Grief is a normal, albeit sad and challenging, part of life. All human beings will experience loss of a loved one at some point and will experience grief. Although acute grief is usually self-limited, we never fully stop grieving.1 But individuals whose grief remains intense and impairing for more than a year are said to experience “prolonged grief disorder” (PGD) or “complicated grief” (CG).1
A recent article in Psychiatry Advisor explored approaches to CG/PGD. This follow-up article focuses on the unique challenges of addressing grief caused by the loss of a loved one due to the COVID-19 pandemic. As of mid-February 2021, the coronavirus had claimed the lives of over 482,500 individuals in the United States,2 each associated with an estimated nine bereaved individuals. The pandemic poses unprecedented challenges to the grieving process, setting the stage for more complex and prolonged reactions on the part of those who have lost loved ones.
To shed light on the impact of COVID-19 on bereavement, Psychiatry Advisor spoke to M. Katherine Shear, MD, Marion E. Kenworthy Professor of Psychiatry, Columbia University School of Social Work, Columbia University College of Physicians and Surgeons, New York, NY, and Director of the Center for Complicated Grief.
What is the typical bereavement process?
Bereavement is the situation of having lost a loved one. Grief is the natural reaction to loss. And, although acute grief is extremely painful and can even feel overwhelming at times, most people adapt to the loss and accompanying changes in life circumstances, reconnect with a sense of purpose and meaning, and find ways to honor the deceased loved one and keep that person in their hearts.
That is not to say this is a smooth and simple process. It takes time and is multifaceted, often accompanied by a sense of upheaval and confusion. However, most bereaved people pass certain benchmarks or milestones in the process of adapting to the loss.3 At the Center for Complicated Grief, we have identified seven Healing Milestones to provide some guidance for grieving people.
|· Understand and accept grief|
· Manage grief-related emotions
· Envision a promising future
· Strengthen relationships
· Narrate the story of the death
· Live with reminders
· Connect with memories
What might disrupt the grieving process?
The natural grieving process can be derailed when some of the complexities of grief are unresolved. A variety of factors might be at play, including characteristics of the bereaved person, the specialness or nature of the relationship with the deceased loved one, and the circumstances and context of the death. These increase the chance that one or more aspects of the meaning or experience of grief take hold as derailers to adaptation.
Complexities of Grief that Can Derail the Process of Adapting to Loss9
|· Protest or disbelief|
· Counter-factual thinking (imagining alternative scenarios)
· Judging grief or trying to control it
· Survivor guilt
· Blaming self or others
· Inability or unwillingness to move forward in a positive way
· Over-cautiousness in close relationships
· Excessive avoidance of grief triggers
Derailers can stall the grieving process, resulting in PGD. Risk factors associated with PGD can be related to the bereaved person (eg, previous depression or anxiety, history of insecure attachment, and previous trauma and loss). Other risk factors include the nature of the relationship to the deceased — for example, whether the deceased person is a child or romantic partner — as well as the circumstances of the death. Violent or sudden death, stressful life circumstances, or other concurrent or secondary losses additionally increase the risk.3
What factors specific to COVID-19 might increase the risk for PGD?
When faced with a major loss such as a death, we often imagine an “alternative scenario” — in other words, we almost automatically think of how things might have been different so the person would not have died.1 This is called counterfactual thinking, and it is a natural reaction to an important loss — although the rational brain realizes that alternate scenarios are not real. It is one way that we cope with the acute pain of a loss. Under ordinary circumstances, these thoughts are not very prominent, but they can be stronger and more difficult to resolve when a loved one dies in a sudden and unexpected way.
In the case of COVID-19, it is very easy to imagine alternatives: What if the deceased person hadn’t been where they were, they wouldn’t have gotten infected. If they hadn’t entered that particular supermarket, attended that party, or gone on that trip, they would not have been exposed to the virus. This can happen even if it is unclear where or how the person contracted the virus. Ease of imagining alternative scenarios can sometimes make it more difficult to accept the reality as it is and increase the risk for PGD.
Does the social distancing necessitated by COVID-19 increase the risk for PGD?
COVID-19-related social distancing has a major impact on the grieving process in a number of ways. Especially earlier in the pandemic, but even now, people often cannot be present with their loved ones during the dying process. This raises a host of potential reactions.
“Survivor’s guilt” is common in many scenarios of a loved one’s death. It is the sense of discomfort or distress about having been spared the adversity that the deceased endured, and can often take the form of feeling “Why was I spared, while he/she died?”
In the case of COVID-19, the circumstances of the loved one’s death augment this reaction. Additionally, knowing that the deceased person has suffered, may have died alone or surrounded by medical professionals clad in protective gear that added further disconnection, and without close family or friends present, is anguishing and can increase feelings of personal guilt. The person thinks, “I should have been there. I abandoned him/her.”
Another component is that the bereaved person may not have had the opportunity to say good-bye to the loved one, leaving many things unsaid and resulting in a lack of closure. And not being with the person, at their side during the dying process and death, can increase the sense of disbelief and make it more difficult to accept that the death has actually occurred.
Social distancing also impacts the usual form of religious and cultural aspects of the grieving process, robbing the mourner of the comfort of usual kinds of community support and ritual. In the aftermath of a death, people usually come to pay their respects through traditions such as shiva observed by Jews or a wake observed by Catholics. Close friends or family members who are ill or at risk cannot attend even a small funeral or memorial service. Conducting these benchmark events via video format robs the mourners of physical touch and comfort, such as hugging and holding hands, which is helpful in modulating emotions and calming physiological reactivity.
The solace in resuming normal activities following a major loss, such as getting together with friends, attending a class, going to movies or restaurants, or exercising outdoors or at a gym, is also curtailed or unavailable.
Are there other factors specific to COVID-19 that can increase the risk for PGD?
A host of stressors beset the bereaved person. Some are practical — for example, funeral homes may be overwhelmed and retrieving the body and making funeral arrangements may be more complicated.
In additional to dealing with the loss itself, people are facing the ongoing stress of the pandemic, including anxiety about one’s own health and that of other loved ones. There are major effects on daily life and routines. Some people face job loss and serious financial difficulties.
Anger and bitterness are natural aspects of grief that can become “derailers” if they are not resolved. In the case of COVID-19, many people feel that political factors were responsible for how the pandemic unfolded and that their loved one’s death might have been avoided had the pandemic been handled differently. Others who have lost family members feel frustrated and pained that some people refer to the pandemic that claimed their loved one’s life as a “hoax.”4
Factors that raise the risk of PGD during COVID-19 are listed in Table 3.
Risk Factors for Prolonged Grief Following the Loss of a Loved One During COVID-193
|Circumstances of the Death||COVID-19-Related Factors|
|● Sudden, unexpected, possibly preventable|
● The loved one died alone
● The loved one suffered at the end of their life
● Restrictions on visiting the dying loved one
|● Physical distancing policies affecting the ordinary mourning process (eg, funerals, burial, rituals, community support, family gatherings)|
● Fear of contamination
● Having others to care for
● Financial worries
● Limited healing opportunities (eg, going out, exercising)
● Other emotions (eg, anger, guilt)
How can clinicians address these issues with clients?
The single most important thing that anyone — whether a clinician or a layperson — can do when trying to help someone who is grieving and struggling with the loss of a loved one is to be a good listener. Paradoxically, this involves curbing the strong impetus we all feel to help a person in pain to feel better. Rather than trying to reassure or actively comfort them, it is usually more helpful to simply be present with them in their grief. When inquiring further into the client’s experiences and feelings, it is preferable to ask warm, inviting, open-ended questions rather than offer solutions.
It is important to allow clients to accept and come to understand their grief. One way to do this is to name painful emotions, such as sadness or anger, and observe and reflect on them. Although feelings might be mitigated by mindfulness techniques, or other emotion regulation strategies if they are part of the clinician’s “toolkit,” it’s important to remember that that painful emotions are a natural part of grief and not a mental health problem.
It is helpful to invite the client to talk about the story of their loved one’s death, allowing them to voice any concerns regarding the illness or treatment. Some clinicians shy away from this out of concern that it might be too emotionally activating for the client, but the ability to share this story with an interested person in an environment that feels safe can be a part of the healing process.
Encouraging people to plan that they will eventually return to the world and deal with reminders of the deceased loved one, even if this triggers grief, can be helpful as well. A commitment to permanently avoid reminders of a loved one can create unneeded restrictions and deprive a bereaved person of positive memories associated with these reminders.
A number of simple techniques are available to address each of the healing milestones. These can be adapted to the specific circumstances of a bereaved person, the time since the death, and each person’s available support system. Together, a clinician and client might develop creative ways to adapt healing mechanisms to the realities of the pandemic in how to mobilize “virtual” community and family support, for example.
Being aware of “derailers” and educating clients about them can validate the complex feelings that the loss evokes for them and facilitate navigation of these in ways that can help stave off PGD. Clinicians should recognize PGD, a condition that can be diagnosed a year or longer after the death. When present, it is associated with impaired physical health, cognitive dysfunction, depression, anxiety, increased risk of substance use disorders, increased suicide risk, reduced quality of life, and premature mortality.3
ICD-11 Criteria for the Diagnosis of Prolonged Grief Disorder10
|A persistent and pervasive grief response characterized by longing for/persistent preoccupation with the deceased and accompanied by intense emotional pain sadness, guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost a part of one’s self, inability to have a positive mood, emotional numbness, or difficulty in engaging with social or other activities)|
|A grief response that has persisted for an abnormally long period of time after the loss, clearly exceeding expected social, cultural, or religious norms; this category excludes grief responses within 6 months after the death and for longer periods in some cultural contexts|
|A disturbance that causes clinically significant impairment in personal, family, social, educational, occupational, or other important areas of functioning|
What interventions might be helpful for people experiencing PGD?
Psychotherapeutic interventions are first-line treatment for people who seek help with grief. The most extensively studied 5-7 and recommended is complicated grief psychotherapy (CGT), which is a short-term approach that addresses derailers and fosters progression through HEALING milestones. The seven core components of CGT are listed in Table 5. Additionally, there are several Internet-based CBT therapies that include similar procedures including some designed to increase involvement in enjoyable activities and reduce avoidance of reminders of the deceased.6
Many mental health centers and hospitals now offer support groups specifically for individuals who have lost loved ones to COVID-19. The National Alliance on Mental Illness (NAMI) also recommends resources to assist in the grief process.
While it is not an “intervention,” there is a national Facebook group called “COVID-19 Loss Support for Family & Friends” with over 3000 members that might be a helpful forum for mutual support.
Core Procedures used in CGT11
|● Daily grief monitoring|
● Aspirational goals work
● Inviting a friend or family member to a session
● Imaginal revisiting (telling the story of learning of the death)
● Situational revisiting (graded exposure to reminders of the loss)
● Imaginal conversation with the deceased
Many psychotherapies are currently offered via telemedicine as a result of concerns about COVID-19 contagion. Can bereaved individuals benefit from them?
Therapists started conducting CGT via video several years before the advent of COVID-19. While there is a dimension missing when we are unable to sit in person with a bereaved client, clients can still benefit and many actually prefer the convenience of not having to leave their homes. Although some older adults may find it difficult to navigate digital platforms, over time, they can become more comfortable and proficient using these platforms.
Is pharmacotherapy helpful for PGD?
Pharmacotherapy can be helpful for depression and anxiety, which can coexist with grief. However, there is no evidence that antidepressants have efficacy in management of PGD.7,8 We also advise against sedative-hypnotic medications, as a rule; and if they are prescribed, they should be used carefully and only for short periods.3 Sleep disturbances can be approached by offering advice regarding healthy sleep practices and other nonpharmacologic approaches.3
Are there any additional thoughts you would like to share?
I have often found that colleagues feel discouraged about how to help bereaved people heal and find new purpose in the future. They sometimes feel that this is not possible — especially for an older person who has lost a life partner or a child. It is important for clinicians to understand that, while grief is permanent, pervasive impairing grief is not, even in older people or after an especially difficult loss. Our work is currently focused on helping clinicians develop confidence in managing PGD. For those working with bereaved people during the pandemic, it’s important to be sure they can recognize PGD and to learn effective ways to address this debilitating condition. It’s not as hard as it seems.
It is also important to recognize that there is no “formula” for COVID-19-related grief. While it is very helpful to focus on healing milestones and possible derailers, clinicians need to focus on the individual client and personalize their intervention. For example, if the bereaved person is experiencing justified anger, the clinician would want to validate it and help them consider how to best resolve the anger — eg, to take some action or forgive the people involved. If the anger seems excessive or unwarranted, the clinician might want to help the bereaved person to think through the situation and develop a more realistic view of the situation.
I believe that the famous “Serenity Prayer” can be another useful guide for clinicians. We can use it to help clients focus on figuring out what else they can or cannot change. We can encourage bereaved clients to move toward accepting what they cannot change and to plan and execute effective action to deal with things they can change.
More information and resources are available at: http://complicatedgried.columbia.edu
- Zisook S, Reynolds CF III. Complicated grief. Focus (Am Psychiatr Publ). 2017;15(4):12s-13s. doi:10.1176/appi.focus.154S14
- Centers for Disease Control and Prevention (CDC). United States COVID-19 Cases and Deaths by State. https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days. Accessed: February 15, 2020.
- Goveas JS, Shear MK. Grief and the COVID-19 pandemic in older adults. Am J Geriatr Psychiatry. 2020;28(10):1119-1125. doi:10.1016/j.jagp.2020.06.021
- Montgomery D. How to grieve during a pandemic. The Washington Post Magazine. December 7, 2020. https://www.washingtonpost.com/magazine/2020/12/07/how-to-grieve-during-a-pandemic/?arc404=true.Published December 7, 2020. Accessed December 21, 2020.
- Shear MK, Wang Y, Skritskaya N, et al: Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA Psychiatry. 2014; 71:1287–1295. doi:10.1001/jamapsychiatry.2014.1242
- Shear MK. Clinical practice. Complicated grief. N Engl J Med. 2015 Jan 8;372(2):153-60. doi:10.1056/NEJMcp1315618
- Shear MK, Reynolds CF 3rd, Simon NM, et al: Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry. 2016; 73:685–694. doi:10.1001/jamapsychiatry.2016.0892
- Zisook S, Shear MK, Reynolds CF, Simon NM, Mauro C, Skritskaya NA, Lebowitz B, Wang Y, Tal I, Glorioso D, Wetherell JL, Iglewicz A, Robinaugh D, Qiu X. Treatment of complicated grief in survivors of suicide loss: A HEAL report. J Clin Psychiatry. 2018 Mar/Apr;79(2):17m11592. doi:10.4088/JCP.17m11592
- Grief White Paper Series. Healing milestones: What to expect from grief with COVID-19 addendum. The Center for Complicated Grief at Columbia University. https://complicatedgrief.columbia.edu/wp-content/uploads/2020/06/HEALING-Milestones_-What-Grievers-Can-Expect-with-Covid-19-Addendum.pdf. Accessed December 21, 2020
- Eisma MC, Rosner R, Comtesse H. ICD-11 Prolonged grief disorder criteria: Turning challenges into opportunities with multiverse analyses. Front Psychiatry. 2020;11:752. doi:10.3389/fpsyt.2020.00752
- Iglewicz A, Shear MK, Reynolds CF III, Simon N, Lebowitz B, Zisook S. Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice. Depress Anxiety. 2020 Jan;37(1):90-98. doi.org:10.1002/da.22965