While Psychiatrists Battle Over DSM Classification Of Grief, Everyday People Struggle To Put Death In Perspective.

Posted on | February 17, 2012 | 1 Comment

Mike Magee

Disagreements are common among psychiatrists. And no debate more reliably leads to an intellectual brawl than the classification of psychiatric illnesses in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). This week’s controversy, summarized in an editorial in the Lancet, is whether grief and bereavement reactions should be classified as a major depressive disorder.(1,2) A larger issue for me, and most health consumers, is how do we put loss of a loved one in perspective and manage our recovery.
Author and psychiatrist Elisabeth Kubler-Ross described the five stages of grief as denial, anger, bargaining, depression and acceptance.(3)  Roberta Temes’ book, “Living with an Empty Chair” outlines three stages – numbness, disorganization and reorganization.(4) While both have merit, and our family (over the years) has encountered all eight of these stages in varying orders and in differing ways, they do not cover the more predictable organizational stages we have encountered, nor do they define the management challenges associated with each stage.
In our experience dying, bereavement and recovery for a family involve  four organizational stages: engagement, release, testimony and recovery.
The first stage, engagement, focuses on confronting the threat, exploring options for combating it, making decisions about how best to proceed, and following through on those decisions. Depending on the threat, time may or may not be an issue. Facing an aggressive cancer, time was of the essence. For my mother-in-law, with diabetes and dementia, not so much. With trauma or suicide, there may be no chance to engage.
My second stage is release. Having engaged and pursued reasonable steps to survive, without success, those involved have to acknowledge that death must now be accepted as a near-term reality. Whether chronic or acute, young or old, when a diagnosis is first made, everyone’s focus is on life preservation. But a sharp decline, results of diagnostic studies, loss of control of activities of daily living, or an internal awareness can signal a transition and lead patients and families to recognize that death is approaching. Hopefulness thus collides with truthfulness. And the truth can be harsh and undeniable, especially for the young who haven’t had as much time to mentally prepare. The focus shifts from life preservation to life enhancement.
With death, we arrive at the third stage: testimony. How should loved ones be remembered? This is under the control of the living. The obituary, funeral arrangements, family travel, eulogy, burial, and various memorial rituals all require attention. Of the four organizational stages of death, this may be the one most routinely mismanaged. It is critically important, not only in communicating the value and meaning of one’s life, and the lives he or she touched, but also in beginning the healing process, and often allowing old wounds to be repaired, and disrupted lives to begin anew. Among the management challenges, first and foremost is inclusion – involvement of as many family members and loved ones as possible. Second is planning, including finances, timing of services, and communication before, during and after the ceremony. Third is performance – readings, eulogies, informal story telling, photo boards, and displays of items important to the individual and the bereaved. Fourth is comforting – coming together to manage those stricken, injured, and weakened by the course of events. And the fifth management challenge is the act of memorializing, which is an opportunity to reinforce goodness, humor, and values that deserve a spot light. By memorializing, we challenge ourselves to live a better and more complete life.
The final organizational stage of dying is recovery – assisting loved ones in absorbing the loss and remembering in a way that advances the physical, mental and spiritual health of the bereaved.3 There is not a perfect path or consistent timetable, but the management challenges associated with recovery are somewhat predictable. They include managing shock, confusion and disorientation; accepting the loss; sustaining individual self-worth; pacing recovery; identifying complicated grief if it persists and seeking professional help if it’s needed; and, finally, reinvesting in relationships. Each of these four stages of the dying process has elements in common. But each is a unique management challenge in its own right. Similarities include that each stage is complex, requires planning, demands decisions, causes fatigue, and requires team support. That said, true success comes with the insight that each of the four stages is fundamentally different – they involve different missions, players, organizational interfaces, support staff, time pressures, and measures of success.
As Elisabeth Kubler-Ross said, “For those who seek to understand it, death is a highly creative force.”(3) And this is true, but I would add that absent the ability to manage the complexity of dying, pain for all involved may be amplified, and understanding can easily slip through the cracks. Under these circumstances, normal grief and recovery can easily transform into clinical depression.
For HealthCommentary, I’m Mike Magee.
References:
1. Living With Grief. Lancet Editorial. Feb. 18, 2012. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60248-7/fulltext
2. Healy M. Psychiatry debates whether the pain of loss is really depression. Los Angeles Times. Feb. 16, 2012. http://www.latimes.com/health/boostershots/la-heb-grief-or-bad-grief-depression-psychiatry-20120216,0,1888566.story1.
3. Elisabeth Kubler-Ross Web site. http://www.elisabethbublerross.com.
4. Cancer Survivors Web site.  http://www.cancersurvivors.org/Coping
5. Prigerson HG, Jacobs SC. Caring for bereaved patients: “All the doctors just suddenly go.” JAMA. 2001;286:1369-

Comments

One Response to “While Psychiatrists Battle Over DSM Classification Of Grief, Everyday People Struggle To Put Death In Perspective.”

  1. Ronald Pies MD
    February 28th, 2012 @ 9:41 pm

    That’s an interesting perspective, Dr. Magee, thanks! As you imply, bereavement does not “immunize” the grieving person against a bout of clinically severe depression. Your readers may also be interested in this blog, which I recently posted on the Psychcentral website:

    http://psychcentral.com/blog/archives/2012/02/28/how-the-public-is-being-misinformed-about-grief/

    “How the pubic is being misinformed about grief”

    Regards,
    Ronald Pies MD
    SUNY Upstate Medical U.
    and Tufts USM

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