How My Own Grief Helped Me See My Patients’ Loss

By Roxanne Almas, MD, MSPH

How My Own Grief Helped Me See My Patients’ Loss

Photo Credit: Lars_Nissen

My day vacillates between two worlds. Every morning, I leave the comfort of my home, family and neighborhood to begin my day advocating for families who begin theirs knowing it will involve struggle. The families I care for as a Developmental Behavioral Pediatrician in a County Hospital are the reason I come to work in-person every single day in the midst of a pandemic. These families are from mostly immigrant communities, work multiple back-breaking jobs, sometimes are single parents and cannot rely on childcare therefore often take their children to work with them. The marginalized communities I serve have endured significant trauma decades before the start of the pandemic. The children have had numerous adverse childhood experiences that have only increased over the last two years given the incredible losses they have suffered from due to Covid. Many of these children have lost a parent, a grandparent, a primary caregiver, essentially their lifeline. Some have moved homes to be cared for by other relatives and/or placed in foster care as a result. Dr. Charles Nelson, Harvard University’s professor of pediatrics and psychiatry, refers to these 200,000 + children in the US as “orphans of Covid”.

Significant racial and socioeconomic disparities exist among those that are most impacted. Common questions I now find myself asking these days in clinic include “What have you lost over the last two years?” The answers have surprised me and have ranged from lost loved ones to lost friends, to a lost sense of community, lost activities and skills. I usually follow up my question with “And what have you gained?” to instill a sense of hope and resilience in the children I see.

Grief is defined as a natural reaction to loss that can influence the physical, emotional, cognitive, behavioral and spiritual aspects of our lives. I was recently confronted with a deep sense of grief myself and nothing about it felt natural, yet everything about it influenced my entire being. What I’ve learned from processing my own grief these past few months after losing

my mother to an aggressive cancer is that it takes an incredibly strong network of compassionate support to work through it. I continue to rely on my family, my friends, my community, my colleagues, a grief counselor, books, long walks in solitude, podcasts, deep reflection, journaling and so much more to scaffold and hold me in my grieving process. But I’m an educated, multi-cultural, multi-lingual physician in my 40s—which comes with great privilege that I wholeheartedly recognize. I have access to a web of healing at my fingertips and I draw it close to me like a yo-yo on a string when I need it most. My reality is far from the norm. However, having experienced the death of my mother, I feel more connected than ever to my patients, but I am also more compelled to support the grief of my patients and others. The urgency to create a network of grief support for our nation’s most vulnerable children and families has never been greater.

Grief took over me like a tsunami. The reaction to losing someone I loved shut down key neuronal connections in my brain literally from one moment to the next. A thick fog settled in and I found myself lost, suspended in the air, unable to feel my own feet on the ground. Nothing prepared me for the stage of grief I like to call the “unable to think” stage. The mere act of making a simple decision became a monumental task for me. The loss of important executive functioning skills required for everyday living took me by complete surprise. While processing my grief, I was able to come back to my baseline of functioning, even though the loss of my mother is felt daily. As physicians, we sometimes experience our own grief alone and we push away this pain. Addressing our own grief as healers and recognizing it as a shared human experience will only serve to help ourselves in the long-run and the work we do daily for others.

I have been paying more attention to grief in my clinic. Children grieve differently than adults. The children I serve have common neurodevelopmental conditions like ADHD, Autism, Intellectual Disability, among others. Grief looks different depending on a child’s developmental stage, their language skills, cognitive abilities, and social emotional profiles. I see a continuous flow of unprocessed grief that comes through my clinic doors among these children. I see the impact of loss on newborns’ and toddlers’ developing brains. I see a five-year-old who may be acting out in response to grief because he may not have the words to express himself. I see an eleven-year-old tween who has a ball of fire deep inside that can’t be released because each day of middle school requires a level of survival that only thickens the walls surrounding her pain. I see teenagers whose social media posts paint a picture incongruent with the reality of their daily lives (a universal habit for many of us) and the noise of their devices that deafens their ears to the world of loss around them. Prior to the pandemic, there was already a crisis of service delivery for my patients. Burnout among caregivers, difficulties using telehealth in this patient population, educational gaps with school closures, and the devastating impact of isolation and delays in therapies altogether have worsened the crisis further.

Many of the families I meet in my clinic daily also experience complicated grief, with one loss after another loss. The compounding effect of this trauma rarely allows them to return back to their psychological baseline thus leading to worsening overall mental health and physical health. These families are surviving one day at a time and their unprocessed grief is the heavy anchor holding them down. It is impacting learning in school, job performance at work, relationships with peers or intimate partners. Dr Bruce Perry, an expert on trauma and its effects on the brain describes the effects of toxic stress as the overactivation of the stress response cycle producing a continuous flow of cortisol in the body leading to further emotional dysregulation and negative impacts on children’s overall development and health.

We are headed towards a nation of chronic grief unless we take action. Unless grief is recognized and supported through immediate access to services, the mental health impact on this generation of children and families will have enduring long-term effects. Addressing grief and loss will require a compassionate approach, seen through a trauma-informed, culturally-responsive, inclusive and developmentally appropriate lens, supported by evidence-based research. Given the toll it has taken among our most marginalized communities, we will need to increase our mental health and grief literacy by training a workforce of providers across many sectors. Healthcare providers should also receive their own support to off-set burnout that is so pervasive in our field from as early as our medical training years. The structural changes needed will be significant.

Addressing the burden of loss should be a right not a privilege. Recognizing that this collective suffering is a shared human experience has brought me closer to my patients and my colleagues and as a result, has helped me in processing my own grief. It is in our best interest as a county, state and country to view this as a national emergency and one our greatest public health opportunities in order to strengthen self-awareness, build resilience, and ignite growth and empowerment among our next generation.

Dr. Roxanne Almas with her late mother, Danièle Aga