In addition to being a nation under quarantine, we are also in many ways, a nation in mourning. We are grieving a myriad of losses. Some may be grieving in the most traditional sense, of having lost a loved one. Others may be experiencing losses related to quality of life: the loss of health, a job, status, of freedom, of access to friends and family, access to healthcare for issues unrelated to COVID-19, loss of access to childcare. Although we don’t always recognize them as such, these losses do accumulate emotionally, both for us as well as for our clients. 

Being aware of this can help us to better understand both our own experiences as well as give some frame to that of our clients. According to Elizabeth Kubler Ross’s model, the stages of grief include: denial, anger, depression, bargaining, and acceptance. As always with the grieving process, these stages as applied to our current situation may occur in the order that I’ve listed, but they also may occur in some other order. People may skip a stage and find themselves back in it later, or move through something only to have a new trigger arise and find themselves processing a particular type of feeling all over again. I’ve found that as this situation is ongoing and continually changing, it’s a common experience for the emotions to come up in waves.

Denial

The denial phase in terms of the reality of COVID-19 is one that we’ve seen very publicly played out in the media – those in positions of leadership denying the gravity of the situation, members of the public blatantly flouting stay at home orders. On a personal level denial can take all kinds of forms. It may include a “flight into health” where clients present that everything is completely fine even after a loss, it may involve escape into substance use, it may mean that clients avoid particular topics in the therapy space.

It’s important to remember that denial is a defense mechanism and when it’s occurring in ways that don’t cause immediate harm to the client, we need to be careful about challenging it directly. Where possible we can gently provide insights or ask questions about a given situation or loss, but it’s important that we stayed cued in to working at the client’s pace. Defense mechanisms can be helping them to cope, and so we need to be aware that it isn’t in our clients’ best interest for us attempt to dismantle these. When the individual is ready they will begin to see the situation differently and that is where we can step in to help with processing coping in new ways. 

Anger

Anger is a powerful emotion that often can be strongly connected to fears of not being in control, or a sense of righteous indignation against a wrong. With anger what I find to be most helpful is to first empathize, but then to focus on helping the client to reduce their level of distress as related to the anger. This can be tricky: by empathizing we don’t want to add fuel to the fire and thus increase distress, likewise by seeking to decrease distress we don’t want to invalidate the client’s feelings.

While empathizing with the experience of our clients we also have to be conscious of our own feelings. We may have very strong emotions or even anger of our own that either aligns with or goes against what our client is feeling angry about. In my experience this is a moment where we have to tread very carefully around our personal disclosures. If we do disclose something about what we ourselves are feeling, we would want it to have a very specific purpose. As I mentioned in a previous post, it is not usually the case that we would be sharing the same stressful or traumatic life experiences as our clients. However, during this unprecedented time we find ourselves all thrown into similar circumstances, so it is important that we are very aware of monitoring our own feelings. Sometimes it can be helpful to ground the client in the knowledge that what they are experiencing right now is likely be similarly experienced by millions of others. This isn’t to dismiss or discount their feeling, but rather to help the client to feel less alone in their experience.

Helping to bring down the level of distress that someone is experiencing during anger that is connected to grief has to be done with a great sense of care and compassion. It is important that this be communicated to the client, otherwise we may be perceived as being argumentative or invalidating, which is likely to be counterproductive. Instead, after we’ve listened and fully understood what the client’s anger is about, we might ask permission to help with it. We can even ask what would feel most useful to them in that moment. Could we understand better if the anger triggered is connected to anything else in their life or history? Could it be okay if we share some thoughts that might broaden the perspective? Would doing an exercise in grounding or resourcing be helpful?

Here we can employ any of the tools that would normally be part of our approach in working on anger keeping in mind that anything that can be done to help the client gain a broader perspective, or even to extend some sense of compassion towards the failings of the subject of their anger will usually be helpful in bringing down distress.

I will note here, however, that this isn’t to say that the client’s anger is without justification. For those who are angry at being let down by leaders or systems which had a duty to care for and protect people, it is completely understandable to feel angry. But our role as counselors isn’t to judge who is right and who is wrong in a situation, instead it is to help our clients with their distress so that their energy can be used for taking care of themselves and their families, for doing their jobs, for functioning in their lives. It may also be that finding ways to help their communities or advocate for what they believe is right can be empowering ways of finding some measure of control in a situation they are angry about.

Depression

The next stage of grief, depression, is one which most counselors are very familiar with treating. All of the approaches that you might normally use for treating depression still apply here, just with the frame that in this context the depression is likely a healthy and normal part of processing loss. It can be helpful to prepare clients that feelings of depression or psychological paralysis can come up in waves during this time and may have varying duration or impact. For example, in working with my clients who were under quarantine for a long period in China, I found that it was not uncommon to have days where they would wake up feeling completely overwhelmed by the magnitude of what was happening or the uncertainty of it. Sometimes these feelings just last for a few minutes and pass, other times they may last more like a few hours or a day or two. Being prepared to encounter these experiences with self-compassion can be really helpful, as can having an advance plan for how they might cope during that time.

Bargaining

Bargaining is the next stage. This stage can look different for different people but for many it involves some degree of self-blame or guilt. If they or a family member have become ill, there could be a lot of retracing steps, wondering if there was something they could have done different to avoid contact with the virus. Or in the case of a lost job they may be asking themselves if there was anything they could have done differently to avoid being among the ones to be let go. This stage can involve a spiritual aspect as well of making promises about how good they will be in the future if only the loss can be avoided or reversed.

Now that many communities have been under shelter in place orders for a month or more, you may have clients who are reaching a certain level of acceptance with how things are at the moment. But its important to keep in mind that this can change from one day to the next. While it’s still important to be cautious and to take care to protect ourselves and our healthcare workers, we can see on the horizon that there are many glimmers of light at the end tunnel. In the words of Stephen Hawking, “where there’s life, there’s hope.”
______________________________________________________________________
Christine Forte is a counselor working in private practice online with the globally mobile community. She has recently repatriated to the US with her family after ten years of living and working in Shanghai, China. You can contact her at Christine(at)forteklotz.com or read more about her practice at www.forteklotz.com