Grief and Sickness Behaviour in Naturopathic Practice: Standards of Care for Screening and Support by Aoife Earls, MSc, ND
Abstract
Lifestyle counselling is a part of practice scope for naturopathic doctors, however, the identification of grief management is not well reviewed or identified for screening in practice. Acute grief has many physical attributes that are similar to sickness behaviour, and when identified properly, can be supported as part of a general health care plan and are within naturopathic care strengths, including herbal medicine and lifestyle resources such as forest bathing, journaling, and creativity. In addition, complicated grief or prolonged grief disorder should be identified and referred to appropriate care as many individuals benefit from complicated grief therapy, and will also have numerous health concerns that will not improve when not getting adequate support. Standards of care for different aspects of grief therapy in therapeutic practice are reviewed, with a unique supportive role for care and referral in naturopathic outpatient settings.
Grief and Sickness Behaviour in Naturopathic Practice: Standards of Care for Screening and Support
Naturopathic doctors are trained to use lifestyle counselling in practice, which includes encouragement of healthy behaviour, listening, and providing therapeutic presence, supporting manageable change, and referring mental health support with licensed therapists as identified. While the mind-body connection is understood, the recent pandemic has highlighted the true relationship between physical conditions such as IBS, hypothyroidism, menopausal appearance or aggravation, and insomnia. The impact of stress through loss of societal norms, including loss of income, support network, life, and identity are now clear in their impact on the physical body.
Sickness behaviour and its relationship to the body’s ability to process loss and grief are not always fully understood, being that time in which the body can be affected by emotional loss can be longer than is understood by a person struggling and their health professionals. Sickness behaviour is a state of being in which inflammation in the brain triggers a series of metabolic and behavioural adjustments in order for an organism to address an infection; the hypothalamic-pituitary-adrenal axis adjusts to increased temperature (fever) and increased circulation of cytokines IL-1, TNF-alpha, and IL-6 in the body which induce change in macrophages in the brain (Dantzer 2006). Outer behavioural changes include fatigue, social withdrawal, an inability to concentrate, and reduced motivation. In sickness behaviour, supporting infection through natural immune modulators such as chaga (Lu et al 2021), cordyceps (Das et al 2021), astragalus, codonopsis, and increased Vitamin C and zinc (Roxas and Jurenka 2007) are well-documented to improve the body’s ability to reduce cytokine activation, decrease IL-1 and IL-6, and improve humoural immunity. Sickness behaviour that does not dissipate after six weeks of a viral or bacterial infection (often due to IL-1) is thought to contribute to mental health disorders such as major depressive disorder and anxiety (Viljoen and Panzer 2005).
Grief is seen primarily as the emotional reaction to the loss of a loved one through death, however bereavement grief is only one of many grief experiences. Ambiguous grief (e.g. a divorce, loss of person through mental illness or dementia, loss of job) (Nathanson and Rogers 2021), anticipatory grief (awaiting a loss such as supporting a loved one through long-term illness) (Coelho et al 2018), and disenfranchised grief (e.g. clinicians for their patients, secondary losses such as the loss of social title, self-identity) (Lathrop 2017) are three of many common grieving experiences, all of which have physical manifestations in the first two years of a loss or separation or beyond (Buckley et al 2012, Iglewicz et al 2020).
Rather than the five concrete stages of grief outlined by Elisabeth Kübler-Ross, grief is more associated with some predictable phases that have a lot of variability within and around them (Buckley et al 2012, Kübler-Ross 1969, Ong et al 2011). In acute stages of grief, similar shifts akin to sickness behaviour are physically seen within the first 12 months after a loss, with the first six months being the most pronounced in terms of increased cortisol, hypertension, decreased activity of NK cells, and increased IL-6 and IL-1 (Buckley et al 2012, Cankaya et al 2009, Holland et al 2014, Latham and Prigerson 2004, O’Connor 2019, Prigerson et al 1997). These changes shift naturally after six months in uncomplicated grief, in which the loss integrates into the person’s life as the person learns to process their emotions, and to accept their loss. The addition of meaning from the experience, and creation of new and fulfilling habits or hobbies will then become known as integrated grief. The person may continue to feel sad, but they are no longer thinking as much about the loss and have learned to regulate intense emotion, confront challenging memories, and create new meaning in their lives (Shear 2010). Physically, cortisol and blood pressure are typically entering normal range between six and12 months, and insomnia has also stabilized (Buckley et al 2012, Iglewicz et al 2020). However, this again is not an absolute experience.
For some, acute grief elongates, and individuals develop complicated grief (CG) or prolonged grief disorder (PGD); a prolonged state of grieving in which grieving intensifies beyond six months and can last for many years after a loss (Iglewicz et al 2020, Shear 2010, Shear et al 2011, Shear et al 2007). Vulnerable individuals include those with intense longing or emotional pain, frequent preoccupying thoughts of the deceased person or inability to accept the loss and difficulty imagining a meaningful future without the deceased person (Nakajima 2018, Shear et al 2011). Dysfunctional thoughts, maladaptive behaviours and emotion dysregulation are hallmarks of the condition, yet also include significant physical manifestations of grief including high blood pressure, heart disease, cancer, headaches, insomnia, psychiatric symptoms, poor quality of life and reduced vitality (Ong et al 2011). Elevated cortisol is also a characteristic of CG and can be elevated for two years after a loss in individuals with CG and can influence cortisol indefinitely following a loss, most often seen in late life bereavement and children with parental loss and emotional abandonment (Luecken 1998, O’Connor 2019, Ong et al 2011, Saavedra et al 2017). It is understood that the nucleus accumbens, the region of the brain associated with reward, is what drives ongoing yearning in CG, and that in non-complicated grief the NA does not show activation with time and healing (O’Connor 2019). Screening for CG is done with professionals trained in the skill and with the PG-13 tool (Iglewicz et al 2020, Prigerson and Maciejewski 2021, Shear et al 2011).
Supporting loss and sickness behaviour for naturopathic medicine is a long process, but a worthwhile undertaking. Those with grief and loss most often need a compassionate ear, a willingness to listen, and the creation of trust (Joplin and Vrklevski 2017, Shear 2010, Shear et al 2011). Supporting physical manifestations of the condition, while encouraging new habits and therapy that confronts the loss with positive coping strategies is something that could be revolutionary for long-term physical ailments related to loss (Bower and Irwin 2016).
Treatment within Naturopathic Outpatient Facilities of Acute and Ongoing Grief
Acute grief, as it mimics (and often also has) sickness behaviour, benefits from improved quality and length of sleep, cortisol reduction, and incorporating easy lifestyle shifts that support these changes as there is often intense fatigue and memory lapses (Iglewicz et al 2020, O’Connor 2019). Creating an environment to develop integrative grief should continue to involve these strategies, while encouraging therapy to confront avoidance and introduce new meaning into life.
To support deeper and more effective sleep, a combination of herbal medicine and lifestyle interventions that address cortisol reduction and support anxiety reduction is most helpful. Entrainment of circadian cycles to support melatonin production will suppress cortisol, but it will also prevent immune inflammation that can occur with maligned circadian rhythms (Wright et al 2015).
Baicalin scullcap inhibits IL-1, decreases NF-kB, and enhances GABA (A) receptor activity to sleep-waking cycles (Bone 2003, Chang et al 2011). In animal models, baicalin scullcap has anti-hypertensive action and shows reduced inflammation at the intestinal lumen (Wu et al 2019, Zhao et al 2016). Skullcap laterifolia is long known for its nervine properties and to support insomnia and anxiety, as is piper methysticum which is a potent anxiolytic (Brock et al 2014, Sarris et al 2011, Zhao et al 2016). Phosphatidylserine also supports cortisol dampening. Phosphatidylserine complex and phosphatidic acid given to students to support stress resulted in blunting of both serum ACTH and cortisol with 400 mg, and a positive emotional response to the Trial Social Stress Test (TSST) (Hellhammer et al 2004). It has also been seen to blunt cortisol with respect to exercise-induced stress in multiple doses (Monteleone et al 1990, Starks et al 2008).
Motherwort, a herb most often affiliated with female reproductive disorders, is known best for its cardiovascular affinity (hence its Latin name, Leonurus cardiaca) (Romm 2010). Being that hypertension is a hallmark of physical grief recovery (and the broken heart phenomenon it is most often associated with), motherwort is an ideal herb to add to a protocol as it relaxes vascular tone, slows tachyarrhythmias, lowers lipids, improves insomnia, improves depression and is used as a nervine (Boyd and Sohl 2020, Fierascu et al 2019, Rauwald et al 2015, Romm 2010, Zou et al 1989). It is also thought to cross the blood-brain barrier to influence cortisol and has multiple antiinflammatory and immunomodulatory properties (Altinterim 2014, Fierascu et al 2019, Reul et al 2014).
It has also been documented that deeper REM sleep is possible when emotions are released before bed. While this may indeed be triggering or initially worsen sleep latency, it will eventually lead to deeper REM, increased length of REM cycles, and generally better mood the following day (Baglioni et al 2010). This can be achieved with journaling about one’s emotional state; tracking one’s moods and their abilities to change and improve is a key component of CGT (Nakajima 2018, Shear 2010, Shear et al 2011). Emotional freedom technique, or tapping, can also ameliorate the worries that may be prone to keeping individuals up at night or releasing intense emotion to promote sleep. Individuals with PTSD were given tapping as an approach to release intense emotion and had significant progress releasing obsessive thoughts and repetitive thoughts associated with relapse and recall of traumatic memories (Church et al 2013). It may also be useful to recommend a funny or joyful television program or book as a daily or alternate day practice, as laughing also reduces cortisol and can be used as a tool after a difficult experience (Berk et al 2008). Laughter and a sense of humour are still present in grief, while often grievers may forget this is okay, it should be encouraged.
Forest bathing, or Shirin-Yoku, the act of being in the forest for health and medicinal practices, is now emerging to be a powerful practice for health and well-being, mentally and physically (Hansen et al 2017). Forest bathing involves either walking or sitting for varying lengths (from 10-90 minutes), and indices of immunity, heart rhythm and volume, stress hormones, and depression and anxiety have been studied (Park et al 2010). With respect to cortisol specifically, forest watching and bathing decreases cortisol in comparison to placebo both in anticipation of visiting the forest, and immediately after being in the forest (Antonelli et al 2019), especially in comparison to walking or watching in an urban area (Park et al 2010). Breathing forest air reduces NK cell activity (Li 2010) due to phynocides in forest air. Lymphocytes are also known to be reduced in mental stress, as is experienced with PTSD and grief, and as such could be supported in this very simple practice, on a daily or weekly basis (Buckley et al 2012, Glover et al 2005).
Immunomodulation can be an important target to modify the inflammatory response, notably elevated IL-1 and heightened NK reactions, that are typical in both sickness behaviour and acute grief. Immunomodulation can be achieved using herbs such as chaga (Peng and Shahidi 2020), rehmannia glutinosa (Kim et al 1999) (which is also used to support cortisol), and rosemarinic acid (which has both immunomodulatory and anti-inflammatory properties), thus supporting many diseases of prolonged immune activation (Friedman 2015, Luo et al 2020). Astragalus, with evidence of immune support and a role in acute MI rehabilitation, can also be considered (Zhang et al 2019).
Lifestyle-based recommendations such as encouraging positive community interaction (in-person or virtual) supports reaching out, creating new neural pathways, and new healthy memories (Iglewicz et al 2020). Music used to “express, experience, or understand emotions” in those with depression and low mood improves depressive outcomes and gives the listener a way to channel and release emotions in a productive way. From painting to doodling, art therapy in structure and unstructured formats all show improved positive affect and protection against CG, caregiver burnout and compassion fatigue (Kaimal et al 2019, Xiu et al 2020).
To summarize, there are many interventions that are effective, easy to find and prescribe, and have multiple cross-linking benefits (e.g. antihypertensive, antidepressant, immunomodulating and cortisol reducing) for support of acute and integrative loss and sickness behaviour within naturopathic practice. Clinicians should use their knowledge of their patients to use other interventions that are evidence-based and beneficial that have not been listed in this paper. As we may meet many people with different losses experienced within the last calendar year and beyond, we need to meet our fellow humans with compassion, humility, and curiosity to support their physical and emotional well-being.
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