At two in the morning, grief looked like psychosis.
I remember being irritated before I even saw her. At the time, I was working back home in Malaysia. The emergency department fluorescent lights were too bright, my head heavy with interrupted sleep, the air-conditioning turned low enough that the corridors felt vaguely refrigerated. Someone from the emergency department had telephoned psychiatry on call (me) requesting an urgent review of an elderly woman who, according to the referral, was “seeing and speaking to her dead husband.”
Her daughter sat rigidly beside her when I arrived, exhausted and increasingly frustrated. She spoke quickly, the way relatives often do when fear has already hardened into embarrassment.
“She keeps talking to him,” she told me. “She says he sits beside her at night. She says he answers her back. She’s becoming agitated. She isn’t sleeping properly. Something is wrong with her mentally.”
Real physician voices, twice a week
Free, and one click to unsubscribe.
At the time, I remember instinctively slipping into the tidy architecture medicine teaches us. Hallucinations. Bereavement-related psychosis. Risk assessment. Organic causes. Differential diagnoses. The clinical machinery of psychiatry quietly arranging itself in my mind before I had even fully looked at the woman herself.
I remember wondering almost immediately: admit or discharge? Which would be faster? But the woman barely looked disturbed. Mostly, she looked tired. She sat quietly throughout most of the assessment, occasionally glancing toward the empty chair beside her. Not frightened. Not guarded. Simply attentive, as though listening for something faint and distant the rest of us could no longer hear.
Then suddenly she started crying. She kept sobbing softly, insisting she was alright, and that her husband was too.
I do not remember much else from that night with perfect clarity. Years in psychiatry sometimes blur together into ward doors, fluorescent lighting, and fragments of conversations carried home accidentally in your body. But I remember the daughter crying quietly near the end of the assessment. And I remember suddenly feeling ashamed of my irritation.
Because at two in the morning, dragged unwillingly from sleep, I had arrived looking for illness. Instead, I found grief.
Medicine likes grief when it behaves predictably. We are comfortable with mourning when it remains brief, articulate, and linear, fitted neatly into the textbook phases of denial, anger, bargaining, depression, and acceptance that I memorized for my exams.
But prolonged grief unsettles people. It begins to resemble pathology. Family members grow frightened. Clinicians grow cautious. The dead, society quietly insists, should eventually stay dead.
But psychiatry is where you learn that the human mind rarely obeys such clean instructions. Years later, I think often about the disguises grief wears inside psychiatric practice. A man with learning disabilities repeatedly checking locked exits after his mother dies because he insists he needs to “go home.” A patient carrying his mother’s picture in his wallet, admitting quietly that he hasn’t felt safe since the day she passed. Another who becomes aggressive every April because Aprils once belonged to someone she lost.
Sometimes grief becomes anger. Sometimes ritual. Sometimes silence. Sometimes it becomes a continued conversation with the dead.
Later, while working in an old-age psychiatry memory clinic back in Malaysia, I encountered another form of grief repeatedly. Families often arrived already mourning people who were still physically alive. I watched husbands answer questions on behalf of wives who no longer recognized familiar roads home. I watched adult children quietly absorb the shock of dementia diagnoses in parents who, in their minds, were still far too young. And I watched elderly patients who had otherwise lived full and remarkable lives slowly lose their grip on names, routines, language, and eventually themselves.
The emotional toll of working there surprised me. Dementia reminded me that grief does not always begin with death. Sometimes it begins gradually, in fragments, while the person you love is still sitting across from you.
Years before I became that on-call psychiatrist, when my own father died, this type of anticipatory grief had already quietly taken root across his five-year illness. Yet when death finally came, it still arrived with a finality the mind could not fully prepare for.
As a medical student, I returned to classes within a week. I forced myself to prepare for a presentation because movement felt easier than stillness. Medicine rewards functionality. We praise the doctor who returns to work quickly, the student who continues presenting, the bereaved person who remains productive.
Partway through, after learning what had happened, my lecturer gently took over the presentation himself. I remember feeling embarrassed more than grateful. I thought I was functional. Prepared. Though I remember fumbling through the slides, mind in a fog yet adamant to continue.
Now, working in psychiatry, I sometimes wonder whether functionality and healing are as synonymous as we pretend. I wonder whether I believed grief had been properly processed simply because I could continue moving through it.
Last year, after my cat Bagheera died, I found myself revisiting a more familiar form of grief: guilt. I had left him behind when I migrated to the United Kingdom. Rationally, I understood the reasons. Emotionally, grief rarely responds to rationality. The mind bargains endlessly with chronology after loss. If only I had stayed. If only I had delayed leaving. If only love alone could reverse time.
Even understanding grief professionally did not spare me from it. Some people seemed surprised by the depth of my grief over an animal. But attachment does not become less real simply because the one lost walked on four legs instead of two.
Perhaps trying to quiet the guilt, I completed a grueling 13,000-mile round-trip to Kuala Lumpur over a single weekend, spending 26 hours in the air just to attend his funeral before returning straight to work on Monday morning. At Heathrow, the border control officer lifted an eyebrow when she asked where I had been for just one day, handing back my passport without a word when I told her I had gone to attend my cat’s funeral.
Hours later, I was sitting in my consultation room, listening intently to the profound struggles of my patients while breaking apart inside. I do not know if I thought the trip would make me feel better. But I knew I had to show up, even after death.
Psychiatry eventually teaches you that unresolved grief is rarely about weakness. More often, it is attachment persisting beyond physical absence. Human beings are not built to sever emotional bonds cleanly simply because biology or time demands it.
I think now of that elderly woman differently. At the time, I assessed her for psychosis. Today, I wonder whether I was witnessing something both simpler and far more ancient: a human mind refusing, even temporarily, to accept that a person loved dearly could vanish completely from the world overnight.
Grief is not limited to death alone; we routinely grieve people who remain alive yet become entirely unreachable to us. It is not always an inability to let go. Sometimes, it is simply love, however complicated, with nowhere left to go.
Loshi Rajen is a psychiatrist in the United Kingdom.
