GRIEVING OUR LOVED ONES IS NOW AN ILLNESS
Despite a new ruling by the psychiatric establishment, grief is not a mental disorder but an existential state
In addition to its extensive coverage of the war in Ukraine, the New York Times, on March 18th, found space on its first page to cover a decision rendered by the American Psychiatric Association (APA) that was ten years in the making. The APA is America's most powerful psychiatric organization. It decided to add “prolonged grief “as a diagnosis to the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders. In other words, those suffering from prolonged grief, sometimes referred to as “complicated grief,” are now defined as mentally ill. The D.S. M. is the bible of mental health clinicians and is employed as a resource by insurance companies in validating reimbursement for mental health treatment. It plays a weighty role in defining, for both the medical world and the culture-at-large, what constitutes mental illness.
I reject and recoil from this maneuver by the psychiatric establishment. I am not a mental health professional and one needs to view journalistic reports of specialized issues with due skepticism. Nor am I a technical expert, but I am an aggrieved person who has reflected deeply on his grief and has written about it. As someone who continues to grieve the death of his beloved wife, I possess internal knowledge of the nature of grief, which an outsider, no matter how learned, cannot possess. I believe it was Bertrand Russell who said “when it comes to pain, the sufferer is omniscient.” The subjective standpoint provides privileged access to emotional states, and credentialed expert or not, I believe that this is a war too important to be left to the generals. As a person who continues to experience grief more than six years after my wife's death, I have a personal stake in this issue.
I am not the only one to feel this way. As the article cites, the designation of prolonged grief as a disease had many opponents among those who deliberated on this issue, both within the psychiatric profession, and practitioners outside of it. The Lancet, the prestigious British medical journal, featured an editorial strongly criticizing their American counterparts.
Why is this an issue? It is my firm conviction that grief is an existential condition, not an illness. Death, loss, and attendant grief are universal facts of the human experience. I have little doubt that there are people who are mired in their grief, who obsess over the loss of their loved one, and cannot move on with their lives. Clinicians estimate that men and women who so suffer comprise approximately ten percent of those who mourn. I also do not doubt that people who are virtually immobilized by grief may often profit from speaking with others, laypersons and experts alike, about their emotional states and their overall condition.
Yet I am skeptical of experts in this regard defining for others and society-at-large what constitutes a normal or normative response to the loss of one whom we loved, shared much of our lives with, helped endow our lives with meaning, and significantly assisted in shaping our identities.
As I have written elsewhere, I have long abandoned a commitment to doctrinaire psychological norms. We are all different, and we all bear our idiosyncrasies. We all develop coping strategies to winnow as much satisfaction and happiness from life as we can and to negotiate problems. What works for one may not for others.
This stance has broadened my compassion, my tolerance, and has caused me to abandon judgment when it comes to the ways in which people adjust to the emotional and psychological challenges of life. This certainly is the case as it pertains to grief. I don't believe there is any dogmatically correct way to mourn the death of a loved one. As noted, there is no place for judgment here, nor do the grief-stricken need to offer apologies.
I am reminded of the oft-invoked adage that each person grieves in his or her own way. I believe this is true and there is no correct way to respond to the loss of a loved one, nor do I believe there are social standards or norms by which how we grieve should be measured. Each person engages grief as he or she will. When it comes to grief, there are multiple variables that inform how people mourn and for how long.
Among these variables are differences in temperament, our relation to the person who has died, and the way in which they died. One's sex, age, working conditions, health, and what is transpiring in the wider world may all make a difference in how a person experiences grief. One's religious beliefs and practices as well as the person's cultural milieu may all inform the meaning of death and grief, and play a major role in how people mourn and for how long. In some religious traditions, a year is an often invoked period for how long to grieve. In some cultures, grief is understood to be life-long.
Those who lose their partners, for example, to cancer or to Alzheimer's disease, in which their loved ones have been actively dying over a course of a long period of time, even many years, may grieve differently from those who lose their loved one suddenly or when the process of active dying is relatively brief.
Human experience is not subject to neat divisions. It is messy. Grief is on a spectrum. Some may adjust to the death of a loved one relatively quickly. Others may take much longer. Who is to dictate the appropriate length of grieving for others? It is possible that those defined as experiencing prolonged grief may merely be slower in getting beyond its most debilitating effects. Their distinctive response should not, therefore, define them as ill. The D.S.M 4, manual states that symptoms of grief should abate by two months! A recent article in the Lancet appropriately defines that conclusion as a “shockingly short expectation.” I can only conclude that the experts who proclaimed this time frame have never been in a loving, intimate relationship with another person for any duration.
My central point is, again, that grief is an existential fact. The aforementioned Lancet editorial states,
“Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated.”
“Building a life without the loved person who died cannot be expected to be quick, easy, or straightforward. Life cannot, nor should not, continue as normal. In a sense, a new life has to be created, and lived with. After the loss of someone with whom life has been lived and loved, nothing can be the same again.”
“Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one. Putting a timeframe on grief is inappropriate—DSM-5... please take note. Occasionally, prolonged grief disorder or depression develops, which may need treatment, but most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills."
I have found the existential character of grief in my own life compelling. My wife, with whom I had a very engaged relationship for 41 years, is no longer present. She has disappeared. As a consequence, I no longer have anyone to share my day with me, to listen to my complaints, to laugh with, to care for. And there is no intimacy in my life. I come home to an empty house and my partner's absence is a brute, hard fact. After more than four decades of sharing daily life with me, my wife had become deeply internalized. With her death, a major part of me was cut away, and I am less because of it. I am left in the paradoxical state of feeling her presence and experiencing her absence as two sides of the same coin.
To be clear, for the first six months after her death I was nearly immobilized and afflicted by strange and negative emotions. But in time, the immobility lifted and I regained functional normalcy. I was able to work, socialize, and to laugh. But the self is multi-tiered. Beneath the surface, loneliness endures and a certain emptiness, which my wife filled as a matter of course, remains. This is not illness. It is, again, I contend, proportionate to the reality, the compelling facticity, of her absence. And I suspect it will be life-long. The writer Julian Barnes noted that every love story is a potential grief story. And I would add that grief is the price we pay for love.
The life instinct pushes us ahead to adapt to this most difficult of realities. But I believe that we cannot transcend the grief of a loved one; the best we can do is adapt. I am quite certain that even if I were to find another life partner, my wife would still very much remain in the picture. Jane Brody, a former science writer for the New York Times, observed that when widowed people remarry, there are always four people in the marriage.
There is much that leads me to be skeptical of the APA defining grief as an illness. Medicine is big business and one does not have to be a Marxist to conclude that financial interests have played a major part in this decision. Dr. Arthur Kleinman, a physician who lost his wife in 2011 and is critical of the APA decision to label grief as an illness, wrote in the Lancet “... APA's experts, lacking the constraint of biological measures of depression and encouraged by the pharmaceutical industry, are seeking to loosen standards and thereby create more patients. Its ubiquity makes grief a potential profit centre for the business of psychiatry.”
The Times piece noted, “Its inclusion in the Diagnostic and Statistical Manual of Mental Disorders means that clinicians can now bill insurance companies for treating people for the condition. It will most likely open a stream of funding for research into treatments --- naltrexoxe, a drug used to help treat addiction, is currently in clinical trials as a form of therapy— and set off a competition for approval of medicines by the Food and Drug Administration.”
Such is another example of the relentless move to monetize every corner of American life. Wait for late-night TV commercials advertising the latest pill to treat your grief in the face of your loss of a loved one.
I maintain that we have good reasons not to trust the experts. It is not so long ago that the American Psychiatric Association (1973) declared that homosexuality should no longer be considered a “psychiatric disorder.” Rather, they reclaimed their virtue by reframing it as merely a “sexual orientation disturbance”
That the mandarins of the psychological establishment have now pathologized grief is not only stigmatizing, it is also imperious.
When they develop a pill that will bring my wife back, I will reconsider my position.
Many thanks, Francesca. In accordance with my view, in a certain sense, I feel that I am where I ought to be. Grief is odd in that it has a "life" or rhythm of its own. It takes me where it will, but I don't feel bad that I feel bad when I do. But of course, that is not always. There is much joy in my life.
Thoughtful article on a complex subject. The APA isn't always right and may have other motives. Yet prolonged grief may be harmful to happiness.