key: cord-1007459-338infoc
authors: Nair, Vasundharaa S.; Banerjee, Debanjan
title: The Heterogeneity of Grief in India during Coronavirus disease 2019 (COVID-19) and the National Lockdown
date: 2020-06-30
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102249
sha: 70d2ce4a2d46382161af8e0d37c293573da98c51
doc_id: 1007459
cord_uid: 338infoc

nan

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 three months accounting for nearly 7.5 million cases with more than four 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, as on 16 June 2020). In India, as of date the Ministry of Health and Family Welfare (MoHFw) stated more than three lakh positive cases with around 10,000 mortalities (Ministry of Health and Family Welfare, as on 16 June 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. 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 & 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', J o u r n a l P r e -p r o o f varied connotations of grief might arise as the 'meaning' and 'significance' of the loss can be widely individualistic. As the nation undergoes the biggest 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.

The theorizing of grief would be different across different populations:

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) 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.

iii) Elderly (geriatric population), especially when living alone or terminally ill, already being frail and vulnerable, are undergoing anticipatory grief as stated by Aldrich 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 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 socioeconomic 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.

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. 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 J o u r n a l P r e -p r o o f 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.

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