When her father died last year of COVID-19, Estefana Johnson, LMSW, a grief and trauma counselor in Phoenix, was present with her two sisters. One sister, an ICU nurse, began experiencing symptoms of post-traumatic stress disorder (PTSD) when she returned to work.
“We were fortunate enough to have an ICU room with a window so we [could] sit by my father’s room until he passed,” she says. “But having those images engrained in your mind when you go back to work in the ICU, and seeing other individuals in that state, could really trigger some of those emotions. I don’t usually treat family members, but [my sister] refused to see a therapist.”
Johnson practices accelerated resolution therapy (ART), which uses eye movements and visualization techniques to reconsolidate memories. “It changes the way the memory is stored in the brain,” she says. “We are really targeting somatic responses to what I would call triggers — the triggers in PTSD when you have a healthcare worker who lost a loved one.”
This negative, triggering image is replaced by something positive so the patient does not keep returning to the visual wound in the memory. In this case, Johnson worked with her sister to erase some of the images in the ICU of their father dying and replace them with happy images of him smiling.
“He was a jokester and always playing pranks,” she says. “When we think of him, having those images pop up brings a sense of gratitude for the life that he lived rather than being stuck in the tragedy of the death and loss.”
Healthcare workers are experiencing a collective grief experience during the pandemic. “If it’s not a direct family member, losses of colleagues are very traumatic for healthcare workers,” Johnson says. “Unfortunately, there is no end. You can’t even get to the PTSD because it is not post-trauma yet. They are still in the midst of toxic acute stress that they are dealing with. I have used this intervention on some healthcare workers. We can work with imagery to help them to feel more in control and more equipped to deal with the emotional challenges.”
Grief is complex, and not always linked directly to a death. “We can grieve any time of loss,” she says. “The loss of what once was. The loss of expectations. The loss of connections that we had. There is a compounded grief that is happening right now, and it essentially goes with trauma as well.”
Although somewhat less so now, from the beginning of the pandemic healthcare workers have faced something they do not fully understand. There is a sense of lack of control facing a disease that does not follow an established progression.
“Even though we are making advances, there is still so much that is unpredictable,” Johnson says. “Even before COVID, I worked a lot with trauma, loss, and grief. A big source of suffering is hanging on to what was, or what you think should be. I constantly encourage the practice of mindfulness and being present. Individuals should practice being in ‘what is,’ and not ‘what if.’”
As people in pain build resilience, they experience “post-traumatic growth,” Johnson adds.
“I learned a lot from my father,” she explains. “He was losing his vision and had hip issues. No matter what state he was in, he had the resilience in him to always find joy in the present and be grateful for the things that he could control.”
A favorite metaphor in her therapy is the concept of “kintsugi,” the Japanese art of repairing broken pottery with gold. “The new piece is more beautiful and more valuable because it is said to be transformed through suffering,” Johnson says. “I’m a staunch believer in that. If you don’t transform your suffering, you transmit it. When you lose something, how can you help others? I’m grateful for that even through the pain of my own loss. It has given me the ability and the capacity to feel compassion for my clients. That vulnerability allows me to connect on a deeper level.”
The Loss of Rituals
Another difficult aspect of grief during the pandemic is the loss or diminishment of longstanding rituals to say farewell, said Christy Denckla, MA, a grief specialist at Harvard’s T.H. Chan School of Public Health.
“[Collective rituals] provide an infrastructure to acknowledge the reality of loss and death,” she said at a recent Harvard Forum. “Death is very difficult to comprehend psychologically. To experience and to process the death and the finality of losing a loved one is extremely difficult. Rituals provide an infrastructure and a platform to acknowledge that reality.”1
These rituals are diverse and performed cross-culturally, depending on religious and spiritual values. Rituals also provide the opportunity to grieve collectively. “That can be emotional support, but it’s also pragmatic and tangible support — food, meals, household care,” Denckla said.
During the pandemic, many of these rituals and gatherings have been relegated to digital images and limited in-person participation. “There’s a lot of concern about the impact this is having,” Denckla said. “Grief alone is very painful. We are not meant to grieve alone. We are forced now to grieve alone, oftentimes in isolation.”
This could lead to cases of prolonged grief disorder, a clinically diagnosable condition of unresolved grief that is impairing. “I don’t particularly like that term, because grief is never really resolved,” she said. “But there’s concern that there are conditions now that are raising the risk for clinically complicated grief. Those conditions are isolation, the inability to mourn and to grieve, the inability or the truncated access to social support. All these things elevate risk.”
A related phenomenon is survivor’s guilt, particularly in people who think they have exposed family members. Healthcare workers have expressed this fear repeatedly, adopting tactics like showering and changing at work, sleeping in the garage, and limiting family contact.
“This is the reality of a very contagious disease,” Denckla said. “However, it is a virus. It’s a virus that behaves as viruses do, and there is no purposeful transmission. Relieving or addressing the shame and this guilt, sometimes the best ways to process it is to acknowledge it, to express it, to voice it. Then, it has the opportunity to undergo some questioning and cognitive challenging, some reinterpretations, so that individuals can feel relieved of this.”
- Harvard T.H. Chan School of Public Health. The coronavirus pandemic: Grieving and mental health. March 9, 2021.