Over 50 years ago, Swiss-American psychiatrist, Dr. Elisabeth Kubler Ross, publish her landmark book On Death and Dying, (1969) explaining the process of grief that human beings experience. As a Swiss- American (my paternal grandfather and his family emigrated from Zurich Switzerland) I have always felt some pride in sharing a part of my ancestor’s nationality with this brilliant woman!
In my professional career I have see the applications of her brilliant work in many different situations, including now. On a micro level and a macro level we are grieving. We are grieving those who have died from Covid-19. We are grieving those who have fallen ill due to are fear of what will happen to them. And we are grieving life on this earth as we knew it.
It is certainly true that the level of grieving may depend on who we are and what our life experiences have been. Those who have struggled all of their lives with poverty, isolation, oppression and violence may be experiencing this differently than those who have had less or little significant adversity in their lives.
With that understanding, I would like to discuss the grieving that those who are experiencing the myriad of feelings that are associated with grief are dealing with and normalize these experiences.
Dr. Kubler Ross (1969) identified five different stages that dying and grieving humans go through: denial, anger, bargaining, depression and acceptance. The length of these stages will vary amongst individuals and the intensity and expression will vary as well.
Denial: Many of us have heard the phrase “Denial, it ain’t just a river in Egypt.” Denial is a defense mechanism identified by Dr. Sigmund Freud in 1925 (Ogden and Biebers, 2011) When we are not ready to confront the uncomfortable feelings of loss, fear and change, we use denial as protection. It may be that those who are running to the beaches, going to parties and refusing to practice social distancing are in denial! Those who start experiencing symptoms may also revert to denial. “It’s just a cold.” “It’s just allergies” etc. This is normal. For those in the latter category, the truth is they may be right. You may need to do some research, talk to your health care professional and ride it out. This is difficult if one has anxiety though. See this very helpful article by Katie Heaney:
For those in the former category, who are in denial that this is a deadly issue, these folks may be well advised to stop, listen to science experts and perhaps talk to someone. This denial is not only risking their health, but the health of exponential others.
Anger: When we feel out of control. When we feel that there is nothing that we can do to stop what is happening, our fear becomes masked by anger. WE become angry at those who can be doing something and, in our opinion, don’t or aren’t doing enough. Sometimes that anger is justified. We become angry when we get conflicting information from our elected and appointed officials or we feel that we aren’t being told the truth. We need to remember that not all elected officials have a history of this kind of behavior, and sometimes it may be either they don’t know, or that the available information has changed over time. Remember, “unprecedented” is a term widely used to describe the current situation.
Often that anger will be directed more locally and directly at those who are closest to us. We can’t yell directly at the president, except maybe through social media so we yell at those closest to us. And at this time, we have a captive audience of those people, with little escape. This will be a time to find outlets for your anger such as exercise or meditation, to reach down and find forgiveness as quickly as possible for the “yeller” and the “yellee!”
Bargaining: When it becomes clear that the fear-invoking situation is not going away, we may start to look to other ways to fix it. Making quiet compacts with your God is a common response. “Dear God, Please spare . . . If you do this I will . . .” or change their behavior, thoughts, feeling, beliefs in the hopes that some higher force will reward the change. It is part of the magical thinking that we utilized in childhood. Children will do this frequently in response to fear and grief. This is the last buffer that we have available before we have to face the reality that we fear: Death, loss, change. And that leads us to depression.
Depression: In this fourth stage, we are no longer able to defend ourselves. We feel despair. We may cry, stop doing the things that we like, sleep all the time, lash out still, lose weight, gain weight, feel ill, develop illness (physical and psychological). We may try to extinguish these painful feeling with alcohol or other non-prescription drugs. We may begin abusing prescription drugs. We may come to believe that we will never feel better again. We may become more isolated because we don’t want to risk caring anymore, or because our family and friends are no longer able to tolerate our negativity and anger! So the person is put in a catch 22. They need to talk about this and vent and process but in a way that they are not alienating their social supports. People need to feel their feelings but also to regulate and manage over time. In this stage a person really needs a therapist who will listen and support, a therapist who knows about trauma, post-traumatic stress and grieving. There are many tools that can help with grief and trauma including Eye Movement Desensitization and Reprocessing, and biofeedback.
Note my use of the term trauma. Not all grieving will lead to trauma and PTSD. But, it can. We each have our vulnerabilities that may exacerbate and complicate grieving. The diagnostic criteria for Post-Traumatic Stress include:
A stressor of experiencing a traumatic event. Direct experience, witnessing, learning that a family member or close friend experience the event, vicarious experience through professional work.
Intrusive symptoms: Re-experiencing the traumatic event through nightmares, memories, flashbacks, physical symptoms etc.
Avoidance: Avoiding places, people, music, food, smells that bring up the memories or painful feelings.
Changes in mood or thoughts such as anger, isolation, not enjoying previously enjoyable experiences, self-blame, and concentration issue
Arousal including hypervigilance, agitation, irritability, sleep issues, panic reactions, anxiety
This has been going on for more than 4 weeks and it is starting to interfere with functioning.
Diagnostic and Statistical Manual 5
The good news is that trauma and PTSD can be dealt with in therapy as well. These days, most therapist are able to provide telehealth services that may be covered under your insurance. Note that some interventions may not be able to be utilized in telehealth but check with your providers.
Now for more good news! The last step of this process is acceptance and resolution! It will get better, on an individual basis, as well as a community basis. It will be different, what we call a new normal. We don’t know what it will look like for each of us. We need to remember though that we have been through national and global crises before and we have arisen from the ashes so to speak. It can be helpful in the depression phase to “act as if.” Not act is if this isn’t a problem. Act is if this will end sometime in the future, we and our loved ones will be OK and regardless of what happens the world, we will survive! Use the resources out there. Talk to a therapist. Find a support group. Stay connected with family and friends who support you. You are stronger than you think you are.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013
Kübler-Ross, Elisabeth. (1970, c1969) On death and dying /New York : Collier Books/Macmillan
Ogden, Sofia, K.; Biebers, Ashley D., eds. (2011). Psychology of Denial (1st ed.). Nova.