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Is grief a disease?

The arbiter of health answers in the positive. That is, the present model of
health categorises grief as a disease of the brain and, a fortiori, a mental
disorder. To offer any remarks on the normative significance of this
categorisation, however, one must be sensitive to the motivations behind it.
This paper traces the key actors responsible for this categorisation, in
particular the institutional interests of twentieth century psychiatry, before
considering its normative value and potentially objectionable effects.
It is not for the individual to constitute disease. That I could provide my own
definition of disease and see whether grief is accommodated evades the
reality of the situation. The reality is one where disease is constituted through
medical paradigms, or models, proselytised by institutional forces. (Sheridan
and Radmacher 1992:5) There are biomedical, sociomedical, pschycomedical,
and fusion biopsychosocial models to name but a few. (Averill and Nunely
1988:86) Whichever achieves dominance for a given social context will be the
determining agent of the nature of disease. A sociomedical model, for
example, will understand alcoholism with an eye to its sociological
foundations, that is, its significance as a constituent part of a broader social
system. A biomedical, however, is likely to view it as a chemical imbalance of
an individuals brain. (Ibid. pg.86) These models then, have very practical
repercussions. We could imagine the difference in stigma and treatment of
alcoholics depending on which medical model is not just in vogue, but the
cultural imperative of the medical times. (Engel 1977:130) The first model
might understand alcoholism as a consequence of social anomie, one whose
treatment depends on undermining its sociological causes. The biomedical
model, by contrast, is more likely to treat alcoholism as a problem of the
individual unrelated to his/her social context. Chemical medication to target
the supposed imbalance may well be prescribed. (Ibid. pg.86) Given these
repercussions, for this paper to be of any practical import is must engage
with the present model of disease. Sensitivity to the medical reality of our
time, that is, psychiatrys incorporation of the biomedical model, must be
upheld less practical criticism give way to abstract philosophical musings.
To reiterate, grief already has been, and is continuing to be, conceptualised
and treated as a disease. The ascendency of the biomedical model has been
named as a primary cause. So what is a medical model? Like Kuhns
paradigms of science, medical models identify the questions that ought to
be studied and determine the research methods that may be used. (Kuhn
1962) Problems that do not fit this paradigm, or model, tend to be ignored or
considered illegitimate objects of study. (Sheridan and Radmacher pg. 3)
Professionals operating within a medical model tend to be relatively unaware
of its influence. Rather, models constitute a kind of cultural background
against which they learn to be professionals. (Engel 1980:535) In short,
medical models are pervasive conceptual frameworks that dictate the terms
of health, disease, study, and treatment.
Let us now move on to the biomedical model. Four tenets can be identified in
the following:

1. Disease is a deviation from normal physiological functioning.


2. Diseases have specific causes than can be located in the body.
3. Diseases have the same symptoms and outcomes regardless of social
context.
4. Physiology and molecular biology is the base science.
(For similar understandings, see Engel 1977, Averill and Nunely 1988, Lorber
and Moore 2002, and Deacon 2013) Shorter neatly captures the nature of this
model with regard to psychiatry when he observes, a biomedically oriented
psychiatrist believes in approaching psychiatric illness just as a cardiologist
would approach heart disease. (Shorter, 1997:108) The models ultimate
goal is the discovery of magic bullets precise therapeutic agents that
specifically target the disease process without harming the organism, much
like penicillin for bacterial infection. (Deacon pg. 848) Eating disorders,
depression, schizophrenia, ADHD, OCD, alcohol and drug addiction, not to
mention grief, have been on this model classified as mental illnesses. And
what is a mental illness? It is, especially with regard to tenets one and two, a
disease of the brain. (Ibid pg. 849) To illustrate the biomedical models
dominance within psychiatry, consider the following:
Many illness previously described as mental are now recognised to have a biological
cause - Thomas Insel, M.D., National Institute of Mental Health Director
Mental illnesses are biologically based brain diseases. - National Alliance on Mental
Illness
The biological basis for psychiatric illness is now well established. - American College of
Neuropsychopharmacology Depression and Bipolar Support Alliance
Perhaps by now the sceptic is ready to concede that grief can be considered a disease
state - George Engel (1977:20)
"The concept of disease is as appropriately applied to the results of a loss as it is to the
results of a wound, burn or an infection" (Bowlby 1961:322-323)

But we cannot move onto an evaluation of these comments, that is,


psychiatrys capitulation to the biomedical model, without first inquiring into
the how and the why it so capitulated.
That is, once we see that grief has been pathologized not because of some
scientific eureka moment, as if there had been discovered a grief gene' or
brain lesion one could treat with a magic bullet, but because of contingent
historical forces and institutional interests, only then will we know what we
are dealing with, and most importantly, how to be critical with it. A
genealogy of grief as a disease would be ideal. But such a feat cannot be
attempted by this paper. It is enough, for now, to identify the key actors
responsible for griefs pathologisation. This will illustrate not only how grief
came to be categorised as a disease, but where this categorisation can be
challenged.

Psychiatrys reaction to Freuds influential 1909 Clark Lectures in America as


well as his Mourning and Melancholia (published 1917) can be identified as
the origins of griefs pathologisation. (Granek 2010:50) Now Freud himself
was explicitly against treating grief as any kind of disease. In Mourning and
Melancholia he quite clearly warns against its referral to medical treatment.
(Freud 1917/1963:252) But of the significant influences Freud had on
American psychiatry, this warning was not one of them. (Granek pg.50) What
it took to be Freuds most influential idea was his onus on the everyday as
sources of psychological interest. Slips of the tongue, dreams, infantile
sexuality, not to mention the power of the unconscious to effect ordinary
behaviour, phenomena that was not previously considered worthy of
psychological interest, were, for the first time, deemed legitimate objects of
study. (Granek pg. 51, see also Freud 1909,1990) By psychiatry adopting this
psychoanalytic emphasis of everyday life as a sphere worthy of investigation
it also adopted a revolutionary epistemological stance. Its confinement to the
state hospital was lifted, its borders radically opened. (Illouz 2008:38) No
longer were emotions, including grief, to be considered beyond its scope.
There is a great deal more to say here, but what is of crucial relevance to our
inquiry is that grief was, after Freud, put on psychiatrys to-do list. When
psychiatry capitulated to the biomedical model of health and disease, grief,
therefore, was bound to go with it. So when did this capitulation occur? Given
there was no eureka moment for psychiatrys understanding grief as a
disease, it is not surprising that the capitulation defies an exact beginning.
We can though, observe that from the 1920s through to the late 1950s works
of some of the most eminent psychiatrists pushed their field towards
integration with the biomedical model. Emil Kraepelin, often dubbed the
father of psychiatry, for example, sought to establish that all psychological
symptoms, including grief, were unambiguous and had physical
foundations. (Granek pg. 55, Kraepelin 1921:115) Note this is an explicit
acceptance of the biomedical models second and third tenets we outlined
earlier. Equally influential was Erich Lindemanns work on grief in 1944. He
claimed to have established grief as a process with an etiology that could be
predicted, managed, and subsequently treated by professionals. (Lindemann
1944:143) Again, consider the similarities with the biomedical models tenets,
especially the first three. Lindemann was also the first major psychiatrist to
explicitly argue in favour of psychiatric intervention for certain kinds of
grieving. (Ibid. pg.147) Religious institutions and the family, he suggested,
were to be deemed as unqualified therapists for grief as they would be for
heart disease. (Shorter 1997)
The work of these two men was fundamental in ensuring psychiatrys
incorporation to the biomedical model. Note though that their work did not
single-handedly force griefs pathologisation, nor psychiatrys biomedical
shift. There were other actors, of equally notable importance, who ensured
griefs trajectory maintained its direction towards pathological categorisation.
Already in movement, though intensified in light of Kraepelins and
Lindemanns work, was a swing away from psychoanalysis towards more
empirically methodological psychiatry and psychology in general. This swing,

however, was not without resistance. By the 1960s psychiatry was becoming
increasingly divided. One the one side, to put it briefly, were Freudians and
those involved in the anti-psychiatry drive (such as Thomas Szaz and R.D.
Laing) who rejected any such swing towards the biomedical model, and on
the other, psychiatrists schooled in the works of Kraepelin and Lindemann
who actively sought it. (Deacon pg. 848) Representatives of the latter
demanded their discipline to join the prestigious natural sciences and utilize
their methods, epistemology, and experimental apparatus. (Ward 2002:43)
Psychiatry would benefit, they argued, from the perception that, like other
areas of science and medicine, it had its own valid diseases and effective
disease-specific remedies. (Deacon pg. 848) In tandem to what was going on
in the United States, British psychiatrists and psychologists similarly began to
emphasis
empiricism
and
psychopharmacological
experiments
to
professionalise their studies. (Moncreiff and Crawford 2001) Come the early
1970s, psychoanalytic theories were being increasingly replaced by a more
empirical, quantitative approach with a focus on biological orientation for
understanding and treating mental illness. (Granek pg.60)
But why, at bottom, did psychiatry feel the need to professionalise, or join
league with the natural sciences? It was, as Deacon notes, fundamentally an
attempt to legitimize psychiatrys validity as an empirical science, one that
blows with, and not against, the positivist currents of the time. (Deacon pg.
848) The biomedical model was already operating in the medical world
beyond psychiatry. To not surrender to this model would amount to
institutional suicide. Note also this fear of the end of psychiatry persists to
the present day. We need to be more medical to be taken seriously
remarked influential psychiatrist Alan Schatzberg in 2010. (Deacon pg. 848)
..
This surrender though was not, as stated, simply the result of Kreapelin and
Lindemanns work. Neither was it the case that every psychiatrist saw the
danger of his/her profession dying out, and so individually sought to
legitimise it via the biomedical model. (Granek 57-58) The imposition of the
biomedical model was more of a top down affair, administered by its
institutional powers. Consider the influence of the American Psychiatric
Association (APA). The APA established a division of publications and
marketing, as well as its own press, and trained a nationwide roster of
experts who could promote the biomedical model in the popular media.
(Sabshin 1981) It held media conferences, placed spokespersons on
prominent television shoes, and bestowed awards to journalists who penned
favourable stories. (Deacon pg. 848) So successful was its carefully
choreographed program, that by the 1980s the media came to hail the
scientific revolution within psychiatry, one dedicated to the development of
drugs and therapies to heal sick minds. (Franklin, 1984:1)
United by their mutual interests in the promotion of the biomedical model
and pharmacological treatment, psychiatry joined forces with the
pharmaceutical industry. A policy change by the APA in 1980 allowed drug
companies to sponsor scientific talks, for a fee, at its annual conference.

(Whittaker 2010a) Within a few years the organisations revenues had


doubled, and the APA began working with drug companies on medical
education, media outreach, congressional lobbying, and other endeavours.
(Deacon pgs. 848-849) Under the APAs direction, the National Institute of
Mental Health (NIMH) systematically directed grant funding towards
biomedical research while withdrawing support for alternative sociomedical
approaches. (Ibid pg. 848) Likewise the National Alliance on Mental Illness
(NAMI) developed close ties with the APA and the drug industry. A powerful
patient advocacy group, the NAMI dedicated itself to reducing mental health
stigma by blaming mental disorder on brain disease, as opposed to
sociological factors. (Ibid. pg. 848) Whitaker concisely summarises the
culminating effects of these actors cooperation,
In short, powerful quartet of voices had come together by the 1980s eager
to inform the American and wider public mental disorders were brain
diseases. Pharmaceutical companies provided the financial muscle. The APA
and psychiatrists at top medical schools conferred intellectual legitimacy
upon the enterprise. The NIMH put the governments stamp of approval on
the story. NAMI provided the moral authority. This was a coalition that could
convince American society of almost anything (Whitaker 2010:280)
The final actor that deserves out attention with regard to the pathologisation
of grief is the development of the Diagnostic and Statistical Manual of Mental
Disorders (DSM). From its very inception, it seems to have always had
something of the biomedical about it. (Lane, 2007) It was, for example,
Kraepelins work and key notion that all psychological symptoms had physical
foundations that became the foundation for the first diagnostic manual, the
Statistical Manual for the use of Hospitals for Mental Diseases (1918). By the
1950s, however, there was an exceptional rise in the number of patients
eligible for psychiatric therapy, largely because of the Veterans
Administration bill, that guaranteed returning World War II soldiers
psychological diagnosis and treatment. (Moore 71:1992) This rise, coupled
with Freuds onus on the everyday as interest of psychological studies, saw
the percentage of psychiatrists working in independent practices, as opposed
to hospitals or asylums, between 1917 and 1941 more than quadruple.
(Granek pg. 56) A new sort of manual was required, one that could assist
psychiatrists in their treatment of non-hospitalised patients and also provide
curative measures to the supposedly pathological elements of their
everyday lives. (Ibid. 56)
Cue the first incarnation of the DSM in 1952. The present manifestation, the
DSM-V (published 2013) is, like its ancestor, still constructed and published
by the APA. This bible of psychiatric and psychological diagnosis has not
only earned the APA, since its first publication, one hundred million dollars,
but it has time and time again provided psychiatrists with the literary backing
to pathologise grief. (Greenberg 2012, Deacon pg. 848-852) The DSM has
served to perpetuate psychiatrys and psychologys adoption of the
biomedical model, encouraging healthcare professionals to treat their
patients concerns as diseases of the brain with chemical based magic

bullets. (Deacon pg. 849) Most pertinent to our inquiry is the present DSMVs inclusion of grief as a kind of major depressive disorder (MDD). Diagnosis
of an MDD must find the individual exhibiting general distress symptoms such
depressed mood, insomnia, decreased appetite, decreased interest, and lack
of concentration, for two weeks or more. (Wakefield 2013:171) These
symptoms are found nearly always in grieving individuals. (Ibid pg. 171) Such
an individual is then, a la the most recent DSM, suffering from a major
depressive disorder. And what is a mental disorder? We have by now learned
from psychiatrys biomedical model that it is a disease of the brain.
The above discussion on how grief came to be pathologised is brief.
Hopefully, however, what is of our interest to our inquiry been made clear.
That is, what was responsible for griefs being treated as a disease was not
the result of groundbreaking scientific research within the field of psychiatry.
Rather, it was the result of a constellation of institutional interests and
contingent historical events. Perhaps this is why grief as a disease lacks the
sound biological basis that the biomedical model demands of its diseases.

But what is of interest to our inquiry has, I hope, been made clear without the
need to go further into the history griefs pathologisation. That is, psychiatry
capitulated to the biomedical model not because of groundbreaking research.
What was responsible for its capitulation was not a eureka moment, but
institutional interests. (Ibid. 848-850)

The incredible recent advances in neuroscience, molecular biology, and brain


imaging...are still not relevant to the clinical practicalities of everyday psychiatric
diagnosis. The clearest evidence supporting this disappointing fact is that not even on
biological test is ready for inclusion in the criteria sets for DSM-V. - Allen Frances, M.D.,
Chair of DSM-IV Task Force.
What we are missing is an understanding of the biology of the disorders and what is
really going wrong. Thomas Insel, M.D., National Institute of Mental Health Director
Chemical imbalance is sort of last-century thinking. It's much more complicated than
that. It's really an outmoded way of thinking. Joseph Coyle, M.D., Editor of Archives of
General Psychiatry
brain science has not advanced to the point where scientists or clinicians can point to
readily discernible pathologic lesions or genetic abnormalities that in and of themselves
serve as reliable or predictive biomarkers of a given mental disorder or mental disorders
as a group. TheAmericanPsychiatricAssociation
Psychopharmacology is in crisis. The data are in, and it is clear that a massive
experiment has failed: despite decades of research and billions of dollars invested, not a
single mechanistically novel drug has reached the psychiatric market in more than 30
years. Surgeon General's Report on Mental Health H. Christian Fibiger, Ph.D., former vice
president of neuroscience at Eli Lilly and Amgen

Few lesions or physiological abnormalities define the mental disorders, and for the most
part their causes are unknown. - Ibid

Freud, biomedical model states mental illness are diseases of the brain.
How does grief qualify as a disease of the brain. DSM, Engel, Glass,
Stroebe

Depression, Multiple Personality Disorder, Attention Deficit Hyperactivity, and


Social Phobia, as well as kinds of grief have been, in Thomas Szaszs words,
wrongly pathologized problems of living by the DSM. (Szasz 1961)

Moreover, the influence of American psychiatry served to reinforce existing


similar movements in the UK and parts of Europe. (Ibid. pg.849)

We have now seen the Freud illustrated the richness of understanding grief.
We have also seen how institutional interests guided psychiatrys capitulation
to the biomedical model. I have not claimed the story to be complete, but
these two elements are fundamental to arriving at our present biomedical
understanding of grief, that is, grief as a disease.
PARAGAPH ON DSM

1.
2.
3.
4.

Freud
Biomedical model
DSM criteria
Normative significance

It is beyond the scope of this paper to undermine the legitimacy of the


biomedical model simpliciter.

Kraepelins work was instrumental in the

Kraepelin, Lindemann in Granek


APA / schism in Deacon

If Freud put grief on the map, it was not left up to him to chart its territory. By
the 1940s a number of eminent psychiatrists had ignored his resistance to
pathologizing grief. Kraepelin, for example,)

Lindemann too,

The essence of Kraepelins work was to shift thinking of pathology on a


continuum to differentiating distinct diseases by observing their outcomes in
psychiatric patients and creating a system in which psychiatrists could
reliably diagnose pathology. (Shorter 1997)

Come the 1930s a schism appeared in

The second effort of Freuds that bore significant influence on American


psychiatry was his discussion of grief work in Mourning and Melancholia.
Freud proposed that the mourner had the task of detaching their
libido/emotional energy from the deceased and sublimating it into other areas

of their lives. (FIND IN FREUD) Failure to do ones grief work, that is, the task
outlined above, was a failure to heal or recover. Now Freud did not intend
to suggest any failure to heal meant the subject was diseased. But this was
not how he was read by psychiatrists. (Granek pg. 50-52) Rather, by
introducing medicalized terminology into the discourse of grief, Freud
provided American psychiatry with a foundational lexicon with which it would
later justify the use of medical intervention. (Ibid. pg. 52) Most notable was
Helenes Deutschs 1937 conceptualization of a normal course of grieving.
(Deutsch 1937) The failure to do ones grief work, she wrote, was a deviation
from this course. Such a failure was represented, crucially, in either excessive
grieving or a lack of grieving. (Ibid. pg.12) This idea was pivotal in the
process of griefs pathologisation. That pathological grieving could manifest
itself in intense outpourings of loss, or the absence of any symptoms
introduced the notion that all grievers are potentially ill and need to be
monitored for the process of their grief work. (Granek pg. 54) Deutschs
suggestion that grief work must be done less it resurface elsewhere put the
onus of responsibility on the grieving subject to self-monitor or risk becoming
ill. To illustrate how influential Deutschs appropriation of Freudian concepts
as medicalized terminology, consider the much later (separate) works of
Archer and Stroebe, both of whom invoke the notion of failed grief work to
justify medical intervention. (See Archer, 1999 and Stroebe et al,. 1992)
One neednt have chartered grief as something to be worked through,
however, in order to locate it as a potential disease. We must turn to the work
of Emil Kraepelin, and his subsequent popularization of the biomedical model,
to gain a further, parallel insight into griefs pathologisation.

One did not need to buy into the notion of grief work, however,

It was, though,
Kraeplin
Lindemann
Legitimization of psychiatry by capitulating to the medical model. APA 1980s
and pharmaceutical revolution Deacon / Engel .77
Modernist condition?
World War II.

If Freud suggested grief was of psychiatric interest, it was the American


Psychiatric Association (APA) that

Mourning is not the spontaneous expression of individual emotions.


(Durkheim, 1968:567)

Rather, let us briefly discuss some of the most fundamental forces


responsible for the pathologisation of grief, less we begin to consider grief as
a disease in the abstract, as if it did not have a formative history, as if this did
not matter to its constitution.

Without sensitivity to present understandings of disease our question will not


make much sense. It is not up to me whether grief is or is not a disease.
There are institutional forces responsible for the nature of disease. I am
obviously not one o
That, for example, depression is classified as a treatable mental illness

Such a definition holds no sway.


What we ought to do, if anything here is to be of some remote importance,

Without sensitivity to this history we will be numb to the meaning of grief in


the present.
Ask a Tahitian and hell answer in the positive. (Averill and Nunely 1988:85)
The same can now be said of psychiatrists. (Granek 2010:49) But unlike the
people of Tahiti, the yes with which psychiatry replies to our question today
is at odds with its no of the nineteenth century. This is our starting point.
Grief has already been pathologized. This paper locates psychiatrys
capitulation to the biomedical model at the hands of its most powerful
institutional forces as fundamental to griefs pathologisation. Only in light of
the history o

In the 1930s a schism opened in psychiatry. In light of recent medical


developments, the field was divided between biological psychiatrists, that
is, psychiatrists who favoured a biomedical approach to their subjects, and
the Freudians who resisted such an approach.

Without sensitivity to this history we will be numb to the meaning of grief in


the present. That is, the normative significance of griefs pathologisation will
depend on an understanding of the how and the why grief came to be so
pathologized. I trace griefs categorisation of disease,
there is no such thing as grief in the abstract, it is not above history. I
therefore trace the trajectory of griefs pathologisation, drawing particular
attention to psychiatrys capitulation to the biomedical model, before turning
to this pathologisations normative significance

Characterised by a mind-body dualism, the biomedical model came to


dominate health understandings from the mid-nineteenth century onwards in
the US and Europe. (Sheridan and Radmacher 1992:5) On this model, only
that which could be located in the body was open to medical treatment and
study. No attention was given to the psychological or the social. The mind
and society were not, after all, in the body. It was therefore left to
sociology and psychoanalysis to pursue these objects in a realm beyond that
of the scientific. (Sheridan and Radmacher pg. 5)
Come the 1930s, however, this attitude shifted. A number of medical
breakthroughs, particularly the discovery that general paresis could be
treated by penicillin, suggested mental disorders could be cured with somatic
therapies. (Deacon 848)

Consider the following quote from Walter, The notion of a mental illness
would have been considered an anathema. (Walter, 2005-2006:63)

In the 19th century, grief was a condition of the human spirit or soul. It might
sometimes be viewed as a cause of insanity, but it was not itself a mental
illness.

Freudian psychoanalysis, therefore, could capitalise on the neglect of the


mind,

The human was increasingly conceptualised in mechanistic terms. Ailing


parts could be fixed or replaced as if the body was a machine.

Andreasen has identified the following tenets


1. Mental disorders are caused by biological abnormalities principally located
in the brain
2. There is no meaningful distinction between mental diseases and physical
diseases
3. Biological treatment is emphasised
- Andreasen 1985.
Engel The B.M takes molecular biology as its base scientific discipline.
A disease be dealt with as as entity independent of social behaviour
Behavioural abberations are to be explained on the basis of disordered
somatic, that is biochemical or neurophysiological, processes.
not, at first, extended to psychiatry.
of health dominated health understandings in much of Europe and the US in
the early 20th century.

plan
What is the bio model?
How did psychiatry come to incorporate it?
Deacon industry
Granek Book on Modernist condition/Foucault medicalisation

Freuds visit in 1909 to America to present the widely publicized Clark


Lectures, the publication of his Totem and Taboo in 1912, and his Mourning
and Melancholia in 1917 fundamentally reoriented the focus American
psychiatry. With regard to his lectures, we can identify two radical ideas Freud
outlined that started the biomedical models path to ascendency and the

subsequent pathologisation of grief. The first was the focus on everyday life
as sources of interest to psychoanalysis. (Granek pg. 51) Slips of the tongue,
dreams, infantile sexuality, not to mention the power of the unconscious to
effect ordinary behavior, phenomena that was not considered worthy of
psychological interest, were suddenly deemed to be objects of intense
scrutiny. (Freud 1909:1990) Illouz remarks the inclusion of these supposedly
unimportant instances of human behavior as fundamental to psychological
analysis represented the making of the meaningful, the trivial, and the
ordinary, full of meaning for the formation of the self. (Illouz 2008:38) It is no
surprise then, that grief, one of the more everyday phenomena, was on its
way to being an object of considerable psychological interest.

Biomedical health biomedical psychiatry

Let us first sketch a picture of the biomedical model of health. What is a


model of health? In brief, is a conceptual structure (though it will have very
practical ramifications) through which health is understood. A sociomedical is
likely to view diseases as social constructions, its most fundamental base
science being sociology. (Averill and Nunely pg. 87) A biomedical model of
health, by contrast, takes physiology and molecular biology as its base
sciences. (Ibid. pg. 87) We can note three fundamentals tenets of this model
in the following:
1. Disease is a deviation from normal physiological functioning,
2. That diseases have specific causes than can be located in the body,
3. That illnesses have the same symptoms and outcome regardless of social
context. (Lorber and Moore 2002:2)
Shorter neatly summarises the practical ramifications of this model when he
observes, a biomedically oriented psychiatrist believes in approaching
psychiatric illness just as a cardiologist would approach heart disease.
(Shorter, 1997:108) This form of practice not so much a popular preference
as it is a cultural imperative. (Engel 1977:130)
So how did grief come to be categorized as a disease in light of this model?
There is no one simple answer, and I am not able to recapitulate the entire
pathologisation of griefs narrative here. The answer is especially complicated
by the fact that, of the three tenets listed above, number three does not even
seem true of grief. I will say more on this later. But, for the meantime, we

must remember grief has nonetheless been categorized as a disease, and it


has been so categorized by the biomedical model. So in order to understand
this categorization, we must turn to how the biomedical model reached its
predominant position today, and how it incorporated grief into its purview. To
do this we can focus on what I identify as three of the most important causes
of this categorization, namely, the rise and influence of Freudian
psychoanalysis, the demand for psychological therapy in the aftermath of
World War Two, and the nature of the modernist condition. Let us begin with
the first.
Freuds visit in 1909 to America to present the widely publicized Clark
Lectures, the publication of his Totem and Taboo in 1912, and his Mourning
and Melancholia in 1917 fundamentally reoriented the focus American
psychiatry. With regard to his lectures, we can identify two radical ideas Freud
outlined that started the biomedical models path to ascendency and the
subsequent pathologisation of grief. The first was the focus on everyday life
as sources of interest to psychoanalysis. (Granek pg. 51) Slips of the tongue,
dreams, infantile sexuality, not to mention the power of the unconscious to
effect ordinary behavior, phenomena that was not considered worthy of
psychological interest, were suddenly deemed to be objects of intense
scrutiny. (Freud 1909:1990) Illouz remarks the inclusion of these supposedly
unimportant instances of human behavior as fundamental to psychological
analysis represented the making of the meaningful, the trivial, and the
ordinary, full of meaning for the formation of the self. (Illouz 2008:38) It is no
surprise then, that grief, one of the more everyday phenomena, was on its
way to being an object of considerable psychological interest.
The second idea of Freuds that was so instrumental to the rise of the
biomedical model, and therefore the pathologisation of grief, was his notion
of grief work. In Mourning and Melancholia, he proposed that the mourner
had the task of detaching their libido, or emotional energy, from the
deceased and sublimating it into other areas of their lives.
Those who do not do their grief work could end up with a psychiatric illness
that resulted from their pathological grieving.

he made between the realm of the everyday and peoples health. (Granek
pg. 51) He suggested health and pathology occupied a continuum without an
overt distinction. The effect of this was to blur the division between the
normal and the abnormal. CUT THIS PARAGRAPH?

The foundations for the biomedical model of health and disease had been
laid. A revolutionary epistemological stance that was broad enough to
encompass everything and anything.
SAY WHY/HOW THIS RELATES TO RISE OF BIO MODEL. See also the continuum
reason.

Mourning and Melancholia included Freuds central ideas concerning grief,


ones that he had built upon from Totem and Taboo.
.

WHAT IS A DISEASE
WHY WOULD A SOCIOMODEL NOT INCLUDE GRIEF AS DISEASE?
the three main causes I will focus on include the rise of Freudian
psychoanalysis, 20th century modernism, and

Is Grief a Disease? MASTER PLAN


We ought to add for whom. For the biomedical model, that is, the dominant
framework of health and disease today, grief is a disease.
Why? Institutional factors
1. Rise of the Freudian psychoanalysis made psychiatry focus on the
everyday.
2. Then it adopted the biomedical model
3. So grief (the everyday) became pathologised
Yes. At least on the biomedical model, so lets look at why.
Biomedical model definitions. Lorbers 1,2, 3.
Grief doesnt fit for three SO VALUE JUDGEMENT?
Outline three reasons why grief became subsumed into this model.
1. Freudian extension into the everyday
2. WWII
3. Conditions of modernism. See too Foucault book pg. 165 rise of stage
theories
Normative significance Medicalisation, individualisation, lack of ritual? Find
study that found those who forgo mourning practices tend to recover worse
off than those who dont.

Difference between the rise of this model and griefs absorption into it.

Yes. Granek Ingrained quote. So why did grief become a disease?


Outline Engels and XYZs arguments briefly.
BUT grief did not become a disease because of Engels arguments. Same for
XYZ. Rather, they were contributing factors of a process of pathologisation
that long predated their publications.
Grief became a disease because of the expansion of psychiatry:
Freud, Deutsch, Lindemann, Parkes
That is, the rise of the biomedical model. SC paper. Graneks Positivism and

Modernist condition. See prior.


The DSM for insurance purposes?
So is grief a disease? Today it is. Ought it be considered so?
Normative remarks love reconceptualization, private mourning, Mersault?

By this point [1988], grief had become so completely ingrained into the
psychological purview it no longer required a justification to be studied or
treated like a psychological object.

Our definitions of health, of disease, and of grief are largely derived from the
output of healthcare professionals, and so, with this in mind, I am not going
to try and answer whether grief really is a disease (whatever that really is
means). Instead, I will look to how grief came to be classified as a disease in
the first place, ending with some remarks on the normative significance of
this classification.
Consider Walters remark, In the 19th century, grief was a condition of the
human spirit or soul. It might sometimes be viewed as a cause of insanity,
but it was not itself a mental illness. (Walter 2006:73) The question is why
the shift in understanding?

Bibliography
Andreasen, N. C (1985) The Broken Brain: The Biological Revolution in
Psychiatry. New York: Harper and Row
Averill, J. R. and Nunley, E. P. (1988), Grief as an Emotion and as a Disease: A
Social-Constructionist Perspective. Journal of Social Issues, 44: 7995.
doi:10.1111/j.1540-4560.1988.tb02078.x
Engel, GL. The need for a new medical model: a challenge to biomedicine.
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(1980), The Clinical Application of the Biopsychosocial Model, Am J


Psychiatry. 1980 May;137(5):535-44.

(1995). Is Grief a Disease? A Challenge for Medical Research.


Washington DC: American Psychiatric Associations

Freud. S. (1963) Mourning and Melancholia, (Johan Riviere, Trans.). In General


Psychology Theroy. New York: Collier. (Original work published 1917)
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(1990) Five Lectures on psychoanalysis, New York, Norton (original


work published 1909)

Granek, L. Grief as Pathology: The Evolution of Grief Theory in Psychology


From Freud to the Present, History of Psychology, Volume 13(1), February
2010, p 4673
Illouz, E. (2008) Saving the Modern soul: Therapy, Emotions, and the Culture
of Self-help. Berkeley, University of California Press
Kuhn, T. (1962) The Structure of Scientific Revolutions. Chicago: University of
Chicago Press
McClelland, D. C. (1985) The Social Mandate of Health Psychology, American
Behavioural Science, 28, 451-467
Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the
age of Prozac. Oxford: Wiley.
Wakefield, J., C. (June 2013) DSM-5 grief scorecard: Assessment and outcomes of
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Whitaker
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Greenberg, Gary (January 29, 2012). "The D.S.M.'s Troubled Revision". The New
York Times

Is grief a disease? ought to be prefixed with a for whom.

The biomedical model is one psychiatry tried to base itself on. GRANEK

Grief is a disease on the medical model of psychiatry.

Is grief a disease?
Ask a Tahitian and hell answer in the positive. (SC 85.) The same can now be
said of psychiatrists. (Granek 49) Grief has already become, or at least, is in
the process of becoming a known disease among healthcare experts. What is
of interest to this essay is how grief came to be categorised as a disease. I
argue the categorisation of grief, as a disease or as something else,
expresses a value-judgement, a judgement derived very much from
institutional factors.
After raising issues of definitions I offer a brief genealogy of grief-as-disease,
with some final remarks on the normative significance of categorising grief in
this way.
Let us begin with some housekeeping nomenclature. By grief I mean do not
mean bereavement. Bereavement tends to be understood as the loss that
has been suffered. (Ibid. pg. 2) Grief, or mourning, meanwhile, concerns
the reactions that follow to this loss. At the same time, however, we must not
locate disease as a synonym of bereavement.
XYZ suggests an interesting formulation of disease. He suggests disease is
the while illness the

But this will not work for grief. The illness is the phenomenology of the
disease. If one loses someone they love, they are going to be forever
diseased, even as the distress, or phenomenology, of their grief rescinds. We
would be permanatly diseased. This is at odds with the present grief
literature, which suggests as our grieving declines, our health recovers. If
recovery is a possibility, then diseases being permanent is an impossibility.
Moving on, note how the ways in which grief is treated is a historical
contingency. Babies in brazil. The aforementioned Tahitians. In Japan, the
positive aspect of grief is emphasised (Cooper).
None of this though warrants the conclusion grief itself is a contingent social
construct. What appears the construct is the varying ways in which societies
deal with grief. (SC paper)
the way in which normal grief was expressed was variable and as far as
Durkheim was concerned, Mourning is not a natural movement of private
feelings wounded by a cruel loss; it is a duty imposed by the group. One
weeps, not simply because one is sad, but because one is forced to weep
(1968:568).2
I want to suggest that the classification of grief represents a kind of value
judgement.

There exists a predominate intuition beyond the circle of healthcare


professionals that grief is not a disease. In a famous 1961 paper, George. L.
Engel seeks to dispel this intuition. He runs through the expected protests
against pathologising grief, such as its being normal or natural, its not
requiring medical treatment
Likewise, so and so has offered an uptodate extension of Engels arguments.
SEE ENGEL SUMMARY PAPER
If we do not want to categorise grief as a disease we would have to seriously
revise the present criteria for what a disease is. Neither Engel nor xyz though
explicitly outline what is a disease. Instead, they argue that according to the
things we usually take to be characteristic of disease, grief meets these
characteristics. It seems to me they are either operating on an intuitive
notion of disease, or a more nuanced, scientific one that, for whatever
reason, is only latent.
Bereavement/grief division

What this and Engels + Xyzs failure to expound a cogent theory of


health/disease point to is a fundamental difficult in conceiving a watertight
notion of disease.

Then into models bit.

Note there is no transcendental criteria of disease, or even definition of


health. Note too the implications of this. It seems we can only explore our
question in relation to particular social contexts.

Our present context, meant in a broadly Western sort of way, does clarify
grief as a disease. Or at least it does at the level of experts. In this essay I
want to explore some the reasons grief has become categorised as a disease,
and whether this presents a category mistake. In other words, I want continue
from where the knowledge that grief is already understood as disease within
our social contexts leaves off, and ask why is it understood as a disease, and
ought it be so?
an interesting spatial and

PLAN
Anti phenomenology man
Mourning vs bereavement vs grief
Culture bound syndromes
What is disease/health - SCs 3 models.
Prominence of biomedical model Granek / modernist functioning /WWII /
Freud / rise of psychiatry in the everyday.

Freuds shift to the everyday


Grief as disease = a value judgement WHY?
1. Grief has not always been classed as a disease walter victorian quote in
granek pg 1.
That it was not exposes a value judgement. Given its temporal/spatial
constancy, arguments in Engel and xyz.
2. The forces responsible for categorising grief as a disease where well under
way before Engels seminal paper.
So how did grief become classed as a disease
Models / Graneks story.
Grief as disease = 20th century invention
What is grief? Same as mourning, but different to bereavement.
What is disease? Anti-phenonemology man
Models of health / what is the base science in our diagnosis

although mourning involves grave departures from the normal attitude of


life, it never occurs to us to regard it as a pathological condition and to refer
it to medical treatment. We rely on it being overcome after a certain lapse of
time, and we look upon any interference with it as useless or even harmful.
(Freud 1917/1963:252)
Here we have the explicit resistance to consider grief a disease. So how did
Freud become the origin of the trajectory of grief-as-disease? One reason
was his focus on the everyday as sources of psychological interest, one that
gained particularly importance with US psychiatrists. (Granek pg.51) These
included slips of the tongue, dreams, infantile sexuality to name but a few.
(Ibid. pg.51) Illouz describes this emphasis on everyday life as a realm worth
of analysis as a revolutionary epistemological stance that set the stage
for the including emptions such as grief, that were once considered beyond
the scope of psychology, as legitimate objects of study. (Illouz 2008:38)
It is interesting then, that despite Freuds protestations against the
pathologisation of grief, his corollary demand, that of psychological inquiry
into the everyday, eventually resulted in the very pathologisation he sought
to resist.
A second reason was the way
hat was so crucial
THE MASS-PSYCHIATRIST DISSONANCE SHOWS THE INTEREST OF THE
PSYCHIATRIST OF CLASSIFYING GRIEF AS A DISEASE
Going further, while Freud believe that grieving was a normal and time
consuming

Two integral parts of the patholoisation of grief

Freuds famous 1917, and his psychoanalytic theories more generally, found
particular influence in the US with regard to shifting the focus of psychiatry.
NEW PLAN
Engel/XYZ
Then why this is not sufficient
Then genealogy

I cant help feel like Nietzsche must have when he heard people discuss the
good life.

My problem with these approaches is that they do not explain why grief has
come to be classified as a disease. They outline some various objections
against such classification and then offer some plausible responses. But this
Socratic dialogue technique never sees either author venture beyond an
abstract conception of grief, or disease, or health. What is treated as disease
in society is not as sensitive to these conversations as their authors might
like to think.
Grief, for example, was already treated in Tahiti as a disease prior to their
publications. Even in social contexts nearer to our own, in the 20 th century US
and UK, for example, forces had been set in motion responsible for classifying
grief as a disease scores of years before their writings.
It reminds me very much of Socrates inquiry into virtue in Platos Meno. It is
all very well and good to debate what virtue really looks like, b
What they do is operate within a given criteria of disease and compare grief
alongside it. Not once do they ask themselves whose criteria they are using,
or for whose gain does this criteria lend itself to?
SEE THE QUESTION BEGGING ANSWERS
They assume there are reasons in favour
NOWHERE DO THEY ASK WHY IS GRIEF CLASSIFIED AS A DISEASE OR NOT AS
A DISEASE,

What it is about grief that has led to its classification as a disease lie beyond
the arguments presented by Engel.

Psychiatrys yes response to our question, I shall argue, comes from the
biomedical model of healths ascendency in the 20 th century.
during the 20th century.

In arguing that the categorisation of some phenomenon as a disease is the


result of complex social process as much as anything else,
Let us begin with some housekeeping nomenclature. By grief I mean do not
mean bereavement. Bereavement tends to be understood as the loss that
has been suffered. (Ibid. pg. 2) Grief, or mourning, meanwhile, concerns
the reactions that follow to this loss. At the same time, however, we must not
locate disease as a synonym of bereavement.

NEW PLAN
1 intro
2. Paradigm intro / no atemporal health
3. Psychiatrys new paradigm was the biomedical model
4. On this model, grief can quite obviously be accommodated as a disease,
given the definitions of grief and of disease. See Engel and Hoffer.
5.