Boredom - Friend or Foe

     GRIEF AND MOURNING “ OVERLOOKED” ,,, a perspective for healthcare professionals

As any other Indian, I joined in the ritual of lightning Diya, banging steel plates and attending almost all the broadcasts in which our Prime Minister addressed the nation. I did everything with the thought of showing and even feeling myself as a responsible citizen expressing gratitude and respect to frontline warriors in the times of Covid,  but it did not help. Every day I come across the articles which mentioned the struggles faced by the frontline workers during the COVID-19. The list of struggles is too long to be mentioned here but the most ignored area was “Grief”, as experienced and managed by healthcare professionals

Grief…. a spectrum: Grief is a universal and fundamental emotion experienced by people witnessing loss in their life. Often bereavement, grief, and mourning are used interchangeably. However, while bereavement is the fact of loss, grief is the emotional, cognitive and physical response towards the loss and mourning and often involves rituals to express that loss. Reaction of grief is determined by age, gender, culture, personality, the availability of support and resources, health, spiritual and social identity and the amount of energy invested in the relationship with the lost person. 

Grief is a process in which the person moves back and forth in the intensity of expressing the response towards the loss incurred. Reactions to loss are dynamic in nature and are determined by the context of the person or community.

Stages of grief: These were proposed to help a person, experiencing grief, to frame and identify what they may be feeling. Stages of grief were proposed by a Swiss-American psychiatrist, Elizabeth Kubler-Ross. It suggests that when a person experiences grief, it goes through five stages. Though the stages are universal, across the cultures and the diversity of population, it is possible that the person may or may not move in a sequential manner across the stages or may move back and forth across the stages. The sequence and the movement could be unique depending on the context and the determinants mentioned above. 

The stages of grief are: 

1. Denial:   Denial is to refuse to accept the reality as the reality is too overwhelming to handle. It is an attempt to process the loss. A person in this stage is overwhelmed by many emotions, which are difficult to process and hence accept. The emotions are not only about the loss of the person but the loss of the relationship and the identity associated with that. 

2. Anger:One aspect is that it is used as a defense to shield a person’s vulnerability towards the fear induced by the loss, the other aspect is that it is expressed due to the loss of control over the situation. It temporarily helps in concealing the pain experienced due to the loss. 

3. Bargaining: the person in this stage tries to minimize the pain by trying to make a deal with a higher authority or a greater power. It is tried to gain some control over the events which appear to be out of control. In this the person also focuses on what else could have been done or could be done to prevent the unaccepted loss. 

4. Depression: a person enters the stage when the situation appears hopeless and the person realizes that nothing can be done to reverse the loss.While it is normal to experience depression during grief, one may benefit by seeking  professional help if the  depressive stage continues for too long. 

5. Acceptance: arriving at this stage does not mean vanishing the pain experienced. It means that now the struggle to change the situation and the resistance towards reality has come to an end.

6. ( Freud described Identification i.e. where some characteristics of the “lost person” are internalized and integrated into the grieving person..this is the last stage of grief. Loss may also lead to altruism as it gives meaning and purpose to live as well as it helps in emotional coping if help is provided to someone in a similar situation or need. 

The nature of loss experienced by healthcare professionals:Even though death is an objective event, it may or may not be perceived as loss. The nature of loss perceived by the healthcare professional is salient because of professional boundaries. Therefore, we need to identify the quantum of energy invested by a healthcare worker or the  extent of attachment to the “person” lost, be it in the patient and his/her family, professional colleagues or the self. This could be an investment in their aspirations, dreams, professional identity and role.  Given the complexity of life each of the above may co-exist  to various degrees.  Each death may be experienced as a loss on one or more of these levels and different caregivers may grieve for a different loss, with a proportionate intensity. These losses may be grouped into six major categories (Papadatou, 2000):

1. Loss of a close relationship with a particular patient with whom one has shared a part of a significant journey which in the case of the COVID is one of fear, confusion and profound sense of helplessness. 

2. Loss due to the identification with the pain of a family member. There is a possibility that the death of the patient may not invoke the grief but identification with the family of the patient may invoke a great deal of hurt and pain for the healthcare professionals.  For example death of a parent, child or spouse may invoke the similar grief, a kind of sympathetic grief. 

3. Loss of one’s unmet goals, expectations, self-image and identity. It results in questioning one’s own self-efficacy and the ability to cure and solve the riddle of the disease or the kind of distress experienced. Self doubt may add to the complexity of grief reaction.

4. Losses related to one’s personal system of beliefs and assumptions about life. This is specifically experienced by professionals who strongly perceive life as being orderly, in control and predictable. Disconfirmation of their belief results in the feelings of meaninglessness, hopelessness and other poignant grief reactions and may lead to existential despair.

5. Past unresolved losses or anticipated future losses. Unfinished grief of death and loss in the past experience of the health care worker may re-emerge or be triggered by the death of a patient and person may feel the similar loss in terms of experiencing flashbacks, memories of the lost person and feelings or sorrow etc while witnessing multiple deaths among patients in a brief period of time or by listening to the survival concerns of clients. 

6. The mortality of “Self”. The dying process and death of a patient will confront healthcare professionals – at a conscious or a less conscious level – with his or her own mortality. And this may lead to the feeling of fear, confusion or loss of meaning in life. 

In addition to the above, during the pandemic, the healthcare providers are experiencing doubts  of safety, of oneself and one’s family, in terms of structural lapses, losing trust of patients and their families as the situation seems to be  spinning out of control. loss of peace, lack of time to process personal reactions, cognitive or emotional  and a lack of space to acknowledge their feelings besides the uncertainty.

Significance of expressing and processing Grief:  acknowledgement, expression and processing of grief is important. Usually, apart from the loss due to death, other losses are not recognised by the society. The same goes within the healthcare system. The healthcare professionals are not allowed to express grief experienced due to the loss of their patients. It may be considered as a sign of weakness and may lead to serious implications on their job. These indicate towards the experience of disenfranchised grief. Disenfranchised grief may lead to the experience of fatigue, exhaustion, anger, sleeplessness, irritability, helplessness and self-doubt.

Intervention: Every healthcare professional has a unique perception of the loss experienced by the death of their patient and so will be her/his style of coping. No generalised technique or mechanism can be prescribed to handle the challenge. For some it could be talking to the colleague, for some it could be taking a good rest. There may be a number of prescriptions available like journaling, taking mini exercises or walking, meditation, breathing exercise etc. available on social media but the important part is to discover what suits you the best. Instead of impetuously following whatever is coming in your way, it is important to take a pause, reflect and practice.

As far as support from others is considered, banging plates and lightening deepak are not the only ways to express respect. It is important to acknowledge and respect the sufferings and hardships of healthcare professionals by acknowledging and understanding their feelings of loss.

Predictably the Covid epidemic is here to stay for a long time, with consequences of increased demand on health care workers. As per recent works and news, the virus is mutating and is coming back with new strains which may lead to uncertainty in terms of the rate of contagion and available means to meet the challenges of surge in the COVID cases, consequently leading to increased emotional and physical demands on frontline workers. It is  therefore very important to notice, acknowledge and work towards the impact of the demands.

Saumya Nigam