» An expert discusses how to cope with a year of grief and guilt.
With coronavirus claiming the lives of more than half a million Americans this past year, friends and family are left to deal with the grief.
We asked Julie Kaplow, executive director of the Trauma and Grief Center at the Hackett Center for Mental Health in Houston, to walk us through the grieving process and how to help others.
Kaplow’s answers have been lightly edited for clarity and length.
Q: Let’s start basic. How do you define grief ?
A: Grief is our psychological, physiological or behavioral response to the loss of something or someone important to us. As a result of the pandemic, many of us have been grieving for different reasons — the loss of opportunities, celebrations, social interactions, or even the loss of a “normal” way of living.
At the same time, a significant number of people have been grieving the loss of loved ones. In fact, a recent study estimated that nine family members are affected by one person who dies of coronavirus. This means that in the U.S. alone, nearly 5 million individuals (including children) are grieving.
Q: We hear a lot about the five stages of grief and a grief timeline. Are those real?
A: What we have learned is that grief is not linear or sequential, and grief does not have a “timeline.” In other words, there is no “right or wrong” way to grieve. Although the stages of grief can help us to think about the different experiences that grieving people may go through at some point (e.g., feeling angry or not wanting to face the reality of the death), we know that not everyone will experience those “stages.”
Q: Are there common experiences in the grieving process?
A: Research and clinical work with bereaved individuals has shown us that people, and especially children, tend to grapple with three primary bereavement-related challenges that can arise at any point following the death of a loved one. These include separation distress, existential/identity distress, and circumstance-related distress.
Q: OK, break those down.
A: Separation distress can take the form of really missing the person who died and yearning and longing to have them back. Existential or identity distress includes feeling lost without the person or being unsure of how life will go on without the person’s physical presence. Circumstance-related distress involves excessive worries or concerns about the way the person died, such as guilt or shame or anger about what caused the person to die.
Q: What does it look like to cope with these distresses in a healthy way?
A: When facing separation distress, people often find healthy ways to feel connected to the person who died by engaging in activities that they used to do with the person, memorializing them, or identifying things that they had in common. In response to existential/ identity distress, people tend to find ways of carrying on the legacy of the person who died or ensuring that they’re living the kind of life that the person would have wanted for them. And when facing circumstance-related distress, people gravitate toward finding ways to transform the circumstances of the death into something meaningful in order to prevent others from suffering in the same way.
We see this in children as frequently as we do in adults.
For example, I was working with a 10-year-old boy whose mother died of breast cancer, and at one point he told me, “I’m trying to raise money every year for breast cancer so that other kids don’t have to go through what I went through.”
Q: How does survivor’s guilt interact with grief, especially with COVID?
A: Survivor’s guilt is when a person believes they have done something wrong by surviving a tragic event when someone else, usually someone close to them, did not. This sense of guilt or responsibility for someone else’s death is relatively common among grieving individuals, especially in the context of the pandemic. Given that COVID-19 is transmitted person-to-person, people can easily become preoccupied with the idea that they may have been “the one” to have transmitted the virus to their loved one.
Survivor’s guilt can complicate the grief process by adding to a grieving person’s distress, especially because it is hard to talk about, and it is not often openly acknowledged, so the grieving person is often left feeling very much alone with those distressing thoughts and emotions. We see this in children as well given that they don’t often have the words to describe survivor’s guilt and require caring adults in their lives to help them to acknowledge and label those feelings. Children in particular often believe that they have more control over their environment than they actually do, which can leave them more susceptible to feeling like they may have been responsible for their loved one’s death. One of the best things that caring adults can do in this situation is to validate the child’s feelings while reminding them, “This was not your fault”.
Q: Is there any “wrong thing” to say to someone who is grieving?
A: We want to be careful about suggesting that there are lots of “wrong things” that someone can say to a grieving person because what we find is that not saying anything at all is much worse than saying something that may be misinterpreted by the person who is grieving.
On the other hand, we know that there are some statements that can actually contribute to a grieving person’s distress. For example, statements like, “It seems like you should be over it by now,” or, “It’s been a year — don’t you think you should move on?” can reinforce the mistaken notions that the person is somehow failing in their own grief process.
Children are also susceptible to well-intended adults who inadvertently say things that can cause greater distress. These statements often come in the form of spiritual beliefs that can easily be misinterpreted by children, such as, “Your Dad is in a better place now,” or “They needed your dad in heaven more than we need him here.” These statements can be invalidating and often leave children feeling as though they should have been more overt about how much they needed and loved the person who died.
Adults can say something like, “I know Grandpa’s death can feel confusing or upsetting, especially since we couldn’t be there to say goodbye to him. What kinds of questions or worries do you have? I’m here to listen and talk whenever you need me.”
Q: If you’re the support system for someone grieving, what are red flags? A: What we know about grief and bereavement is that most people will be resilient after the death of a loved one and can even grow and learn from the experience in ways that are life changing. However, we also know that a number of individuals will require more than just support from friends and family. Below are what we would consider “red flags” that may indicate that a bereaved person requires an evaluation from a trained grief therapist and possibly therapy:
• Functional impairment — for young children this can look like behavioral regressions or significant changes in behavior such as extreme aggression or extreme fear to the point where a child refuses to leave a caregiver’s side. For adolescents or adults, this can involve trouble getting out of bed in the morning, constant tearfulness, extreme social withdrawal, or significant changes in eating or sleeping. Many of these behaviors are common in the more immediate aftermath of the death, but if they continue to persist for more than six months following the loss, that is when we would recommend an evaluation.
• Excessive risk-taking behaviors in adolescents or adults, such as excessive alcohol use, drug use, or reckless driving, should also be considered concerning.
• Any expression of a wish to die or hurt themselves requires an evaluation with a therapist.
Q: What have I not asked that you wanted to add?
A: It is important to recognize that children do not grieve in a vacuum, and they are greatly influenced by the adults in their lives who are grieving around them. If a parent or caregiver feels overwhelmed and excessively distressed after the death of a loved one, the best thing they can do for their children is to ensure that they themselves are getting the support they need.