There is much about Alexis Washington’s story of pandemic bereavement — the family trauma, the lonely deaths, the truncated rituals, the months of restrictions that put even a new normal out of reach — that sounds sadly familiar now.

That is why some experts on grieving worry that the millions of Americans affected by COVID-19 deaths may need extra time and support to come to terms with harrowing, unexpected losses compounded by isolation.

“The grief experience and even the death experience was profoundly changed by the pandemic,” said Carmela McDowell, bereavement coordinator for the Jefferson Home Care Hospice Program.

“It has added layers of challenge, and I think that needs to be acknowledged.”

Washington’s family met for a small, indoor gathering on Mother’s Day 2020 — May 10. They thought everyone — Alexis; her father, Lanxton; her mother, Deborah; her twin brother, Langston; an aunt and a great aunt — had been careful. They still don’t know who brought the virus into the great aunt’s condo.

Lanxton Washington, the 72-year-old pastor of First AME Church Sharon Hill, was the first to have symptoms. A cancer survivor with diabetes and heart and lung problems, he was soon in the hospital. Then everyone in the group except young Langston tested positive. Alexis and Deborah Washington were sick, but not sick enough for the hospital. Only Langston could visit his father.

A ventilator was not enough to save Lanxton Washington. He died on May 25 as his daughter, son and wife watched on FaceTime. The great aunt, 92, died on May 27. The aunt had a pulmonary embolism on May 31, but survived. Over that awful year, Deborah Washington lost another aunt to kidney failure and, in December, her mother, who “just slept away” in a nursing home.

“I have never had a year when I’ve lost so many people,” Deborah Washington said.

Lanxton Washington’s funeral was graveside, with no repast afterward. Relatives from out of state couldn’t visit. Alexis Washington couldn’t see her best friend, who had moved to Seattle. Alexis and Deborah, who live together in Aldan in Delaware County, had each other, but there were many fewer hands to hold, many fewer hugs to accept, than normal.

Alexis, who is 28 and was very close to her father, had little previous experience with grief. A school counselor in Philadelphia, she was already stressed from helping children affected by virtual schooling and the city’s epidemic of violence. Her father died the day George Floyd was killed, setting off a wave of protest that affected her deeply.

Alexis felt anxious, nervous, confused. “I felt, well, sad, of course, but devastated,” she said. “It felt like my whole world sort of crumbled.”

» READ MORE: What you should know about normal and abnormal grief

Grief is always painful, and it’s a lasting pain that, at best, becomes part of the griever, less intense and capricious, but never gone. People grieve at their own pace and in their own way, but most are resilient and feel more stable within six months after the death, research shows. Experts said it is too early to know whether the pandemic will lead to a surge of prolonged, dysfunctional grief, but said restrictions have made it harder to do some of the things that typically help the bereaved, such as spending time with loved ones and returning to social and physical activities.

It is possible that the normal grieving process will take a little longer, some said, but there is also reason to worry that the traumatic nature of some COVID-19 deaths will make it harder for some family members to grieve in a healthy way. They could need help adjusting to their losses.

A pandemic of grief

So far, there’s sparse data on the long-term effects of the pandemic on grief. A study from the Netherlands last year found that deaths from COVID-19 caused higher levels of symptoms than those from other “natural” causes. ”We predict that pandemic-related increases in pathological grief will become a worldwide public health concern,” the authors wrote.

Sherman Lee, a psychologist at Christopher Newport University in Virginia, is one of the few to ask bereaved people in the United States about their experiences. Lee, who studies negative emotions, and Robert Neimeyer, director of the Portland Institute for Loss and Transition in Oregon, surveyed 871 people in the early stages of COVID-19-related grief — an average of three months after the death — about their feelings in November 2020.

Two-thirds were classified in the “clinical” range, which means they were experiencing such high levels of grief that they are not able to function normally and “could probably benefit from some form of professional support,” Lee said. Nearly three-quarters had symptoms of depression and anxiety while 64.5% were functionally impaired. Forty-three percent had already sought professional help. The survey, the authors wrote, “raises the specter of a second pandemic in the shadow of the first … characterized by widespread intense and problematic grief … .”

Lee, though, is reluctant to say that grief for COVID-19 victims has been worse than grief over other deaths, and it is hard to tell who among early grievers will still be preoccupied by thoughts of a loved one or unable to work and take care of themselves months later.

Still, he said, research consistently shows that losing a spouse is a top stress event, with the loss of a close family member or friend not far behind. “Losing a loved one … is just simply bad,” he said.

While ritual is not important for everyone, he said, what matters is that a lot of people felt especially bad because they could not be present for a loved one’s death, could not have a funeral, could not hug their relatives. “Those people that felt like they needed that suffered,” he said.

Others point out that the deaths occurred during a period of economic and social disruption, which adds to stress. Plus, news coverage of the pandemic meant constant reminders of death for the bereaved. “I think what made this particularly difficult was the global nature of this,” said Dina Goldstein Silverman, a psychologist at Cooper University Hospital. “It was everywhere.”

So far, though, she has not seen unusual manifestations of grief. “I’m seeing more of what I’ve always seen,” she said.

Complicated grief disorder

Kathy Shear, a Columbia University psychologist, was among the first to study what was initially called complicated grief. It is now transitioning to a new name: prolonged grief disorder. She directs the soon-to-be-renamed Center for Complicated Grief. Under normal circumstances, 7% to 10% of people developed prolonged grief. This means that, more than six months after the death, they’re still feeling intense grief and having trouble working or maintaining social relationships. They may be fixated on aspects of the death or loss. Some avoid doing anything that reminds them of their loved one.

Prolonged grief is twice or three times as common when people are grieving for someone who had a violent death, such as an accident, murder or suicide. Natural disasters also increase risk. Shear thinks COVID-19 deaths should probably be included in this higher-risk category.

Grief researchers and therapists often don’t see people who are struggling with prolonged grief until two to four years after the death. New patients have not yet flooded Shear’s center, but she thinks that’s because “we’re still pretty early in the grieving process.“

Shear said COVID-19 may cause more difficult grief because the deaths were often sudden and unexpected. There was a random quality to who got really sick and who sailed through. Family members, who often tested positive, too, may feel responsible. Some may become preoccupied with their inability to offer comfort in person as a loved one was dying. Certain psychological factors, such as previous experience of traumas, multiple deaths or a history of mood disorders, also raise risk.

It’s too early to know whether families will react differently to the current rash of deaths among the unvaccinated, deaths that could have been prevented.

Whom to be angry with?

Alexis and Deborah Washington both say they struggled with their grief, but are doing much better now.

Deborah Washington said 2020 was “very, very, very hard.” Her friends couldn’t visit and, at first, her cough was so bad she had to limit time on the phone. But she has kept in contact with her husband’s best friend and his wife and talks frequently with a friend who was widowed before her. By the time her mother died, she wondered how much more she could take, but she just dealt with issues as they arose. She thinks it helped that she quickly accepted that her husband was gone. “This is the way it’s going to be,” she said. There was no point in anger. “You don’t know who to be angry with,” she said.

She celebrated her son’s graduation from seminary in June, and her faith was a great comfort. She became missionary president at the church. She’s planning to visit family in Denmark in August.

Alexis Washington thinks she’s had a harder time than her mother and considers her grief prolonged. She had trouble finding the support she needed. “Being so young, my friends, they were there, but none of them had gone through what I had gone through.” Now, unfortunately, more of them have. She has also found others with similar experiences. After some time on a waiting list, she found a good therapist.

She still really misses her father some days, but the worst is behind her. “I’m definitely in acceptance and trying to find ways to honor him and give back,” she said.

She did a chaplaincy internship at Lankenau Medical Center and is considering a career change to some sort of spiritual care. She and her mother have both become advocates for vaccination in the Black community. Their church, which has not yet reopened, will be a vaccination site this fall.