The Grief Elaboration Process in the Pandemic Scenario: A Group Intervention

Abstract

The COVID-19 pandemic has claimed thousands of victims worldwide. To deal with loss is a formidable challenge for all, especially those who experienced losing their loved ones. The grief elaboration process is complex, and the pandemic adds some specific challenges, such as the restrictions to funerals and farewell rituals or the impossibility of saying goodbye due to the sanitary measures. This chapter presents a group psychological intervention aimed at people who lost their relatives to COVID-19. The therapeutic groups were carried out virtually through six sessions and brought together people from all over Brazil. Narrative therapy was the theoretical model adopted. The participants mentioned the moment of diagnosis as decisive for experiencing the disease’s terminality and anguish, promoting guilt and anxiety in the family. In the group, the participants found space to share the painful experience, and throughout the sessions, they were able to develop coping resources. They mentioned strategies, such as activating the family and social support network, recalling legacies and moments they shared with the deceased, and elaborating farewell rituals adapted to the pandemic circumstances. The participants evaluated the group intervention as very important for reframing the pain of loss and restoring future projects since they counted on the help and inspiration of the other participants who went through this painful experience in similar circumstances.

1. Introduction

One of the greatest challenges to Psychology that arose from the COVID-19 pandemic was the accommodation of several mental health demands. The cases of anxiety, depression, sleep disorders and so many other complications resulting from the collective trauma faced by the global population are undeniable [1, 2]. However, after more than one year of pandemic, especially in Brazil, where in May 2021 the tragic mark of over 450,000 deaths was reached, grief has been one of the most frequent and significant reasons for requests for interventions in mental health. The complex process of mourning involves several variables and, with the sanitary restrictions that have prevented meaningful rituals practiced in the culture from happening, the impacts have been intense. The purpose of this chapter is to present a psychological intervention experience aimed at people who have lost their loved ones to COVID-19. The sessions were held virtually and gathered people from different regions of Brazil, and also abroad, for six weekly two-hour meetings. The theoretical basis adopted was that of Narrative Therapy, for proving itself a conceptual model that has contributed significantly to redefine the experiences of loss and trauma.

2. Death, mourning and meanings in narrative therapy

Understanding death and losses in natural situations is, in itself, extremely difficult, for it invokes the theme of finitude of the materialized form in a society in which this theme is taboo. In the pandemic scenario, large-scale deaths, associated with deprivation of physical contact as a result of sanitary measures, require the bereaved to have even more resources to deal with adversity and get in touch with their own pain. In several situations, the thinking that prevails among people who offer social support is that the mourner should let go of the person who passed away, be involved in actions that distract them, and avoid thinking about the deceased. According to Campillo, it’s reprehensible what modern thinking advocates about recovering from the pain of loss through the mechanism of moving on with life without a loved one, letting them go [3]. The postmodern proposal expands and enriches this vision, proposing a new look. In this conception, death is not considered an end, but an invitation to a new relationship, in which connections may keep on growing and improving even after death. White in his work “Saying hello again” develops this less hegemonic way of acting with people devastated by the loss of loved ones, because faced with this suffering, the author understands that one doesn’t lose only a person, but with them also goes part of one’s sense of identity [4]. The author’s proposal is that the emptiness and paralysis that the mourners experience should move towards the recovery of the relationship with the departed. Listening to the experiences with those who have passed away and bringing the importance of their presence in the life of the mourner and their contributions to the mourner’s sense of identity becomes a work with grief capable of promoting new meanings.

3. Building a welcoming space: the conditions and attitudes for working with grief

Imagine the pain of one who has experienced mourning in the conditions of the pandemic. Receiving the COVID-19 diagnosis is culturally represented as a sentence in which death is quickly considered. Therapists, from the moment of first contact with the mourner, already need to convey the idea of a space where they should feel comfortable. It is necessary to clarify that the participant is the one guiding the conversation, electing what to share and when to do so, characterizing a respectful and collaborative process [5].

For White, it is very important that the therapeutic interaction is centered on the person being assisted and not on the therapist [6]. According to White and Epston, the narrative method places the person as the protagonist or as a participant in their own world [7]. For the author, retelling a story is telling a new story. It is understood, therefore, that the therapist is the specialist in the process and the client is the specialist in the content, hence the importance of the questions and of the accommodating space without judgment or restrictions that may intimidate the spontaneous retelling of those who want and need to share their stories.

Campillo points out the importance of the double listening in the therapist’s job in the case of mourning and of people who have undergone recent traumas [3]. What does that mean? While the therapist must give full importance to what the person wants to report from their traumatic experience, they must also be attentive to expressions that show how a person responded to this traumatic event. The double listening observes any sign of events, values ​​and desires that the person shows, even when reporting the story saturated with problems, which is the description of trauma. Through the double listening the therapist plays the role of the external witness, who will seek to identify in the conversation words that imply other meanings, and in reflecting them to the participant, allow them to listen in their own words their desires, values, dreams, life principles, resources and everything that was observed in their narrative that was obscured by emphasizing the problem.

4. Conversations of re-membering

The main bases of this work of reconnecting with significant people is what White called conversations of re-membering [8]. This therapeutic practice was inspired by the work of cultural anthropologist Bárbara Myerhoff. The metaphor is based on the idea of ​​a life club, in which there are members that are validated or canceled. Thus, the mourning process rescues the relationships built with the person who has passed away, considering the identities, life knowledge, legacies and mutual learning. White warns that they are not passive memories, but intentional engagements that promote identity marks. These conversations are based on two sets of questions for this mapping. The first set refers to retelling how the meaningful figure has contributed to the person’s life, detailing how this connection has promoted this process, while the second set invites the person to see the contributions that they themselves have given to the life of this meaningful figure, detailing how this has happened.

It is important to mention that conversations in Narrative Therapy generate contexts for activating skills for creation of meaning. The process allows deconstructing ideas contained in the stories to find different conceptions, allowing new meanings for the lived experiences.

5. Accommodating people who lost their families to COVID-19: mourning and their stories

The pandemic declared in March 2020 in Brazil brought as one of its most nefarious effects the death of over 450 thousand Brazilians in the period of 14 months. Unfortunately, even with the advent of vaccination, control over contagion and the intense need for hospitalizations has not yet occurred and the number of deaths is still on the rise. Therefore, there are thousands of mourners who demand an urgent look at their mental health and help in the grieving process.

As members of the Committee for Mental Health and Psychosocial Support of the University of Brasilia, we offered a support group, with a proposal for six weekly two-hour long sessions, in which, based on the work of narrative therapy, we developed a welcoming space to people from all over the country and even abroad who shared the experience of having family members who passed away due to COVID-19.

The groups were open to anyone who was 18 years older and had internet access. We published invitations to the support group on social networks, the university’s website, and the local media. It was offered for free. Those who were interested in participating fulfilled an online application form. After applications, the groups were divided according to the participants’ age. Two psychologists acted as co-therapists and facilitators of each group, accompanied by undergraduate psychology students who observed the sessions and were responsible for their written records. The two authors of this chapter supervised both the psychologists and the students. The weekly supervisions were divided into two moments. In the pre-session, the team discussed the topics that would be approached in the following session and possible doubts or questions. In the post-session, the team discussed what had occurred in the session, the therapists’ interventions, feelings, and resonances, as also plans for the next session. During the sessions, the supervisors were online available to assist the therapists in case of need.

We will now describe the procedure and report the experience, connecting it with the theoretical aspects on which we have based the intervention (Table 1).

Themes of the sessions

1. Knowing the group and establishing agreements.

2. Investigating the support network and resources

3. Introducing the loved one and their stories

4. Connection between the people introduced and resonances

5. Searching for community resources and networks

6. Moving forward and revitalizing projects with the strength of legacies

Table 1.

Themes of the sessions.

In this proposition, the first meeting is crucial for the construction of a collaborative, dialogical proposal, in which members of the group can feel that their emotions will be welcomed in all their expressions. It is fundamental that in the online model, the bond and the creation of a welcoming virtual space are ensured so that all of them can feel belonging to this community that has signed up to share their painful experience with people who are able to understand it. In the groups we offer, it is very common for this moment to be one of openness and expectation. After clarifying how the group will work, it is common for participants to be anxious to reveal their painful processes of accompanying their loved ones, from the moment of diagnosis until death, revealing the hurtful, intense and fast period in which the disease develops and worsens. Participants usually bring impactful reports and, for the most part, describe the experience as traumatic, touching others with their emotional narratives.

This session clearly shows what Campillo points out about the need for people who experience recurrent trauma to be heard about everything they elect to share about the traumatic experience [9]. But at the same time, it is vital that in our listening as facilitators we notice the signs that the person continues to value their life, despite what they have experienced. The author states that no person is a passive recipient of trauma. As severe as the experience of loss may be, it is always possible to recognize a movement and this can and should be recognized by those listening. Even in the face of a trauma of great magnitude, people tend to take the necessary measures to protect themselves and preserve what they value.

The initial question of the session is intended to promote the narrative practice of double-listening, where we are interested in listening to more than one story [10, 11]. The tendency is that people present only a narrative of negative effects, which hides responses of resistance and resources, seeming to trap them in their impotence. Double-listening allows us not only to listen to the first story, centered around the effects and impacts of trauma, but to a second story, based on the responses, on the strategies used, and on what they value in their lives. For narrative therapists, committed to an emancipatory action, this will allow to awaken the sense of agency and the discovery of a favorite story, which shows that despite the trauma, there is no submission and passivity [12]. A clear example, in the grief for having lost family members by COVID-19, is the attitude of wanting to be in a group, sign up, be present and bravely share their emotions. Another example is when one participant exposes how inspired they were by the attitude of another in regards to the responses and resources; they feel surprised and are able to see through the eyes of the other their own sense of identity recognized. The idea of ​​Michael White (2006) was to deconstruct the “no pain, no gain” saying, creating a space in which is possible to relive less of the details of trauma and instead create a safe territory of identity for people to express their experiences. It is not avoiding the description or intimidating it, but warning about conversations about only one story.

In the second session, people who have not yet described their traumatic experience of loss are encouraged to speak. The beginning of the session happens with people speaking about how it felt to be in a group sharing so much pain and resources. Although the reports mention the pain experienced in listening to the traumatic losses, the group members recognize the positive stories even through adversity. As facilitators, we have also chosen not to emphasize the dominant discourses that are destined to tragic stories, highlighting the horror of death and lamenting the details of the rapid assisted degeneration. We invest, as facilitators, in the exceptions that compose the alternative story, such as the ways of expressing love and care, so delicately described by the participants when reporting their actions along this journey. Our questions and interventions always look for practical stories of hope and it is possible to see that in the retellings. For example, in one of our groups, a daughter blamed herself for not being able to say goodbye. Instead of emphasizing the practice of this ritual that is suspended by the pandemic, we revisited all the manifestations of celebration of her father’s life, while she was in his company. These positive expressions took the daughter away from her helplessness and filled her with hope about how good it was to know that her father died having received so many gestures and words that showed her love.

This session is also dedicated to the narratives about which support they could count on at that time. According to Campillo, all support is valid, whether it includes people, communities, spirituality or others [3]. The conversations should center on how these resources worked in other situations and whether they could be used in this moment of death of family members by COVID-19. The kind of questions that are asked invites not only to investigate the support received, but also the way in which they are seeking this support and whether they are managing to formulate this request.

To illustrate, we observed that there are surprises around this network capable of supporting this moment. For instance, in one of our groups a person brought their outrage about the way the inventorying process occurs, with tight law deadlines which disregard the pain of the mourner. To help solve this, they counted on professionals who worked with their deceased father and who knew how to conduct this moment with great sensitivity, helping with practical resolutions as well as being emotional supportive. The group also frequently expresses how much some of its members have played this supporting role, by promoting identifications with stories and resources reported in the group. Even if no answers are obtained, it is very important to suggest reflection. In this regard, something else that appeared were networks which, instead of supporting, judge and prescribe behaviors for the experience of mourning, and which are also narratives that must be accommodated. At the end of this session, we propose a conversation of re-membering and how they would like to introduce in more detail the people who passed away, bringing the metaphor of the life club and how it would be their action to make this person a member, seeking the permanent connection, regardless of their physical absence, and sharing their legacy. So we propose that this introduction be accompanied by photographs, objects, songs, and whatever else the mourner wishes to bring to represent the deceased person and illustrate their relationship with them.

The third and fourth sessions are dedicated to conversations of re-membering, which are mediated by sets of questions that retrieve stories and testimonies about the person who has passed away. According to White, the questions are specifically to create a space where those in the group can incorporate the presence of the deceased person in their own life and identity in a more enriching way [6]. Speeches that recommend forgetting the one who has passed, overcoming the pain and moving on seem to belittle the richness of the stories that are lived by people with their loved ones. So the questions turn to another aspect: recovering this connection with the deceased person, which allows them to see how much this person is present in their life and that this relationship remains after death, although they need other ways to relate. For this, we suggest that these people be introduced to us through photographs, stories, songs, objects, texts; in short, that they seek this connection so that, when telling about the person, they recover affective memories that also transmit values ​​and legacies.

The participants work hard to share these narratives in the group and this moment is accompanied by a lot of emotion. Initially we invite them to retell how this significant figure contributed to their life, and following that, how this connection impacted their identity and who they are today. This first set of questions is very easy to detect, since the countless stories and adventures lived with these people quickly flood the session with laid-back moments. It is common for very beautiful narratives to emerge, narratives that describe scenarios of action, with adventures, strolls, family habits, recent and old photos that retrieve an account of many contributions from this person to life and to what they take as learning and transformation of themselves from this relationship.

However, this is not the biggest challenge of the conversation of re-membering. The most difficult, but necessary, is the second set of questions, which address the contribution that the participant left in the life of the person who has passed away. Here, the way in which this person contributed to the identity of the deceased person is also recovered. These are questions that many times were not considered by the participants. The power of this last set of reflections is in the concept of agency. The person who lost a loved one so far only saw a void left by their absence and saw themselves as a victim of this loss. But seeing the transformations they have promoted in the life and identity of the deceased person also shows the reciprocity of this transformation.

After the loss of a dear person by COVID-19, it is common for one to have their sense of self reduced and to feel lost about what to value. Invigorating this sense from their values ​​and the restoration of their projects is the objective of this session. In some of our groups, we observed participants who managed to revitalize these connections based on our questions about this contribution: a mourner daughter made it clear that her deceased father had not known how to express gestures of affection and that it was in his relationship with her that he learned. Another participant pointed out how much her mother was able to understand that her strictness and perfectionism were unnecessary stressors and this was learned with her as a daughter. Other members of the group pointed out the deconstruction of prejudices and other forms of revision of values ​​as a merit of living with the deceased, which led to the awareness of their active role in the contribution of values ​​that were also transformed in the lives of those who had passed away. At that moment, it is clearly observed that the bereaved person does not see passively the legacy of those they have lost, but sharpens the sense of agency, as they themselves have also promoted changes and left legacies in those who passed away.

A common point between the third and fourth sessions was the resonances that the members of the group shared, revealing how much they felt touched and inspired by the stories of relationships presented in these conversations of re-membering. Many started referencing to images, songs, words that reverberated in them from the others’ stories.

Session five has as its main purpose seeking community resources and networks which allow facing this moment and assist in the restoration of personal and family projects that can be remodeled in the face of the physical absence of that member. Group participants are invited to think about strategies observed in the group that dialogue with their own coping stories. In some of the groups that we mediate, people have identified themselves with forms of records that could eternalize the stories of the deceased, some with the goal of generational transmission, others of searching and getting in touch with their family ancestors. The way to deal with meaningful dates such as Christmas, Mother’s Day, Father’s Day, birthdays and anniversaries are usually challenges that lead the group to reflect a lot on the resources in themselves that they have made available to deal with these moments and that are very inspiring for others. This session always brings back very concrete experiences about the complexity of the grieving process and allows for very profound reflections about how this does not happen in a linear way or with determined times and manifestations. Accepting this ambiguity of feelings and expressions without judgment is always pointed out as a positive factor in the group, as the idea is not to prescribe guidelines or to assess crises as pathological, but to manage them in a healthy way with the collective understanding that their paths are personal and dynamic.

The sixth and final session proposes a more prospective look at the grieving process, including the theme of revitalizing projects with the strength of the loved one’s legacies about whom we have talked so much in the conversations of re-membering. Instead of advising on forgetting and moving on, suggesting avoidance or distraction behaviors, it is in our life club, with the departed member re-associated, that the projects that restore the sense of identity and future projects will be outlined. This session has a conclusive tone, in which people revisit the way they arrived at the group and how they have developed over these weeks. We do not romanticize here an elaboration of grief or any miraculous change in the way of understanding their pain, but recognize this space as a dialogical opportunity that has allowed many constructions, each in their own way and anchored in their past experiences.

In general, the data collected from what was experienced in the group corresponds to what Campillo recognizes as principles of the grieving process within the narrative perspective: the conclusion that life and the relationship with the person goes on and does not end with death [9]. For the author, discussing the death provides opportunities for stories and experiences full of love that last for a long time after. The questions play an important role: they generate meaningful memories that in the future can be useful when reminiscing, and highlight creative thinking within the constraint of reality that would be fixed as time and proximity. The narratives allow us to seek for resources that are within ourselves and recover the flexibility of stories that transcend death. Promoting the act of membering again lives and relationships is also a very strong principle that manages suffering in a healthy way, refusing to limit it to the insignia of saying goodbye and being a fertile ground for the co-construction of stories of hope and love. According to Hedtke, loved ones who have passed away can continue to play a crucial role in our ‘life club’ [13]. Re-membering practices represent ideas that distance us from the notion of finitude, while supporting a continued symbolic connection with the departed person. This connection is respectful, as it facilitates a person’s continued legacy in the context of the work with death [6, 7].

The sixth session allows us to recover these steps that were taken collectively to prevent the aggravation of a possibly complicated grief situation and to modify its effects, making room for the preservation of what is important to the person and, in a concrete way, identifying tools and skills which are necessary for this knowledge not to be submerged in the experience of loss, without our being able to see it. Such knowledge is built throughout life and is related to what we value. According to Campillo, everything we value in life brings purpose to live, gives us meaning and marks the path ahead [3].

We end the sixth session by asking them to give us a word on how they felt in this group, encouraging them to express themselves in writing. But the common oral feedback in the various mourning groups we offered mentioned how much the members felt affected by the each other’s stories and the reverberation this promoted when they got in touch with their own content. These interpersonal learnings presented themselves as important therapeutic factors, as they clarified the participant’s memories in relation to facts that at that moment they would not have selected to tell. Acknowledging several positive aspects of the process and gratitude for the members’ trust in sharing such intimate stories, the session concludes with the clarity that the process does not end there and that the challenges are daily. The final moments represent exchanges of personal contact information, networking with group members and scheduling a new group meeting, usually on a date in the following month, for an opportunity to follow up on what was experienced in this dialogical space, when they begin to observe what was experienced there in their everyday demands.

6. The therapist and the group of mourners: emotional mobilization and learning

It is not possible to address this experience with a group of mourners without mentioning what this work is able to promote in therapists who are facilitators. Initially, it is important to highlight the challenge of living during the pandemic, which is faced both by the therapists and the group members, who are equally inserted in the pandemic collective mourning process. While this insertion favors great empathy, as we are also experiencing close and significant losses, it can also promote discomfort and paralysis in the face of so many touching contents reported by the participants in their trajectories of intensive care that were unable to prevent death.

Although this is a group whose main characteristic is dialogue and collaboration, the therapists do not play a leading role. In the role of facilitators, the therapists are experts in the process and invest in asking questions that help participants identify what White called absent but implicit, that is, finding insights into what people plan in their lives, but that they do not always identify in their stories [14]. In each session the therapists promote that, in this collaborative space, in which respect for the narrative of the other is always exercised, meanings are articulated that, when recognized, help create a platform that allows re-examining the effects of the problem, taking an alternative position and creating new lines of identity. To illustrate this process, we mention an excerpt from a letter from one of the participants of the group, who describes among so many positive and emotional impressions, a clear view of the process by mentioning:

“… I think the implementation of these groups is really effective, for it’s through them that we open up our weakness, but in the end are surprised by our strength. And that’s how I saw myself, having a space for speaking, listening, venting, building and rebuilding, of common ties, of gathering reasons and purposes to remain strong. Looking at myself and seeing myself is something I was already doing, but looking at myself and seeing my mother and seeing myself in her was something magical.”

There are several aspects that we could illustrate about this short excerpt selected, but the main one is observing the attributes of identifying strength in face of weaknesses and the power of reconstruction and purposes. There is also mention of the connection with the deceased mother through the legacy and preferred identities, in which the problems and impotence of mourning give way to reconnection.

Regarding the therapists’ assessment, the management of grief groups is reported as an indescribable experience, which at the end of the process allows several gains not only for the therapists, but also for the participants. We highlight here the importance of getting in touch not only with the content of others, but with oneself, seeing the emotional mobilization promoted by the tragic stories, but also the power of the process that sets all the pain in motion, aiming for resignification. And this involves all the actors in the process. To sum up, therapists verbalize the opportunity to transform and be transformed by the complexity of all the experiences that the group allows them to feel.

7. Final considerations

This chapter was intended to describe the experience of a group of mourners who had lost family members due to COVID-19. Seeing as this was about an extremely delicate and, at this time of pandemic, very necessary clinical management, it is considered that the social relevance of this work is indisputable. Death by COVID-19 is a reality that affects people all over the world and that requires initiatives from professionals trained to work in mental health. The positive assessments from the participants encourage our attitude to multiply and publicize the adopted methodology, seeking to inspire new experiences and encourage professionals to promote offers of these actions. Psychological work involving grief is not limited to the period of the pandemic, but will be necessary for a long time, due to what the countless losses represent. Assertive actions that rescue affective connections and resignification of relationships with deceased people may be a good path through sadness and longing.

Constructing and re-constructing narratives is an essential part of the process of understanding our experiences, attributing meaning to them, and becoming who we are [15, 16]. Therefore, narratives represent a valuable resource for professionals from different areas who seek to develop socially equitable relationships that place clients or patients at the center of the care process [16]. Narrative Medicine is an important representative of this trend. Rita Charon, also influenced by White and Epston, developed a theory based on the principle that "recognizing, hearing out, receiving, and honoring the stories of illness may give doctors and nurses and social workers to ease the suffering of disease" [16, p. 199].

Finally, although we believe the group’s potential to develop resources that may contribute to preventing complicated grief, professionals must be aware of signs that suggest the need for additional referrals. If signs of suffering remain constant or seem to worsen throughout the sessions or suicidal ideation is present, referral for psychological or psychiatric treatment should be considered. Other risk factors they should keep in mind: a history of mood or anxiety disorders, alcohol or other drug abuse, the coping strategies used, attitudes towards death, the experience of multiple losses, scarce social support, conflicts with family and friends, and financial strains [17, 18]. Considering the high number of deaths faced during the COVID-19 pandemic, governments and civil society need to prioritize developing and promoting strategies to deal with the emotional and social impacts of losing one or multiple family members.