(This article is excerpted from three blog posts: The Six Phases of Grief During Covid-19 (March 24, 2020), and now published in the anthology “Navigating the Pandemic, stories of hope and resilience”)
As a health care professional, I have watched the progress of the COVID-19 pandemic with alternating measures of horror, dread, fascination, frustration, and fear.
The five stages of grief (denial, anger, bargaining, depression, acceptance) as outlined by Elizabeth Kubler-Ross to describe the emotional journey of preparing for the death of a loved one, plot a useful map as we transit through the uncharted emotional aspects of the COVID-19 pandemic. Others have added meaning as an important 6th step.
For some time, many people, including some in important positions of leadership, appeared to be in denial about the risk of this virus. For many of us, it was an event happening in another part of the world. Concerning, of course, but not immediately impactful. We went about our springtime lives, planning conferences, basketball tournaments, and vacations unaware of what could befall us. Denial always looks foolish in retrospect, but at the time of the threat, denial is adaptive as it permits us to navigate a world of unpredictable threats without becoming paralyzed with fear.
As the threat of the virus came close, our collective anxiety turned to anger and fear of harm and scarcity. which led to absurd behaviors – hoarding toilet paper, or worse, hand sanitizer and N95 masks. Those conditions led to genuine, appropriate anger as health care workers were left to improvise personal protective equipment, leading well-intentioned citizens to organize sewing bees to make surgical masks and we all asked the question, “why didn’t we start preparing sooner?”
Anger led to bargaining, as we realized the potential harm of this pandemic and the need to enforce social distancing through closure orders of bars and restaurants and, increasingly, shelter in place orders that turned some of our largest cities into ghost towns. Stock markets buckled, unemployment claims skyrocketed, and a question began to be asked – can we still maintain a healthy economy and still contain COVID-19? How many people would we be willing to allow to perish to continue a robust economy?
Indeed, in a time where the pandemic of coronavirus has made shelter-in-place orders essential, everyone and every surface becomes a potential threat. When I walk in my usually bustling San Francisco neighborhood, the streets are eerily quiet, and people cross the street rather than pass on the sidewalk with less than 6 feet separating us. I come home, wash my hands, and hope that somewhere, somehow a virus hasn’t found its way into my respiratory tract.
At the start of a crisis, anxiety is adaptive because it is hard-wired into us to get us to pay attention, to mobilize for action. This energy can only be used for so long to motivate hand washing and house disinfecting before sheer exhaustion sets in. When that begins to occur, the anxiety turns to depression and demoralization as we begin to feel the duration of the threat, and the grief that comes from not only current losses, but the anticipatory anxiety that stems from not knowing what loss will come next. Sometimes called ambiguous loss, it is the sorrow over things that are uncertain and incomplete. Will we not be able to take that trip of a lifetime that we had planned for this summer? Will we see our kids graduate? Or worse, will we lose our jobs and livelihoods? Still worse yet, what if we lose our lives or we lose people close to us to this virus? So much feels uncertain.
So how do we navigate the mental health challenges of the early stages of the pandemic, the ones that are responsible for the palpable anxiety right now?
The first thing we can do is begin to divide the world and our choices in it into two categories. That which we can control and that which we cannot. We can’t know or control how long this will go on for or how bad it will get. We can’t control if other people hoard all the toilet paper. We can’t control if the local or state government issues a shelter-in-place order that closes your workplace or leaves your kids at home. And let me be clear: all of these things stink. No one likes them. But these disruptions are necessary for the safety of the community. In this fractious time, this is one point on which we can all try to agree.
The second category of things is that which we can control. The first part of this list are things that we can choose not to do. For those of us who can work from home, we can get done what we need to do and call it a day. We can release ourselves from the expectation that we’re going to write that novel or finish those photo albums when we’re stuck at home. It’s ok just to get by right now. Much of our bandwidth is taken up by managing the situation and our anxiety. As tempting as it may be to pour that additional drink to manage the nerves, we can choose to pass that up, too. Of the things we can choose, probably the most important one is our attitude. As Viktor Frankl noted from his vantage in a concentration camp, everything can be taken from us except our freedom to choose our attitude about a given circumstance. It is in this choice that we begin to find the seeds of meaning.
We can still control when we go to bed and when we wake up. We have an opportunity to practice slowness and to turn our attention inward. We can choose to have a meditation practice and choose to cultivate our inner lives. We can mindfully wash our hands or wipe down our doorknobs. We can choose how much news we consume or how much we engage with others on social media. We can choose to reach out to supportive people that buoy our spirits and steer away from those who drag us down. We can choose to smile at people at the grocery store and wave to our neighbors. We can let the other guy go at the stop sign. We can be kind. We can savor the time spent with family. Beauty is medicine. Most of us, even if we’re sheltered in place are still permitted to go outside (just away from other people or crowds), and on these walks and bike rides, we can notice the color of the sky at sunset or the way that spring is announcing itself with a riot of flowers all around us.
Depression, Grief, and Sorrow
TS Elliot begins his epic poem, The Waste Land with the line “April is the cruelest month.” And indeed, April 2020 turned out to be just that. Our first responses, marked initially by denial and then anxiety-driven anger and bargaining, have for some, now given way to depression. Perhaps not clinical depression, but we certainly find ourselves in the grips of grief and sorrow. The breadth of this event has left no one untouched, but not all those who are touched have been impacted equally. This leads to a disorienting sense of separation while at the same time, a singularity brought about by a unifying event.
The losses have taken many forms. The world has been stripped of its familiarity and its safety. We feel unable to control what comes next. There is a loss of the routine of going to work each day and the myriad of small interactions – saying hello to the person across the hall, the few minutes of banter before the staff meeting - that bring texture and pleasure to our days. The simple joys of social life – seeing a family member, meeting a friend for coffee, exchanging a laugh and a hug – have been reduced to phone calls and boxes on a teleconference screen. But these losses pale when compared to those who have watched a loved one succumb to this illness, navigate the chaos of an overtaxed hospital, and to die alone on a ventilator.
The feeling of loss is palpable right now, even if we don’t know anyone who has been sickened or died. We are suffering the loss of our ordinary lives, and we didn’t even know how much we loved these lives and how much we were taking them for granted, until they were gone. There is lassitude in the air and there is deep sorrow. Meanwhile, spring announces itself with a riot of flowers and glorious cloudscapes.
My teacher, Francis Weller, has taught me that grief is an appropriate response to loss, but that losing the things that we love is not the only reason for grief. We are experiencing grief for other things too, including the things which we had hoped for but did not get. There is also the grief of feeling alone and not been seen and witnessed by a supportive community. And there is also the ancestral grief that we carry and the collective grief of the world. All of these places of grief are alive right now.
We do not grieve that which we do not care about. But sometimes it is only when the ordinary has been taken from us do we realize how much we loved our ordinary life before the loss. When it is gone, we wish we had praised it more, we wish we could savor that which we once took for granted.