Grief in the COVID-19 times: Are we looking at complicated grief in the future?

Grief is a universal phenomenon and a normal response to loss and bereavement.[2] It is temporally preceded by a loss ranging from personal to societal. Grief reactions range from being a normal phenomenon to diagnosable psychiatric conditions. This elucidates the importance of discussing this concept of grief, which is identified as an intense yearning for what is lost, as a pathognomonic feature, along with accompanying emotional, cognitive, physical, and behavioral manifestations.[2,3]

The seed of grief may sprout from the soil of the psyche, nurtured by bereavement or non-bereavement-related losses. The shade of grief may provide respite to cope with the harsh loss and leads to recuperation of the individual from the loss. The process of mourning is an important protective factor against pathological grief.[4]

Pandemics and Grief

It is imperative to acquaint oneself with the sequential pandemics that have molded our understanding of grief’s dynamic interactions with pandemics. The bubonic plague (13th century) was considered a consequence of “bad air and bad emotions,” which compounded the stigma in diagnosis and resulted in unwarranted ostracization even while grieving. The Spanish Flu (1918) did see some discussion on scientific understanding of the illness; nevertheless, prevalent socioreligious etiological models perpetuated fear about sexual routes of transmission and impaled the dignity in dying and the bereaving. In the more recent pandemics of Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), Ebola, Nipah, and Zika viruses, though the models of transmission have been elucidated, the social understandings of the shadow pandemic of grief is still far from being completely understood. Pandemics are associated with multiplicity of losses, which are different from losses occurring due to cancer or other illnesses. A review on the experiences of grief during previous pandemics, with lessons for the COVID-19 times, highlighted the possibility of risk of complicated grief.[5]

What Is Complicated Grief?

Periods of loss and grief can translate into positive consequences of readjustment and healing responses, resulting in resilience and post-traumatic growth.[6,7] However, in some individuals, grief reactions can differ from the normal resolution, either in intensity or duration. This is considered as complicated grief, which is described as “an intense and prolonged, impairing form of grief wherein an individual gets indefinitely stuck in the incapacity to process the loss and move on in life, with a persistent yearning.” A systematic review of risk factors for complicated grief identified factors present prior to death such as insecure and disorganized attachment styles, adverse childhood experiences, traumatic experiences in the past, and past history of psychiatric illness. Risk factors identified with death included bad or violent death, sudden unexpected death, lack of adequate caregiving, and a difficult dying experience.[4] Perceived social support, secure attachment, and self-disclosures are potential protective factors in developing complicated grief.

How Are COVID Times Potentially Contributing to Complicated Grief?

The spread of COVID-19 has been rapid, and at present, it has been detected in almost every country. Globally, there have been 62,363,527 confirmed cases of COVID-19, including 1456,687 deaths, as reported by the World Health Organization (WHO).[8] COVID-19-related deaths can strike anyone, the risk increasing dramatically with age.[3] There is delay in identifying cases due to asymptomatic carriers and subsyndromal symptomatology which may often overlap with similar viral infections. Patients with COVID-19 are often admitted in isolation wards in designated COVID-19 hospitals, with minimal face-to-face contact with family members, and may progress to complications within a few days. Death may ensue in an isolated setting. Most of the time, health care professionals may be by the side of the dying. They too often are wearing personal protective equipment, which may inadvertently mitigate their ability to reciprocate and/or gauge the patient’s emotions.

The deaths and consequent grief arising from the ongoing pandemic possibly shares features with grief related to natural disasters and after intensive care unit (ICU) treatment.[9] In situations of pandemics and natural disasters, along with the loss of loved ones, there is the closure of facilities, stopping of productive activities, reduction in services/supplies, strictly controlled visits, and quick descent to deterioration in health.[9]

The healthcare system is overwhelmed in the ongoing pandemic, and many may not find access to adequate health care, which may result in unnecessary suffering and prolonged turmoil. Even when admitted, the consequent intensive treatment and uncertainty of the duration of hospital stay may surpass the families’ paying capacity, further adding financial issues as a source of impedance in grieving. The mental health care system, despite best intentions, may not be able to cater to the psychological needs of the impoverished. The COVID-19 may not have precipitated healthcare deficits, rather may have highlighted the unpreparedness of the healthcare system in handling a pandemic.

Deaths occurring due to COVID-19 invariably have been labeled as “bad deaths” as they include physical and psychological suffering, with physical separation from family members, lack of preparation, being treated without respect, unwanted medical interventions or inability to access medical interventions due to financial restraints,[10] sudden progression, and unexpected demise.[2] The suddenness of these outcomes may result in the absences of wills and advance directives, and there could be multiple losses within the family, also called “bereavement overload.”[11]

Family members who are survivors could also experience bereavement guilt, described as “remorseful emotional reaction in grieving with the recognition of having failed to live up to one’s own standards and expectations in relationship to the deceased and or the death.” The grief may be exacerbated with the guilt of having survived the illness, unlike the deceased, resulting in “survivor guilt.”

The risk of infection may necessitate the disposal of the body without the family members being able to see the deceased’s face and body and not being able to perform cremation and final rites. Mourning and performing the final rites is a cultural defense[12] that is not done during the ongoing pandemic and results in lack of these ceremonies, like face-to-face mourning and consequent closure, potentially leading to guilt in survivors.[13] “Physical distancing” has invariably resulted in “social distancing”; the isolation and quarantine results in “touch starvation.” The travel restrictions and forced separations imposed by the government can compound the expression of grief. The possibility of both over- and underestimation of COVIDrelated deaths to avoid fear in public may leave one either being overwhelmed with impending loss or leave them blissfully unaware regarding the severity of the situation.

The multitude of deaths in a family may culminate in a lack of recognition of each member’s bereavement experience. Death of chronically ill, especially the older adults, may be overlooked or minimized by the society. Such pent-up emotions may not be adequately tended to in the absence of adequate resources and financial constraints following the pandemic. The above factors may result in “disenfranchised grief” and interfere in adequate coping.[11]

The interdynamics of various predisposing factors such as age, gender, past history of psychiatric illness, social support systems, loss of livelihood, and the financial burden of treatment that can be supportive and indefinite may culminate into the final outcome of complicated grief. A possibility of prolonged grief disorder in the wake of COVID-19 has been published.[14]

How to Mitigate the Development of Complicated Grief?

Identifying and discerning the various forms of loss and consequent grief may facilitate the requisite prevention and treatment strategies. The loss of a close one is in itself considered a primary loss and the consequences of this primary loss such as loss of companionship, sexual intimacy, and changes in family roles are conceptualized as “secondary.” The mentioned problems, compounded by multiple losses in a single family and the often-prevalent ambiguity around such losses, make closures hard. This could bolster frustration, helplessness, and disempowerment,[15] especially in vulnerable and marginalized communities such as daily wage earners and migrant populations. Furthermore, the loss of jobs and lack of financial resources during the pandemic might add burden to the ongoing grief. The progression of grief into complicated grief is a possibility that can be prevented and mitigated.

Communication

Communication between patients, family members, and health care workers is the key. About COVID-19, one especially needs to communicate the need for isolation and its resulting separation from family; a rough estimate of the number of days helps in psychological preparedness for the individual and family alike. The family needs to be told about the restrictions regarding visits and face-to-face interactions lest they be left distraught and misinformed. The possibility of unexpected deaths, asymptomatic carriers, and risk of transmission of infection needs to be explained in simple language.

The Dignity of the Dying

The nearest one can come to his/her near and dear ones is through the use of video calls and virtual images. They provide respite, albeit temporary, from the physical and psychological turmoil, while fostering a sense of belonging and social support.

Given the rapid progression and sudden death, planning in terms of the will, advance directives, and treatment choices might not be available, more so in the Indian setting. Hence, they need to be proactively sought out for.

Opportunities and Space to Grieve

Breaking bad news has to be done sensitively and cautiously lest it may precipitate an emotional turmoil. Facilitation of acceptance of loss is aided by adequate social support and expressive writings in essays and letters. The sharing of positive memories helps in the upliftment and “continuing bonds.”[16] The current invisible and physical barriers, such as healthcare workers garbing protective equipment, the paucity of time, and multiplicity of losses necessitate the need to modify the previous models used and the need for innovative, nevertheless feasible, modifications. One novel approach conceptualized is the “COVID” practical recommendations, which entail C—custom-made cubicles to minimize the risk of transmission whilst donning minimal protective gear, O—on admission, briefing about the result, diagnosis, treatment, prognosis, and expected duration of stay, V—video chatting between the critical patient and family should be facilitated and encouraged, I—information regarding the demise should be communicated at the earliest and should be done by a person with training or expertise who was involved in the treatment, D—dead body transportation and cremation has to be done as per protocol and the same should be clearly informed to the family members at the end of communicating about the death of a loved one.[17]

A space or specific area for grieving may help in easier expression of emotions without hesitation and facilitate healthier acceptance of death.

Validation

Counseling via telepsychiatry and/or telephone by mental health professionals, with people who have suffered similar losses may act as healthy expressive modalities and provide comforting validation of their distress.

The COVID-specific HEALING process and DERAILERS in therapy[17] which highlight the elements that facilitate healing and the barriers in the resolution of grief can be adapted in the Indian context but would probably need more focus on meaning-making. The inability to verbalize emotions and the social acknowledgment of these feelings often lead to substituted physical complaints that may need to be identified. Facilitating psychological and social aspects of grieving becomes imperative. A collectivistic society may act as a buffer for losses as familial support may be available. At the same time, those away from family may find it difficult to deal with such losses, due to the unusual circumstances of current travel restrictions. Turning to spirituality or religion may also foster faster acceptance.

“Grief therapy,”[19] which facilitates grief management, may act as a template for developing a specific intervention for complicated grief. Complicated grief psychotherapy (CGT) is the best-studied intervention for prolonged and recalcitrant grief disorders. It facilitates progression through stages of mourning and checks for any derailments. It has been found to be more effective than interpersonal psychotherapy and antidepressants.[18]

Ritual Substitutes

In current times, a virtual funeral as a substitute method of grieving is relevant and also accessible, given the technological advances and universal availability of smartphones. To circumvent the problem of ambiguous loss, the use of digitized photos of the deceased’s face as an evidence of death is a viable alternative to an in-person embrace. Virtual memorial services and performance of final rites may provide short -term support for survivors of COVID-19 deaths. The use of such services may provide participation of family members and friends who would have otherwise been devoid of the opportunities to offer their condolences due to travel restrictions, financial constraints, work commitments, and people who are at high risk for contracting the infection and developing complications.[20]

In the Indian scenario, the multitude of faiths, religions, and customs makes it challenging to follow their faith-related practices of final rites. While trying to maintain the safety of those who are mourning and bereaving, health care professionals need to be sensitive to the cultural practices of the deceased.

Stigma

Stigma could be a potential barrier to family members of the deceased patients of COVID-19 in disclosing their distress and participating in any rituals related to the death.[21]

Grief Among Health Workers

Health care professionals who are frontline workers have been documented to undergo significant psychological distress during this COVID-19 pandemic.[13] They witness not only their patients but also professionals from their own field dying due to COVID-19. It is important to address the grief symptoms among them and provide psychological support.

Vicarious trauma is an interesting concept that holds much relevance in the current scenario. The unprecedented and sudden deaths, with a forced isolation to contain the spread of infection, behoove the health care workers to be more integrated with the grieving process. The concept of “vicarious grief” thus becomes more important as the successive witnessing of traumatic events, while being short-staffed due to an acute imbalance in demand and supply, predisposes health care personnel, especially frontline workers, to internalization of loss and burnout. This may manifest as loss of appetite and sleep, irritability, inattention, numbness, fear, and despair, thus increasing the risk of impaired psychological well-being and diminished psychological resilience, predisposing to grief and its complications.

Thus, COVID and its interface with psychiatric manifestations, especially grief, is a potent public health concern. The need for acceptable and affordable psychotherapeutic and psychopharmacological interventions in the Indian context needs to be looked into.

What Does the Future Entail?

Grief is a universal phenomenon; however, pandemics like COVID-19 might make the grieving process challenging and potentially act as a gateway to complicated grief. We have predominantly focused on grief in adults; but it is important to address grief among children and other special populations (pregnant women, military personnel, migrant workers, etc.). Although evidence for psychological interventions for grief is available across other countries, the same from India is lacking. It is important to consider the cultural aspects in the manifestation as well as the treatment of grief. A focused training in providing support for people in grief as an aftermath of COVID-19-related deaths may help in mitigating the woes of the grieving.