The COVID-19 pandemic is an epidemiological crisis, but also a psychological one. While the situation provokes anxiety, stress and sadness, it is also a time of collective sorrow, says Sherry Cormier, PhD, a psychologist retired from private practice who now focuses on grief training and mentoring. “It’s important that we start recognizing that we’re in the middle of this collective grief. We are all losing something now.”
Many people are confronting the loss of a loved one to the novel coronavirus—a challenge made even more difficult by physical distancing orders that prevent them from saying goodbye in person or gathering with others to mourn. Deaths aren’t the only losses that people are reckoning with, however. Millions of people are facing loss of employment and financial upheaval as a result of the pandemic. Yet even people who haven’t lost anything so concrete as a job or a loved one are grieving, Cormier says. “There is a communal grief as we watch our work, health-care, education and economic systems—all of these systems we depend on—destabilize,” she says.
The crisis isn’t just shaking our faith in those systems. It’s upending our understanding of the world around us, says Robert Neimeyer, PhD, director of the Portland Institute for Loss and Transition and professor emeritus of psychology at the University of Memphis. “The losses include our sense of predictability, control, justice, and the belief that we can protect our children or elderly loved ones,” he says.
In the wake of the COVID-19 pandemic, psychologists will play a key role in helping people manage the many losses they’re mourning, Neimeyer adds. “We’ll have an immense challenge as a profession, but also a vast opportunity to help people address these elements of suffering.”
Grieving a living loss
Research from the bereavement literature shows that the nature of a person’s attachments has an effect on their grief reactions. Of course, we aren’t only attached to other humans, Neimeyer says. “We’re capable of losing places, projects, possessions, professions and protections, all of which we may be powerfully attached to,” he says. “This pandemic forces us to confront the frailty of such attachments, whether it’s to our local bookstore or the routines that sustain us through our days.”
Many of the losses we’re experiencing now are so-called ambiguous losses. “These lack the clarity and definition of a single point like a death,” Neimeyer explains. That fuzziness can make it hard to move forward. As the pandemic has evolved, people have had to confront a series of losses: the loss of a sense of safety, of social connections and personal freedoms, of jobs and financial security. Going forward, people will experience new losses we can’t yet predict. “We’re talking about grieving a living loss—one that keeps going and going,” he says.
We don’t only grieve for what’s missing, but also for the ways in which those losses affect our senses of self, says George Bonanno, PhD, a psychologist who heads the Loss, Trauma, and Emotion Lab at Teachers College, Columbia University. “You can experience grief over anything that feels like a loss of identity.” Research shows, for instance, that losing a job can trigger a period of prolonged grief distinct from anxiety or depression. That prolonged grief seems to be related to the impacts of job loss on self-esteem and belief in a just world (Papa, A., & Maitoza, R., Journal of Loss and Traumaopens in new window, Vol. 18, No. 2, 2013).
Though grief is difficult, it helps to recognize that it’s natural and useful, Bonanno says. “Grief is really about turning inward and recalibrating, and thinking: ‘This is not the way the world is anymore, and I need to adapt,’” he says. “It’s okay to feel grief over what we’re losing. When we do that, it allows us to let grief do its job, so that we can move on.”
His research suggests that once a crisis has passed, most people are able to bounce back and move on with their lives. Grief is also transient, even when we’re in the midst of its clutches. People should expect to fluctuate between moments of sadness and mourning, and moments of acceptance or even happiness, he says. “People who cope well with loss usually move in and out of those states. It’s OK to allow yourself to be distracted and entertained, and even to laugh.”
It helps to ‘name and claim’ our grief
With almost the whole world confronting losses large and small, how can people cope as they mourn their pre-pandemic lives? For starters, mental health providers can help patients “name it and claim it,” Neimeyer says. “People often have a vague sense of anxiety or wordless suffering. We can help them wrap language around that,” he explains. “We can ask people to consider what they’re losing in the context of this pandemic, what they can do to strengthen those ties.” It’s not a fatalistic view, he says. Rather, it’s an organized way of taking action to help people cope with their losses, from jobs and relationships to sources of self-worth and self-efficacy.
Cormier suggests people keep journals to put words to losses and to help identify ways to move forward. As the work of psychologist James Pennebaker, PhD, at the University of Texas at Austin, has shown, writing about emotional upheavals can improve both physical and mental health (Perspectives on Psychological Scienceopens in new window, Vol. 13, No. 2, 2018). “Name what you’re losing, individually and collectively, and write about your personal strengths and coping skills,” Cormier suggests. “Most of us have never been through anything like this, but we’ve been through other challenging transitions. It can help to write about how you got through a divorce, or losing your job, or other challenging transitions. How did you heal and recover?”
Social support is another well-established tool that can be critical in helping move on from grief, instead of getting stuck in it. That poses a problem in an age of physical distancing, when people are isolated in their homes away from loved ones. “During this time, there may be an erosion of social support and the meaningful social roles that buttress our identities,” Neimeyer says.
Psychologists can encourage people to stay connected with their social support networks through phone calls, text messages, video chat and social media. And those reminders should continue even after we emerge from isolation, says Erika Felix, PhD, a psychologist at the University of California, Santa Barbara, who treats and studies survivors of trauma and disasters. “One thing we’ve learned from disasters is the ongoing importance of social supports. The lesson is to keep checking in on people, and keep the support going even after this period of lockdown ends,” she says. “For some people, the stress will continue after quarantine ends, especially if their jobs or relationships are affected.”
Saying goodbye in the age of physical distancing
While we’re mourning the loss of our pre-pandemic lives, many people will also face the grim task of mourning the deaths of friends or family members. Whether it’s sitting shiva, lining up for a New Orleans–style jazz procession or sharing a meal with loved ones after a secular memorial service, cultures and customs around the world share a key element of mourning: social connection. In the age of COVID-19, physical distancing is driving a wedge in those moments of connection.
“One of the most time-tested ways of coping with grief is to practice social connection, to be with other mourners. Now, we may be having to cope with grief and sorrow alone, socially isolated, where we don’t get the physical comfort we need from friends and family,” says Cormier. “We’re having to figure out new systems and new rituals for trying to honor death when everything else around us is shifting.”
The act of saying goodbye to a loved one often begins well before a funeral or burial. For many people, the days and hours at the end of a loved one’s life are especially poignant. “Normally, we can hold a loved one’s hand, have meaningful conversations, affirm the bond, make amends,” says Neimeyer. “When we are able to practice these things, it softens the blow of loss.”
With strict isolation measures in place in most hospitals, people are missing out on those final farewells. That’s true when people die from COVID-19, but also from more familiar causes such as heart attacks or cancer. While critical to slowing the spread of the disease, those measures also make it hard for mourners to come together to grieve. Some people have begun filling that void with virtual shiva and funerals, but technology is an imperfect substitute for an in-person embrace. “Being in close physical proximity with friends or other mourners helps us produce feel-good hormones like oxytocin, dopamine and serotonin,” Cormier says.
When people aren’t physically present to say goodbye and grieve with other mourners, they may be more likely to experience a sense of ambiguous loss, she adds. “With an ambiguous loss, it’s very hard to get closure. There’s often a lot of frustration and helplessness, because people feel disempowered,” she says. “The question becomes, how can we construct new rituals to help us cope with death and dying for this situation that we’re in right now? We’re facing the question of needing to find some new way for honoring the dying process and also coping with our grief. And we might have to look to psychologists, along with faith leaders and others, to find those new mechanisms.”
Prolonged grief disorder
Such difficult circumstances may increase the odds that a bereaved person will develop complicated grief, also known as prolonged grief disorder, says Neimeyer. Prolonged grief is an intense grief that is distinct from depression. The DSM-5 favors the term “persistent complex bereavement disorder,” defined as prolonged grief lasting at least 12 months. A proposed addition to the forthcoming ICD-11 defines prolonged grief as lasting at least six months. Though those diagnostic criteria disagree on the timepoint at which grief becomes prolonged, they agree on the key feature of the condition: grief that endures and interferes with normal functioning. “It keeps going and going like the old Energizer bunny,” Neimeyer says.
Prolonged grief is marked by persistent longing and sadness for the deceased, and a sense of disbelief or inability to accept the loss, as M. Katherine Shear, MD, at Columbia University, has described. Without treatment, prolonged grief increases the risk of substance use, sleep disorders, impaired immune functioning and suicidal thinking (New England Journal of Medicineopens in new window, Vol. 372, No. 2, 2015).
Over the past decade, researchers have learned a lot about prolonged or complicated grief, Neimeyer says. Risk factors include social isolation, attachment insecurity, anxiety and experiencing a loss that is sudden and inexplicable. “The circumstances under which deaths are now occurring, with plenty of unresolved relational issues, represent a perfect storm for producing complicated grief,” he says.
Depression and anxiety can coexist with prolonged grief, and pharmacological treatments can sometimes help address those co-occurring symptoms. But for prolonged grief disorder itself, psychotherapy is the gold standard. Shear, for instance, found that adding an antidepressant to her complicated grief treatment did not improve symptoms of prolonged grief (JAMA Psychiatryopens in new window, Vol. 73, No. 7, 2016). “The core of complicated grief is unaffected by pharmacotherapies. The only evidence-based treatment is psychological,” Neimeyer says.
Psychology can embrace its purpose
Even after the COVID-19 crisis has subsided, many people will continue to struggle with grief and trauma for some time, says Felix. “As things return to normal, most of us will also return to a kind of normal, albeit changed by going through this experience. But there is a subset of people who will be chronically disrupted and will need support,” she says.
Psychologists may have to build their expertise on grief and trauma to meet that need, through continuing education in areas such as disaster mental health, psychological first aid and trauma-focused therapies, Felix adds. “When working with people who have experienced trauma, it’s important to know your strengths and to know what you can and can’t do.”
Unfortunately, grief and loss are given cursory attention in many psychology training programs, Neimeyer says. “Few of us have any serious training for dealing with grief and loss. Deepening competencies around treating grief will need to be a priority of many psychologists for years to come.”
But the field is up to the challenge, he adds. “One thing about crisis is that it can galvanize creativity and commitment,” he says. “Psychology has a purpose and direction in this crisis that is quite clear. We can retreat from it, or we can embrace that moment.”
