COVID-19 and the Burden of Secondary Grief

I ask that if any of the stories I share below are too much for you right now, please stop reading and allow yourself space to rest and heal. We've been through a lot over the last few months. Come back to it if and when you can.

She called EMS, but he wasn't taken to the hospital because he had been dead for hours. Instead, she arranged for his body to be taken to a funeral home. She got rid of the bed. She quarantined for two weeks and saw family from a distance when they dropped off food. She didn't go back to work immediately after quarantine because when she tried, she had a severe panic attack.

Her voice stayed even, reciting the story like she had told it many times. I was shaken, but I wrote the letter, refilled her medications and scheduled a follow-up telemedicine appointment. I also asked if she wanted grief counseling.

"You know what?" Diana replied, voice still unwavering, "I just might take you up on that. I've never experienced anything like this before: waking up to someone dead."

Stunned and amused at the understatement, I involuntarily smiled to myself. That small bit of emotion cracked my composure; tears welled up uncontrollably, sobs built in my throat. I ordered a referral to mental health for her and excused myself from the call.

I was physically unable to see patients for a day and a half because I cried every time I tried to talk.

I've met with Diana many times since our initial call. She took longer than she expected to go back to work, but she is back now without panic attacks. The intensity of her initial grief has dissipated a bit.

Vicarious Bereavement

Since our first meeting, I've wondered if grief is transferable or whether, as physicians, we've witnessed and internalized so much secondary trauma that it simply takes a high-pressure situation (like a pandemic) and a slight nudge toward guilt and shock to completely undo us.

A lot of research has been done on vicarious trauma, especially for those in caregiving professions. We often unknowingly internalize stories, triggering change in our perceptions and behavior. Sustained exposure to trauma can cause apathy, lack of creativity, insensitivity and hypervigilance, among other symptoms that are also present in post-traumatic stress disorder.

Within the same paradigm is something called vicarious bereavement.

In 1987, Robert Kastenbaum, Ph.D., a psychologist and professor who studied death and grief, first coined the term "vicarious bereavement" and defined two types. In Type 1, the vicarious mourner feels intense grief but is able to identify it as "what the actual mourner might be feeling." In other words, there is some sense of separation from the grief itself.

In Type 2, which is likely what I experienced, the vicarious mourner experiences not just deep empathy and sadness for the mourner's loss, but also sustains a sense of personal loss, such as an inability to function normally or a fundamental change in beliefs.

Risk factors for experiencing vicarious bereavement include identifying, empathizing or sympathizing with others; factors of the death itself (suddenness, associated violence, preventability and child loss); and volume of exposure, often exacerbated by constant media coverage/overexposure to images. Vicarious bereavement can help us work through deep emotions and incomplete grief cycles. However, if not identified and processed, it can compound and worsen secondary trauma.

Secondary grief is complex. The lack of ownership over someone else's experience means we may not feel entitled to the accompanying grief. For example, I internalized Diana's story as one about bringing home the virus to family members and being unable to save them. I felt ridden with fear, guilt and loss and was overwhelmed by grief that I thought wasn't mine.

We're not trained to identify or detangle ourselves from that internalization. And it becomes even more difficult when the stories are constant.

There were many days in April when every patient I talked to had COVID-like symptoms, was recently discharged from the hospital and recovering from COVID-19, or knew someone who was in critical condition or had died from the disease. Even a simple visit for a 10-year-old's eczema was actually about grief; her young father had passed away from pneumonia and a pulmonary embolism (highly suspicious for COVID-19).

I wanted to write about grief then, but the only line I could bring myself to write was this:
"I may not have the acute wound of watching people die of COVID-19 in the hospital. Instead, I have a chronic wound: the secondary trauma of holding space for surviving family members. By the end of each week, I feel as though I carry the grief of thousands."

Disconnecting

I was finally able to write during a two-week vacation in August. It was the first time since February that I had given myself space to reflect and process the trauma of the past six months. Writing allowed me to accept the reality of how this pandemic has stripped us bare of our coping mechanisms. It is not lost on me that my obsession with grief is more about the trauma that leads to grief: the primary and secondary trauma that, as physicians, we inadvertently internalize because we are distracted by both the sheer volume of unrelenting experiences and the need to keep calm and keep moving forward (to the next patient, the next chart, the next message, the next result).

Even worse, we're not just facing grief from death right now, and health care workers are not the only ones affected. Collectively, we are undergoing grief due to loss of jobs, loss of our way of life, loss of hope, loss of physical contact, loss of travel. There's constant media coverage of COVID-19 and a plummeting economy, and then there are the deaths of George Floyd and Breonna Taylor, which shocked our already grieving collective psyche into anger, disappointment and frustration. The unrelenting events of the past six months include breakdowns in leadership, natural disasters, power outages, explosions, the death of cultural icons and stalwarts, fires and repeated injustices.

Disconnecting from these repeated trauma triggers is crucial to allow space for healing. It was only because of my two-week vacation that I could even access the grief and trauma I felt. That meant minimal news, limited social media, lots of naps and walks outside. It also meant pausing or stopping when I was exposed to something that brought up anxiety, even when it was in the form of a good book, a television show or a conversation with a friend. Creating that moment to breathe meant that I had more energy to handle the trigger mentally and emotionally at another time (because frankly, I often still had to address whatever the trigger was).

Nonlinear Emotions of Grief

Many of us in medicine are taught composure as a virtue in providing care to maintain clear thinking and calm decision-making. However, we've confused monk-like equanimity with an unhealthy stoicism. We're not trained in the art of meditation or mindful, compassionate detachment or how to observe our emotions. (Maybe we should be.) Instead we're subjected to toxic work cultures and broken systems and are left to our own devices to figure it out, often to devastating consequences like suicide.

This summer, I was asked by a group of high schoolers to speak about COVID-19. I think they expected a talk about symptoms or spread. Instead I talked about grief in the context of the pandemic. We talked about the five stages of grief: denial, anger, bargaining, depression and acceptance. (Sometimes people grieve by getting angry about wearing masks, other times by denying a pandemic exists; at other times we lift each other up by coming together to support businesses or social justice causes.)

I tried to emphasize the lack of linearity in processing grief, how we flow through each stage multiple times. Sometimes all five stages happen at once. Sometimes not at all. I've started thinking of it as a "Jeremy Bearimy," which is how The Good Place humorously describes the TV show's space-time continuum. Time in The Good Place, much like grief, is not linear. Rather it "doubles back and loops around and ends up looking something like … the name Jeremy Bearimy in cursive English."

Community Building

Evolutionary biologists hypothesize that there is a benefit to grief that helps build community. Grief stems from empathy, and the sharing of grief alleviates burden and pain for individual mourners. It is healthy to process the pain of loss and love by coming together.

Managing individual grief is hard, even with community support. Without that support, and with continuous bombardment, it is brutally demanding. While physical distancing allows us to curb the spread of the virus and save lives, we've lost community rituals in the process. Funerals and memorials are being deferred until "things go back to normal." Waiting has caused grief to stagnate.

Some have turned to online memorial services for solace. Most patients who have done something similar for their loved ones found it so healing that I have started recommending it to anyone struggling with grief.

I wonder if we, as health care workers, can incorporate these community rituals into our practice, too. Perhaps, in this age of COVID-19, we need time for health care workers to acknowledge grief together. As physicians, community rituals to process the death of patients are often not extended to us, however attending online funerals and services may be healing.

Even if we can't be together in person, we can develop an emotional closeness by asking, "How are you managing your grief?"

I've started asking patients this question, resulting in healing conversations. I've also asked others that question, some of whom, like myself, have absorbed countless patient experiences and have held space for the grief of many. That might be the first step to normalizing our own grief as health care workers: open dialogue about our grief and how we manage it.

Ultimately, I plan to manage my grief by relying on community and by accepting that grief is nonlinear and unpredictable (so that I give myself grace when I ugly cry on a random Sunday afternoon). I also commit to giving myself space to meditate, rest and heal and, when I am ready, to take action to ensure others have space to breathe and grow, like new saplings from scorched earth.

Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.

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