Kamalamani - Therapist and mentor in Bishopston, Bristol
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A Crying Shame?
Thoughts on the inclusion of 'bereavement-related disorder' in DSM5
Kamalamani, August 2011
The next edition of DSM (the Diagnostic and Statistical Manual of Mental Disorders) - DSM5 - is looking likely to include a new entry called 'bereavement-related disorder' when it is next published in 2013. The DSM is the name given to the classification of officially recognised psychiatric conditions, published by the American Psychiatric Association and used worldwide by mental health professionals in psychiatric diagnosis and assessment.
The proposed disorder is known by different names in the psychological and scientific fields: prolonged grief disorder, complex grief, traumatic grief, pathological grief and, perhaps most commonly, complicated grief. It also means different things depending on who you talk to, but it is generally applied to people whose lives are considerably affected for 'longer than average' periods after the loss of a loved one. The controversial proposal will allow for medical treatment for depression within the first few weeks after a death, whereas under DSM4 two months must have elapsed before a bereaved person is diagnosed with depression.
I felt dismayed in hearing of this proposal. It feels like another nail in the coffin - quite literally - of a culture in which we won't - or can't? - accept the reality of death and give due time and space to the grieving process which follows. If the new proposal becomes part of DSM5 the psychiatric practices will effectively be pathologising the death of a loved one within a few weeks of that death. By 'pathologising' I mean viewing or characterising something as medically or psychologically abnormal, when the majority of people will experience grief as an inevitable part of being a related, feeling being with a heart and a unique history.
Grieving is an essential part of being human. We have all lost, or will lose someone we love. Or a job we love, or the end of a relationship, or grieve the loss of a place we have to leave. Yet it is an all too common occurrence in my therapy room to be with clients who have lost a much loved person and berate themselves for still being upset after a few weeks, months or a year. They apologise for their tears or their anger, thinking that they are abnormal in still feeling upset. The most important job in those early sessions is to simply be there, making sure that that person knows that the raft of emotions accompanying the grieving process are quite 'normal', they are not 'mad' - as they so often fear - and those emotions are better out than in and witnessed by a supportive other.
I find it astonishing how we are culturally programmed to still express so little emotion, particularly in public, or witnessed by others, even in the face of the death of one we love. Emotion still equals weakness in so many contexts, even though it is vital in complementing our reason and rationality. The taboo surrounding loss and depression are sobering, and perhaps exacerbated by the current emphasis upon happiness and positivity. Positivity is great, but it can't be manufactured or make it up. You can cultivate the conditions to invite a sense of positivity, but there's little point (in fact, it's detrimental) to pretend you're absolutely fine when, in fact, you're knee-deep in grief. That's exactly the situation when you are more likely to suffer from 'complicated grief', because you are not allowing yourself the time and space, or perhaps enlisting the support of others for healing to take place.
Grieving very often is a complex process and does take time. The fact that it takes longer than a few weeks to grieve for a loved one does not make that grieving process somehow abnormal. Time in and of itself isn't necessarily a great healer. In this complexity it is useful in supporting clients (or friends and family) in being aware of some of the factors that can contribute to this complication rather than judge them or chivvy them along. Complexity can be influenced by the closeness of the relationship to the mourned, the nature of the attachment, whether there was 'unfinished business', the nature and circumstances of the death, how the mourner has responded to previous losses, and wider social factors (e.g. the support systems of the person), and whether there were other stresses going on at the same time (see Worden and Parke's books below). Why on earth should a parent who has lost a child in a shocking accident or someone whose closest friend has committed suicide be classified as having a 'bereavement disorder' for 'still' grieving three weeks after the death?
Grief stops us in our tracks and reminds us of the constant fragility of life. What might even seem at first like quite an insignificant death can un-hinge us, perhaps as it reminds us of earlier losses or coincides with a time of heightened personal vulnerability. Perhaps we don't 'move on', as the language goes, perhaps we have 'continuing bonds' in the words of the bereavement writer Tony Walter (Walter, 1983). People die and their legacy continues. Few of us forget how we have been shaped by the person we mourn, and, most likely, them by us, for good and ill. Quick fixes don't tend to work in the grieving process. After the initial shock of a death grieving can often make us gradually take stock, re-evaluate our new place in the world and in the network of our relationships, throwing light on who we are, what we're about and what matters. This isn't necessarily an easy or inspiring process, but it can have its moments. Let us give time and space to the grieving process rather than turning it into another problem which somehow needs to be treated.
References:
Parkes CM (1972) Bereavement: Studies of Grief in Adult Life, Penguin. ISBN 0 14 025754 3
Walter T (1999) On Bereavement: the Culture of Grief, Open University Press. ISDN 0 335 20080 X
Worden JW (1983) Grief Counselling and Grief Therapy, Routledge. ISBN 0 415 07179 8
Return to the main homepage. Return to Kamalamani's page of articles. Go to therapy for grief, loss and bereavement
Thoughts on the inclusion of 'bereavement-related disorder' in DSM5
Kamalamani, August 2011
The next edition of DSM (the Diagnostic and Statistical Manual of Mental Disorders) - DSM5 - is looking likely to include a new entry called 'bereavement-related disorder' when it is next published in 2013. The DSM is the name given to the classification of officially recognised psychiatric conditions, published by the American Psychiatric Association and used worldwide by mental health professionals in psychiatric diagnosis and assessment.
The proposed disorder is known by different names in the psychological and scientific fields: prolonged grief disorder, complex grief, traumatic grief, pathological grief and, perhaps most commonly, complicated grief. It also means different things depending on who you talk to, but it is generally applied to people whose lives are considerably affected for 'longer than average' periods after the loss of a loved one. The controversial proposal will allow for medical treatment for depression within the first few weeks after a death, whereas under DSM4 two months must have elapsed before a bereaved person is diagnosed with depression.
I felt dismayed in hearing of this proposal. It feels like another nail in the coffin - quite literally - of a culture in which we won't - or can't? - accept the reality of death and give due time and space to the grieving process which follows. If the new proposal becomes part of DSM5 the psychiatric practices will effectively be pathologising the death of a loved one within a few weeks of that death. By 'pathologising' I mean viewing or characterising something as medically or psychologically abnormal, when the majority of people will experience grief as an inevitable part of being a related, feeling being with a heart and a unique history.
Grieving is an essential part of being human. We have all lost, or will lose someone we love. Or a job we love, or the end of a relationship, or grieve the loss of a place we have to leave. Yet it is an all too common occurrence in my therapy room to be with clients who have lost a much loved person and berate themselves for still being upset after a few weeks, months or a year. They apologise for their tears or their anger, thinking that they are abnormal in still feeling upset. The most important job in those early sessions is to simply be there, making sure that that person knows that the raft of emotions accompanying the grieving process are quite 'normal', they are not 'mad' - as they so often fear - and those emotions are better out than in and witnessed by a supportive other.
I find it astonishing how we are culturally programmed to still express so little emotion, particularly in public, or witnessed by others, even in the face of the death of one we love. Emotion still equals weakness in so many contexts, even though it is vital in complementing our reason and rationality. The taboo surrounding loss and depression are sobering, and perhaps exacerbated by the current emphasis upon happiness and positivity. Positivity is great, but it can't be manufactured or make it up. You can cultivate the conditions to invite a sense of positivity, but there's little point (in fact, it's detrimental) to pretend you're absolutely fine when, in fact, you're knee-deep in grief. That's exactly the situation when you are more likely to suffer from 'complicated grief', because you are not allowing yourself the time and space, or perhaps enlisting the support of others for healing to take place.
Grieving very often is a complex process and does take time. The fact that it takes longer than a few weeks to grieve for a loved one does not make that grieving process somehow abnormal. Time in and of itself isn't necessarily a great healer. In this complexity it is useful in supporting clients (or friends and family) in being aware of some of the factors that can contribute to this complication rather than judge them or chivvy them along. Complexity can be influenced by the closeness of the relationship to the mourned, the nature of the attachment, whether there was 'unfinished business', the nature and circumstances of the death, how the mourner has responded to previous losses, and wider social factors (e.g. the support systems of the person), and whether there were other stresses going on at the same time (see Worden and Parke's books below). Why on earth should a parent who has lost a child in a shocking accident or someone whose closest friend has committed suicide be classified as having a 'bereavement disorder' for 'still' grieving three weeks after the death?
Grief stops us in our tracks and reminds us of the constant fragility of life. What might even seem at first like quite an insignificant death can un-hinge us, perhaps as it reminds us of earlier losses or coincides with a time of heightened personal vulnerability. Perhaps we don't 'move on', as the language goes, perhaps we have 'continuing bonds' in the words of the bereavement writer Tony Walter (Walter, 1983). People die and their legacy continues. Few of us forget how we have been shaped by the person we mourn, and, most likely, them by us, for good and ill. Quick fixes don't tend to work in the grieving process. After the initial shock of a death grieving can often make us gradually take stock, re-evaluate our new place in the world and in the network of our relationships, throwing light on who we are, what we're about and what matters. This isn't necessarily an easy or inspiring process, but it can have its moments. Let us give time and space to the grieving process rather than turning it into another problem which somehow needs to be treated.
References:
Parkes CM (1972) Bereavement: Studies of Grief in Adult Life, Penguin. ISBN 0 14 025754 3
Walter T (1999) On Bereavement: the Culture of Grief, Open University Press. ISDN 0 335 20080 X
Worden JW (1983) Grief Counselling and Grief Therapy, Routledge. ISBN 0 415 07179 8
Return to the main homepage. Return to Kamalamani's page of articles. Go to therapy for grief, loss and bereavement