What we might expect, and what we can do about it

Current policies on Covid19 patients in hospitals and care homes, exacerbated by the sheer numbers, do not bode well for those bereaved by this pandemic. Unless we begin to address this now, many of those bereaved by the pandemic will suffer more than they need to.  In this article I draw on my practical experience and theoretical stance to elucidate the problem and suggest a viable way forward.

I have worked as a bereavement counsellor for twenty years. For the past ten years I have conducted case study research on people bereaved of somebody close to them. By recording and analysing what clients say in their grief therapy, I have built a detailed model, not just of what clients go through in grief, but of the process by which they emerge at the end of counselling with their mental health intact.  Research over the past decade has shown that most people manage their loss well, but suddenly, bereavement counselling is in new territory.

We don’t even start with a level playing field. Bereaved or not, all of us are, to a greater or lesser extent, grieving the loss of the lifestyle we had before the Coronavirus pandemic. What is known in bereavement and trauma theory as our Assumptive World, has been radically altered, be it by lockdown, social distancing redundancy, isolation and many of the other unprecedented changes wrought upon us. Many people on social media report classic grief symptoms, including anxiety, depression, low motivation, difficulty in concentrating on a task, fear, tearfulness and anger. We may find our anger exacerbated by political decisions, overstretched health and social care systems and the tragic fate of individual health workers. Now thousands have had the distress of bereavement added to this pre-existing baseline.

Before bereaved people are able to adapt to their loss, my research suggests that they meet all the following criteria:

Able to talk in detail, about the death, without becoming overwhelmingly upset.

Make some sense of the death.

Move comfortably between sadness and getting on with life.

Form a continuing bond which takes their lost loved-one into their future.

Find new meaning and purpose in life going forward.

I would argue that the typical circumstances being reported for Covid-19 deaths will frustrate and confound the grieving process.

The nature of grief is well understood by those of us working in the field. To successfully come to terms with the loss and move forward, each of us goes through a sequence of thoughts and feelings.  Most importantly, this involves accepting that the death has really happened. Until we do that we are stuck with the numbness and denial of the early phase of grief. We accept this reality by talking, in detail, about what led up to the death. As we talk, we construct a narrative by which we make sense of events. This driven need to make sense of and find meaning in our personal world, is a fundamental human characteristic. Making sense of the death is, at the best of times, difficult if you are not able to witness the progress of the illness, the final hours, and the final goodbyes. In normal times, even if you are not present at the death, there may be relatives who can tell you the story, nurses and doctors who will meet you and explain. Deprived of the opportunity to construct a meaningful narrative, people risk filling the gaps with negativity. They may become consumed with guilt at not being there for their loved one, for still living when they have gone. Add to this any uncertainty about a cause of death. Knowledge helps us to find closure. If, for whatever reason, a Covid19 death is not recorded on the death certificate, this aspect of our grief may remain unresolved.

Accepting and understanding the death is just part of the story. The usual rituals which follow the loss of a loved one are driven by our need to find meaning, both in the life of the deceased and in our own reaction to their passing. In normal times we do, at best, find some positive meaning to palliate our distress. The funeral service marks an ending, offers a chance to bid farewell and reprises a life in the eulogies and recalled tales. Times, however, are no longer normal. Even if a funeral can take place, numbers able to attend are restricted.  In many communities, the value of a life is measured by funeral attendance. So many of my clients find comfort in the numbers of people who gather to say goodbye. The pandemic is depriving the bereaved of the healing power of funeral rituals, and it will leave scars.

The lockdown, quarantining of vulnerable groups, and the effects of social distancing, will deprive many of the usual ways of taking time out from grief. Bereaved individuals, particularly those with a history of anxiety and depression, are at risk of descending into a vortex of rumination. Rumination, a dwelling on negative emotions which can enter a destructive cycle, is a recognised complicator of the grieving process. Isolation also denies a bereaved person the opportunity to talk about the person they have lost, and to begin to form a new symbolic bond with the deceased that they can take into their future. The opportunity to form a continuing bond with the deceased is recognised by bereavement counsellors as a helpful means of coming to terms with loss. At best, by talking to others about the deceased person, a renewed companionship is formed in stories and memories. Social isolation will hamper this process.

Many people come to terms with loss when they find a renewed sense of purpose. In the best of times, life can feel pointless when we are newly bereaved of a partner. Older bereaved people often find comfort and a sense of purpose in their grandchildren.  Without face to face connection during this critical period of grief, it will be hard for the isolated bereaved to adapt and find purposeful meaning in their life.

What is to be done? In normal times resilient people cope. Grief, in nearly all circumstances, is a normal, healthy process and I would be one of the last to label grief as a disorder. Before the pandemic, few people needed the support of bereavement specialists. Most got by on their own or by talking to friends, family and voluntary organisations. Just 10% to 15% met complicating factors which warranted professional intervention. Complicating factors include the deceased being young, death of a spouse or child, sudden unexpected deaths, issues related to the notification of the death and low levels of social support. All of these are likely risk factors for Covid19. There may well be more which emerge from the research which will be needed in this field. All this points to increased referrals for stretched bereavement services, often staffed by volunteers and, in many instances, short of funding from the austerity years.

Solutions to this potential crisis come from understanding the rationale behind talking therapy, including bereavement counselling. The act of speaking or writing down problematic thoughts and feelings is the beginning of therapeutic change. Assimilation theory posits that through these words we form a schema, or mental construct. Once the construct is expressed, we can explore, validate, challenge, refute, or modify it. In short, we either accommodate the construct seamlessly into our existing narrative or, if it does fit, assimilate it into our changed narrative. Assimilation is the way we adapt to new situations.  Sceptical clients in bereavement often say that counselling has no point because “it can’t bring them back.” This true, but it can, and usually does, change the way a client adapts to the loss.

In the aftermath of the current pandemic, most people will manage their grief by talking to friends and family. A few will need the support of volunteers, often with basic training in listening skills and often affiliated to religious groups. There will be an increased call on these services, and a need for training in counselling skills to meet this demand. Those with the most complicated grief will need qualified bereavement counsellors. These specialists will understand the theoretical context of the complication and have the skills and empathy to support the complex process. Specialists, however, are likely to be in short supply. Most are employed by charities who will be financially stretched by the pandemic. Private counselling is out of the financial reach of many and in any case, few counsellors are specifically trained in this field. The expertise and technical networks exist to deliver specialist training to counsellors as an urgent priority. It requires the political will to implement what is needed.

I have set up a Facebook mutual support group specifically for people bereaved by Covid-19, and will be available to facilitate the group and offer support.