Susan Cappaert

So how can those grieving move forward against the backdrop of this pandemic?

Models For Coping

Susan Cappaert, who has spent the better part of the last decade and a half working in a hospice and with bereaved people says that “The grief process is not a straight line, as you can imagine, and at times it’s like a rollercoaster, a wave of emotions, so I work through those waves with the client."

She uses integrative therapy for grief since it "is well suited because we don't work with a fixed ‘theory’ about how the therapy will work or what we will do. It helps me be more adaptable to working with the client, providing support they need at the time, rather than trying to get a theory to work.”

Alongside her private practice, Joyce Howitt has also volunteered for almost two decades at bereavement charity, Cruse where she is a supervisor to other therapists. She is an integrative and psychodynamic therapist.

"I find quite often when clients are looking for a way forward we can use a dual process where we work through the emotions of the bereavement while helping them to find a life for themselves on their own," Joyce Howitt says.

In more normal times, our usual routines can provide some continuum and some other place to go to be away from grief - they can be the conduit for re-entry to life after loss. Those grieving a loss, over which they had no control, get to exercise some control again in a reliably familiar setting. It stands as a bulwark against the turmoil of grief. But right now nothing is usual or routine, and there is no continuum save the "new normal" - which is far from normal and so there is no easy separation for learning coping methods.

However, now as we emerge from lockdown and our lives return incrementally to normal, various models for coping can begin to be integrated - these include the Dual Coping Model (Stroebe and Schut 1999), the Task Based Model (Worden 2008), Resilience theories developed by Bannon, and ideas of Post Traumatic Growth (PTG), albeit with the proviso that they need to adapt these to fit current circumstances.

What Can We Do Now?

But in the short term, there are things we can consciously do in the privacy of our own company and our own homes to address some of the grief and suffering.

Conscious Actions And Personal Rituals

Private rituals which are expressed in a way that public outings of mourning are not proves more cathartic and ultimately more productive for moving through grief, according to well-received research in the last decade. It contrasted the role of public ritual in mourning with private and more personal or idiosyncratic rituals, such as the woman who continued to wash her husband's car on the same days as he used to do, long after he died even though she no longer drove - everyday motions that carry particular meaning and connection to the loved one.

Many who have lost someone they have mourned no doubt have a story of what matters to them, which memories are the most precious, and how they choose to remember that person.

Is this then a silver lining to a year when there is no access to the more public mourning rituals? That the solace we can find in doing things in private that bind us in memory to those who have departed is more helpful now than ever.

Susan Cappaert and Joyce Howitt recommend finding creative ways to do this even when rituals that might otherwise involve travel, easier access and social interaction were off the cards?

Memory boxes and journalling allow for commemoration. Physical and tangible belongings take on added importance in the absence of proper farewells. We also live in an age where the experience of our life is recorded and digitised but perhaps not catalogued nor made tactile - compiling an album which can be physically held and shared can be a more tangible expression of that life's record. Story telling is a powerful thing and well documented as a tool in therapy.

This commemorative approach ties in well with the movement away from certain counselling or therapy models around "letting go" of the deceased to instead finding an "ongoing" connection with that loved one, as pointed to in various research.

Focus On Self

The importance of experiencing nature or making time for mindful exercise, including the slower forms of walking or gardening are emphasised by both Joyce Howitt and Susan Cappaert - physical activity that is in the moment and which may allow some space away from other emotions.

Susan Cappaert also talks about the need for some quiet "me" time which offers both a meditative quality and also a sense of progress in making or finishing something - painting, photography, knitting. Hobbies old and new.

But equally important in this scenario are the routines of basic self-care; they are integral to coping.

It is important to stay the distance with this. Joyce Howitt sums up, “It's vital that those, especially those on their own at this time, are taking steps to look after themselves to help them avoid developing low moods,” she says.

Communication

Over the last year and more, where physical social interaction was rendered virtually null, it has been replaced by the "virtual" access of Zoom and other internet enabled communications. While zooming en-masse as a social catch-up or office-substitute has drawn its share of frustration and criticism, it's good to remember that the memes and lampooning in Zoom's wake (eg Zoom bingo scorecards) are testament to various human tendencies - inclination towards community and tendency to find humour in the foibles and follies of our communities, tendency to adapt quickly across the generations.

The only drawback here is that it can be harder for these new virtual communities to know how to support the bereaved - the setting is usually work-related, by and large functional and meeting oriented. As a setting that is unfamiliar in the context of grief, it may be less appealing as a place into which someone brings their own grief.

With the likely continued WFH - working from home - after Freedom Day on 19th July, the importance of how work places and office cultures adapt to engaging with and helping their people with grief and loss cannot be underestimated.

Howitt emphasises the importance of telephone calls and the human voice at the other end of the line. She highlights the initiative that friends and family should take here.

"Think instead of what you might do for someone who is bereaved than leave it to them to ask a favour of you."

That is even more imperative in times of lockdown when isolation can breed a tendency to become reclusive. And Resilience theory, which is often associated with an exclusive focus on someone's intrinsic nature as a key factor, in fact emphasises the equal importance of social support and bonding in finding that resilience.

Although we have been distanced from other people, we should not forget the value of our four legged friends too - “Pets can be such a great source of comfort in these times,” says Susan Cappaert.

Therapist As Middle Ground

Although family and friends are traditionally the closest networks for support, it’s common for support to fall away after a while, and even more likely in lockdown and as we emerge from it too, where people wish to make a clear break from what has gone before. And a person who is grieving might have uncomfortable or anti- social feelings about their bereavement so they may not choose to talk to those around them.

Seeing a therapist gives someone a regular window each week to talk about those feelings, and work through their grief without judgement and with support.

Susan Cappaert also points out that someone who has been through trauma might find they need to go over and over the event of the death itself before they begin the grieving process – something with which many family and friends may struggle to deal. "If the bereaved wants to go over the events with others, obviously that's putting that pain back into the room and others may not want to hear it.

As a therapist, I can sit with the bereaved and I can hear what they want to express as often as they want to tell it."

Bereavement Support In The Immediate Aftermath Of Loss

The national bereavement study referred to earlier has also made some interim recommendations which focus on areas of priority in what might better shape the response to this pandemic: improved communications, more flexible support bubble arrangements and a focus on those regions and NHS trusts where bereavement support is hampered by long waiting lists.

Another related study also acknowledged what the media reports attested to week in and week out during the height of the pandemic, that bereavement care is further impacted by the changed in hospital settings. Healthcare workers are under extreme stress in having to adapt to provide palliative care as well as primary clinical care with little training, less time and least energy, not to mention the disproportionate rate of bereavement withint their own work force because of their front-line exposure to the virus.

As reiterated in much research in this pandemic about Health Care Workers (HCW), "Special attention must be paid to HCW trainees, who may have not yet developed personal or professional grief management strategies and are coming into healthcare practice during a time of great disruption to both teaching and clinical care."

Future consideration needs to be given to tooling up healthcare workers with sufficient education around this for the benefit of the bereaved and for themselves on the front line.

The Nexus Between Prolonged Grief Disorder (PGD), PTSD And Therapy

"Notably"Notably, a key understanding about grief is that the quality of dying can predict complicated grief [also known as Prolonged Grief Disorder (PGD)]. The end-of-life experiences and the relationships of the person who died and their loved ones (what happens before death and as people face the end-of-life) appear to be as important or more important to the quality and outcome of grief than what is done after the death to console the bereaved."

Given the likely surge in PGD, therapists will be key to helping here. PGD should not be left untreated - it is well documented that it can lead to physical and cognitive impairment, and to more severe issues such as mental disorders including substance use and increased suicide risk, reduced quality of life, and premature mortality. (Research about the impact of PGD across the board is referenced in a publication that looked at the risk for older adults in this pandemic.)

It's also important to distinguish PGD from other ways that grief can manifest for example PTSD and depression.

This is why a trained therapist who specialises in grief in its myriad forms can be of real help. It allows for differentiation of treatment and response.

As one of the key researchers and academics in this field, Dr Holly Prigerson said about sufferers: “They’re getting treated for depression, and no one understands why they’re not able to move on."

Different Types Of Therapy And Treatment

Recognised modes of treatment specifically addressing PGD is in its infancy relatively speaking although as Joyce Howitt pointed out that as a condition, it has been more prevalent than people might imagine. Targeted approaches can vary from a broad flexible interpersonal psychotherapy like that practised by Susan Cappaert and Joyce Howitt to more targeted and defined models of intervention such as the Complicated Grief Treatment (CGT) and screening tools such as the Bereavement Challenges Scale.

Therapists will often use a combination of therapies and tools that align better with the individual's needs; some are specifically trained in therapies such as CBT and EMDR.

CGT includes elements drawn from both interpersonal pyschotherapy (IPT) and Cognitive Behavioural Therapy (CBT). Although CGT can be flexibly applied in clinical practice, the manualized form tested in research studies consists of 16 sessions, each approximately 45 to 60 minutes long. The Bereavement Challenges Scale developed by Dr Holly Prigerson, a leading researcher in this field, is a tool for measuring the challenges facing someone who is bereaved using a 35 item scaled index to assess this.

Treatment with various drugs (eg SSRIs) can be helpful but only to the extent that they are treating associated depression rather than PGD per se. (Drugs as an adjunct to therapy has been studiedpreviously against the backdrop of a reported deficit of research in this area.)

Some combine treatments with trauma therapy models such as Eye Movement Desensitisation and Reprocessing (EMDR), which, as the UK body explains,"aims to help the brain “unstick” and reprocess the memory properly so that it is no longer so intense. It also helps to desensitise the person to the emotional impact of the memory."

Words Are Hard To Find

The intensity of memories that flow from this pandemic are not just relevant to EMDR. A recent study that looked at thoughts, feeling and behaviour during disaster considered the “indescribability” of certain traumatic experience. This is an important factor in its own right as preventing people from taking the initial steps in moving forward. Talk therapy can be difficult in this context - emphasising again that imagery, drawings, body movement can and should be used by therapists in supporting someone so affected.

And it also points to the risk that the intensity of such feelings and memories are not given voice because of the weight of the hurdle in expressing it to others; it then goes unnoticed by others, and remains unresolved and buried for the the person so grieving.These risks have also been studied in other psychological work on dissociation. A grief therapist should be experienced in noticing such risks and exploring the grief experience to facilitate "opening up" in a supported framework.

Community Help For Grief

Some experts point out that a diagnosis of PGD can "pose the risk that grief becomes simply the province of specialists, rather than the responsibility of caring communities." This leads us to the matter of community and its key role in the healing process. Joyce Howitt says that lockdown has stopped vital therapeutic work of grieving groups and community initiatives - it has changed the scope for organisations such as Cruse. Although some of these have moved online, information around this and access can still be difficult.

So what else can we do as a community? What have others done before?

Collective Trauma - What Can We Learn From The Past?

The devastation of Hurricane Katrina and the Boxing Day Tsunami are among collective trauma events that have taught us much about how to frame community responses to bereavement and grief.

Reviews of all research to date on collective trauma could not be more timely. More needs to be written and spoken about the impact of this last year, and how to anticipate a properly supportive response at a national policy level. But research about other collective trauma events shows that certain factors are key and they are extracted below.

And although Resilience theory continues to be debated, a key outcome of research here is that some social groups are more vulnerable to the harmful impact of collective traumatic events than others, which then impacts their ability to be resilient.

There is of course a defining difference to the source of collective trauma in these studies - that is, that the pandemic is not time limited or an "event" - it is ongoing and changing course. This creates a limbo-land which makes for a sort of delayed resolution to the "event" itself.

Making Sense And Reframing Our Grief

There is no comparable or recent frame of reference for this global lockdown and the loss of 2019 - 2021 although the spectre of the Spanish influenza of a hundred years ago or so looms large. A recent publication that draws on a body of research attests to the importance of ascribing meaning to death or loss, in terms of 'making sense' of it, in moving forward. This is as relevant for one who is in mourning as it is for society as a whole.

In a world that is now dominated by 24 hour access to information across a saturated but also fragmented media landscape, from the traditional outlets familiar to the older generation to the recent rise of social media favoured by millennials, we still await the sense or the story that our society through the media will make of this pandemic and its great loss. When will the time come to take stock, and what legacies for change and reflection will come from this as a society?

We Remember - Commemoration As A Society

For Mick Todd’s elderly mother, the very thought of shielding in lockdown was too much to bear. “I can’t go on like this until Christmas,” she told her son in the days before her death last April.

With a hint of Yorkshire humour, he says today: “She is out of pain now. She may have tried to get away from my dad and we can smile about that. I didn’t think it at the time, but now I see it [their passing] as a blessing for them both.”

Todd has since signed his Pontefract leisure club up as a Covid vaccination centre - catering to up to 400 patients daily - which keeps both his mind and body active.

He hopes one day in the future to be able to fully celebrate his family members’ lives. Charity leaders hoped that 23 March 2021, which was the anniversary of the first day of lockdown, would become in the future a national day of remembrance for all lives lost during this pandemic.

In the fog of loss and lockdown, dates for remembrance or milestones such as Freedom Day can stand out on an individual level as a point to allow those people, still waiting or in a kind of stasis, to take stock and for permission to grieve. At a national level, it can stand for the end of one cycle and the beginning of another - time for reflection and renewal; in the future it can represent our commemoration of those lives lost and a collective moment to mark the universal suffering in all its forms that came with this pandemic and our resilience as a society.

Todd, who owns Pontefract Squash & Leisure Club in West Yorkshire, first lost his 85-year-old mother in April of 2020. Twenty-four days later his father died due to Covid complications. They had been married for over 60 years.

To compound matters, within a week of his parents dying, he then lost his aunts in the space of a fortnight. “It has been impossible and horrendous regarding the Covid restrictions on funerals,” he says.

Todd, a well-known business figure in the market town, was present at the double funeral for his parents. In all, he has been to eight funerals during lockdowns in the UK. He says that the rule of six limit at the crematorium meant many people in the community were standing outside for his own parents’ funeral, with the speakers not allowed to be turned on. “We couldn’t really say our goodbyes,” he adds.

No-one could have imagined the isolation in which millions of people in the UK would be expected to cope with grief and bereavement through 2020 and into 2021. Even for those without recent losses, lockdown created a vacuum in which grief – new or unresolved – rose to the surface.

To put this into perspective, the six digit numbers quoted in daily press briefings, and the red line that climbed ever upwards to the right in daily graphs equate to the most excess deaths in the UK since World War Two.

Grief is deeply personal and in the isolation of lockdown it has become deeply lonely as traditions and rituals for mourning have disappeared.

We talk with two grief and bereavement specialists at ProblemShared, Joyce Howitt and Susan Cappaert, to draw on their experience and take a look at what has emerged in related areas of research and ways to move forward.

Lost Grief Rituals

In a national survey of people bereaved in 2020, 94% said they had had to restrict funeral arrangements. Simply put, Covid-19 has changed the way we have mourned and the restrictions of the pandemic have made bereavement ever more stressful and painful.

Susan Cappaert said that this had been heartbreaking for her clients: “It has caused a lot of anger, frustration and confusion." Like so much else in this pandemic, an experience that has been so restricted that it feels watered down or token in gesture cancels out some of the benefit of being able to participate at all.

What Makes This So Much Harder To Bear?

In some ways, the answer to this question seems obvious to our collective understanding of what has unfolded over 2020 and 2021.

The particular mix of suffering that has unfolded means that the grief which follows is likely to be complicated at a level that may be hard to shift.

Factors that complicate grief in this pandemic are myriad and have trauma, shock, a void of control or self-directed choices, and a lack of resolution in the mix.

As Susan Cappaert says, “For many bereaved, there is constant worry about someone dying alone and the only connection they had to their loved one was a daily phone call to the hospital for an update."

As Joyce Howitt says,

"Even the most basic action - touch - has been lost."

Contact with those who are ill in hospital has not been possible; it is impersonal - often reduced to as little as the sharing by healthcare workers of a patient's stats and numbers - the "obs" of interval monitoring in a hospital ward (the observations of a patient's vital signs), and as reiterated in various research, this is partly because of the time pressures on hospital staff and care providers, partly because of the pressure on resources, but also because there is little other means of contact available to gauge matters given the physical impediments of PPE gear and ventilators. This means that there has been no opportunity for those bereaved to bear witness themselves and prepare for the inevitable, nor has there been an opportunity to give comfort to the loved one or resolve any unresolved aspects to that relationship.

The associations the bereaved may have with their loved one's physical struggle with Covid-19 can also play a role in exacerbating grief and other responses - for example the worries about a patient not breathing peacefully or dying while intubated.

"Bereavement care fell to a wide range of staff members, including some with limited experience or training in supporting bereaved people who had to rapidly develop the required communication skills," a survey of bereavement care found this year.

And then there is the added weight of conscience in accepting that there are limitations for those working the back-breaking hours in hospitals to deliver care in order to save lives in the face of what were mounting death tolls. It is a situation in which it can be hard to find an appropriate target or place to direct the anger, confusion, and lack of control that follows bereavement in these circumstances since everyone is trying their hardest.

Setting this against the backdrop of millions of people isolating at home for so much of last year and into this year, with limited social contact and restricted physical engagement with the outside world, it is a very particular context that gives rise to such intense grief.

Grief Can Be Different The World Over And That World Is Right Next Door

Although first-hand accounts of bereavement and the restrictions to our grief rituals have been played out in the media on an almost daily basis, the impact of varying cultural & religious sensitivities to bereavement is less talked about. There can be different cultural & religious emphases with regard to how to honour the departed, the number of mourners, the duration of the proper mourning period, traditions in the displays of grief and outpouring of emotion, and the rituals of the attendant physical bodily rites. Lockdown has been ever more compromising of the mourners' perceptions and hopes for the departed's journey onwards.

Another aspect to the cultural context is that the community in the U.K. which has suffered most disproportionately in terms of rate of bereavement has been the BAME communities. That these communities' share of loss is higher is in part due to the close-knit settings of extended family life in such communities which underlines the further fracturing of this community.

These communities are also broadly more likely to be involved in frontline "key worker" roles which cannot be done from home, especially with respect to healthcare. As reported in a study last year "One country, two crises", BAME groups number 44% of medical staff and 20% of nursing staff and it is these jobs where risk of infection was greatest. The first 11 doctors to die in the UK were from BAME communities.

A wider number of kin can also be affected by bereavement, due to the larger family size of BAME communities, as attested to by a study out of the United States. Those undertaking the national UK study on bereavement have also pointed out that one of their primary goals is to understand better bereavement across all population groups in order to provide more equitable bereavement support to those groups.

Understanding Different Types Of Grief As A Roadmap For Healing

The human ripple effect of bereavement means that there were at a minimum close to 4 million people bereaved in the UK on the anniversary of the first lockdown earlier this year in March, regardless of cause. The same bereavement study out of the United States that looked at differentiated weighting for different population groups put the multiplier for bereaved as high as 8 - 9 kin for every death based on factors specific to the ages of those who have died during the pandemic, being on average older and leaving behind several generations of family. This is well north of the usual bereavement multiplier of 5 kin, putting the number of bereaved well in excess of 4 million.

“Grief is an extremely powerful emotion; it is painful and exhausting in ‘normal times’, let alone this last year", says Susan Cappaert.

There are various psychological models of grief and schools of thought about processes that someone goes through in order to heal. Even usual uncomplicated grief cannot be easily boxed into a tick box of symptoms or experience. There is "wide diversity in the timing, expression and intensity across population groups and within families".

Prolonged Grief Disorder

However, the particular environment of 2020 and 2021 with its associated shocks and trauma makes for a different type of grief to the norm. Joyce Howitt says that although Prolonged Grief Disorder (PGD) (previously known as Complicated Grief) was already more common than most people might expect, it is likely to predominate now. Dozens of research papers over the last year have certainly anticipated a "surge" in this as a result of the pandemic" (Boelen et al., 2020; Eisma et al., 2020; Gesi et al. 2020; Goveas & Shear, 2020; Johns et al., 2020; Kokou-Kpolou et al., 2020; Masiero et al., 2020; Mortazavi et al., 2020; Wallace et al., 2020; Zhai & Du, 2020)

PGD is a form of grief that is distinct from the normal grieving process. Without treatment, the condition can persist indefinitely. According to the ICD, PGD persists beyond six months after bereavement or beyond the social, cultural or religious norms of grieving that might fit that person's profile. It involves pervasive thoughts of the departed, is accompanied by intense emotional pain and causes significant impairment in personal, family, social, occupational or educational settings, that may have complicating factors & trauma at its core but which is distinct from PTSD. It may also involve heightened emotions as compared with the more muted emotions of depression.

It was recently included as a diagnosis in the World Health Organization International Classification of Diseases, 11th edition (ICD-11) and is now proposed for inclusion in the USA's Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5); these are the two main clinical catalogues of mental disorders. The descriptors for diagnosis in the ICD-11 have been much simplified and this implies a more flexible and sensitive approach to diagnosing this debilitating form of grief.

Rise Of Wider Mental Health Conditions

There is also broader grief over other losses or "endings" in this pandemic. Life stressors abound - an end to social interaction as we knew it; financial stresses of redundancy, furlough or failed businesses; social and educational disruption for children and students and an end to school as we knew it with the new multitasking required by home schooling; disruption in living arrangements during relocations to form bubbles or where one member of a family needs to shield from the rest within the same house; strictest isolation for some individuals. This has triggered the parallel widespread rise of mental health conditions such as PTSD, anxiety, depression, loneliness, and anger. This has been compounded by the constant exposure to grim news. And compromised sleep and lack of proper exercise over the last year and a half have meant there has been no relief or other outlet for recharge.

These factors only serve to compound grief and also negatively impact the network of family and friends that might ordinarily be a source of support to the bereaved.

Depression, anxiety, and trauma-related disorders can arise with bereavement too even without the presence of PGD.

Unresolved Or Buried Grief

There is also unresolved grief which can become buried. "This can manifest itself later as physical or emotional illness" says Joyce Howitt. "Many of us have spent a lot of time on our own, with less to do than usual,” she adds, “and this can be the time that negative thoughts and memories including unresolved grief come to the fore.”

The Accelerating Factor

That grief can divide as often as it unites is something that at times is only understood by learning it the hard way through first-hand experience of it.

And with families divided physically and isolating in separate configurations, there has been the dissonant combination of remoteness that comes with physical distance on the one hand, and the hothouse environment on the other of isolating alone or with the smaller immediate family. This can risk accelerating division and isolation.

Disenfranchised Grief

Disenfranchised grief taps into another hurdle facing the bereaved in this pandemic - the risk of thinking that one's grief is dwarfed by the collective grief - "because during lockdown, people are conscious of having to get on with things. Well, I say get on with things, in fact you can't do all that much. And there is the tendency to think that others have it worse than you", as Joyce Howitt says.

For someone whose loved one died from a cause that is not Covid-19, there can be a misguided perception on the part of the bereaved or other people that this other cause of death somehow sidelines their grief - that they are excluded from the community of those who lost someone to Covid-19. Such disenfranchisement was reinforced in certain instances in the delivery of bereavement support - "In some cases, funding was allocated only for those who had been bereaved by COVID-19, which ‘could create inequality of service provision’."

Net Effect

This multiplication of stressors makes for a very particular grief landscape. The pandemic and the grief that it generates will continue to be a source of stress even when life finally does normalise.

M. Katherine Shear, whose pioneering research has contributed to the recognition of grief as a disorder in its own right, recently noted the difficulties of this pandemic: "Though we are often heartened by human resilience in response to death and other hardships, for some, the burden of this pandemic will be too much."

As Stroebe and Schut, jointly responsible for one of the most widely accepted bereavement models currently used in therapy, the Dual Coping Model, state in their most recent research on the impact of the pandemic: "Finding a place for the deceased in ongoing life, relinquishing the old ties and moving on may not be tasks that can yet be dealt with".

So even if we were permitted to observe our usual grief rituals or adopt more usual coping strategies, their value may be compromised in any case because of the complexity here. They would not be without value, of course, but having access to our usual rituals would not necessarily stave off the tidal effects of grief in this pandemic.

Recognising these factors and their impact on shaping grief is key. It allows us some space to be gentle on ourselves, our families and our communities as we start to normalise after July 19 2021, and it lays the foundations for considering how to move forward.

In Part 2 we talk about how to cope with grief through different lenses - what can be done day to day on a personal level, what can be done on a therapy footing, and more broadly as a society. As the tides of this pandemic recede a little and we make our way out, we must also shore up our ways to grieve and heal.