When The Sun Sets in A Pandemic: Holding Space for Grief, Loss & Transition
Working in the ICU, I saw grief each and every day. It came in all shapes, sizes, and languages. I witnessed some loved ones who fell to their knees and sobbed from the deepest depths of their souls. I witnessed others who shed silent tears. I also witnessed loved ones who did not shed a tear. There were others who responded with anger and frustration.
In those moments, I held space for my patients’ families, friends, spiritual and religious groups, co-workers, and all who had known them before they took their last breath. Whether they cried, yelled out to the sky, punched the floor, or stood silently to the side of the room, I recognized that grief was occurring.
Regardless of how my patients’ loved ones responded, their grief was valid. Their pain was real. Their stories deserved to be heard and their pain deserved to be witnessed.
When the COVID-19 pandemic began, the grief became more complex for many. Hospitals everywhere responded accordingly by shutting down elective surgeries and prohibiting visitors from entering.
In Hawaii, when someone becomes sick or gets injured, it is culturally traditional that the patient’s loved ones come to the hospital to provide support, encouragement, food, prayer, guidance, and presence. It’s not uncommon to have the waiting room be full of family members (both blood and Hanai relatives) who sleep overnight as they take round-the-clock shifts watching over their loved one.
It’s also very common to have a family meeting with the medical team and 10+ family members physically present as well as others teleconferencing in via phone and video.
With the pandemic ravaging its way across the world, all of this came to a screeching halt.
For my patients, this meant that their loved ones were not able to be in the rooms with them. This meant that their loved ones could see them via an iPad for a few moments once a day. Many of my patients died in the hospital without their loved ones being able to be with them. It also drastically limited their resources for skilled nursing or hospice placement and burial arrangements.
For my patients’ loved ones, this meant that they couldn’t hold their special person’s hand. They weren’t able to offer encouragement and support as the patient recovered from their illness or injury. They couldn’t be in the room with them as the patient took their final breath. They couldn’t engage in spiritual, religious, and cultural practices to promote healing or to help the patient transition from this life to the next. They couldn’t talk to the doctors and nurses in-person as they made their rounds or discuss treatment plans. For those who were able to recover and go to rehab to get stronger, their loved ones could not be present for this process.
For those who did not survive, this meant that families could not go visit their loved ones as they died in the hospital. It also meant that they often had to postpone rites of passage, such as funerals.
For my colleagues, their suffering has been immense. As they have been on the frontlines risking their lives for others, they have had to witness all the pain that their patients and loved ones have experienced. At the same time, they are also experiencing suffering in their own personal lives. I witnessed seasoned veteran nurses who have “seen it all” break down and leave their profession. The acute suffering and grief my colleagues have experienced is complex and will likely have long-term impacts on their lives.
In response to our colleagues’ suffering, three Social Work colleagues and myself worked together to create and implement a Critical Incident Stress Management team (CISM) known as Hui Mālama. Our aim was to utilize solution-focused, evidence-based practices to debrief our colleagues, stabilize the situation and environment, and assist with guiding them to the resources they need to cope with traumatic experiences.
I remember feeling so helpless and recognizing that even once the pandemic “is over”, that there will be grief and pain for years to come. I decided that I wanted to be a part of helping my community’s grief as COVID-19 shifts and changes today and in the future. So, I left the hospital and opened my own practice in the winter of 2020.
As a private practice therapist, many of my clients are deep in their grief. Shutdowns, quarantine, social isolation, job loss, fear for their health, fear for their loved ones’ health, continued loss of life, financial concerns, disrupted traditions/plans/events, political discourse, depression, anxiety, uncertainty over the future, and loss of routine and overall safety are just some of the elements of our lives that have been forever changed.
Why does any of this matter?
It matters because this collective grief we are experiencing is complex and will impact our world for years to come. It’s essential that we learn about our grief so we can provide support for ourselves, our loved ones, our communities, and our world as we try to cope with the impacts of loss and transition during a global pandemic.
What Is Grief?
Grief itself is about loss. It is what we experience inside. Others may not realize the sorrow we feel in our hearts. While this may include death, grief can also show up through the many losses, adjustments and transitions we face in our lives.
Grief is a normal, human response and can feel very intense. As humans, we will all experience loss and grief during our lifetime.
It is the pain of missing what was or what could have been and trying to figure out what is as you try to pick up the pieces to move forward.
Mourning is the outward expression of the pain we feel as we grieve. This can be expressed in a lot of ways, such as crying, attending funerals, and yelling up to the sky.
Bereavement occurs during the periods of our lives where mourning and grief happen.
Types of Grief
Anticipatory Grief—The grief that happens before the death or loss.
Acute Grief—When the loss just happened and disrupts function. It can range from 3-6 months in duration.
Early Grief—The first two years of grief.
Mature Grief—2+ years following the loss
Delayed grief—This is rare and usually occurs when it’s about survival and the person is not able to attend to their grief until it is safe to do so.
Disenfranchised grief—The grief we judge, minimize, or diminish as a society. It is not able to be openly acknowledged or supported. For instance, LGBTQIA2S+ partners often miss out on the support following the loss of a loved one that is offered to heterosexual partners in grief.
Ambiguous grief—There may not be a physical body to grieve. This could be grieving a person who has been diagnosed with Dementia and is “not the same person” you once knew.
Collective Grief—Something we all grieve together. The COVID-19 pandemic, natural disasters, a public person or celebrity could all be examples.
Traumatic grief—Occurs when there is a traumatic situation or the meaning of the loss is recognized as traumatic. This is different for everyone. An example could be a loved one dying during the pandemic in the hospital without: any family present, any goodbyes, any religious, traditional, or spiritual rites of passage, or anyone being able to attend the funeral.
Masked grief—A person may not realize that their emotions or behaviors are related to the loss. An example of this could be angry outbursts towards others.
Cumulative grief—Multiple losses.
Secondary grief—The ripple effect of additional losses after a major loss occurs. For instance, if a spouse passes away and they were the primary income earner for the home, this could lead to additional shifts and losses.
It’s important to note that it’s possible to have more than one type of grief. The type of loss we experience can ultimately shape the grief we have.
We experience grief in spaces such as:
The death of a loved one—Was this death sudden? Was it prolonged? Violent? Expected? Was it a child or an adult? Were there multiple people?
Living Through a Pandemic
Divorce & Interpersonal Estrangement
Changes or loss of identity
Loss of health, mobility, independence due to illness, injury, or pain
Loss of safety
Symbolic loss
Loss of bodily autonomy due to health or trauma
Facing systemic and institutionalized oppression, racism, generational trauma, microaggressions
Missed opportunities
Moving
Loss of important social and familial support
Financial loss
Each of these examples I listed represent the end or death of something. For instance, if you are diagnosed with End Stage Renal Disease and are told that you will need dialysis for the rest of your life, there can be multiple endings that you might grieve. This can range from:
· Lost wages due to difficulty working
· Having to say goodbye to a career you enjoyed and worked hard for
· Changes to your identity
· Limited control over your schedule as you navigate dialysis appointments and doctors’ appointments
· Missing the health and opportunities you once had before your diagnosis
· Missing the freedom from pain
· Missing the independence you once had
· Changes to intimacy and social connection
· Fears and uncertainty about the future
Each of these alone can be challenging enough to face. Combine any of these together (or many of the examples I didn’t list) and it’s highly likely that you will begin to feel overwhelmed very quickly.
Grieving in a Pandemic
If we consider the COVID-19 pandemic and the ever-evolving nature of the toll it has taken on the World, it becomes easier to consider the immense amount of grief we are collectively experiencing. To date, we have lost almost 4.5 million people to COVID-19 and almost 215 million total cases of COVID-19 worldwide since the pandemic began in early 2020 (Worldometer, 2021).
Many people have died without their loved ones present.
Many people have died, period.
More people will continue to die.
Many of those who survive COVID-19 will now live with prolonged illnesses.
Hospital staff have been sleeping in tents in their yards to avoid getting their families sick.
Hospitals everywhere are filling back up and resources are scarce.
Many people have lost their jobs.
We’ve faced shutdowns, quarantines, and social isolation.
Overnight, we had to learn how to work remotely. We simultaneously had to learn how to work with our children’s teachers and schools to provide virtual learning.
We’ve worried about our health, our kids’ health, our family’s health for so long. We continue to worry.
We’ve had to cancel plans and trips. Again.
We haven’t hugged the dearest people in our lives for fear that one of us will get sick.
We’ve had to face our own mortality.
Standing 6 feet apart, masking up, and sanitizing our hands has become second nature to many of us.
We’ve heard the phrase “new normal” more times than any of us care to list. This “new normal” signifies that we’ve lost our routines and what was. We recognize that we cannot ever go back to the way things were before and our world is changed forever.
There’s no end in sight.
There is a lot of pain and suffering in the world right now. We’ve had to grieve many losses, transitions, and adjustments to just this pandemic alone. What types of grief do you think you might be feeling?
What We Get Wrong in Grief (Hint: There’s a lot)
Common misconceptions about grief are everywhere! Consider these ways where we put more challenges on ourselves and others who are in grief.
“I went through the stages. I should be done grieving!” –It’s very likely that you’ve heard about the 5 Stages of Grief that were coined by Elisabeth Kübler-Ross in her book On Death and Dying (1969), which include: denial, anger, bargaining, depression, acceptance.
During her lifetime, she was very vocal about the stages of grief being a guideline, not a prescription. This means that these stages are meant to help normalize our experiences and give us guideposts. They are not meant to be one-and-done feelings we go through and never experience again. They also may not go in any particular order!
Grief is something we experience over the course of our lifetime. It doesn’t follow the rules we think it should. Grief isn’t linear and there is no timeline. Grief also never goes away. It can change over time, but we never completely close the door to it.
“If someone isn’t crying, they’re not grieving. They’re in denial.”—This is a tough one for people to experience, as we make judgments on others and ourselves if we feel we aren’t “doing it right”. I’m here to tell you that there isn’t a “right way” to grieve. No two people experience loss, transition, and pain in the same way.
“They’re crying (yelling, doing) too much. They’re not handling it well.”—
It is also important to consider cultural, gender, religious, and spiritual expectations and behaviors around expressing our grief. Every culture has its own rituals and traditions around mourning that need to be understood in its own unique way. Not giving time to seriously consider this can lead to pathologizing grief as being unhealth or abnormal.
I would often receive urgent referrals from the medical team when family members would be “maladaptively coping” to the loss of their loved one.
Here in Hawaii, there are certain cultures which express their mourning through death wail rituals. Death wails are loud, guttural, moaning cries that serve as a testament to how loved and respected this person was. This practice has been around dating back to the ancient Celts.
When I would receive a consult to see a family about “maladaptive coping” after their loved one died, it would routinely result in me providing education to the medical team about different expressions of mourning and grief. It would also routinely result in me advocating for the family to have space to grieve their loved one. Advocacy is so critical here because assuming that someone is not grieving “well” or in the same way we would can lead to inappropriate and inaccurate pathology, isolation, shame, and poorer mental health outcomes.
This became exceptionally difficult during the pandemic, as families were not able to participate in ceremonial or traditional rites of passage or expressions of mourning—either at the bedside or at the funeral home.
So I repeat—there isn’t a right way to grieve. Give yourself and those around you the permission to be human.
“I shouldn’t be so sad. Other people have it way worse than me.”—
Your pain is real, complex, and valid.
Let me repeat that. Your pain is real, complex, and valid.
You are a human who is experiencing loss. You are a human who is living through a pandemic that creates its own losses and exacerbates the losses we innately experience as humans.
Are there people out there who “have it worse”? I’m sure that if we dug deep enough, we could find someone somewhere who is dealing with some pretty rough stuff themselves. This is called comparative suffering and it’s a very dangerous space to get into.
When we view our suffering as somehow less painful or traumatic than another person, it does three things—1) Puts pity on the experiences of others. 2) Ranks our suffering as somehow less painful. This tells us that it’s not ok to feel our feelings and so we deny ourselves the right to feel. It delegitimizes our feelings. 3) It keeps all of us in suffering.
What People Living With Grief Need
Someone to witness your grief
Space to share your feelings without being bright-sided or told to “look at the silver lining”
Space to release any guilt and self-judgment you may be holding onto
Tending to your wounds
Integrating pain & love
Finding meaning: “We don’t find meaning in the loss itself. The meaning we find comes afterwards so we can create a life that honors who and what we lost.” (Kessler, 2020)
How Do We Cope When the Sun Sets in A Pandemic?
First of all—please remember to be gentle with yourself on the tough days. You don’t need to be fixed because you are absolutely not broken.
It’s not about what is wrong with you, but what has happened to you.
Be patient with where you are in your grief.
Take care of your health and listen to your body. It’s important that you take the time to consider that you might be more on edge because we’ve been primed for underlying, chronic stress since March 2020.
Find supportive people in your life who can listen to you without judgment or bright-siding. There are a number of great support groups online that you can find with a quick search.
Participate in rituals that keep you connected to the important people and things from your life.
Preserve the important memories you have in a way that’s meaningful to you.
Learn about your grief. Talk about it. Acknowledge your pain. Find a therapist who specializes in grief and loss. In therapy, you don’t have to show up being “put together” or “over it”. In therapy, you’ll get the support you need to process the loss you have experienced. You’ll also develop practical coping skills to manage hard moments and feelings so you can find your direction again.
Lana Lipe is a Licensed Clinical Social Worker and founder of Hoosier Mental Health, LLC. She is a private practice therapist in Indianapolis, Indiana who helps adult clients living with: chronic conditions, grief, loss, stress anxiety, perfectionism, as well as gender identity & sexual orientation exploration.
Lana earned her Master’s Degree in Social Work from the University of Maryland School of Social Work in 2017.
She has over six years working in healthcare and non-profit settings to include: a skilled nursing facility and nursing home, a non-profit Chronic Kidney Disease agency, and 4 intensive care units (ICUs). During this time, Lana has worked with countless patients and their families as they navigate the challenges associated with critical illness, chronic illness, and end-of-life care. She has extensive training in crisis intervention, grief counseling, end-of-life planning, advocacy, intersectionality and health equity & trauma-informed care.
During her time as an ICU Social Worker in a level-one trauma hospital, Lana helped co-create a Critical Incident Stress Management team (CISM) that was implemented hospital-wide.
In addition to her work as a healthcare professional, Lana’s work has been published in The New Social Worker Magazine. She has been featured as a recurrent guest mental health expert on James Fabin’s Chronic Kidney Disease Channel—Dadvice TV. Her work has also been featured in numerous other online publications.
As of October 2021, Lana is training to become a Certified Grief Educator with world-renowned grief expert, David Kessler.
To learn more about Lana and her work, please visit her website at HonuTherapy.com.
Works Cited
Kessler, D. (2020). The Six Elements of Grief. Retrieved from: https://www.facebook.com/watch/?v=3483826778380427
Kübler-Ross, E. (1969). On death and dying.
n.a. (2021). Worldometer: Covid-19 Coronavirus Pandemic. Retrieved from: https://www.worldometers.info/coronavirus/
