May 26, 2020
By Shane O’Neil-Hart, LCSW
As the tragic death toll from COVID-19 continues to rise, mental health care providers are likely encountering more grief among their clients than ever before. People are not only grieving lost loved ones and lost jobs during this pandemic, but also more abstract losses such as drastic disruptions to our way of life. This article offers a framework for understanding grief and guidance to support your clients through it.
Grief is a normal and expected reaction to loss that can present in many different forms and often involves strong emotions. These emotions serve as messengers, letting us know that we cared about something or someone deeply. Grief helps us remember the impact of people, animals, circumstances, or experiences that will ultimately come to define our lives. While it can be challenging to cope with, grief is something we all face at some point. It’s also a powerful opportunity to connect with what’s most meaningful to us and to practice acceptance of difficult emotions.
Just as COVID-19 is disrupting our lives, it is disrupting our deaths. Because of the precautions needed to prevent the virus’s transmission, people are more often dying alone rather than surrounded by family, and many of the customs usually observed to celebrate and honor a deceased loved one have been put on hold indefinitely. Under these circumstances, clients are more likely to become preoccupied with how things could have gone differently, which can inhibit the grieving process.
For example, a client with a family member who died from COVID-19 may ruminate about how transmission of the illness could have been prevented or may regret allowing them to go to the hospital when they could have died at home. Validate that these disruptions are real and difficult to cope with on top of the loss itself, while helping your client find creative and meaningful ways to commemorate the loss and to connect with others in their life who are also grieving.
Grief often involves a sense of shock and disbelief–especially in the period immediately following the loss–along with strong emotions and physical sensations, which may seem to come and go without any clear or predictable pattern. It’s normal to question the reality of the loss or to fixate on how things might have been different, but as time goes on, it can be unproductive or even harmful for a client to stay stuck in this place. Gently and compassionately guide your client to accept the reality of what has happened and their inability to change it, while normalizing their experience.
It’s hard to know what to say to someone who’s overcome with grief, especially if you’re worried about saying the wrong thing. Grief can involve a mix of strong and surprising emotions, including sorrow, fear, anger, guilt, and resentment. You might find yourself wanting to change the subject, cheer the person up, or move on to something more solution-oriented. But often the most important thing you can do for someone who’s grieving is to listen, validate, and make space for difficult emotions. As the conversation continues, you can also help them derive meaning from what they’ve lost.
A great way to start out with a client presenting with grief is to ask, “How can I help?” Our clients often have good insight into what they need, which may just be someone to listen to stories or memories of their loved one who has died. Go slowly and give your client lots of space to process their thoughts and feelings. Ask open-ended questions and avoid the need to settle on clear answers.
Your client will be looking to you for guidance on how to make sense of and respond to their grief. Use this as an opportunity to model a flexible and compassionate approach to sitting with difficult emotions, while continually seeking to understand what your client needs from you.
If you feel the urge to help your client “move on”, it’s time to take a step back and examine whether you are avoiding your own discomfort with emotions that are surfacing. Clients need permission to grieve in their own way, and they may be looking to you for that permission. You may feel helpless or ineffective if you aren’t working to solve a problem, and that’s okay.
If you feel the need to set a goal for yourself, choose something like allowing the client to tell their story or exploring the meaning of what or whom they lost. Grief is a natural process that plays out differently for each person, and it’s important to avoid giving your client the impression that they’re doing something wrong.
Some clients respond to grief with harmful or even self-destructive behaviors. If a client is isolating or self-medicating in response to grief, we can help them change those behaviors, but we can’t necessarily change the underlying emotions. For example, you can educate your client about how certain behaviors tend to perpetuate certain emotions, such as how isolation can keep you stuck in loneliness.
However, attempts to suppress or ignore grief will inevitably backfire and increase suffering. Grief can take a toll on our sleep hygiene, diet, exercise routine, and other important habits that help keep us resilient and emotionally healthy. If you see this with your client, validate that these kinds of disruptions are normal while emphasizing the importance of maintaining self-care.
The goal is not to get over or move past grief, but to learn to carry grief with you as you continue living your life. Fighting with the emotions that arise may feel natural, but can become a futile distraction from life. Meanwhile, everyone has their own way of grieving and can choose to distance themselves from or focus on their grief according to their needs. Trust that your client will be able to find a healthy balance.
For some people, the intensity of grief tends to fade over time. For others, it can feel just as strong as it did the day of the loss. Either way, there is the possibility to grow through grief, to be changed by it in positive ways, and to once again connect with a sense of joy and hope about life. Helping clients cultivate acceptance and awareness of their grief and related emotions will help them stay present with what matters most in life.
Grief work often involves looking back and deriving meaning from what has been lost, but clients also need help envisioning what life will look like going forward. Avoid rushing into this topic haphazardly, as you can easily invalidate your client’s pain. Instead, it’s a good idea to slowly introduce questions or observations about how they will adapt to the future.
Compassionately help your client expand their awareness to include other things they care about in life. One way to do this is to introduce values and valued domains such as family, work, health, hobbies, and civic engagement–including those that the client may be neglecting. If your client has lost a loved one, you might carefully inquire about what this person would have hoped for the client’s life to look like now.
Clients who are grieving will often express strong emotions, and there’s nothing wrong with that. Validate them and express appreciation for their willingness to share and be present with difficult emotions. Encourage exploration of strong emotions while also offering grounding or distress tolerance skills clients can use if they become overwhelmed. At the same time, look out for signs your client has trouble regulating their emotions, such as rushing into painful memories or thoughts without awareness of their own emotional state, being unable to stop crying, or leaving sessions unable to focus on the next task.
After an emotionally heavy session, use the last five or 10 minutes to help them transition out of this space by practicing some deep breathing, leading them in a mindfulness exercise, or discussing a more lighthearted topic such as a favorite hobby or plans for the weekend. Help your client understand that they can experience strong emotions without becoming consumed by them, and that inside of deep grief exists deep caring.
Complicated grief can happen when a person doesn’t get the space needed to grieve, suffers multiple losses or a particularly traumatic loss, or has pre-existing mental health problems that are exacerbated by the loss. Signs of complicated grief may include: prolonged difficulty accepting the reality of the loss, nearly exclusive focus on the loss, persistent rumination, excessive preoccupation with or avoidance of reminders of loss, feeling empty or numb, significant functional impairments, and poor self-care.
Complicated grief is different from depression but may look similar, and is typically not diagnosed until at least six months after the loss. If you think your client is experiencing complicated grief and this is not an area in which you specialize, it’s a good idea to seek consultation or consider referring the client.
It’s important to pay attention to your own emotional experience when you work with clients with grief. It’s okay to slow down, take a few deep breaths, and in some cases even share what’s going on with you in the moment. While you shouldn’t make the session about you, it could be valuable to share something like, “I lost my father a few years ago and I notice some of those emotions coming up now. They can be difficult to sit with, but we don’t need to run from them. It’s okay to feel these things.” Grief is a common human experience, so the more we can normalize it and model acceptance of difficult emotions, the better.
If you’d like help connecting with a therapist or mental health coach, Lyra can assist you. You can get started today if Lyra is offered by your employer. Sign up now.
The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Shane O’Neil-Hart, LCSW, is the Senior Clinical Manager of the Mental Health Coaching Program Lyra Health and an expert in Acceptance and Commitment Therapy (ACT). He serves as the Vice President of the San Francisco Bay Area chapter of the Association for Contextual Behavioral Science (ACBS), and provides psychotherapy, supervision, and training in ACT.