What We Know About Grief 20 Years After 9/11—And How It's Helping Us Cope With Loss From COVID-19

The news came in a text message. That's how Sandra McGowan-Watts, a Chicago-area family physician, learned that Steven, her husband of 12 years, was about to be placed on a ventilator.

Their last conversation in the spring of 2020 was a brief exchange of I-love-you's. He died of COVID-19 a week after his own mother passed from the disease.

How do you begin to process that kind of loss?

McGowan-Watts says she didn't deal with her grief at first. Instead, she went through the motions of everyday life, busying herself with her medical practice and keeping life on an even keel for her 12-year-old daughter.

Working through her emotions was tough, and she struggled in those first few months after Steven's death. She also mourned not just his passing but all the "firsts" without him—all the holidays, birthdays, and anniversaries they would have shared. Only recently has the reality sunk in that he's not coming back.

McGowan-Watts eventually surprised herself by finding solace in a sort of sisterhood with two women she met through a Facebook support group. Their husbands also died of COVID-19 at the same Chicago-area hospital. Now the women talk or text daily and celebrate milestones together.

"Other people don't understand when you wake up in the middle of the night and your person isn't there," McGowan-Watts tells Health. But her "sisters" do. "We love each other and have made each other's journey a little easier."

No single story can capture what it's like to grieve as an individual or collectively as a nation. It's the patchwork of experiences that helps us understand the complex role of grief in our lives. Through the lens of the COVID-19 pandemic and the 9/11 terrorist attacks some 20 years earlier, researchers have gleaned new insights into how we mourn in America—and the consensus seems to be that it's messier than we ever thought.

More than 50 years after psychologist Elizabeth Kubler-Ross described the five stages of grief (beginning with denial and ending with acceptance), many experts now agree that grief isn't ladled out in predictable portions. It hits us in different ways at different times, affecting our thoughts, emotions, and physical health.

Here's what experts have learned about the complexities of grief through the eyes of people who have navigated loss, plus advice for coping with the losses in your life.

Acute grief comes first, and it's the most painful kind

Grief is "the normal process of reacting to a loss," per the National Library of Medicine. It's not a state of being or a singular event; it's a journey.

"Loss" can mean many different things, Lucy Hone, PhD, author of Resilient Grieving: Finding Strength and Embracing Life After a Loss That Changes Everything, tells Health. "We fall in love with people, pets, projects, and possessions," she says. Each severed attachment can cause us to feel powerless. Yet humans have a remarkable capacity to endure loss, however painful it may be, she adds.

Different types of grief tend to strike at different times during bereavement. Immediately after a death or loss of a relationship, for example, you enter a phase of acute grief, yearning for the person no longer in your life while grappling with the emotions that accompany it, from anger and guilt to disbelief. Over time, you begin to accept the loss and adapt. Sharp pangs of sadness stretch farther apart.

On the morning of September 11, 2001, Miosotys Santiago was running late to her job as an administrative assistant in Tower One of the World Trade Center. Her fiancé, Andrew Bailey, a security supervisor, was already on the 93rd floor. It wasn't his normal shift, but he arrived early that day so a co-worker who was expecting a baby could attend their partner's ultrasound appointment.

As Santiago emerged from the subway below, a deafening noise rang from above. A Port Authority police officer grabbed her as she headed into the building anyway. "My fiance's up there! I need to find him," she protested.

She waited all night for him—and wept. Hundreds of attempts to reach him on his cell went unanswered. Andrew never came home.

Her deep grief eventually receded. Now a motivational speaker and the author of a memoir, God's Diamond, Santiago tells Health, "I've dedicated my life to turning my pain into my purpose." Yet every September 11, amid TV flashbacks of burning-tower images, "it's like I'm reliving it all over again," she says. The reel in her head rewinds and she recalls seeing Tower One ablaze and ruminating about Andrew's fate.

Where was he? Was he looking for me? Did he jump?

Triggering events can plunge you back into grief

Even when the acute stage of grief seems to pass and emotions around loss become less intense, deep feelings of bereavement can come roaring back again after a triggering event, as Santiago says she experiences when 9/11 comes around again every year. Experts call this an "anniversary reaction," a callback to the same intense emotions first felt after losing a loved one. It isn't always tied to a date but can be triggered by sights, sounds, or smells. For some frontline health care workers who've struggled to save the lives of people with COVID, even a poster that thanks them can evoke strong feelings.

September 11 isn't an easy day for Ashley Bisman. Twenty years ago, she was sitting in a high school English class when students began whispering that a plane had flown into the Twin Towers. Forty-eight hours later, it was clear that her father, who worked for Cantor Fitzgerald on the 101st floor of the North Tower, wouldn't be coming home. Media attention and the nation's collective grief didn't make it easy for a 16-year-old who craved a normal life. "I wanted to suppress my feelings and move on," she tells Health. But 9/11 was everywhere, and people would either pepper her with questions or share where they had been and all the emotions they felt.

Even today, "everyone has an opinion," says Bisman, author of the memoir, Chasing Butterflies: The True Story of a Daughter of 9/11. "If I'm happy or enjoying myself, people think I don't care or I'm not thinking of my dad. If I'm sad, people say, 'But it's been 20 years!" Her message: "It's okay to cry sometimes…but it's also important to keep going and power through."

Some people get stuck in their sorrow. It's estimated that 15% of people continue to be immobilized six months after a loss. Often misdiagnosed as depression, it's called prolonged grief disorder (PGD). Women are more likely to have PGD than men, and the risk is also higher if your loved one died unexpectedly or violently.

People often describe grief as feeling "broken-hearted," and it turns out grief really does have a cardio effect. Hormones and neurochemicals released as part of the stress response after loss cause heart rate and blood pressure to rise. The stress of losing a partner can even lead to a condition called "broken-heart syndrome." This is when part of your heart temporarily enlarges and doesn't pump well, while the rest of your heart functions normally or with even more forceful contractions, according to the American Heart Association. (The symptoms of broken-heart syndrome mimic a heart attack, but it's usually treatable.)

Grief leaves its mark on the brain as well. Right after a loss, the regions of the brain that process intense emotions and memories slow down. This might be why many grieving people say they feel unfocused, foggy, almost zombie-like, especially early on.

For most of us, such physical changes tend to subside as time goes on and the intensity of our grief recedes, becoming "integrated grief," Katherine Shear, MD, founder and director of the Center for Complicated Grief at Columbia University in New York City, tells Health.

"We don't want to think of grief as staying intense for the rest of our lives. It doesn't usually," Dr. Shear explains. "It quiets, softens, and moves into the background." It's what grief and loss coach Hope Edelman refers to as "AfterGrief." She coined the term to describe the period of time that "starts when the most intense reactions to a loss start to diminish." It "extends pretty much for the rest of our lives," Edelman, author of The AfterGrief: Finding Your Way Along the Long Arc of Loss, previously told Health.

"Ambiguous" loss is just as hard to process

Although we equate grief with death, it can be caused by any loss that shakes up your life in a major way, from a divorce to a layoff to a chronic illness that robs you of a body part or function, to your kids going off to college. Even if you didn't know anyone who has died of COVID, you can legitimately grieve for your pre-pandemic way of life. Work changed for many people; the ease with which we traveled or socialized largely evaporated as well.

There's actually a term for this kind of grief: ambiguous loss, or a loss without the finality of death or true closure, which can make it even harder to start the grieving process. It's the kind of loss society experienced during the pandemic, Pauline Boss, PhD, author of Ambiguous Loss: Learning to Live with Unresolved Grief and professor emeritus in the department of family social sciences at the University of Minnesota, tells Health.

"We lost trust in the world, we lost the ability to physically be with friends, and we lost our routines," says Boss. "None of these are actual deaths, but they're serious losses of control over our own lives. That uncertainty can cause great distress."

Ambiguous loss hit Anna Lange of Kansas City, Missouri, when she became a new mom on the cusp of the pandemic. By the time she felt comfortable enough to take her son on outings, COVID hit. "Being home with a toddler isn't how I imagined motherhood, and it has me missing how life used to be," she tells Health. "I miss being able to go places without making a reservation, going into stores without a mask, people not arguing online about vaccines or other COVID protocols."

As a result, Lange's anxiety has escalated. "I feel guilty for relaxing or enjoying things because there are so many [people] suffering," she says. "I feel guilty for being healthy when I know someone my age who is now on permanent oxygen due to COVID complications. Our city just reinstated their mask mandate, and I know that's safest, but I'm also so frustrated because I just want my pre-pandemic life back."

There's resiliency after grief

It's been more than eight months since Valerie Villegas, a hospice nurse, lost his husband Robert to COVID, and she's still grieving. Losing her husband, an ex-MMA fighter in excellent health, was a shock. Now as a single parent, the Portland, Texas, mom is responsible for making house payments, scrambling for daycare, and keeping her family together. She isn't just mourning her husband but the less complicated life she had before the pandemic. In that sense, her grief is "harder to deal with now," she tells Health.

So what's the path forward?

"Even in our darkest of days, we can make small, tiny choices that help us get through," says Hone. "They won't take away the pain of the loss, but they will help you steadily re-learn to live in the world."

Support is crucial, but if you don't have close friends or family to lean on, look online. From Black Women Widows Empowered to Tuesday's Children, which helps families affected by terrorism, military conflict, or mass violence, you'll likely find a group that fits. "If not," says Boss, "think about starting a group yourself—a peer group."

If you find it difficult to accept assistance, "recall a time when a friend was coping with bereavement or another form of life crisis, and think back to how much you wanted to help them," Hone suggests. Pay that help forward once you're feeling stronger.

"On days when you really are feeling like you cannot move from the couch or your bed, set yourself the smallest goal imaginable," suggests Hone. Maybe that means taking a walk, or perhaps it's just taking a shower.

"Some days you'll feel you're inching forward, others you'll feel like you're knocked down and heading backwards," Hone says. Actively working to show yourself some self-compassion can make navigating those tough days so much easier, she adds.

If you have a friend who is grieving, accept that you won't be able to take their pain away, as much as you'd like. "Just be there with them," advises Boss. "There's not much you need to say besides, 'I'm sorry.' But as time goes on, you can invite them out so they begin moving through the world again."

During a chaotic time, rituals can help us feel grounded. For instance, research from the Journal of Pain and Symptom Management in September 2021 shows that small gestures—like reading a poem or lighting a candle—help health care workers process their grief after a patient dies. If lighting candles isn't your thing, choose another expression of grief that feels right to you.

Binary thinking—that you must either be happy or sad, that unless you forget the person you lost, you can't be happy again—isn't helpful. "Your accountant can think in absolutes, but it certainly doesn't apply to grief," says Boss.

"Focus on finding a new purpose in life," says Boss. "You will forever remember someone you love, but the goal is to find meaning in your loss—and new hope."

Villegas is trying. Getting involved with online groups like COVID Survivors for Change has helped. She's also starting a nonprofit to help disadvantaged kids afford martial arts training. "Whenever something went wrong, Robert would always say, 'Keep pushing forward,' so, it's going to be the Keep Pushing Forward Foundation," she says. "Trying to help people gives Robert's life some purpose."

How to Be OK When You're Not OK Check out Health's special series on life after loss.