Based on continued discussion about the upcoming DSM-5 guidelines for diagnosing depression and “complicated grief” in the bereaved, I am compelled to post a follow-up on this thorny, complicated topic.
While the impassioned position of “don’t pathologize our grief” has merit, and it's worthy to advocate for the entire community of bereaved persons, I propose that the real question is not "What is best for the bereaved?” but "What is best for this bereaved person sitting right here in front of me?"
To answer this pointed question, here are some thoughts for practitioners to ponder:
Be mindful of your focus. When contemplating the DSM-5 guidelines, rather than focusing on the broad “right to grieve,” focus on each person’s right to individualized diagnosis and treatment. Focus on your ability to provide nonjudgmental, personalized care.
Embrace the complexities. Diagnosing depression or complications related to grief is complex because grief is complex….and so are grieving people. Also, guidelines are simply guidelines. It is their implementation that accommodates the nuances and complexities of grief.
Diagnostics will never be “one size fits all”—especially when it comes to the brain’s cognitions and emotions. There's a saying in dementia care: If you've seen one person with dementia… you've seen one person with dementia. So it follows, if you've seen one bereaved person…. you've seen one bereaved person.
Consider each person’s unique experience of grief. Even though bereaved people share much common ground, every bereaved person is different, experiencing each death uniquely, grieving uniquely, struggling uniquely, coping uniquely, adjusting uniquely, and healing uniquely. Walk with each person you meet and be a witness to their distinctive experience.
Acknowledge what compounds grief. Each bereaved person also experiences a unique tapestry of trials that can compound grief. Some people walk alone, not having a supportive family and/or community to accompany them. Some may be enduring additional losses—unemployment, illness, divorce, etc.—adding to their stress and grief. Sometimes, a death dredges up grief from previous deaths. Some bereaved parents have also experienced the added burdens of infertility, a string of perinatal deaths, the death of an only child, the death of more than one child, or the death of one or more of a set of twins, triplets, etc. By accommodating these complexities in your diagnosis and treatment, you are offering a kind of validation that is a balm for the bereaved person.
Acknowledge the trauma. I’d like to see more recognition and treatment of the trauma inherent in many bereavements. Perinatal death in particular can have many characteristics of traumatic loss (e.g., the baby died suddenly, unexpectedly, from perhaps preventable causes; a NICU stay, prolonged resuscitation, agonizing medical decisions made; plusbeing the caregiver, which is also associated with complicated grief.) As one clinician pointed out, if you can treat the trauma, you can facilitate the grief.
Be aware of the limits and imprecision of diagnoses. Given the uniqueness of each individual and his or her circumstances, how is any clinician supposed to fit anyone into a neat little diagnostic box? This is beyond me, and the clinicians I've talked to acknowledge this quandary. As one clinician who specializes in bereavement care told me, “I’ve been in practice for 20 years and I still can’t quite discern precisely between what’s complicated grief and what’s not; what’s depression and what’s not.” Grief is messy. Recognize that any diagnosis only represents a partial synopsis of an epic journey.
Update the DSM’s title in your own mind. Rather than embracing it as a diagnostic manual of "Mental Disorders" think of it as a descriptive manual of "Mental Experiences." Then you can offer diagnoses as informative descriptions rather than disapproving labels.
Help patients see themselves as separate from their diagnosis. Just as an oncology patient isn’t a cancer but a person experiencing cancer, a bereavement patient isn’t a depression or a complication, but a person experiencing depression or a complicated grief. Emphasize that a diagnosis isn’t a label, but a tool—an illuminating framework to guide insights and treatment, plus handy for record keeping and insurance company billing. With your guidance, a patient is less likely to see a diagnosis as a burden that complicates life or is taken to heart.
Focus on providing relationship-based care. One hallmark of relationship-based care is to engage in dialogue with your patients. Rather than handing down a diagnosis from on high, offer compassion and support, along with individually tailored exploration, discussion, and treatment in collaboration with the patient, who may then be less likely to perceive a diagnosis as judgment.
Be aware of your own grief. Other keys to relationship-based care are self knowledge, self-care, and reflective practice. If you are suffering from acute or chronic grief, be mindful of the inherent limits in your ability to provide quality bereavement care. Get the respite, assistance, and counseling you need in order to continue your important work. Know when it’s time to step down.
To me, the bottom line is this: No matter how carefully researched and crafted, the DSM’s beneficence relies on the practitioner’s intent and competence, as well as the patient’s interpretation of any given diagnosis. Everyone would benefit from better public and medical education on grief, sufficient training and support for bereavement care practitioners, and the implementation of relationship-based care across the board.
To those of you who work with or advocate for grieving families, you are to be commended for the individualized, relationship-based care you offer each bereaved person you meet.