Tag: grief

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Issue 22

A Conversation With Dr. Arvinder Singh About Grief, Mental Health and Well-Being

OpenAxis had a conversation with Dr. Arvinder J. Singh, a psycho therapist and trainer, about the recent addition of prolonged grief in the DSM-5.  

Lakshya Sharma

Hello, Dr. Arvinder! This conversation is pegged by the recent inclusion of prolonged grief in the Diagnostic and Statistical Manual. Grief is a part of normal human experience. It is inevitable. So, by including grief are we reducing the horizon of normal human behavior?

Dr. Arvinder J. Singh

Pathologizing is not always the way out. We need to ensure that a normal human emotion such as grief should not be stigmatized. I stay away from diagnosis because diagnosis has a way of stigmatizing and pathologizing. Moreover, anxiety and grief affect different people, differently, and conversation is the way out. Even at Ashoka we have the gatekeepers programme to ensure that situations of anxiety and grief are smoothly taken care of.

Lakshya

In your clinical experience, have you ever felt, need for such a diagnosis?

Dr. Arvinder

I stay away as far as possible and refrain from diagnosing and labeling. I think because what it does is it just limits the kinds of ways you look at it because any kind of mental health concern has many strands to it. So it’s not necessarily just this one diagnosis and you operate out of that one. Moreover, there are no medical or blood tests to pinpoint a cause.

I think what is important is for us to see emotions like grief or  anxiety could impact different people differently and there’s no predicting. Even the duration after which grief is tagged prolonged is highly debated. Six months is politically incorrect whereas one year sounds better because it is the anniversary of everything. The conversations around such issues are very nuanced. It is not only about generational gaps but differences in personalities. Due to the pandemic we saw a loss in the grieving spaces, and a loss of contact and spaces.. 

Coming to DSM, how do we know if the grief is prolonged or delayed? How do we label it? And if you indeed label you need to understand the consequences of that label. If you club prolonged grief with depression, you end up stigmatizing the person. Grief might come up as an illness rather than a very normal human emotion. 

Lakshya

Grief can be triggered by numerous different causes, and sometimes small triggers lead to a huge impact and vice-versa. So, how do we understand the complexities of grief? 

Dr. Arvinder

So I think there are many factors involved. One is the preparedness. How prepared are you for the change? For instance, graduating from high school or losing a terminally ill relative leads to a less severe form of grief compared to unexpected losses.

Secondly, it depends on your coping mechanisms. How do you deal with your emotions? DO you talk or do you isolate? Thirdly, is it about how robust your support structure is? A stronger support structure helps in healthy grieving. Finally, it is about attachment. How attached were you to the person or item that you lost? While working in Gujarat, during the Bhuj Earthquake, a girl was grieving for her dog while her mother was grieving for her father. The two cannot be compared because both are grieving according to their attachments. Acknowledgment of pain is also really important. Denial might suppress the emotions for some time, but they will come back again and again. Final step is to seek support from people you can while following well-being practices.

Lakshya

When talking about well-being and accessing providers of well-being services, there is always an aspect of elitism. Seeking mental well-being services is perceived as elitist. So how do we bridge that gap? How do we make well being services more accessible?

Dr. Arvinder

That is an excellent question, because the gap between the number of professionals available and number of professionals required is humongous. Now, to bridge this gap, there are two ways. One is that it need not completely depend on professionals. So what we do is to bring the issue of a model, where we do capacity building from within the community, and we encourage open conversations around mental health and wellbeing.

Secondly, to not see well being as a time waster but rather as investment. Even at Ashoka our current model in place follows these principles of emotional robustness at the heart of education. That is why we promote conversations around problems people are facing, it is okay to talk about them and we need this kind of model in our community as well. 

Before, joint families were the norm and it provided a safety network. Now the family system has disintegrated, and we ended up with two working parents and a single child, leading to isolation. With the advent of the digital medium people have lost real connections  that end up with people living in their silos. But if we have these connections and spaces we must go and talk. I always encourage students to go and check on each other. In the worst case scenarios they might end up not talking. Or they might find a company, and will be grateful that you checked on them. The notion, however, is very individualized. 

Finally there is awareness. People have very little awareness about terms and well-being. They throw words like ‘OCD’ and ‘depression’ like that, but we don’t wish that on anyone, because it is hard. For the longest time, people did not know the difference between mental illness and mental retardation. Many other things in the illness spectrum also get the same treatment. What is a disorder? What is behavior? These are all nuanced conversations about which people don’t know much because they haven’t been talked to. Moreover, mental health is such an invisible space whereas physical disability is visible to all. People are compassionate about them and it is easy to talk about. On the other hand, mental health has a lot of stigmas around it. Most people don’t understand how crippling any anxiety or depression can be. So we need awareness to bridge the gap and make spaces for open conversations. 

Mental Health should not be seen from only an illness spectrum, it should be seen from a wellbeing spectrum. Practice various practices that are informed by positive psychology, whether it’s mindfulness, gratitude, or self-care. You don’t need to go to a specialist everytime there is a mental health concern, you can also deal with it yourself. If you can listen to somebody passionately without judging, advising, and moralizing. People will themselves come up with solutions, you won’t have to give it to them. It all starts with stress, if you don’t deal with stress, it becomes distress, and distress becomes crisis. If we deal with it at the stress level itself, the situation becomes much easier for both the professional and the patient. People also feel empowered enough to say, we can deal with this. So if these are the things that we work upon,  and empower or enable the community capacity building, it definitely would bridge the gap.

Dr. ArvinderJ. Singh is a psycho therapist, consultant and trainer who has worked for over 20 years in the area of leadership as well as building healing spaces through listening and stories including in areas of political violence and natural calamities.  She is the founder of an initiative called Listening Circles Healing Spaces that builds on this aspect of her work. She is currently Director of Ashoka Centre for Well-being and guest faculty for the course ‘Effective Leadership Strategies’ at IIM, Ahmedabad where she teaches mindfulness and empathic  leadership.

Interviewer: Lakshya Sharma

Picture Credits: Harper’s Bazaar

We publish all articles under a Creative Commons Attribution-NoDerivatives license. This means any news organisation, blog, website, newspaper or newsletter can republish our pieces for free, provided they attribute the original source (OpenAxis).

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Issue 22

Prolonged Grief: A New Mental Disorder?

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) features a new diagnosis: prolonged grief disorder—used for those who, a year after a loss, still remain incapacitated by it. This addition follows more than a decade of debate. Supporters argued that the addition enables clinicians to provide much-needed help to those afflicted by what one might simply consider a too much of grief, whereas opponents insisted that one mustn’t unduly pathologize grief and reject an increasingly medicalized approach to a condition that they considered part of a normal process of dealing with loss—a process which in some simply takes longer than in others.    

By including a condition in a professional classification system, we collectively recognize it as real. Recognizing hitherto unnamed conditions can help remove certain kinds of disadvantages. Miranda Fricker emphasizes this in her discussion of what she dubs hermeneutic injustice: a specific sort of epistemic injustice that affects persons in their capacity as knowers1. Creating terms like ‘post-natal depression’ and ‘sexual harassment’, Fricker argues, filled lacunae in the collectively available hermeneutic resources that existed where names for distinctive kinds of social experience should have been. The absence of such resources, Fricker holds, put those who suffered from such experiences at an epistemic disadvantage: they lacked the words to talk about them, understand them, and articulate how they were wronged. Simultaneously, such absences prevented wrong-doers from properly understanding and facing the harm they were inflicting—e.g. those who would ridicule or scold mothers of newborns for not being happier or those who would either actively engage in sexual harassment or (knowingly or not) support the societal structures that helped make it seem as if it was something women just had to put up with. 

For Fricker, the hermeneutical disadvantage faced by those who suffer from an as-of-yet ill-understood and largely undiagnosed medical condition is not an epistemic injustice. Those so disadvantaged are not excluded from full participation in hermeneutic practices, or at least not through mechanisms of social coercion that arise due to some structural identity prejudice. They are not, in other words, hermeneutically marginalized, which for Fricker, is an essential characteristic of epistemic injustice. Instead, their situation is simply one of “circumstantial epistemic bad luck”2. Still, Fricker, too, can agree that providing labels for ill-understood conditions is valuable. Naming a condition helps raise awareness of it, makes it discursively available and, thus, a possible object of knowledge and understanding. This, in turn, can enable those afflicted by it to understand their experience and give those who care about them another way of nudging them into seeking help. 

Surely, if adding prolonged grief disorder to the DSM-5 were merely a matter of recognizing the condition and of facilitating assistance, nobody should have any qualms with it. However, the addition also turns intense grief into a mental disorder—something for whose treatment insurance companies can be billed. With this, significant forces of interest enter the scene. The DSM-5, recall, is mainly consulted by psychiatrists. In contrast to talk-therapists like psychotherapists or psychoanalysts, psychiatrists constitute a highly medicalized profession, in which symptoms—clustered together as syndromes or disorders—are frequently taken to require drugs to treat them. Adding prolonged grief disorder thus heralds the advent of research into various drug-based grief therapies. Ellen Barry of the New York Times confirms this: “naltrexone, a drug used to help treat addiction,” she reports, “is currently in clinical trials as a form of grief therapy”, and we are likely to see a “competition for approval of medicines by the Food and Drug Administration.”3

Adding diagnoses to the DSM-5 creates financial incentives for players in the pharmaceutical industry to develop drugs advertised as providing relief to those so diagnosed. Surely, for various conditions, providing drug-induced relief from severe symptoms is useful, even necessary to enable patients to return to normal levels of functioning. But while drugs may help suppress feelings associated with intense grief, they cannot remove the grief. If all mental illnesses were brain diseases, they might be removed by adhering to some drug regimen or other. Note, however, that ‘mental illness’ is a metaphor that carries the implicit suggestion that just like physical illnesses, mental afflictions, too, are curable by providing the right kind of physical treatment. Unsurprisingly, this metaphor is embraced by those who stand to massively benefit from what profits they may reap from selling a plethora of drugs to those diagnosed with any of what seems like an ever-increasing number of mental disorders. But metaphors have limits. Lou Marinoff, a proponent of philosophical counselling, puts the point aptly:

Those who are dysfunctional by reason of physical illness entirely beyond their control—such as manic-depressives—are helped by medication. For handling that kind of problem, make your first stop a psychiatrist’s office. But if your problem is about identity or values or ethics, your worst bet is to let someone reify a mental illness and write a prescription. There is no pill that will make you find yourself, achieve your goals, or do the right thing.

Much more could be said about the differences between psychotherapy, psychiatry, and the newcomer in the field: philosophical counselling. Interested readers may benefit from consulting Marinoff’s work. Written in a provocative, sometimes alarmist style, it is both entertaining and—if taken with a substantial grain of salt—frequently insightful. My own view is this: from Fricker’s work, we can extract reasons to side with the proponents of adding prolonged grief disorder to the DSM-5. Creating hermeneutic resources that allow us to help raise awareness, promote understanding, and facilitate assistance is commendable. If the addition achieves that, we should welcome it. And yet, one may indeed worry that practitioners are too eager to move from the recognition of a mental condition to the implementation of therapeutic interventions that are based on the assumption that such afflictions must be understood on the model of physical disease. The issue is not whether certain mental conditions are real—they are. It is how we conceptualize them and what we think treating them requires.

No doubt, grief manifests physically. It is, however, not primarily a physical condition—let alone a brain disease. Grief is a distinctive mental condition. Apart from bouts of sadness, its symptoms typically include the loss of orientation or a sense of meaning. To overcome grief, we must come to terms with who we are or can be without the loved one’s physical presence in our life. We may need to reinvent ourselves, figure out how to be better again and whence to derive a new purpose. What is at stake is our sense of identity, our self-worth, and, ultimately, our happiness. Thinking that such issues are best addressed by popping pills puts us on a dangerous path, leading perhaps towards the kind of dystopian society Aldous Huxley imagined in his 1932 novel Brave New World. It does little to help us understand, let alone address, the moral and broader philosophical issues that trouble the bereaved and that lie at the root not just of prolonged grief but, arguably, of many so-called mental illnesses.

Footnotes:

1 For this and the following, cf. Fricker 2007, chapter 7.

2 Fricker 2007: 152

3 Barry 2022

References:

Barry, E. (2022). “How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer.” The New York Times, 03/18/2022, URL = https://www.nytimes.com/2022/03/18/health/prolonged-grief-
disorder.html [last access: 04/05/2022])
Fricker, M. (2007). Epistemic Injustice. Power & the Ethics of knowing. Oxford/New York: Oxford University Press.
Huxley, A. (1932). Brave New World. New York: Harper Brothers.
Marinoff, L. (1999). Plato, not Prozac! New York: HarperCollins Publishers.

Professor Raja Rosenhagen is currently serving as Assistant Professor of Philosophy, Head of Department, and Associate Dean of Academic Affairs at Ashoka University. He earned his PhD in Philosophy from the University of Pittsburgh and has a broad range of philosophical interests (see here). He wrote this article a) because he was invited to do so and b) because he is currently nurturing a growing interest in philosophical counselling.

Picture Credits: CBD Oracle

We publish all articles under a Creative Commons Attribution-NoDerivatives license. This means any news organisation, blog, website, newspaper or newsletter can republish our pieces for free, provided they attribute the original source (OpenAxis).

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Issue 11

Issue XI: Editors’ Note

The past year saw COVID-19 and lockdowns as the only issues one extensively engaged with, both in their personal and professional lives. The question, “how has the pandemic been treating you?” slipped into every catch-up conversation with peers, friends, family and colleagues. With the current surge of cases in India once again, it is safe to say that even with the vaccine, the pandemic still continues to dominate a major part of our lives. We are constantly reminded of it every time we have to step outside our homes or log in to an online meeting or a Zoom birthday call. 

With this issue, we aim to provide our readers with a ‘pandemic-break’ and delve into stories that are equally important but may have been sidelined with constant COVID updates from newsrooms. 

To begin with, Madhulika Agarwal addresses an essential question revolving around what makes an event ‘newsworthy’ in the first place? And who has the authority on prioritising which news is worth the consumers’ attention? With Amazon’s Twitter antics having grabbed the attention of the media, Samyukta Prabhu and Rohan Pai use this opportunity to highlight the gig workers’ rights that have been sidelined by tech giants such as Amazon, specifically during the course of the pandemic. 

Akanksha Mishra covers the consequences of the Afghanistan peace deal on the country’s population, revealing a critical understanding of the negotiations between three stakeholders – the Taliban, the Afghan government and the United States. Speaking of the United States, Karantaj Singh analyses 100 days of Biden administration by critiquing as well as applauding his contribution towards restoring America’s identity in the global community. With New Zealand’s recently passed miscarriages bereavement leave law, Advaita Singh captures the reader’s attention by examining the relationship between workplaces, the economy and personal grief.

Closer to home, Saaransh Mishra confronts the structure of quasi-federalism in India and its exploitation by the ruling central government in implementing controversial laws such as the recent GNCTD Bill. Furthermore, Muskaan Kanodia explores the vote-bank anxieties behind the intense dedication of political parties towards temple beautification, which appears to complement the rise of religious politics in the country. Ridhima Manocha analyses the ruling government’s contradictory campaign attitudes towards CAA-NRC when contesting the current Assam Assembly elections. Meanwhile, Vaibhav Parik questions India’s Election Commission’s decision to hold the ongoing Assembly elections in multiple phases in the state of West Bengal.

Aarohi Sharma brings back the essential climate change debate and delves into why individuals continue to deny its existence and widespread impact. For our sports enthusiasts, Kavya Satish explores the possible reasons for the increasing loss of viewership and sponsorship in F1 and what it means for the future of the sport. 

To emphasise the immense strain that Coivd-19 has placed on our global healthcare systems, Saman Fatima explores how this has resulted in the marginalisation of treatments of other prevalent diseases among several populations. 

While other stories may continue to struggle to win the fight for our attention with the intensity of the pandemic, we hope our readers are able to take a step back and keep themselves updated with events beyond rising Covid-19 cases and vaccinations. 

-Ariba, Ashana Mathur, Harshita Bedi, Rujuta Singh

Picture Credits: REUTERS/Athit Perawongmetha

Categories
Issue 11

To Have Loved and Lost

Trigger Warning: mentions of death, mental health issues

“Grief is a most peculiar thing; we’re so helpless in the face of it. It’s like a window that will simply open of its own accord. The room grows cold, and we can do nothing but shiver. But it opens a little less each time, and a little less; and one day we wonder what has become of it.”  

― Arthur Golden, Memoirs of a Geisha

Death is inevitable. Ultimate. Irreversible. As the fundamental truth of life, we are bound to encounter death. Unfortunately, to grieve is a matter of privilege; to allow yourself the time to break down and build back up again is a luxury not many can afford. In the past, people have returned to the workplace after demises, pushing against the inner storm of despair. Barring the few designated days of mourning, grief never became a strong reason for seeking paid leave, thereby, forcing employees to resume work within days of such life-altering tragedies. 

New Zealand recently became the second country to implement miscarriage bereavement laws — granting women and men the right to paid leave after miscarriages and stillbirths. India already had a similar legislation in place that entitled women to a six-week paid leave under the Maternity Benefit Act, 1961, in such cases. These governments have recognised the soul-crushing pain experienced by parents by passing such legislation. Hence, these acts are symbols of our humanity; our understanding of life and loss. 

While they are certainly socially evolved and humane, given their intrinsic link to the labour market, these laws provoke questions about their economic impacts. The impact of grief on productivity and employment raises some important questions: What are the economic consequences of paid leaves? Is grief a good enough reason for granting days off work? 

Productivity Pause

Grief is more than just a fleeting emotional state — it is the source of psychological and physical stress that can range from depression to anxiety and hopelessness. In fact, a medical side effect of bereavement is an impaired immune system. Since mental and physical health are integral parts of human capital, when emotions and grief run wild, productivity takes a severe hit. 

Despite realising their inability to work, workers feel the pressures of presenteeism.  If you have ever been to work even though you did not feel up to it, you understand presenteeism. A recently studied phenomenon, it refers to employees still habitually working long hours/attending work even though they are not fully functioning well (mostly due to medical reasons and even other concerns) ultimately leading to lower productivity. Workers who are insecure about their jobs often display presenteeism.

Presenteeism is harming businesses as the illusion of efficiency prevents managers from planning better. When six  workers are on the job but two are working at reduced capacity, information asymmetry prevents the manager/owner from efficiently allocating the workload because presenteeism is not apparent. Hence, the quality of output suffers and average efficiency is dragged down. In contrast, if the unproductive workers were on leave, the reduction in team size and efficiency would be glaringly visible and the managers would be able to better plan the tasks knowing fully well that they are working with a smaller, but productive team. 

Given that long bereavement breaks are not normalised, and their medical impacts are not understood, many workers feel insecure about their job status while considering taking time off work. Hence, employees are ultimately faced with the unfair choice of either resuming work with a diminished ability to perform or quitting the labour force. 

Workers deciding to quit the labour force would imply forgoing a source of income. The absence of financial stability can further reinforce any depression or anxiety felt by the employees. They might also lose out on new skills by being out of work for long periods which, in turn, would reduce their human capital relative to the rest of the workforce. With lower human capital, their employment prospects would further decrease. These consequences for workers translate into bigger problems for the economy as unemployment leads to wastage of resources and lower economic output. 

In this lose-lose situation, data estimates the economic cost of bereavement in the UK workplaces to be nearly £23bn a year. This renders a loss in tax revenue estimated to be around £8bn a year. Behind these massive figures, the study indicates that “the majority of the economic cost arises from lost productivity in the workplace (presenteeism), rather than from time away from work.”

A viable solution? 

Neither declining productivity nor workers’ exits from the labour force are optimal cases for the economy. Therefore, a solution would include retaining workers or preventing productivity dips. By providing paid bereavement leaves, firms ensure that workers have the option of staying employed. In a way, paid leave lifts the pressure of ‘showing up’ at work and allows workers to recuperate emotionally without worrying about economic welfare and finances. Once workers do finally return to work, they are relatively more emotionally stable and will be able to perform better, preventing any problems caused by presenteeism. Paid leaves also foster a stronger attachment to the labour force with workers more committed to working and staying in employment. With a more dedicated and stronger labour force, the national output  is expected to increase. 

Understanding the merits of paid leaves, the miscarriage bereavement laws passed by the New Zealand government are a giant leap forward. They recognise the significant emotional implications of stillbirths and miscarriages — losing a child has been ‘classified as one of the most extreme stressors a human can face’ which causes the parents’ productivity to reduce to a quarter of what it was before. Most importantly, these laws standardise access to paid-leave and propagate equality. Given that all workers do not have the financial background to quit their jobs, the legislation ensures that despite varied working conditions, workers have the ability to avail the option of paid leaves. Hence, it fosters an environment of equality while prioritising workers’ welfare. 

At its core, such laws recognise that workers’ welfare need not be at odds with the economic well-being of the country. Workers are 13% more productive when they are happy. Hence, it is difficult to isolate economic growth from the emotional welfare of the workforce. By providing adequate time and opportunity for employees to process their loss, these paid leaves act as a safeguard for the interests of the workforce against the tragedies of miscarriages and stillbirths. 

Picture Perfect? 

Despite their merits, these laws come with strings attached. Paid leave is a controversial issue amongst employers since they are paying the employees for essentially no work. Some firms might prefer workers showing up at offices despite the recent deaths of loved ones. By availing paid leaves, a worker’s contribution to output is zero. By using the logic of ‘something is better than nothing,’ employers would still prefer to enforce their older methods. 

Paid leaves for parents after stillbirths or miscarriages are certainly a social issue. However, the effects of grief on productivity make it an economic issue in tandem. This gives the opportunity for inclusive legislation that can improve economic conditions and boost economic growth. The unpredictability of death makes it all the more important to recognise the various losses humankind shares and subsequently address them in legislation. Because let’s face it, for someone still reeling from the shocks of the death of their loved ones; for someone still braving that gush of grief blowing through the window in that frigid room; even a few days off work mean everything. 

Advaita Singh is a second-year student of Economics at Ashoka University. She is also the President of the Economics Society at Ashoka. 

We publish all articles under a Creative Commons Attribution-Noderivatives license. This means any news organisation, blog, website, newspaper or newsletter can republish our pieces for free, provided they attribute the original source (OpenAxis).