Hoping to Cope

Written by Dr. Prathap Addageethala

Last month, I wrote an article about grief, and the theories surrounding how human beings feel when confronted with a loss. Too often, people are left in the dark, grasping for positive ways to channel the myriad emotions that accompany grief. Many times this can lead to destructive behaviours such as alcoholism, drug addiction, or channeling anger towards friends or loved ones. The truth is that no loss is easy to deal with, and depending on your personal experiences, each loss can reside in you differently, as they might from the person to person.

Grief, in its many forms and variations, can be complicated in unexpected ways. At times a fleeting memory or thought can trigger a rush of emotions and can have automatic physical effects. Surely anyone with a failed romance can recall a loss of appetite upon seeing a picture of the ex-partner, or that pang of anguish when you think of the moment that favourite sweater caught a snag and tore. The important things to remember are that these are natural reactions, and that losses are bound to happen.

The following is a list of suggestions that can help you get through tough times positively, and may also have lasting effects to improve many other areas of your life. Some are "common sense" applications, and others have been found through my interactions with healthcare practitioners. Take a deep breath and enjoy.

EXERCISE

Let's be honest, you knew this was coming. But I'm not making it up! Oodles of research shows that through various groups, controls, and trials, exercise unequivocally can improve various mood states, anxiety and depression. Aim for 30 minutes of low intensity exercise daily, and jazz it up every so often with something new, like a leisure sport or activity. Take your dog for a walk on a longer, more scenic route. Join a running group that suits your experience level. Play tag with your kids at the park! Exercise doesn't have to include a gym, yoga pants, or profuse amounts of sweating. If you're feeling the effects of a loss, just changing your scenery actively is a step in the right direction, quite literally.

Go have fun! Yay!

MEDITATION

Common misconception: you don't need to be a Buddhist monk or a professional yogi to know how to meditate. Meditation is a simple focus based exercise for the mind and body. The response from meditation is so pronounced, even from short periods of time on a daily basis, that it is regularly prescribed by progressive MDs as opposed to medicines. On Functional MRI studies, the areas of the brain responsible for attention, mood, anxiety, and emotional responses were highly active in subjects engaged in meditation. The benefit of this is similar to giving your brain a workout - only it doesn't tire out - it feels rejuvenated (also similar to the runner's high distance runner's may experience). It gives the brain a boost, just where it's needed. If you're new to meditation, start with simple "Noticing your Breath." The process is simple. Take 5 minutes, turn off your phone, turn your monitor off, and close your eyes. Breathe in through the nose slowly, and breathe out through the nose as well. All you want to focus on is the feeling of the air passing in and out of your nostrils. If any unwanted thoughts arise, anything outside of the concentration of air passing in and out of your nose, gently bring yourself back. That's it! You can also try one of my favourites - yoga nidra - which is also referred to as "guided meditation" or "body scan." This may require a slightly longer amount of time, the use of headphones, and preferably a mat to lie on. Try this 10 minute clip, care of my friends at YouTube.

All you need is yourself and a chair.

MINDFULNESS

The art of mindfulness has really picked up steam in the last few years among mental health practitioners. While technically a method of meditation, mindfulness goes a bit beyond focused attention and concentration. Instead, this thought process focuses on the present-time, and aligning your day to day activities with a level of detachment. The core beliefs of mindfulness involves "staying present" and treating yourself with kindness. From Psychology Today, the definition is:

Mindfulness is a state of active, open attention on the present. When you're mindful, you observe your thoughts and feelings from a distance, without judging them good or bad. Instead of letting your life pass you by, mindfulness means living in the moment and awakening to experience.

In other words, realize that we as human beings are subject to a number of thought processes about everything. The key is to approach each situation with kindness to yourself. Instead of kicking yourself about feeling one way or another, simply take a moment to recognize that you are feeling a certain way about something, and allow yourself that moment. Another staple of mindfulness is to refrain from being reactive, giving yourself space to feel. Bringing every moment back to the present is a life-long learning process, and requires just a bit of patience. In each situation, gently bring yourself back to the present and avoid judging yourself on your actions. For some additional information on mindfulness, please visit Psychology Today - a great collection of articles regarding how you can start to include mindfulness in your everyday.


VOLUNTEERING
Our time has become ever shorter as we advance through the age of technology. From the same position at our desk, we can order a pizza, donate to disaster relief, and diagnose ourselves with various conditions (WebMD syndrome). In other words, we can keep ourselves remarkably busy with relatively little physical effort, but we tend to exhaust our mind's resources. We tend to stay fixated within our own world, constantly thinking of ways to survive in or improve our current station. Volunteering is a form of constructive escapism. Mahatma Gandhi famously said "The best way to find yourself is by losing yourself in the services of others." By helping others, whether human or otherwise (shout outs to our furry friends), we are able to escape our current situation and let another benefit. This has tremendous potential to uplift us, out of whatever funk we may exist. Sometimes it's the change of perspective, such as working with the homeless, which can show us that our current situation could always be worse. Other times, it could be the gratitude shown by those we are helping. Lastly, it just feels good to help, without any expectation of compensation. An hour a week can have huge impacts on your community, your neighbours, and most importantly, on your own self-belief.

HOBBIES/SKILLS
We all don't want to be surrounded by loved ones when we're grieving or dealing with loss. Quiet reflection is a wonderful way to clear your mind, clarify your intentions, and even chart a course. A line can be crossed if we spend all of our time in isolation. It's one thing to be introverted and shy. It's completely a different ballgame once we let our grief and unhappiness create an unintentional space around us. Enter the hobbies you always wanted to have. Why not now? This is one of the best times to get creative, to use the time to yourself to be productive and constructive towards your own life. Start learning a new language, take up crocheting, perfect your rock skipping at the local pond. Take pleasure in gaining new skills or polishing old ones. Create!


THE PROFESSIONALS
This is less of a coping strategy than it is a recommendation. If you've ever thought about seeking the help of a mental health professional, by all means, please go and see how they might be able to help. A few years ago, amidst the stress of preparing for board exams, regular class work, and balancing a roster full of patients as a student intern, I had a personal relationship end in calamity. I felt broken! I swallowed my pride, and entered the office of one of our college's counselors, and to this day, I feel like it was one of the best decisions I ever made. I had no idea what I would talk about, and I had no idea how she could help me, still I went. She very quickly made me see that the room we met in, her office, was a safe environment. Over the next few weeks we met once or twice, for a full hour. The most positive part of the experience was that she never judged, decided anything for me, or "diagnosed" illnesses. She simply made suggestions, steered conversations around or towards certain topics, and allowed me to come to my own conclusions. Oh, and she also opened my world up to mindfulness.

There's a lot of stigma surrounding accepting care from a mental health professional. Don't let that stop you. No, you're not crazy, nor should you let anyone make you feel that way. You should be proud of yourself, you're taking steps towards bettering your health. Mental health practitioners offer objective, 3rd party advice; something you cannot receive from your parents or your friends. Having an outside professional work with you can deliver clarity, and often be invaluable in removing clutter from complicated situations.

- Dr. P

On Death and Dying

Written by Dr. Prathap Addageethala 




Just being thankful for what I got.

My absence from social media activities has been noticeably lengthy, at least it felt like it, but behind it lies  a sad reason. One week ago today, we laid to rest my grandmother, whom we affectionately called "Nainamma" (Dad's Mother). Being halfway across the globe, language barriers, and her inability to pen letters were all factors in not having an exceptionally close relationship with her. I was able to visit her a few days before she died, and although she did not have the cognitive ability to recognize me, I felt that spiritually she had realized that her eldest son's eldest son had come to visit. It made my heart glad to have been able to feed her a tiny bit as she lay there breathing heavily, and to have seen someone I know had so much love for me in their last stages. But still, last Wednesday, seeing someone so closely related after having taken their final breath was a shock to my system.

I was very young when my mother's father passed away; I was lucky to have had the opportunity to see him in his final stages. My Dad's sister eventually succumbed to a vicious stomach cancer some years later. Even then, I didn't feel the sting of the loss. I never met my paternal grandfather who left us when my Dad was still a boy.

As an aware adult, this was the first loss of a family member with whom I had a connection or bond. Nainamma was in poor health for the last several years. The most recent trauma was a slip and fall, where she suffered a broken tibia. Being from a rural area in South India, and having exceedingly problematic vitals, the local medical specialists sent her home having not been able to treat her adequately. Again, even though the loss was expected, it was a surreal experience. Hearing the news last Tuesday, I felt unable to concentrate, and an immediate need to be by myself. I took the afternoon off to reflect, and prepared to go to the funeral the next day.

It occurred to me later that I was grieving. From an excerpt of a book entitled "Handbook of bereavement research and practice: Advances in theory and intervention," endorsed by the American Psychological Association grief is defined as "the usual reaction to bereavement [i.e. intense distress]... as a primarily emotional (affective) reaction to the loss of a loved one through death." That was where I was - although it may not have been intense - I was definitely distressed.

I looked at it a little closer and I realized that there are more folds to this particular dough. When applied to a loss - as in death - this strict and austere definition applies. What if you've just lost something of significance? Indeed a definition with a larger breadth and scope is much simpler: grief is a response to having lost something of personal significance. For perspective, it's perfectly normal that people "grieve" over a stain on a favourite sweater, others a scratch on their car, or a misplaced swanky hat. Others may grieve over a lost job, a missed opportunity, or the end of a relationship over divorce. Certainly the diagnosis of serious health conditions qualify here as well. The underlying aspect of grieving is that something had a value for the grieving person, and now that something is gone, or unalterably changed. The difference lies in the level or volume of the grieving response.

Since 1969, from her book On Death and Dying, the gold standard in evaluating grief has been Kubler-Ross' "Stages of Grief." While there have never been definitive studies regarding this model until recent times, this has been widely accepted in medical and psychological circles, commonly being taught in medical curricula. The stages are a progression, as one learns to cope with and "get over" their grief. Again, this model is typically applied to death of a loved one. The model also acknowledges that it is an incomplete list of all possible emotions experienced, and that it does not always apply to each and everybody. The final provision also states that the stages can be experienced in any order, but the following order of the stages are most common:

*it should be noted that ranking severity of grief can be a very personal thing, allowing for differences among individuals

• Denial - where the grieving person ignores the reality of the situation, or imagines a more "false, preferable reality"
• Anger - this is commonly witnessed as a "lashing out" by the grieving person to those close to him or her. The moot nature of denial sinks in, and is replaced by a deep-seated frustration which needs to be transferred to the nearest personal lightning rod.
• Bargaining - depending on the severity of loss, this stage can be looked at with "let's make a deal" lenses. In less severe cases, a bargain can be struck by making a compromise (instead of buying x, I'll replace [lost item]). Other times, bargaining manifests as a swap, usually in stark change in behaviour in return for an extended life or a return to health.
• Depression - this topic could fill every health related blog from now until the end of times. Common signs of depression in response to loss are despondence, low affect, loss or gain of appetite, and lack of concentration.
• Acceptance - there still may be strong emotions surrounding the loss, but there is an overall stabilizing of the affect. A person comes to terms with the loss, and returns to a calmer, more rational state. Integrating new information into old beliefs has almost completely occurred by this stage.

This model does not come without it's share of critics. As mentioned earlier, many academics have outright shunned this model, referring to grief being an unimportant and somewhat contrived emotional defect. Some have taken a more rational and conventional approach, offering constructive changes to the model. A study from The British Journal of Psychiatry (2008) by Prigerson and Maciejewski seemed to offer the most fair and sensible explanations:

• proposed 4 states of grief that co-exist as a psychological construct, rather than individual, ascending stages of grief
• indicators of grief include anger, sadness, yearning and disbelief 
• anger, sadness, disbelief decreased over a period of two years (acute bereavement period); peaking at 6 months
• the feeling of yearning, or intense longing was consistent (read: did not decrease) over the same time period
• acceptance increases with relation to decrease in grief indicators
• "At its core, grief may be the state of emotional unrest and frustration associated with wanting what one cannot have"

In my next article, I'll address some strategies when coping with loss, grief, and the frustration or stress involved in the process. These helpful hints will come in handy for anyone going through a loss, however minor or traumatic.

Support from family can be extremely important in progressing through grief.

The states of my grieving felt like they were actualized in a day. My anger manifested towards people who I perceived as being disrespectful during the last rites. My sadness was directed towards my Dad, who seemed utterly alone, and to my grandmother who had a very tough older life. My disbelief suspended when I saw her lifeless body on the dais, adorned with garlands. The yearning I felt was to have been more involved with my granny while she was alive; just a need to have told her that even though she was suffering, I was still there for her.

In my case, I found peace through realization that Nainamma was no longer suffering through her array of illnesses. The spiritual connection we shared prior to her death was an actual palpable thing, I could feel her grow more calm when I went and spoke to her, whether she recognized me or not. I was surrounded by family, people who have been supportive influences in our lives from the very beginning. I had shed a few tears, and ultimately it helped the overwhelming feeling of being at the centre of something so sad. There were cousins, uncles, aunts, and well wishers, all braving the ridiculous village heat, came from hours away, started journeys in the early mornings, and navigated with me through confusing customs. I was lucky to have a support system like that, and I recognize not everybody can be so fortunate. A sincere, heartfelt thank you to all who have stood by our family in our time of mourning. Your sympathies and condolences have moved mountains.

- Dr. P