Academic journal article Ethical Human Psychology and Psychiatry

Grief as a Border Diagnosis

Academic journal article Ethical Human Psychology and Psychiatry

Grief as a Border Diagnosis

Article excerpt

Grief is sometimes poetically described as the price of love: An inescapable existential condition of human life. However, throughout the 20th century, grief has increasingly come to be understood as a pathological condition that requires psychological and/or medical intervention. With the release of Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; American Psychiatric Association, 2013), grief came close to being included as a separate mental disorder. However, the diagnostic revisions concerning bereavement have been met with criticism of medicalizing grief and of exceeding the territory of psychiatry beyond its legitimate borders. On this basis, I argue that grief is currently a border diagnosis, that is, a condition whose meanings are informed in heterogeneous ways by medical, psychiatric, and psychological understandings yet constantly challenged by alternative, nonmedicalizing discourses. Drawing on empirical findings from an ongoing interview study with bereaved parents after infant loss, I analyze and discuss 4 different accounts concerning the question of diagnosing grief: (a) diagnosis as a legitimating and normalizing practice, (b) diagnosis as a demarcation practice, (c) diagnosis as pathologization, and (d) diagnosis as a normative ideal. Through the examples, I attempt to demonstrate how bereaved individuals do not merely passively adopt but reflectively use these kinds of understandings to deal with their grief.

Keywords: grief; mental disorder; Diagnostic and Statistical Manual of Mental Disorders (DSM-5); parental bereavement

Historically, death, loss, and grief have been experienced and practiced within an interpretive framework of religion and morality. However, in Western societies since the beginning of the 20th century, the disciplines of psychology and psychiatry have played an increasingly central role in our understandings and practices related to loss. This is part of a general historical line of development in which "in short, more and more people and problems were opened up to the diagnostic gaze and therapeutic interventions of psychiatry" (Rose as cited in Rose, 2006, p. 475). Bluntly put, the main problem of death in premodern societies concerned the destiny of the deceased person's soul in the afterlife. In contrast, the main problem of death in modern secular societies is that of the health and well-being of the survivors. Walter (1996) argues that the very concept of bereavement is a secular notion, in the sense that it reflects a shift from religious to secular concerns: From questions of salvation and condemnation to questions of health and illness, normality and pathology, risks and prevention.

This inclusion of bereavement under a "diagnostic gaze" has given rise to heated debates on the legitimate territory and limits of psychiatry. Most recently, this debate has been raised in relation with the release of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; American Psychiatric Association [APA], 2013). The two most contested revisions concerned the elimination of the bereavement exclusion criterion for major depressive disorders and the inclusion of complicated or prolonged bereavement reactions (currently named persistent complex bereavement disorder) in Section III of the manual as a condition for further studies (APA, 2013; criticized, e.g., in Frances, 2013; Wakefield, 2013). Without the bereavement exclusion, studies indicate that one-third to one-half of bereaved individuals will meet the diagnostic criteria for major depressive disorder within the first month after the loss (Clayton & Darvish and Zisook & Shuchter as cited in Horwitz & Wakefield, 2007, p. 31-32). For bereaved parents, the prevalence rates are estimated to be even larger, more intense, and long lasting (Horwitz & Wakefield, 2007).

This is not the place to account for the various arguments that have been raised in relation to these revisions. …

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