of grief really is informed very much so by many colleagues who have now done work looking closely at that process in different kinds of situations. And I think that I put it together in a slightly different way than maybe some other people do, but I think that what actually happens when someone dies –again, that your very close to – that's really what we're talking about here because you don't go through such a dramatic process when it's someone that you know. So this is someone very, very close. So what happens – how I understand what happens is that we have to start with what is that love relationship to start with. And love is something that we all feel and that we're biologically probably programmed to feel.

In psychology or psychiatry, we talk about a love relationship as an attachment relationship. And so the attachment system is a biological system that actually occurs in other animals, not only in humans. And it begins even before we're born. So a baby can recognize its mother on the very first day of its life. And then, of course, you've got that very strong attachment relationship between an infant and its caregiver – usually its mother and other people in its environment. And as the child grows older, there may be a couple of other people to which it's very, very attached. And actually what starts to happen also as a child gets older is that he child starts to learn how to be a caregiver. Because, of course, the mother is the caregiver early on, so as we get older and by the time we're adults, we are caregivers for the people that take care of us. So what happens when someone dies is that we lose not only the person who's taking care of us, but also a person who we put a lot of energy and a lot of ourselves into, taking care of them. And actually, it turns out that for adults, if you make them decide is it more important –you know, if you make them choose – is it more important to take care of someone else or to be taking care of yourself, do you have any idea what they'd say? So basically they will always say – most of the time say – that it's much more important to feel good about taking care of someone else.

So now let's go back to the bereavement situation. Because what's happened is someone has died who's very important to you to being sort of – it's the person who you turn to when you're under stress or the person who's kind of behind you, cheering for you when you're trying something new or having confidence in you when you're doing something, and that's very important. But this is also the person that you do those things for and that you try to protect and help in their life. So when they die, by definition, you failed as a caregiver.

So basically the two things that happen when someone dies is that attachment system gets very activated and so does the caregiver system. And what does that mean in everyday life? Well, that means that you start to think well, how am I going to manage without this person? And then you also think, why didn't I prevent this death? I should have done something to make it better. Take the World Trade Center; a lot of people had the thought, why didn't I stop this person from going to work that day, even though these are not rational thoughts, of course, you're going to manage without this person. Of course you didn't do something to lead to this person's death. But they're automatic, instinctive thoughts. So that's the first thing that happens.

And so you start to have these different kinds of problems to solve, and that's really acute grief. That's what you start to think about and you start to think a lot about you try to find the person for both reasons, in your mind. Because we think of a very special place in our minds for the person who we're so attached to. And so what we have to do is we have to gradually come to terms with the fact that that person is gone forever. And that information is very difficult to accept. And so we don't accept it right away.

In the beginning, we feel a sense of disbelief and we also people will feel like they're going to see the person walk into the room. Sometime they have that feeling. And so they oscillate between facing it and then setting it aside. You get this kind of oscillation during acute grief and gradually you find some way – and people do this differently – but to think about the fact, okay, they're gone and that it's natural for people to die. And you come to terms with that emotionally as well as kind of cognitively or in your thoughts. So you have two basic forms of grief. And you have this oscillating trajectory that eventually leads to a place where it's in the background and where you just kind of revisit it from time-to-time in your life.

Question: Is Freud dead?

Dr. Katherine Shear: Oh, that's a hard question. I would have to say in my case personally, I don't think a lot about this, I have to say. But I'm quite sure that there – Freud was an incredible observer. He was a very, very good observer and what he wrote about, the clinical phenomenon, were very insightful. And also things like his ideas about the concept of transference – how people basically bring to a new relationship the expectations and predictions they have gleaned from other earlier relationships, especially attachment relationships. That's my background. And I'm sure it still informs what I do.

Question: Will one-on-one therapy always be part of psychiatry?

Dr. Katherine Shear: Yes, I think. I absolutely think and very much hope, but I mean, I think it's an essential part of healing people and we know this, regardless of what other ways we develop and whether they be neurobiological methods. And now we're talking not only about psychopharmacology but a lot of other kinds of brain stimulation, for example, and even some kinds of very focused neurosurgeries seem to be things that have promise for certain people in certain situations. So I do very much see psychiatry developing in the direction of neuroscience and neurobiology. I think we've made some great leaps in that direction and I think we will and we should continue to work in that area.

At the same time, one of the things about psychotherapies is that the more focused, psychotherapies actually are better able to target specific behavioral syndromes than any kind of somatic treatment that we have so far. So I definitely think that there's a role for very focused kind of technical interpersonal interventions that are, so to say, psychological interventions. I don't think that will ever go away. But I think we're learning more and more about those kinds of interventions and again, specific techniques. Like there's a very interesting recent report of using training in attention in attentional processes in some anxiety disorders and social phobia and generalized anxiety – probably for any of the anxiety disorders. Because one of the things that you do when you have an anxiety disorder is you over-focus on certain kinds of cues like we were talking about with panic. You know, if you're a socially anxious person, you're going to do that with social cues. You're going to be overly sensitive to social cues. And you can train people apparently away from that by training their attention. And so that's one kind of thing I see happening in the future. But for many of the – I would say virtually all of the conditions we treat – there's always going to be some way in which the person who has the problem will need to kind of get close to – really close – to very distressing emotions and thoughts. And to do that, I think you really need to feel safe. And to feel safe in any treatment, you need another person. You need a person who can be there for you. So I think that will always be there.

Recorded on November 3, 2009
Interviewed by Austin Allen