To medicalize mourning

What are the implications of formally pathologizing grief?

Since the beginnings of modern psychiatry, the study and diagnosis of mental disorders has been surrounded by a burgeoning cloud of contention. Certainly, the history of psychiatry is fraught with issues regarding the definition of and conflicts over the inclusion and exclusion of certain illnesses (homosexuality, included until 1973, is a prime example) as disordered conditions. Over the past 25 years in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has expanded to allow room for a number of “new” disorders. Included in this growing group is “Complicated Grief,” or “Prolonged Grief Disorder,” which is being considered for a spot in the DSM-V, due out in 2013. While many psychiatrists believe that pathological grief has long deserved a place in diagnostic nomenclature, its potential inclusion as a mental disorder has great implications for how we understand and negotiate a fundamental human experience: the death of a loved one.

Until recently, grief has maintained a foothold in the realm of human emotion largely untouched by the world of psychiatry. Grief, mourning, and bereavement were seen as natural human reactions to trauma and tragedy. When encountered in a clinical context, grief was understood as an extended manifestation of existing disorders such as posttraumatic stress disorder or Major Depressive Disorder. However, many psychiatrists, such as Mardi J. Horowitz at the University of California, San Francisco have argued that extreme grieving is a pathological disorder that requires crucial medical and therapeutic treatment. While the debate continues as to how to define and diagnose pathological grief, a greater question emerges: why are we so keen on defining grief as a disorder in the first place?

Leeat Granek is a Toronto-based critical psychologist who specializes in grief and loss and has been at the forefront of a movement toward re-thinking our perceptions of and attitudes toward grief in the North American context. Granek suggests that rather than focus on definitions of what is “normal” and “abnormal” when it comes to grieving, we should be more concerned with what the desire to pathologize grief reflects about our societal beliefs and attitudes. “Many of the mental illnesses in the DSM are social constructions that are based on the cultural zeitgeist at the moment,” said Granek. “We already live in a culture that is intolerant of grief and loss in general. The message is often, ‘You need to move on, you need to see someone.’” The inclusion of pathological grief as a clinical diagnosis would serve to reinforce the perception of grief as a problematic, rather than a natural human reaction to loss and bereavement.

Granek’s concerns over the inclusion of grief in the DSM stretch beyond the realm of negative societal perceptions and attitudes. Grieving has traditionally been done in tight-knit communities made up of family, friends, and close community-members. In recent years, these support networks have shrunk or largely disappeared, which has changed the way individuals are able to grieve. Granek explains what is happening is a “diagnostic creep” which has meant that more and more people are being screened for grief “disorder.” Indeed, as Granek pointed out, anyone who has ever experienced a loss or grief falls into that purview, and can face diagnosis. As grief becomes an increasingly common diagnosis of disorder, human experiences are relegated to the institutionalized sphere: the offices of therapists, psychologists, and psychiatrists. “There is less space for grief and loss, and less space for tolerance in our culture,” said Granek. Indeed, the doctor’s office has taken the place of community rituals and traditions that in the past created space and support for grief and mourning.

But Granek is hopeful, and with good reason. In mid-February, she held a number of meetings at York University in Toronto and the City University of New York with a wide range of individuals including clinicians, healthcare workers and community activists who work in the area of grief and loss to discuss alternatives to pathologization. The aim was to generate discussion drawn from on-the-ground experiences of people with a variety of perspectives and backgrounds. Granek emphasizes the need for a “multiplicity of voices” when it comes to the field of grief and the ultimate need for more dialogue in order to narrow the space between research and the human experience.

In describing the outcomes of her meetings, one of the only things that everyone could agree on, said Granek, is that grief is complex and diverse – indeed, as is the depth and capacity of human emotion.