When the world is grieving, please don’t walk on eggshells

There is nothing more certain in life than death; we just don't know how or when it will happen. When my dad died when I was 20 years-old, no one spoke about him again, perhaps scared of the upset speaking his name may cause. My mum died a few years later, followed by my grandparents, and then my partner just a few years ago. Over the last two decades, I have learned a lot about grief, both personally, and professionally. I've watched my children grieve for their dad, and heard the stories of strangers through my research. 

Since the COVID-19 pandemic began, death has become part of daily conversations, and the number of people losing their life has been plastered over the news like the Hunger Games death cannon. Mass loss of life can change the world indefinitely, such as the impact of 9/11 on airport control. These changes act as long-lasting reminders, around the need to prevent future tragedy. Covid-19 will have its own legacies, one based on the inability to physically comfort people outside of our household during times of grief. 

Impact of grief

When someone you love dies, it hurts, both physically and psychologically [1,2]. Yet those who have been bereaved describe others who haven't as walking on eggshells around them, seemingly scared to cause any more upset [1]. I've seen and felt the comfort that being around others who have experienced the death of a loved one can bring, and that sense of an 'unspoken knowing' of the pain that loss can cause. Great support can be found in bereavement groups such as Widowed and Young; Adults Bereaved as Children and Child Bereavement UK, that normalise the process of grief. Enabling conversations about someone's 'person' can reduce feelings of loneliness and isolation, because even in death, they will always be your dad, your mum, or co-parent of your children. Continuing these bonds is important for those who have been bereaved. 

Collective grief, even when the bereavement is not personal, could lead to grief responses. Grief impacts upon our mental health, cognitive abilities and health behaviours, and we can experience many grief outcomes at the same time, at different rates, intensities, and durations [1]. Sudden, unexpected, and mass loss of life are not uncommon (e.g. terror attacks/ national disasters), and grief in these instances may follow a different course to more 'natural' deaths [3]. While grief is an individual process, there are some common outcomes that may occur. Levels of emotional distress such as low mood, anxiety, depression, and complicated grief (such as yearning or lack of acceptance) can develop across all ages [3-5]. Concentration, self-esteem or quality of sleep may decrease [6]. In an attempt to escape or cope, detrimental levels of alcohol or drug use, poor diet, lack of activity [6], self-harm [7] or overworking may be seen. Yet behaviours such as physical activity [2] and the practice of mindfulness can counteract these negative outcomes. 

Re-grief during COVID-19

Traditional models of grief suggest phases of denial, anger, bargaining, depression, acceptance, and meaning [8]. However, these concepts have come under criticism, cautioning health professionals in their use, and deeming them simplistic [9]. Evidence suggests [1, 2] individuals can experience re-grief, with feelings from a past bereavement returning following a significant trigger. This is common for those who have been bereaved at a young age, and can occur at significant milestones, such as passing a driving test, graduating from university, getting married or having a baby [1,2].  For those already bereaved, the COVID-19 pandemic may trigger thoughts and feelings related to the loss of their person, evoking a re-grief response.  

A more helpful concept to the stages of grief, is that of 'Your world and the ball of grief', that I have adapted from 'the ball and the box' analogy [10]. Many would argue that we do not 'get over' or 'move on' from grief, but that it stays with us and instead your world grows around it and you learn to move forward. In this analogy, at the time of a bereavement, your world is almost completely consumed by a ball of grief, which can repeatedly hit a pain button leading to grief outcomes. Over time, rather than the ball of grief getting smaller as some would suggest, it is argued that the ball of grief stays the same, but your world gets bigger, making it less likely to constantly hit that pain button. During times of remembrance, the ball of grief may resurface and hit the pain button, causing re-grief. However, in this bigger world, that re-grief experience is less consuming as the ball of grief has more space to move around, and thus causes less pain.

Covid-19, re-grief and grief empathy

Those who have been bereaved often feel better understood by others who have experienced a loss [1,2]. In our research, we've interviewed young people who have experienced the death of a parent, who tell us how hard it is to be 'that girl at school whose Mum died'. They know the pain that is felt when someone you love dies, and feel comfort in being around 'someone like me,' giving them a greater sense of empathy [1, 2]. Covid-19 and the national bereavement that is has caused may be leading those who have been bereaved before to feel unsettled, and think of their person more than usual. But they may not realise why this is. It may be linked to a sense of grief-empathy, that perhaps intensifies feelings of re-grief as, additional 'balls of grief' are added to their world, making it feel overwhelming (see Figure 1). This may also be the case for multiple bereavements. This analogy can help people become aware and normalise those feelings of unsettlement during COVID-19 and beyond.  

Covid-19 and anticipatory grief

During times of mass death, a sense of anticipatory grief may also occur, leading people to imagine a scenario where someone else they care about dies. This can evoke feelings of anxiety, and news reports and official advice of ways to reduce risk of death may make us feel overwhelmed. When we feel anxious and overwhelmed, it is common to enter a 'fight or 'flight' response, which could lead to unintended negative outcomes such as denial of the threat, anger, isolation, substance use or self-harm. Social support can help during these times; however, the rules of social-distancing during Covid-19 limit physical contact from friends and family, taking away even simple forms of comfort, such as a hug. These restrictions to physical connectedness are likely to be detrimental. As a society we need to find other ways to reach out to those experiencing grief and re-grief during these times. This is particularly important for those who have loved ones who have been taken to hospital, with no ability to visit them due to infection control or following new cases of bereavement. 

Behavioural medicine for grief: Physical activity 

Physical activity can provide significant benefit to those who have been bereaved [1, 2], supporting the expression and processing of emotions, providing an escape from grief, and a sense of freedom [11, 12]. This is particularly found in outdoor activities [1, 2, 12]. Recognition of the importance of outdoor physical activity has been seen during the Covid-19 'lockdown', whereby it is one of the few reasons people are allowed to leave their home. Being physically active can reduce many grief outcomes, such as levels of depression, stress, loneliness and post-traumatic stress disorder (PTSD) [1,2,13]. It can also build social support [1,12] and a sense of belonging. While physical distance will protect us from the coronavirus infection, physical activity can promote our physical and mental health. With this in mind, we have developed the #ECLIPSETogether programme [1]. This aims to see Everybody Connected through Loss In Physical activity, Sport and Exercise, Together. This name was chosen for many reasons, but one highlighting that when the world becomes a little darker, as the moon eclipses the sun, one thing is for certain, that it will get light again. This programme encourages everybody around the world to take time each day to be physically active and join others to connect and remember those that you love. We hope, like in our previous research, people will connect through physical activity during times of grief.   

BPS Covid-19 Bereavement and Care of Relatives workstream

I have had the honour of being part of the British Psychological Society's Covid-19 Bereavement and Care of Relatives work-stream, producing a series of documents to support people in times of grief. Led by Professor Nichola Rooney, and alongside Drs Becci Dow, Frances Duffy, Theresa Jones, Elaine Johnston, Elaine Kasket, Sarah Meekin, Benna Waites, Elaine McWilliams and Polly Kaiser, this group has come together from different angles of psychology to support both health professionals and relatives before, during and after someone's death. One aspect of this work that has been personally rewarding is that on 'Continuing bonds' with our loved ones, led by Dr Theresa Jones. This work encompasses many activities that can help to keep your person's memory alive, especially during times of physical distance. These include lighting a candle, holding a virtual memorial, making a memory box, creating a Facebook page, gathering a legacy and planting seeds. 

Embrace ways to connect

Being aware of grief responses with and without a direct bereavement, and the promotion of physical activity to benefit grief outcomes, could be supportive in times of grief. Given the current wide-scale bereavement, as a society, we must recognise and allow for the process of grief, openly. So I urge everyone, while the world is grieving, please don't feel alone in grief or walk on eggshells around those who have been bereaved. Instead, embrace ways to connect together and continue bonds with those you love and care for.   

- Dr Angel Marie Chater 

Reader in Health Psychology and Behaviour Change; 

University of Bedfordshire, Institute for Sport and Physical Activity Research

The British Psychological Society's resources for the public include some on bereavement and grief.

See also our archive collection.

References

1. Chater, A., Williams, J., Shorter, G. & Howlett, N. (2020). Physical activity for the benefit of mental health outcomes in young people: a focus on parental bereavement. The Sport and Exercise Scientist, 64, 16-17.

2. Williams, J., Howlett, N., Shorter, G. & Chater, A. (2019). Benefits of physical activity for young people who have been parentally bereaved: A report to the Forces Children's Trust. United Kingdom: Forces Children's Trust. 

3. Kristensen, P., Weisæth, L., & Heir, T. (2012). Bereavement and mental health after sudden and violent losses: A review. Psychiatry: Interpersonal & Biological Processes, 75(1), 76-97.

4. Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavement-related psychological distress in health outcomes. Psychological Medicine, 29(2), 367-380.

5. Shulla, R. M. & Toomey, R. B. (2018). Sex differences in behavioral and psychological expression of grief during adolescence: A meta-analysis. Journal of Adolescence, 65, 219-227.

6. Stahl, S. T. & Schulz, R. (2014). Changes in routine health behaviors following late-life bereavement: a systematic review. Journal of Behavioral Medicine, 37(4), 736-755.

7. Guldin, M. B., Ina Siegismund Kjaersgaard, M., Fenger‐Grøn, M., Thorlund Parner, E., Li, J., Prior, A., & Vestergaard, M. (2017). Risk of suicide, deliberate self‐harm and psychiatric illness after the loss of a close relative: A nationwide cohort study. World Psychiatry, 16(2), 193-199.

8. Kübler-Ross, E., Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. New York, NY: Scribner.

9. Stroebe, M., Schut, H., & Boerner, K. (2017). Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief. OMEGA-Journal of Death and Dying, 74(4), 455-473.

10. Herschel, L. (29th Dec 2017). The ball and the box. https://twitter.com/LaurenHerschel [Accessed on 13-04-2020]

11. Brewer, J. & Sparkes, A. C. (2011a). Young people living with parental bereavement: Insights from an ethnographic study of a UK childhood bereavement service. Social Science & Medicine, 72(2), 283–290.

12. Brewer, J. & Sparkes, A. (2011b). The meanings of outdoor physical activity for parentally bereaved young people in the United Kingdom: Insights from an ethnographic study. Journal of Adventure Education and Outdoor Learning, 11(2), 127–143. 

13. McClatchey, I. S., Vonk, M. E., & Palardy, G. (2009). Efficacy of a Camp-Based Intervention for Childhood Traumatic Grief. Research on Social Work Practice, 19(1), 19–30.