Sean Joe, Ph.D., MSW

Black Thought

No Time to Say Goodbye

Pending waves of complicated grief following the COVID-19 pandemic.

Posted Aug 30, 2020

Typically, when I hear of a loss a dear one of any kind, I share the book No Time to Say Goodbye by Carla Fine with the grieving person. Although the book focuses on pain of loss from a suicide, the book provides guidance through grief for those without the opportunity to say goodbye. The global pandemic caused by COVID-19 has left us all struggling with grief in a new way. This year, I received word that a beloved brother of my fraternity, Kappa Alpha Psi Inc., died from COVID-19 after weeks of battling for his life. I recently spent time with him at his Brooklyn restaurant this past December and am fortunate to have those recent memories to hold through my grief. As we all gathered in our new normal, on his video conferenced funeral, I realized many others were not as fortunate. Many others did not get to “say goodbye."

For many friends and families of those who have died from the coronavirus, what pains them is that their loved ones died alone, in the hospital or at nursing home, surrounded by essential workers who are total strangers. This ‘poor’ death often leaves the bereaved helpless and painfully unsettled. Unfortunately, many Americans across the nation either have or are about to have their own experience of “no time to say goodbye."

The coronavirus pandemic has left many of us without the opportunity to be together while fighting the virus, during the dying process as the body begins to shut down, and when it is time to make bereavement decisions. Families are experiencing shockingly abrupt realizations that this pandemic is challenging their cultural traditions and coping responses to illness and death. Many are left confronting intensely troubling, very deep and endless amount of challenging grief. This is what Dr. Ken Doka, author of Grief is a Journey, refers to as “disenfranchised grief,” so much loss, not culturally or publicly sanction or mourned.

America is also experiencing vast amount of loss and stress, not only to death, but the loss of jobs, wages, intense physical insolation, and the inability to celebrate momentous occasions, like graduations, holidays, anniversaries and even weddings. All while increasing news reports share stories of families on the brink of hunger, bankruptcy or homeless, months after learning of the pervasive experiences of citizens dying alone in nursing homes or hospitals. The impact is traumatic and some feel inconsolable. The full measure of this type of emotional injury is not equitably distributed among Americans due to a long-standing racism or discriminatory practices that divides the chances for health and well-being in America. When conscious or institutional racism-2020 is added to underlying health conditions that put African-Americans and other communities of color in a vulnerable position, these citizens are faced with not only higher infection rates and death rates but also greater grief.  

The next eight to 24 months 
Soon the nation and the world will begin to return to some sense of economic and social normalcy. As medical science advances the threat of the virus will begin to diminish. We will have new treatments and improved testing capacity and accuracy. We will begin to see rising tides of lower risk perceptions among citizens who feel they are no longer at eminent risk of contracting the coronavirus virus or don’t perceive it to have lethal consequences. We will then see a vast amount of grief and emotional trauma blossom throughout the nation. Why the lag? The bereaved are appropriately preoccupied with current concerns for their own mortality and health, which is blunting the severity of their grief and length of their personal grieving process.  

Escalating waves of individuals in emotional crisis due to complex grief will begin confronting the fragile behavioral health systems in our states and cities, on college campuses, and in the work place. Structural challenges today inhibit the ability of many municipality, including Saint Louis Metro, to ensure we can meet the current or pending increased behavioral health care demand. 

In 2018, the National Council of Behavioral Health reported notable gaps in nation’s behavioral health on workforce. They found that there was a demand for at least 8,000 more psychiatrists, 19,000 more psychologists, and 47,000 more mental health social workers. Without critical policy or capacity investments now, such as a targeted mental health CARES Act, our towns, cities, states, colleges, and businesses will be left scrambling and unable to fully meet the forthcoming needs of the people. 

Prior to the pandemic, there existed several signs that Americans in rural and urban spaces were uniquely experiencing dangerous levels of mental distress associated with the corrosive effects of unmitigated Wall Street greed and severe economic inequality. Economists, Case and Deaton, reported on this inchoate phenomenon in their book, Deaths of Despair, citing rising rates of suicide and all deaths among middle-aged white men and women, due in part to something having gone wrong with the American dream. Strikingly, in the past decades we have witnessed unprecedent levels of suicide among the young and old, regardless of ethnicity. For instance, Black children under 12 now have rates of suicide higher than whites of similar age. The putative explanations for the increases in “deaths of despair” are many, but consistently noted is the explanation that feelings of emptiness and purposelessness, especially among those of prime working ages that are unemployed, may be the root cause.  

Significant investments in the behavioral health care workforce, technological infrastructure, and new treatments, particularly for those that are considered the social determinants of health (e.g., unhoused, job stress or anxiety, food insecurity) are what is needed. Some of the investment priorities needed are consistent with recommendations from the 2019 National Academies of Science report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, and includes:

  • Recommendation 1: Expand the Behavioral Health Care Workforce by expanding and standardizing the scopes of practice of social workers and other professional therapist, as well as community health workers to fill the gaps in psychiatry or psychological care in many areas. Specifically, social workers, who provide a lion share of the behavioral care in the nation, and other professional therapists should be considered to be providers who are eligible for reimbursement by payers and where applicable trained and licensed to proscribe medication.
  • Recommendation 2: Amend Payer Rules to enhance the behavioral health providers’ ability to more effectively coordinate mental health care with human service organizations capable of providing critical social care (e.g., income relief, food pantries, utility, rent, mortgage assistance). Medicare/Medicaid payment advisory commissions should evaluate models in which social workers and other social care workers are reimbursement-eligible providers of social care services.
  • Recommendation 3: Expand Tele-Mental Health Care and to integrate social care into behavioral health care through infrastructure development to redesign and refine workflows, provide novel localities technological assistance and support staff with the ability to develop the redesign. These champions of the redesign can curate best practices, focus on health information technology to enhance integration, and create support systems for community partners and their infrastructure needs. 
  • Recommendation 4: Payers Expanding Behavioral Health Care Coverage for longer periods of time with little additional charges for individuals and families unable to absorb more cost.

We have the opportunity to avoid being unprepared for the emotional health needs of families whose cultural traditions around death and grieving have been savagely disrupted leaving many extremely vulnerable to profound level of untreated remorse, guilt and anger. Mental health relief is also needed for the essential workers on the frontlines suffering traumatic losses, while carrying the burden of being the only one there to hold the hands at the time of death for so many COVID-19 victims.  

We might be approaching a tidal wave of despair and our behavioral health systems cannot adequately prepare without prudent federal legislative action. As noted, legislative action is needed:

  • To address the lack of a national surveillance infrastructure
  • To understand outbreaks of suicidal behavior or the onset of psychotic illness
  • To address noted workforce challenges
  • To aide municipal planning or resource distributions of urgent behavioral services
  • To expand demand for psychiatric beds

We should not be tolerant of unintended or cascading consequences or of poor planning and commitment, due to any lack of leadership on this issue. After all the many congressional legislative phases of economic stimulus relief, behavioral relief is also needed. History will tragically remember if congress and the current administration do not provide support to the many Americans who had “no time to say goodbye."

Our future depends on the decisions we make today!

References

Fine, Carla (1999). No Time to Say Goodbye: Surviving the Suicide of a Loved One. NY: Harmony.  

Case, A. & Deaton, A. (2019). Deaths of Despair and the Future of Capitalism. NJ: Princeton Press.