Dear Editor,
We were encouraged to draft this article after going through a reflective editorial of the same journal, that mentioned the varied crisis this pandemic has brought upon all of us (Tandon, 2020). The Editor recollects his fear of infecting others and consequently quarantining himself for two weeks, critically balancing the uncertainty and decision of returning to work. The article also highlights the important intersection of the outbreak and mental health and calls upon global support in response to the viral challenge. Setting this in background, we plan to initiate this commentary on an unspoken aspect of mental wellbeing, which the pandemic has forced us to think upon.
Early in December 2019, individuals from the Wuhan city of the Hunan Province in China were identified to have symptoms of pneumonia from an unidentified origin. This Coronavirus disease (COVID-19) spread like a forest fire across countries in six months accounting for nearly 10 million cases with more than five lakh deaths with a continuum of 96 percent in the mild condition and the rest 4 percent in serious or critical phase of the illness (World Health Organization Situation Report 163, as on 1st July 2020). In India, as of date the Ministry of Health and Family Welfare (MoHFw) stated more than six lakh positive cases with around 17,000 mortalities (Ministry of Health and Family Welfare, as on 1st July 2020). The numbers are rising as we speak and the outbreak has shaken the modern world in all its dimensions. Borders are closed internationally, economies slashed, millions jobless and billions confined to the isolation of their houses, in an attempt to contain the pandemic.
As the conditions seem to worsen across countries, in response to the World Health Organization (WHO)’s declaration of COVID-19 as a public health emergency of international concern (PHEIC) and to forbid the further community transmission the Government of India has taken the decision of a National Lockdown wherein the movement of individuals across various parts of the country was completely brought to a stop. The important point to be noted is that with every decision made by the government for the betterment if individuals, comes the aspect of psychological and psychosocial difficulties wherein individuals feel difficulty in managing their emotions and quality of life within self and with respect to others. This is a historical 21-days lockdown for a country like India, which was necessary but unprecedented and sudden. Subsequently, it got extended to prevent the surge of cases but at the same time took a heavy toll on the socio-economic structure of the country. Though often termed as the 'great equalizer', the effects have hardly been the same for all. The impoverished sections of the society, especially the homeless, migrants, lower social strata and daily-wage workers have taken the financial and psychological brunt disproportionately. Unemployement has been massive, and panic about safety has been rampant in many slums and rural areas where social distancing, is but a luxury. Resource and psychological preparedness have been studied as important factors for the readiness of biological disasters like pandemics. Especially in low and middle income countries, lack of preparedness can be detrimental to public health.
The initial studies from China reported several cases of severe anxiety, traumatic stress, confusion, anger, despair, boredom and stigma (Shojaei and Masoumi, 2020). One among the major psychological factors is that of grief and bereavement. Grief is a term that was originally defined by Freud focusing on the breaking of ties with the individuals who have passed away, accepting the changes and readjusting to the new circumstances of life and also structuring patterns to build new relationships (Hamilton, 2016). Traditionally associated with ‘loss’, varied connotations of grief might arise as the ‘meaning’ and ‘significance’ of the loss can be widely individualistic. It can classically range from the loss of a loved one to the perceived loss of autonomy and dignity, especially in the marginalized populations. Socio-cultural contexts also shape the 'idioms of distress' in grief and hence the manifestations can be culture-bound and polymorphic. Especially during such a large-scale pandemic like COVID-19, the disruption of 'usual living structure' and social distancing lead to loss of two most important facets of life: freedom and relationships. As the nation underwent the longest lockdown in history, the manifestations of grief in various sections of the population are unique in their context and the expression. This becomes all the more important in a socio-economically diverse country like India with innumerable divisions based on class, caste and ethnicity. Failure to understand this context might eventually lead to under-detection of the problem, thus increasing psychological morbidity and impairing the quality of life.
The theorizing of grief would be different across different populations, namely:
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i)
A person who has limited resources may undergo Grief through a “Stage theory” as proposed by Kübler-Ross wherein a person comes to know of the condition and then passes through the stages from denial to acceptance (Kübler-Ross and Kessler, 2005)
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ii)
A person with adequate resources not being directly affected but living through the lockdown may undergo grief as stated by Stroebe and Schut (2010) as ‘dual process model’ where the person finds it difficult to understand the days and the emotions faced. The person is ‘lonely’ and gradually moves to restoration phase when he/she is trying to solve the problems through structuring.
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iii)
Elderly (geriatric population), especially when living alone or terminally ill, already being frail and vulnerable, are undergoing anticipatory grief as stated by Aldrich (1974)
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iv)
While the other populations with the special needs (like those with physical or psychological disabilities) are undergoing grief as proposed by Niemeyer and Sands (2017) from being in a continuum of difficulty to have one standard emotion at a point, as the disability interferes with the classical processing of the grief.
The National Task Force was started in India on March 29, 2020 by the Ministry of Health and Family Welfare (2020) for the provision of psychological helpline services to the distressed individuals. This was based on the initial model in China, where online counselling services were initiated at Xiangya Hospital coordinated by the Institute of Mental Health, that reported marked improvement in the quality of life and perceived satisfaction among the health-care staff and general public (Chen et al., 2020). Under this Task Force, 40–50 percent of the calls received through the helpline have been from the migrant populations, people who are locked inside their homes staying alone, people who are anticipating concerns and having difficulty, while others might have lost someone but could not organize a religiously congruent funeral due to the limitations of lockdown and travel. The remaining calls have mostly been related to general enquiries about precautions and viral testing as well as from patients already having mental disorders. Mostly, the distress calls are associated with anxiety, low mood, lack of sleep and appetite, nightmares, fear and apprehension, paranoia and absenteeism from work. The underlying grief is only revealed after establishment of rapport, understanding the context and exploring the sequence of events in the client’s life. Often over telephonic counselling, it takes multiple sessions, given the usual limitations of a digital consultation. It is also vital to understand that in this diverse sub-continent, the access and ease of technology is available to only a limited sector of population. Rural areas devoid of internet connectivity and lack of practice, can further impair the process of tele-therapy or tele-counselling. Grief is considered to be an internalized emotion (Kubler-Ross and Kessler, 2005) and hence social touch (face-to-face) conversation often helps in eliciting this, which has been hampered during the COVID-19 situation.
It needs to be understood that though grief is a complex process, it is still a natural phenomenon. In the current condition where individuals cry over phones in the wish to go home, grief has become inwards and recalibrating. One tends to feel sad and undergoes grief as a universal concept, but it depends solely on the person and the condition one is in. A migrant labourer or a person undergoing violence in different formats may not have access to any resource and hence maybe undergoing grief as a result of helplessness and trauma which can also be termed as a complicated grief. Grief is also felt when a person is not able to attend the funeral of an individual who really means a lot to them. A daily wage labourer with the lack of availability of the resources finds it difficult to provide for all members in the house hence stays hungry and eventually grieves as there is no job to provide for the basic needs. Individuals in middle socio-economic status tend to incur multiple loans but are scared of the expected recession due to the financial concerns which will cost their jobs or salary while the higher social classes might find the ‘new change of structure’ difficult with the constant confinement to home and the family in the absence of travel. Work from home, though apparently attractive, has caused to be a reason for stress irrespective of the social divisions. Crux being, across the socio-economic classes the ‘loss’ of various factors or needs is homogenous while the perspectives and priorities are quite heterogenous. This ironically blurs the social divisions at times of such disasters.
As mentioned before, many lives have already succumbed to the pandemic and many have lost their family members and friends. In the midst of all this, the individuals who have lost their loved ones suffer from chronic grief as they are not able to be present for their funerals which would include individuals who might be close to the members but are not living with them, that further worsens the emotional isolation. There have been numerous instances of this in the current scenario, where people have lost their loved ones to the infection in another country, unable to pay their last respects. Re-living the grief through adequate social rituals for the deceased person ensures a 'psychological closure' and hence helps in the grieving process. Though, virtual funerals have been attempted in various parts of the world, it might not be suddenly adapted by the communities with ingrained practice of sharing the 'sorrow of loss' in person with families and relatives. Ironically though, the pandemic has made humankind realize the importance of social touch: a pat on back, a hug, a handshake, etc. as a sign of consolation which helps the person in their coping process after a loss. Implications are different for people who have their relatives living in different locations across borders and could not be present for any family ritual. One might feel that one is ‘over the edge’, anxious, continues to be hypervigilant or socially withdrawan or develops avoidant behaviours and exhaustion but feels confused and helpless about the same. Resilience, positivism and adequate biological need-fulfilment determines the coping of individuals in these difficult scenarios but balance remains the key (Weir, 2020). Hence it is important to focus on what would be the possible methods to handle this grief, wherein it is understood that at times giving a label or context to the grief helps to validate or affirm one’s feelings, maintaining social support system through virtual human connections, prioritizing relaxation and exercises by maintaining a structured scheduling and if situations get difficult to manage, one could express ones feelings better by seeking help from a professional. In countries with limited resources, even brief sessions of supportive or solution focused therapy delivered telephonically or online can help. The lay-counsellors and grass-root health workers can be trained through the tele-medicine facilities to identify such symptoms, their relevance and deliver simple forms of counselling or necessities for referrals to the higher centres. Suicidality a major risk for complicated grief can often go undetected, especially in the elderly and needs prompt attention and interventions. Isolation and loneliness are the two major factors amplifying it and hence social integration and connectedness are the keys to fight a ‘loss’, irrespective of the heterogenous context, at such times of crisis. This brief commentary thus attempts to sensitize the readers about the social and contextual implications of grief during the COVID-19 crisis and consequent lockdown in India, which might help in understanding and exploring the psychological underpinnings of 'loss' for each person. Tailored interventions (especially psychotherapy) need to include these personalized factors. These are still the earlier months of the pandemic. Systematic research into the manifestations of grief and associated comorbidities in the post-pandemic aftermath might help shape management and preparedness for such futuristic crises.
Funding
Nil.
Declaration of Competing Interest
Nil.
Acknowledgement
Nil.
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