This reflection is based on a paper which I presented at a conference yesterday. The main theme of the conference was evidence-based practice in counselling, with a sub-theme being recent changes to psychiatry’s diagnostic manual. I began with some words from Australian philosopher, Raimond Gaita:
"Our sense of the preciousness of other people is connected with their power to affect us in ways we cannot fathom and in ways against which we can protect ourselves only at the cost of becoming shallow. There is nothing reasonable in the fact that another person's absence can make our lives seem empty. The power of human beings to affect one another in ways beyond reason and beyond merit has offended rationalists and moralists since the dawn of thought, but it is partly what yields to us that sense of human individuality which we express when we say that human beings are unique and irreplaceable. Such attachments, and the joy and the grief which they may cause, condition our sense of the preciousness of human beings."
Previous editions of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, have included a "bereavement exclusion" in the case of depression. This was a direction in the manual that when diagnosing a possible case of major depression, if the symptoms can be properly interpreted instead as a case of bereavement, then bereavement rather than depression should be the diagnosis. This is because depression and bereavement can look like one another in certain aspects, but they are different in important ways and it is inappropriate to treat bereavement as a mental illness.
It was proposed that this bereavement exclusion be removed from the new DSM-5. As a result a debate emerged while the new edition was being drafted based on the concern that this removal would lead to grief being increasingly viewed as a mental illness. It seemed to me that there were no meta-analyses of the controversy which adequately surveyed the arguments pro and contra the removal, so as a philosopher and counsellor I engaged in this analysis.
The key argument against the removal of the bereavement exclusion was that it would likely lead to "the pathologisation of grief". That is, grief and bereavement – a natural, meaningful experience – would become re-described in our cultural practices as a medical problem, something to be treated by GPs and psychiatrists and drugs. Beyond the obvious problem that some clinicians see everything in medical terms and will be very happy to prescribe antidepressants for grief, it was also suggested that many more time-pressured clinicians would opt to treat bereavement as depression out of compassion - misguided compassion - as a means of increasing client access to psychological help and dulling their pain. It was noted that profiteering pharmaceutical companies would probably become very active in ‘raising awareness’ of the supposed biological roots of our bereavement and how their products can treat it.
These arguments certainly resonate with the widespread criticism that we currently pathologise many forms of anguish, visiting physicians and popping pills rather than looking at the real roots of our despair and anxiety. Psychological technologies often serve as culturally approved yet nonetheless superficial evasions of life's deeper challenges. This has already happened in the case of anxiety and melancholia, and with the latest edition of the DSM it appears that this distortion is spreading to grief and bereavement.
Grief – a pained response to a significant loss - can be terrible, but it is also a vital good in our lives. It is a condition for experiencing others as valuable. The value we can have in each other's lives means that death can occasion profound suffering - our suffering is an expression of that value. It is not a medical condition.A reduction of grief and bereavement to a medical pathology would surely obscure and threaten its vital, meaning-filled - and meaning-bestowing - place in our lives. I am reminded of Gaita's words above about rationalists and moralists - this time around of the medical sort. I am reminded of what he says in the second part of that sentence. The pathologisation of grief may reduce our pain, but it will rob us of our sense of the profound meaning and value that we have in one another's lives. And that is too great a cost.
My name is Matthew Bishop. I am a counsellor, with a background in philosophy. I have spent years exploring how philosophy enters into therapy, both theoretically and practically. One of my big influences is existential therapy. Although uploaded here recently, these are reflections written at different times over the last ten years.