This long read is by Dr Sarah Appleton, Central London Community Healthcare NHS Foundation Trust. In a time of huge loss and uncertainty this blog provides clinical insights into the pandemic grief process; helping to normalise what we may view as “abnormal” and promoting a compassionate voice with which we can seek to understand and effectively navigate grief.
As the COVID-19 pandemic progresses, we find ourselves stranded further from our idea of normality, with change and uncertainty looming large for both our current and future selves. As this disparity between our imagined futures and our reality grows larger, we are likely to all be grieving for the multiple sources of loss in our lives; loss of loved ones, our routines, our jobs and our roles, our social support, our financial security, our futures as we may have imagined, and our freedom.
We may at times find ourselves standing and staring at these waves of bereavement with a sense of calmness, clarity and hope. At other times, we may find ourselves struggling to surface as the waves crash down upon us.
Whilst individual grief responses will vary, Dr Elizabeth Kubler-Ross provides an insight into the universal experience of grieving. The Kubler-Ross Grief Cycle outlines the five common stages of human grieving (namely denial, anger, bargaining, despair and acceptance). Importantly, it is acknowledged that these stages are fluid rather than fixed and may be experienced at varying intensity, duration and frequency throughout the grief process.
During my work as an NHS clinical psychologist, most recently counselling front line healthcare workers who are affected by COVID-19, I find myself discussing the topic of loss (and our reactions to it) ever more frequently. Dr Kubler-Ross’ work provides several helpful insights into the “normal” human response to the COVID-19 pandemic.
In a time of huge loss and uncertainty, I wanted to share my clinical insights into the pandemic grief process; helping to normalise what we may view as “abnormal” and promoting a compassionate voice with which we can seek to understand and effectively navigate grief.
Stages of Grief
Denial: Denial is, from an evolutionary perspective, a somewhat protective response that allows us to shield from potentially painful emotional or physical experiences. Whilst denial is rarely an effective long-term strategy, and can actually cause us greater difficulty, it temporarily soothes distress where the alternative (i.e. acknowledging COVID-19) may be too overwhelming. Thinking COVID-19 is “no worse than the flu”, or that “I’m young, therefore I’m fine” may all be examples of denial.
Anger: Again, anger is a protective response that is likely to emerge during times of threat. When we are feeling anxious or vulnerable, it’s often easier for us to switch to anger rather than to sit with uncomfortable emotions of fear or helplessness. We may notice anger within ourselves, manifesting as us wanting to “break free” from isolation and rebel against the restrictions placed upon us. An anger response may also be particularly common amongst children and teenagers; the parts of our brain responsible for reasoning, planning and complex problem solving are less developed at this age and may therefore be easily overridden by sources of threat.
Bargaining: As denial and anger begin to subside, we start to allow some of the new information we were trying to escape to assimilate into our reality. We may find ourselves trying to make compromises and creating new rules that acknowledge some of the changes we were trying to deny. Bargaining allows us to maintain, albeit an illusion of, control in a situation where we are likely to feel helpless. An individual who is in a stage of bargaining is likely to develop rules and justifications that are non-compliant with government recommendations such as “I’m only socialising with people who are healthy so it’s okay”.
Depression or Despair: This may look like us catastrophising or imagining the worst case scenario, feeling overwhelmed as reality begins to overpower our attempts at denial or bargaining. We may feel powerless and without hope, questioning “what’s the point?” or struggling to identify a future beyond the here-and-now. At this stage, we may be so overwhelmed that it is difficult to think calmly or clearly; our threatened “fight, flight, freeze” response has been activated and our wise, logical brain has gone offline.
Acceptance: As the emotional dust begins to settle, we may find ourselves transitioning into a stage of acceptance. The rational “wise mind” begins to re-engage and we can start to identify new ways of living that incorporate the reality of our new circumstances. This may include us continuing to move forward with life, finding new ways to connect with areas of value and meaning. We may start working from home, establishing new routines, and finding new opportunities for joy and happiness.
Grief as a universal human experience
Reflecting upon the “normal” grief process allows for compassion for both ourselves and those around us. We all grieving and at differences paces; what may be acceptance for us may be denial for another, and the next day we may switch. This is normal.
Whilst our current understanding of loss acknowledges fluidity between these stages, personal and professional observation suggests that progression through each of these stages in relation to COVID-19 is likely to be increasingly volatile. COVID-19 brings multiple sources of loss; we are navigating not only our own losses but the losses of those around us, and within an ever changing socio-political context that provides a constant reminder of the threat we are hoping to escape.
When there is any threat, emotions run high and “in group/out group, us/them” divisions form. We find ourselves again in a polarised society that is divided between those who follow government guidelines versus those who don’t; between those who are deemed “essential” versus those whose jobs and livelihoods have now been reduced to “non-essential”; and ultimately between those who are helping and those who are not.
Stepping back from this, whilst there may be surface level disparity in our responses to COVID-19, it’s important to note that we are all likely to be at different stages of a universal response. Through viewing our responses to COVID-19 and the responses of those around us as part of a normal grief process we can start to separate ourselves from the day-to-day differences and identify the what, why and how to help.
Approaching grief with curiosity
In times of emotional turmoil we can often get stuck in our own experience, being quick to experience feelings of shame and self-criticism (i.e. “I shouldn’t be feeling this way!” or “why can’t I cope like others can?”) or feeling increasingly threatened or frustrated by the responses of those around us.
My most recent discussions in clinical practice have highlighted the importance of learning to slow down, effectively regulating our “fight, flight, freeze” response and engaging the “wise mind”, and approach grief with curiosity.
Gently investigating the grief response of ourselves and those around us, using a “what, why, how?” framework, can create a compassionate space within which the normal stages of grief can be navigated most effectively.
For ease of reading, I have framed the following questions to prompt reflection on your own experience of grief. However, I would encourage you to follow the same framework to best understand the experience of grief for those around you.
What stage of grief are you at?: Take time to notice the presentation of grief symptoms and approach these with compassion; what difficult emotions are you experiencing? Where do you feel these within your body? What might you be doing to cope with these difficult emotions?
Why might these difficult emotional experiences be occurring?: Acknowledge the multiple losses that may have occurred. If a grief stage has persisted, is there anything that may be keeping you stuck? It may be helpful to consider the impact of other psychosocial stressors on symptom presentation. For example, an individual who experiences an unsafe home environment may be in a heightened threat state and thus more likely to respond with feelings of anger or denial, and to find it increasingly difficult to move towards acceptance.
How can you be most helpful?: Now that you have a better understanding of what challenging emotions are present, try to consider what it is that you need. This may include space to talk about the areas of difficulty, gently breathing and allowing the emotion to be there (recognising difficult emotions as a normal part of the human experience, and seeking comfort that “this too shall pass”), or just understanding and patience as you allow the natural stages of grief to progress at their own pace.