The Search for Acceptance and Meaning in COVID-19

(Part 3 of a 3-part series)

In my last two blogs, I borrowed from Elisabeth Kübler-Ross’s seminal work on the stages of grief as a frame to understand the emotional work we are all engaged in as we face the COVID-19 pandemic. After a disorienting quick descent through denial, anger, and bargaining, we find ourselves now in the long sea journey of grief and loss. The first four stages were easier to write about: all I had to do was describe what is happening now. What comes next is harder to write about because we are living into the questions, and it taxes my imagination to even be able to conjure the shape that will take.

Awaiting us is the process of acceptance (the fifth stage) and finding meaning in our loss. How do we begin to imagine accepting sickness, disruption, and death, or even more, finding meaning in it?  Let me be clear, I cannot be prescriptive in telling others the meaning of their own losses or even telling others the path through this time.

Part 1 in the series: Navigating the Emotions of a Pandemic 

Grief writer David Kessler has written about the sixth stage of grief, finding meaning. We each must find our own meaning from this event. This is a process that will take time, introspection, and community. And even when we find the meaning, it will remain a poor simulacrum of that which we have lost. What I can do is share guideposts left in the histories and humanity of others who have experienced loss, and to suggest that we try to transit as a community through the difficult days of reckoning that lie ahead.

California, more so in recent years, has been ravaged by wildfires in the autumn. After the flames are gone, the scorched hillsides seem lifeless. Yet, as soon as the winter rains begin, a hill walker will see mushrooms emerging from the seemingly dead ground, turning the sooted earth into the canvas for new life. Later in the spring, lupine shoot forth in thick sheaves of deep-blue flowers, a fungus that lives symbiotically in their roots fixing atmospheric nitrogen into the soil. Before long, only a few blackened trunks reveal the history of the fire, so quickly does it recover.

For certain, like a wind-swept wildfire, this virus is burning through our world. There will be many dead to bury and much loss to mourn. When the proverbial curve has at last been flattened and rejoined the X-axis, we will breathe a sigh of relief, especially for those whom this is not a story on a news site or even a significant disruption of our daily affairs, but rather a moment in time that marked the loss of a loved one. For those health care workers on the front lines of our emergency and critical care departments, I expect to see the dull-eyed shock of those who have seen too much horror.

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

We will be called upon to experience all that we don’t have bandwidth to feel right now. For those who have unexpectedly lost loved ones and who could not be with them in their last moments (because of infection control), this pain will be even greater. To be sure, we are experiencing a trauma, as a society, and for many of us, before this is all over, a personal one. Our grief will be felt both individually and collectively and we will need to mourn both as individuals, but also as a community. Grief is not meant to be navigated alone, but rather to be held in the soul of the village in ritual and remembrance, however we define that.

Finding Growth in Trauma

Post-traumatic stress arises, in part, when our assumptions of safety in a benevolent world have been shattered. I suspect that the return to our new form of normal, whatever that looks like, will be a reversal of the process through which we took up defenses against the virus—only much slower. While we may ache for a return of public life, we will likely come out of our shells gradually. What will it be like when we can gather again, to fly on a plane, or to shake the hand of a new friend? Will we ever shake hands again? Or will we regard everyone with the vague suspicion that has befallen us now, where all at once, the threat seems omnipresent and yet nowhere to be found? And what if, in the absence of a vaccine, we have flare-ups of infection? Our response to a renewed threat may be excessive or disorganized, as can be expected from a population that is traumatized.

Fortunately, we know from the post-traumatic stress literature that humans are incredibly resilient. The vast majority of people who experience trauma do not go on to develop post-traumatic stress disorder (PTSD). This is the good news. Even better news is that some can come out of the experience stronger. This is the story of post-traumatic growth. But in order for us to grow from this traumatic experience, we must work through that which we have endured.

To do this, a certain amount of engagement with our loss is essential. While brooding over the trauma is not helpful, thoughtful, purpose-driven reflection can move us towards an experience of meaning and resolution. Traits such as optimism, acceptance, and a search for meaning support the post-traumatic growth process on an individual level, while social support, spiritual groups, and community engagement support healing the larger whole.

So how can we use this horrible event to bring us closer to our values and ensure that the change that emerges will endure? I suspect the change and meaning-making will need to occur on both a personal and societal level.

(Page 2 of 2)

Rebecca Solnit, the polymath historian and sociological critic, wrote about the enduring and unexpected changes that occur in communities in the wake of disaster in her book A Paradise Built in Hell. She notes that at times when larger authorities failed to help the people, the people banded together to help one another. For example, in the wake of Hurricane Katrina, the makeshift “Cajun Navy” of boat-owning Gulf Coast residents organized themselves in New Orleans to help people trapped by floodwaters while the Federal Emergency Management Agency (FEMA) dithered. Contrary to the Hobbesian notion that disaster begets chaos and selfishness, disasters often have the effect of bringing people together to help one another.

Ironically, the most important way we can help each other in this pandemic has been to stay apart through social distancing and sheltering in place to slow the spread of the virus. But even apart, there has been solidarity as seen in images of nightly cheering from windows in appreciation of first responders and essential workers. I have seen this unity and courage among health care workers, left to manage this crisis without adequate equipment as the public stepped in to sew masks and 3D print face shields for their local hospitals.

Lasting Change

Sometimes, outrage is the seed of meaning. Nurses and doctors have taken to the media to expose the failings of our health care system, sometimes at the cost of their jobs. Despite being asked to work without adequate protective equipment, conditions that could sicken their families or cost them their own lives, and the terror of working in an overwhelmed system, never at any time during the pandemic did health care workers threaten to leave their posts. The American health care system only works because it depends upon the nurses and doctors who put professionalism and the care of their patients in front of their own self-interests. This selflessness has been exploited by a health care system interested in squeezing as much efficiency from the delivery of care as possible. Many health care workers, who felt betrayed and unprotected by their hospital administrations and the ineptitude of the federal government, are angry, and when this is over will band together to demand safer conditions and a focus on the safety of patients and workers over the profits of hospital organizations. We may have deferred our anger at being betrayed, but we will not forget this moment as we work to find meaning in it. Our fury and courage will undoubtedly be galvanizing to our profession, and it is unimaginable that we will go back to how it was before.

The changes brought about by this outbreak will extend well beyond health care. The domestic events of World War I and the 1918 influenza pandemic underscored the essential role of women, who had stepped into the workforce in record numbers, making it so that their contributions could no longer be ignored and disenfranchisement from voting was no longer acceptable, leading to the 19^th Amendment to the Constitution. As this indifferent virus has stricken everyone from prime ministers to the homeless who walk our streets, we have been shown a powerful lesson that own health is only as safe as the weakest members of society are protected. The 1918 pandemic showed the value of epidemiology and public health, a lesson that had perhaps become an abstraction in the absence of pandemics, and we are again seeing their value. It is unimaginable that this event will not bring tectonic shifts to American society.  

On a personal level, the pandemic has been disruptive, knocking us out of the stupor of our daily lives. For some, these are changes are inconveniences of adaptation—we now must work or learn from home or have had to cancel trips. For others, the disruptions have been profound—the loss of jobs, income, and businesses. And for others still, the losses are the most profound, as loved ones have succumbed to the virus.

For many, the disruption has been an invitation to slow down, to go inward. For some of us, myself included, this can be uncomfortable, as the flow into outward action is more familiar and comfortable than the recursive involution of stillness. Crisis and the threat of loss bring that which is important into sharp relief. Our relationships, time with people we love, beauty, meaningful work, the natural world around us: these are the things we savor when our lives are threatened.

The time between now and when the pandemic is over will be liminal, that is it will lay in the uncharted space between that which we knew and that which we do not yet know. Solnit recently wrote of the paradoxicality of this liminal space, “We are both becalmed and in a state of profound change.” Post-traumatic growth, wrote Stephen Joseph and colleagues in 2012, comes not from returning to the world as it was but rather from adapting to the world as it is now. The biggest mistake we could make is to try to return to things as they were without first examining if the changed world is actually a better world. We must not let a perfectly good crisis go to waste.

As both people and a collective society, we continue to ask the question “How could we be better?” How can we acknowledge the essential lesson of this virus, that we are all vulnerable and we are all connected? And if we are all connected, how can we be more humane and just with each other? How do we create a society in which health is the foundation of our wealth and that we create structures to ensure the well-being for all of its members? No longer can we see the health of our neighbors as a silo that is separate from our own. When one member of the village gets sick, we all suffer. As we turn our attention to our personal lives, we are asked if we wish to return to the same frantic pace that was exhausting many of us before it suddenly, unexpectedly ground to a halt. We have been shocked into asking, “What is important to you? What really matters?”

As Mary Oliver asks in her poem:

“Tell me, what else should I have done?

Doesn’t everything die at last, and too soon?

Tell me, what is it you plan to do

With your one wild and precious life?” 

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.