So when exactly do you pathologize a normal human process?
I have been thinking quite a bit about this recently because I remember, as the second anniversary of my wife's death approaches, a time where I was sitting in a conference about nothing particularly interesting, at least not to me, and surfing on my smartphone, which is what most bored conferees do. For some reason I happened to alight on a heated debate between psychiatrists about removing the 'Bereavement Exclusion' from the diagnosis of Major Depressive Disorder, and since my wife was already dying of the cancer which would kill her...had in fact less than a year to live . . .I thought the topic had some relevance to me. And since this is the forum where we all explore our grief, and our response to it, I suspect it has relevance to everyone here as well.
And now the DSM-5 is out, and the so-called bereavement exclusion is indeed gone. This gets us thinking what do we mean by the terms grieving and depression anyway?
Welcome, fellow travelers on the grief journey
and a special welcome to anyone new to The Grieving Room.
We meet every Monday evening.
Whether your loss is recent, or many years ago;
whether you've lost a person, or a pet;
or even if the person you're "mourning" is still alive,
("pre-grief" can be a very lonely and confusing time),
you can come to this diary and say whatever you need to say.
We can't solve each other's problems,
but we can be a sounding board and a place of connection.
Unlike a private journal
here, you know: your words are read by people who
have been through their own hell.
There's no need to pretty it up or tone it down..
It just is.
That grief is a profound and very human reaction to sorrow and loss has been well known and quite transcultural. Freud himself was careful to draw a distinction between grieving, which he felt was normal, and Depression, which is a psychiatric condition which needs treatment, and needless to say, has a not inconsiderable fatality rate if untreated.
although mourning involves grave departures from the normal attitude toward life, it never occurs to us to regard it as a pathological condition and to refer it to a medical treatment. We rely on its being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful
That was from "Mourning and Melancholia"
Moving onto modern times we have the DSM-V, the 'Diagnostic and Statistical Manual of Mental Disorders' an often revised compendium of criteria that is, well, at least in theory, a commonly agreed set of criteria on which to base diagnoses of mental health disorders. It is not without controversy, and like most of psychiatry tries to be as rigorous and evidence based as possible while leaving room for uncertainty and the limits of what we know. Up to the last revised edition, the DSM-IV-R, there was an exclusion for recent bereavement if you were making a diagnosis of depression on anyone (the long shadow of Freud lingers); that seemed logical because most grief symptoms will lessen over time. And yet, what if you had someone whose grief tipped them into major depression or coexisted with prior depression? It seemed cruel to deny them treatment just because they had a loss recently, and so this 'bereavement exclusion' was removed, although as I mentioned, with a significant controversy. Why stigmatize and medicalize a normal human response to pain? And anyway, how many of us, in our acute grief really want to go see a psychiatrist, assuming we could afford one? I think many will relate to what was the most common thought that came into my mind, during the aftermath of my loss: "leave me alone". And I can certainly say there was no way I was going to take any drugs for this, besides that which came out of a Scotch bottle, which was for a time the way I medicated myself for symptom relief.
Making things more complicated yet, there is grief, and there is complicated grief. There seem to be symptoms of this condition that accord with uncomplicated grief (and by the way, I cordially detest the term 'normal grief'. What the hell is so goddamned normal about feeling as if the sun had turned black?) but are more intense, interfere with basic life functioning and don't get better. They are the "time heals nothing" people and for that I am truly sorry. I direct your attention to a free paper that unsucessfully advocated for Complicated Grief to be placed in the DSM-V and if any here recognize themselves or a loved one in the description then maybe some help would be worthwhile. By the way, they did include it in a category of conditions that merit further study; I have seen it on websites and I think it will get there eventually.
And then we have Major depression, which most mental health professionals agree is a condition that needs, and often though not always responds to treatment. It is characterized by profound feelings of low self worth, an inability to experience pleasure, and sometimes hallucinations or other psychotic manifestations. This is where medications can sometimes be helpful, particularly as an adjunct to cognitive therapy. What I might say is that this is the part of the spectrum of grief that can be lethal. Robin Williams is an all too sad example of this. Closer to home, I well remember an event that happened four months after my wife died: A young associate of mine went home one night and killed himself with a single gunshot wound to the head. It was my second funeral in four months. And by the way, depression seems to be increasing
I tried to think of clever analogies to drive the point home, and the best I can come up with is this: Grief is a deep, inflicted wound. It hurts....by God, it hurts...but it does get less painful over time and it does heal, but with a scar. Sometimes the scar aches, and it may not look pretty, but the wound heals all the same.
Complicated grief is like a wound that will not heal. Some wounds don't for any number of reasons. And it can be real hard to function with a wound that does not heal; wounds of that sort require more intervention than just a loving bandaid. Real treatment is here indicated
Major Depression is just like a wound that becomes infected. Of course it won't heal; infected wounds do not heal by definition. But the infection can spread and become lethal. In the days before antibiotics otherwse healthy people died that way.
I suppose I would place myself on the side of the spectrum of complex grief, but not complicated. It is complex, because, as I think I have already described, it is mixed up with feelings of anger and betrayal and estrangement. I still have some deep conflicts which will take a long time to resolve, if ever. How different from the way simple, and simplistic grief is usually portrayed. But I do function; maybe having a child to support makes me be functional. And I will share this: I see her sometimes in my dreams, but they are not always happy ones. At times both she and I seem puzzled; why am I not living where I was, why am I not with her, why would I think she even died in the first place? In my dreams, I have no answer. Sometimes she is . . . threatening. You know what I don't get and really want, in my dreams is the way she was before the illness, the her as I try every time I think of her to remember.
All of us, no matter where we lie on the spectrum need something. There really is nothing pathologic about that
Pass me that cup
My dearest friend
For my arms are weary
And my vision's gone
Put your arms around me
And sing me that sweet song
Of well lived chances
When my will was strong
I cannot face tomorrow
For my song is sung
I had my chances
Now what's done is done
Let's sit awhile together
As the sun goes down
Let's talk and laugh at memories
We wove as one
Then slip quietly away
A new day has begun.
But I will not be here
To greet the morning sun.
Alison Stormwolf 'Tripping Softly'