Navigating the Emotions of a Pandemic

The 5 Stages of Grief as a Framework for the Journey

(Part 1 of a 3-part series)

As a health care professional, I have watched the progress of the COVID-19 pandemic with alternating measures of horror, dread, fascination, frustration, and fear. The nurse in me wants to jump onto the front lines, don scrubs, and volunteer at the nearest emergency room. As I watch the understandable human response to this unprecedented circumstance, I know my skills as a psychiatric clinician will be needed soon enough to help with the emotional impact of this pandemic.

The five stages of grief (denial, anger, bargaining, depression and acceptance), as outlined by psychiatrist Elisabeth Kübler-Ross to describe the emotional journey of preparing for the death of a loved one, plot a useful map as we transit through the uncharted emotional aspects of the COVID-19 pandemic. For this first in a 3-part series, I will explore the journey that we are all on through these stages, and their attendant anxiety, depression, and trauma, and how we can help our patients (and ourselves) navigate it. This first blog will examine the first 3 stages of grief.

Denial, Anger, and Bargaining

For some time, many people—including some in important positions of leadership—appeared to be in denial about the risk of this virus. For many of us, it was an event happening in another part of the world. Concerning, of course, but not immediately impactful. We went about our springtime lives, planning conferences, basketball tournaments, and vacations unaware of what could befall us. Denial always looks foolish in retrospect, but at the time of the threat, as my blogger colleague Dr. Holly Hendin recently noted, denial is adaptive as it permits us to navigate a world of unpredictable threats without becoming paralyzed with fear.

Once denial became untenable (each day I look at the Johns Hopkins dashboard and am astounded at the power of exponential growth curves), our collective anxiety turned to anger and fear of harm and scarcity. The latter led to absurd behaviors—hoarding toilet paper, or worse, hand sanitizer and N95 masks. The latter of these led to genuine, appropriate anger as health care workers were left to improvise personal protective equipment, leading well-intentioned citizens to organize sewing bees to make surgical masks, and we all asked the question “Why didn’t we start preparing sooner?”.

Part 2 in the series: Making Room for Grief During COVID-19

Anger led to bargaining, as we realized the potential harm of this pandemic and the need to enforce social distancing through closure orders of bars and restaurants and, increasingly, shelter-in-place orders that turned some of our largest cities into ghost towns. Stock markets buckled, unemployment claims skyrocketed, and a question began to be asked—can we maintain a healthy economy and still contain COVID-19? How many people would we be willing to allow to perish to continue a robust economy?  It’s a perverse version of the runaway trolley problem, except we’re now trying to save the trolley and not the people who lie in its path. All the models of an unmitigated pandemic predict an overwhelmed US medical system, as it was in northern Italy. When that happens, a cruel triage will become essential: who is most deserving of a ventilator or an intensive care unit bed? This is a decision I would not want to faced with, and a moral trauma that I wish to prevent my colleagues from ever having to make. This is why we are staying home and missing out—so that our Emergency Department colleagues don’t have to decide who lives and who dies.

The Road Ahead

So, what lies ahead for us and our patients? It’s not an easy road, and it’s likely to involve a period of depression and post-traumatic reactions before arriving at last to acceptance and growth. But before we get there, we’ll invariably cycle through all the stages of grief again and again, with each new development, with each new loss. While fortunately, I have not yet had to face the grief of losing a loved one to this illness, I and everyone else has lost the normalcy of regular life. I miss seeing my friends, of going out to dinner in a restaurant, to going on a vacation during spring break. Of course, these are minor sacrifices when we are trying to curb a pandemic, and ones that I willingly make, and with each one comes loss. Further still, there is anticipatory anxiety about what losses are coming next. Will our kids finish this school year? Will we lose our jobs? Will family members and friends die? We don’t know.

Part 3 in the series: The Search for Acceptance and Meaning in COVID-19

I was talking to a friend this week about her psychotherapy practice during the time of COVID-19. She remarked, “Normally, my patients are working on seeing the irrationality of their fears, but what do you tell someone like that in a time like this?”

Indeed, in a time where the pandemic of coronavirus has made shelter-in-place orders essential, everyone and every surface becomes a potential threat. When I walk in my usually bustling San Francisco neighborhood, the streets are eerily quiet, and people cross the street rather than pass on the sidewalk with less than 6 feet separating us. I come home, wash my hands, and hope that somewhere, somehow a virus hasn’t found its way into my respiratory tract.

Addressing Anxiety

What do we tell our patients who are understandably anxious about the pandemic? First of all, tell them their feelings are normal, to be expected. Who wouldn’t feel anxious about a pathogen that can’t be seen, seems to live a long period of time on common surfaces such as doorknobs (this is a really rough time to have obsessive-compulsive disorder), and appears to be infecting the population at a logarithmic rate every 3-6 days? If you’re not anxious, you’re probably not paying attention. For those who already struggle with anxiety, it may get worse for a while. How could it not?

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At the start of a crisis, anxiety is adaptive because it is hard-wired into us to get us to pay attention, to mobilize for action. Post-traumatic reactions occur, in part, when we can’t actually utilize that mobilizing energy to protect ourselves, according to Dr. Bessel van der Kolk in his book “The Body Keeps the Score.” I suspect this is why so many people leveraged their initial fears to stock up their houses with food and supplies and spent the first few days of quarantine cleaning out long-neglected closets and garages—it was a place to discharge the nervous energy generated by an invisible foe.

This energy can only be used for so long to motivate hand washing and house disinfecting before sheer exhaustion sets in. When that begins to occur, the anxiety turns to depression and demoralization as we begin to feel the duration of the threat, and the grief that comes from not only current losses, but the anticipatory anxiety that stems from not knowing what loss will come next. Sometimes called ambiguous loss, it is the sorrow over things that are uncertain and incomplete. Will we not be able to take that trip of a lifetime that we had planned for this summer? Will we see our kids graduate? Or worse, will we lose our jobs and livelihoods? Still worse yet, what if we lose our lives or we lose people close to us to this virus? So much feels uncertain. 

So how do we navigate the mental health challenges of the early stages of the pandemic, the ones that are responsible for the palpable anxiety right now?

The first thing we can do is begin to divide the world and our choices in it into two categories. That which we can control and that which we cannot. We can’t know or control how long this will go on for or how bad it will get. We can’t control if other people hoard all the toilet paper. We can’t control if the local or state government issues a shelter-in-place order that closes your workplace or leaves your kids at home. And let me be clear: all of these things stink. No one likes them. But these disruptions are necessary for the safety of the community.  In this fractious time, this is one point on which we can all try to agree upon. 

The second category is things which we can control. The first part of this list are things that we can choose not to do. For those of us who can work from home, we can get done what we need to do and call it a day. We can release ourselves from the expectation that we’re going to write that novel or finish those photo albums when we’re stuck at home. It’s OK just to get by right now. Much of our bandwidth is taken up by managing the situation and our anxiety. As tempting as it may be to pour that additional drink to manage the nerves, we can choose to pass that up, too.

Of the things we can choose, probably the most important one is our attitude. As Holocaust survivor Viktor Frankl, a neurologist and psychiatrist, noted from his vantage in a concentration camp, everything can be taken from us except our freedom to choose our attitude about a given circumstance.

We have an opportunity to practice slowness and to turn inward. Pablo Neruda wrote in his poem “Keeping Quiet”:

“If we were not so single-minded
about keeping our lives moving,
and for once could do nothing,
perhaps a huge silence
might interrupt this sadness
of never understanding ourselves
and of threatening ourselves with death.
Perhaps the earth can teach us
as when everything seems dead
and later proves to be alive.”

We can still control when we go to bed and when we wake up. We can choose to have a meditation practice and choose to cultivate our inner lives. We can mindfully wash our hands or wipe down our doorknobs. We can choose how much news we consume or how much we engage with others on social media. We can choose to reach out to supportive people that buoy our spirits and steer away from those who drag us down. We can choose to smile at people at the grocery store and wave to our neighbors. We can let the other guy go at the stop sign. We can be kind.  We can savor the time spent with family. Beauty is medicine. Most of us, even if we’re sheltered in place, are still permitted to go outside (just away from other people or crowds), and on these walks and bike rides, we can notice the color of the sky at sunset or the way that spring is announcing itself with a riot of flowers all around us.

Neruda noted how spring has a way of reminding us that at the end of a long, cold winter, everything that seemed to be dead has been quietly conspiring underground to return to life, and that we are invited to join in the conspiracy, waiting, resting, reserving our energy for when this time is over.

Andrew Penn, RN, MS, NP, CNS, APRN-BC was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.