Abstract
The Nordic countries are currently attempting to implement prolonged grief disorder as an official psychiatric diagnosis, as enacted by The World Health Organization in 2018. The enactment has been controversial and, especially in Denmark, the forthcoming diagnosis has met resistance from scholars and clinicians alike. In this article we will outline what we believe to be lost considerations during the debate of the so-called “grief diagnosis.” We argue that scholars’ attention should not focus on the diagnosis itself, but rather on the overall theoretical challenges in conceptualizing and handling mental suffering, which the debate should reflect and address. The article’s main purpose is to accentuate why we, as psychologists, must welcome the prolonged grief diagnosis, whilst simultaneously working to more actively politicize mental suffering in general, and criticize the societal function of diagnoses. This should be attained through dialogue and recognition between cultural psychologists and health psychologists.
Keywords
In 2018, The World Health Organization’s (WHO, 2022) 11th rendition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) established a new psychiatric diagnosis, Prolonged Grief Disorder (PGD). PGD is defined as grief-related suffering with considerable health deteriorating consequences (Larsen et al., 2018, p. 19). Nordic countries are expected to implement the change within the next few years (O’Connor, 2021). As of March 2022, the same diagnosis was implemented in the newest version of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5-TR; American Psychiatric Association [APA], 2022; Boelen & Lenferink, 2022).
PGD was implemented on the basis of years of clinical observations and research contributions primarily from health psychology. Individuals with PGD exhibit debilitating longing after bereavement of someone close, which has lasted 6 months in ICD-11, and for at least 1 continuous month, 12 months after the loss in DSM-5-TR, respectively (Prigerson et al., 2021).
The implementation of PGD in ICD-11 has become a topic of debate, which will most likely last for some time. The debate fundamentally revolves around the reasonableness for a diagnosis describing pathological grief, and is characterized by strong opinions both for and against PGD. This debate is most prominently led by representatives from a cultural psychological background, who criticize the potentially undermining consequences the psychiatric diagnosis could have on other central aspects of the grief phenomenon (Køster et al., 2018).
We perceive that the implementation of prolonged grief disorder as a diagnosis is controversial and provocative to a lot of scholars for two main reasons. The first being an existential or philosophical question pertaining to what extent grief could and should be understood as a disorder requiring treatment (e.g., Brinkmann, 2018a). This point is also the one most commonly expressed outside scholarly discussion in the general public. There seems to be something unnatural about perceiving the reaction to losing a loved one as a medical condition requiring treatment. 1 Secondly, the implementation of “the grief diagnosis” raises the larger scientific discussion of “diagnostic cultures” (Brinkmann, 2016) and “psychologicalization of society” (Madsen, 2018). Those authors contend that more and more aspects of human existence are becoming the subject of diagnostics, and are handled by medical authorities.
The pronounced disagreement about grief between cultural psychologists and health psychologists is detrimental to the scientific dialogue (see Johansen et al., 2021), and furthermore, we believe, to the public’s comprehension of the rationale and actual limitations of psychiatry. An important notion is that the PGD diagnosis is aimed at a group of people who, in definite terms, experience a significant and debilitating degree of suffering and that universal human grief does not fit this description. Naturally, there are some challenges to this distinction (which we’ll see later), but when discussing clinical or pathological grief, two distinct groups will emerge (the patient population and the general public). This distinction is often overlooked or under-communicated.
In this paper, we will discuss and critique central arguments in the grief debate, with the purpose of making the discussion more transparent and accessible. We believe the true psychological academic challenge involves the general treatment of mental suffering, and not grief specifically. Clarifying and steering the debate towards this focal point will improve the professional dialogue and the transparency of psychiatric practice.
This article centers around two main arguments. First, we hope to shed light on why the patient population, which the diagnosis is aimed at, does not exhibit common grief experiences, but namely pathological grief reactions. We are concerned that uncritical, existential opposition against the grief diagnosis risks framing the concept of grief in a way that creates larger distances between the two academic perspectives. Second, we address why diagnoses’ current societal function is problematic and worth evaluating, especially if presented as neutral and apolitical. This paper thus outlines the need for cultural psychological insights in clinical practice. In this regard, the implementation of PGD should definitely generate a critique of diagnoses leveled at the overall psychiatric handling of mental suffering, including the diagnoses’ various functions. Crucially, this is not a problem restricted to grief diagnosing, and should neither be formulated as such.
This article was written while awaiting implementation of the diagnosis in the Nordic clinics, in a context where the subject of grief engages and provokes several professional groups and individuals. We hope to illustrate how we, as psychologists, can respond to the establishment of the diagnosis of PGD, and at the same time actively incorporate critical reflections about diagnoses’ societal impacts.
Prolonged grief disorder
Prolonged grief disorder (PGD) is a diagnosis situated under the umbrella term of “complicated grief reactions.” PGD was conceptualized after observing a clinical subgroup whose symptoms did not correspond with those of other subgroups of complicated grief (Horowitz et al., 1993; cf. Prigerson et al., 2021). The motivation for a separate diagnosis for pathological grief reactions was further accentuated by the fact that certain clinical groups did not seem to benefit from established psychological interventions, that is, depression treatment (Prigerson et al., 2021). The criteria for the PGD diagnosis were formulated after years of research in the area, performed primarily by Holly Prigerson and colleagues. In 2018, the diagnosis was established in its final form by the WHO (in ICD-11, WHO, 2022), and as of March 2022, it was implemented in DSM-5-TR (APA, 2022). The final diagnosis includes symptomatological elements of extensive grief reactions characterized by longing and intense emotional pain, that is considered to be impairing. According to ICD-11, PGD can be diagnosed 6 months after the bereavement, in which it is a criterion that the reaction surpasses contextually appropriate norms. The specific formulation of PGD is shown in Figure 1.
Diagnostic criteria for Prolonged Grief Disorder (ICD-11).
In Denmark, it is estimated that up to 10% of all bereaved people might qualify for the diagnosis PGD (Lundorff et al., 2017). Since the diagnosis is so recent, there are currently no validated clinical diagnostic interviews for ICD-11 PGD, and prevalence rates for a regular diagnosis based on the newest diagnostic criteria and a structured interview are therefore not yet available (O’Connor et al., 2020). In the field of research, PGD has been linked with heightened risk of suicide, reduced quality of life, and development of somatic disorders (Larsen et al., 2018). Although the establishment of PGD as a diagnosis has been approved, research on the disorder is still in its early stages. Therefore, any estimate of its prevalence is more or less assumptive. Even if patients who are diagnosed with PGD seem to profit from treatment, it is not yet determined which moderators in the treatment are most effective. This is partly due to the challenges of publication bias in this field of study (Johannsen et al., 2019).
In spite of the initial challenges of the diagnosis, the conceptual formulation of PGD as a distinct population within the umbrella term “complicated grief” is expected to progress treatment for and accommodate bereaved individuals (Larsen et al., 2018). At the same time, it is apparent that the specific diagnosis is not as well devised as other existing categories. This can lead to problems in clinical practice (such as the risk of over-diagnosing; Petersen et al., 2021), however, this is to be expected, and also something the health psychology field recognizes (O’Connor, 2021). Furthermore, the enactment of PGD entails an actual psychiatrization of grief, which must be handled with caution (Boelen & Prigerson, 2013; Jacobsen & Petersen, 2018). In a similar vein, Larsen et al. (2018) have acknowledged that both the enactment of PGD itself and the research that has cleared its way, has lacked cultural and qualitative aspects. Despite these limitations, PGD is still considered a pragmatic tool and a necessity in order to address the suffering of individuals within the current conceptual framework (O’Connor, 2021).
The debate about prolonged grief disorder
The appropriateness of PGD as a diagnosis is one of the most heatedly debated topics in Nordic psychiatric circles. Especially in Denmark, the debate has been occurring for some time, led by the two research centers, “The Culture of Grief” at Aalborg University 2 and The Danish National Center of Grief, 3 and has resulted in several journal editions and anthologies (Kofod & Sköld, 2020, 2021; O’Connor et al., 2018, 2019; Petersen & Brinkmann, 2021). In Norway, the debate about grief diagnostics has been less prominent, but has been problematized by psychologist Pål Kristensen (2013) among others, and was publicly debated during the fall of 2015 (see Bale & Bondevik, 2017).
This debate is permeated by strong feelings, which interfere with productive discussion of the topic. We witness that relevant points and insights are bogged down because of conflicting attitudes. Where advocates for the grief diagnosis justify the diagnosis with regard to clinical utility (see Killikelly & Maercker, 2017), critics tend to particularly emphasize two points of criticism: one existentialist and the other socially oriented. Below, we analyze these two critical viewpoints and address what we believe are fundamental points that are often lost during the debate.
Critique 1: Grief as an existential phenomenon and a fundamental emotion
The first criticism of a diagnosis for grief asks whether grief realistically can be formulated as a mental disorder (Brinkmann, 2018a). This argument is based on an existentialist assumption that grief, as a phenomenon, is a fundamental emotion or “the price we pay for love” (Brinkmann, 2018b). Furthermore, it is something all of us will experience simply because we are human. Consequently, the question is raised whether grief can be understood as a disorder in and of itself, though the bereavement certainly may lead to other psychiatric disorders such as depression (Brinkmann, 2018a).
The technical point here is whether the grief phenomenon can embody a pathological dimension. Within this argument are certain premises and assumptions about what grief is, which often leads to a difficult, if not insoluble, philosophical discussion. From our point of view, the discussion is more about whether the concept of mental disorders may also incorporate grief reactions.
In the next section, we will demonstrate why this question calls for a clarification between categorical versus dimensional understandings of mental disorders. Following this, we argue that the psychiatrization of grief mainly illustrates an overall challenge in psychological theoretization, especially with regard to understanding mental disorders as discrete categories. Thus, we propose that since these difficulties are not restricted to the grief phenomenon, this perspective should be applied to psychological constructs in general.
Categorical and dimensional understandings of mental disorders
Because today’s diagnostic manuals operate with distinct disease categories, it is a prerequisite that diagnosable disorders are understood as both demarcated and dysfunctional (Dahl & Løvlie, 2018). For example, depressive episodes (F32 in ICD-10, WHO, 2022) are described as something qualitatively different and more serious than general sadness, and so they can be diagnosed. This is an example of a categorical understanding of psychiatric disorders, and resembles the diagnostics of somatic conditions (e.g., that one can have a cold or not; cf. Huda, 2021).
By virtue of being a formal psychiatric diagnosis, PGD will implicitly suggest that pathological grief is qualitatively different from natural grief, in that prolonged grief is significantly more long-lasting, painful, and disabling than its universal counterpart. In a practical context, this also means that PGD is directed at a group of people who exhibit something other than the form of grief we typically experience and are exposed to (O’Connor, 2021, p. 347). Thus, it is a group of people who, in a categorically different way than people who suffer naturally from grief, call for professional medical treatment.
What determines if an individual’s grief warrants treatment? This fundamentally seems to be attributable to a form of medical telos to limit suffering and prevent mortality (see Young, 2015). The boundaries of when a condition requires treatment are thus unclear and changeable (Dahl & Løvlie, 2018), but the prototypes of PGD are, by definition, people with a demonstrable risk of health deterioration and significantly reduced quality of life (Boelen & Prigerson, 2013).
Prototypes of PGD exhibit an intervention-demanding form of mental suffering, however, the patients we meet in everyday practice rarely exhibit prototypical expressions of suffering. Consequently, a significant subclinical population of grieving people will have to be accommodated in practice (O’Connor, 2021). These individuals exhibit a grief that may be considered abnormal, but not necessarily pathological. In turn, these cases may challenge the theoretical distinction between nonclinical grief and PGD variants, and thus, this kind of “borderline of pathology” directs us towards the second form of understanding disorders; as dimensional.
The dimensional understanding of mental disorders perceives a given phenomenon as being on a continuum, where one end of the continuum represents pathological variants of the experience. In other words, mental disorders are seen as a dimension of otherwise common, and thus not pathological, experiences; albeit these can be painful and difficult as well. For example, in contrast to the categorical understanding of depression as something other than sadness, this concept of depression primarily refers to problematic or excessive sadness, to a degree that proves to be severe and treatment-demanding (Conway & Krueger, 2021). The dimensionality of mental disorders can be seen in the ways we categorize depression as either mild, moderate, or severe based on the assumption that we are not distinguishing between three different disorders, but instead degrees of the same phenomenon. Despite this, the dimensional understanding of disorders is underemphasized in today’s formal diagnoses (Dahl & Løvlie, 2018).
Although grief reactions are to be seen as being on a continuum where the disorder degenerates changeably and into different extents, it is relevant to bear in mind that this is also the case for other psychiatric diagnoses, and that there is little to suggest that grief is in a special position in this regard. For example, one would argue that anxiety also makes up a generally well-acknowledged existential condition, whilst sometimes also developing into a treatment-demanding state (see Duval et al., 2015). From our point of view, it is not appropriate to suggest that diagnosing grief differs from diagnosing other existential human phenomena. Grief as a dimensional phenomenon, stretching from unproblematic responses to loss to extreme cases of dysfunction and suffering, therefore still warrants the possibility of psychiatric engagement. Framing every dimension of grief as a necessary consequence of love (see Brinkmann, 2018b, p. 201) neglects the treatment-demanding aspects also seen and acknowledged in other generic human conditions.
There is, of course, much truth to the existentialist critique, but—as is also the case with other serious clinical psychopathology—it is problematic to claim that the diagnosis pathologizes common emotions and reactions. People who satisfy the criteria for PGD are in a situation that is unusually long-lasting and extremely painful compared to bereaved people in general, and it can therefore be reducing to convey that these are “just ordinary feelings.” As we will discuss later, the diagnosis will have an impact on the subclinical population, but from a technical argumentation, it is clear and necessary to underline that the concept of mental suffering may in fact also include grief reactions.
Whether grief can reasonably be understood as a diagnosable disorder depends on one’s perspective of the concept of mental suffering. In this section, we have shown how both the dimensional and categorical understanding of grief disorder allows the phenomenon to be conceptualized as potentially pathological. Despite this, the diagnosis of PGD is still subject to theoretical challenges relating to our understanding of psychological categories. Thus, the first point of critique offers relevant observations and concerns regarding the grief diagnosis though mainly related to psychological theorizing in general. This concern, however, should be taken seriously, and below we will discuss the argument that we believe is actually put forth when grief is criticized on an existential basis.
The theory crisis in psychology
The critique presented in the previous sections and put forth by, for instance, Brinkmann (2018a) underlines the argument that the psychologization of grief (e.g., via PGD) is problematic. Brinkmann (2018a) concludes that there are inadequate theoretical arguments for the legitimacy of a diagnosis for grief (p. 157). The author is supported by Leeat Granek’s (2010) historical review of the phenomenon’s evolution into the medical sphere, where grief at some point is formulated as a construct worth psychological theoretization. The changeability of the phenomenon reminds us that the premises from which health psychology operates are rooted in certain theoretical assumptions (see Zachar & Kendler, 2017).
The preconditions for diagnosing psychopathology are embossed in several theoretical and historically conditioned presumptions—despite an explicit wish for an ahistorical and operationalized classification of disorders (Aftab & Ryznar, 2021). The scholars Eronen and Bringmann (2021) have thus argued that psychology as a scientific field is subject to a definite theory crisis. With reference to psychologist Paul Meehl, the authors claim that the progression of psychology as a science should represent an iterative process. In spite of this, little cumulative theory evolution has occurred. The core problem, Eronen and Bringmann (2021, p. 780) argue, is that formulation of good, psychological theories is extremely difficult, and the reasons for this are three-fold: first, psychological phenomena are not robust; second, little focus is directed at validating psychological constructs; and third, the phenomenon presents difficulties in discovering causal mechanisms.
Essentially, this means that classification of disorders de-emphasizes validation of the constructs being used (in this case, “so-called” complicated grief), and rather orients around other aspects such as reliability and utility (Aftab & Ryznar, 2021). The construct validity of grief as a psychiatric disorder is almost certainly low, but what relevance does this have for the legitimacy of the diagnosis? Overall, mental disorders are perceived as practical kinds (Zachar & Kendler, 2017). This implies that diagnoses derive legitimacy from their usefulness. However, this view of diagnoses as “pragmatic summaries” still warrants the question of how to aggregate validators for distinct psychiatric categories (Fried, 2022). Solomon and Kendler (2021) argue that this problem leaves us with a form of functional validation of psychiatric disorders. That is, the way we distinguish categories of disorders are based on their pragmatic value rather than their status as a “real” disease entity or as a natural kind.
Indeed, this does make it possible to argue that psychiatric categories present weak concepts and thereby to contest the scientific status of diagnoses. This position is in part presented by the influential Horwitz and Wakefield (2007) who, in the context of diagnosing depression, argue that the phenomenon of grief should not be seen as a disorder, but rather as the “prototype” of “normal sadness.” Although the authors assume that special cases of complicated grief rightfully can be diagnosed and treated as it expresses a “breakdown in . . . psychological functioning” (Horwitz & Wakefield, 2007, p. 33), they argue that the response to loss via sadness is mistakenly seen as depressive symptoms, as they are normal responses to loss. Arguably, this view is further formulated in the argument of a theory crisis in psychology: the psychiatric concepts of depression and (complicated) grief lack validated dimensions due to theoretical challenges, which again challenges the way we adequately can approach and treat psychiatric suffering appropriately (i.e., via causal mechanisms). The currently dominant way of seeing mental disorders is theoretically unsound, which in some opinions has contested the very basis of current nosologies.
The theory crisis ascertains that problems of validation are pressing for most cases of psychological phenomena (including psychiatric constructs), and relates to a greater theoretical challenge rather than the sole pathologization of variants of bereavement. This makes it problematic to criticize the grief diagnosis for being a special case (as often indicated in the Nordic debate). Rather, we would argue that the psychiatrization of grief illustrates and illuminates an underlying theoretical problem in psychology at large, also evident in the unsatisfactory division between dimensional and categorical understandings of disorders in the current diagnostic system overall.
Critique of construct validity and theory issues within psychopathology, then, is most certainly warranted, but the critique should be directed towards the bigger problem, not one specific diagnosis. This is especially important as the reverse argument of grief as exceptional will wrongfully create a focus on PGD as a pathologization of common grief reactions. As we will see later, current psychiatric nosologies (including the diagnosis PGD) may affect common experiences of grief, because pathology is included on the same continuum as normal responses (see Kofod, 2017). However, this ambivalence is not unique to the grief phenomenon. Quite the contrary, we find that the philosophical critique of the grief diagnosis addresses more general challenges in psychological theorizing; but these problems, however, do make up a real and pressing predicament for the field’s progression (see Eronen & Bringmann, 2021).
Critique 2: Diagnostic cultures and psychologization of society
The second criticism of the grief diagnosis concerns the significance a psychiatric diagnosis has for society and for citizens maneuvering their everyday life with grief (e.g., Kofod, 2017). This point is therefore part of a broader discussion of what has been called “diagnostic cultures” (e.g., Brinkmann, 2016). This position argues that an increasing number of aspects of human existence are being converted into medical issues, which impairs the complexity of the experiential world (Brinkmann, 2014; Køster et al., 2018), and may contribute to social problems being reframed as psychological and individualistic (Madsen, 2018).
Below, we will evaluate the critique of grief as a continuation of diagnostic cultures, and what significance the psychologization of grief has for our practice with grief. Then we will illustrate, with a case from Greenland, how a strong individualistic, psychological diagnostic approach may be a serious limitation to the complexity of the phenomenon, partly due to a lack of cross-cultural validity.
Negotiation of the notion of suffering
The criticism of contemporary diagnostic cultures is multifaceted, but is fundamentally related to the question of how we, as a society and as professionals, should respond to mental suffering. The concern is about how we are taking part in a problematic, societal phenomenon which may negatively influence the well-being of the public, and specifically in this context, the maneuvering of grief (see Brinkmann & Petersen, 2015).
Underlying this concern is what could be termed the negotiation of the notion of suffering, and the influence of interests in formulating treatment-demanding suffering. It has been said that psychiatry is a societal assignment for the administration of mental pain (Skårderud et al., 2018), which is why it has gained ever increasing prominence for human conditions. Within the debate of the grief diagnosis, critics have proclaimed the enactment of PGD as “psychiatry’s colonization of grief” (Petersen et al., 2021, p. 362, our translation). With great skepticism, they argue that grief has gone from being an existential issue to now being adopted in psycho-scientific contexts.
In a more inquiring manner, psychologist Ester Holte Kofod (2017) asks what consequences this may have for the common bereaved and the maneuvering of their grief. She describes the progression in terms of risk-pathologization. This means that pathological grief becomes a possibility (both a risk and a potential), and that it may influence how mourners understand their experiences (Kofod, 2017). The diagnosis could therefore become a part of the guiding frame for interpretation of grief reactions. Furthermore, the diagnosis can be seen as a symptom of a general diagnostic culture, which influences the normative premises within which the bereaved individual maneuvers—as a medical issue (see Brinkmann, 2014).
We believe that the considerations about diagnostic cultures are timely, but they become especially relevant when we concurrently note the features of psychologization; where focus is transferred from potential societal problems in favor of individualistic approaches (see Kofod & Brinkmann, 2021; Madsen, 2018). Psychologization can be understood as the way conditions outside the individual, which indeed manifest in the individual, are evaluated primarily from their individual–psychological qualities (see Madsen, 2018; Smail, 2005). That is, the psychological reality comes first.
Psychologization is problematic because it could dismiss structural problems which lead to individual suffering, but at the same time, we must recognize that conceptualizing suffering as psychological causalities is more clinically available than large-scale societal analyses. The interests in formulating mental disorders as individual–diagnostics are therefore possibly fair, but at the same time, this raises the question of whether current diagnoses are capable of including cultural perspectives adequately (see Køster et al., 2018; Smail, 2005). There may be potent political and clinical interests in framing a form of suffering as one that demands treatment. The progression of diagnostic cultures may in turn be an indication that our general societal attitude about what is endurable is changing, perhaps to accommodate suffering better, but perhaps also inappropriately away from structural problems (Skårderud et al., 2018).
Case on prolonged grief disorder’s difficulties with cross-cultural validity
In the following section, we present reflections on PGD’s challenges with cross-cultural validity with reference to a case from Greenland. The case illustrates how usage of PGD, without acknowledging the person’s embodiment in a cultural and normative framework, may cause a psychologization of true structural problems not inherent to the individual.
To be able to diagnose PGD, the grief reaction must exceed the individual’s context-specific cultural and social norms. The only research about grief in Greenland, to our knowledge, has been performed by Østergaard et al. (2019). The authors expect that complicated grief, and therefore the potential risk of developing PGD, is the norm in Greenland. This is because every fifth death in Greenland is defined as sudden (i.e., as result of accidents, murder, and, most often, suicide), which the authors describe as a risk factor for developing PGD. Life circumstances are thus argued to be so thoroughly pathological that complicated grief is almost expected as a standard (Østergaard et al., 2019, p. 19).
However, two main questions arise about this conclusion. First, Østergaard et al. (2019) seem to undermine the clinical utility of the diagnosis, by ignoring one of the criteria of PGD in ICD-11: “The grief response . . . clearly exceeds expected social, cultural or religious norms for the individual’s culture and context” (WHO, 2019, para. 1). By considering every Greenlander to be at potential risk of developing complicated grief, they consequently undermine the diagnosis’ criteria—and potentially its clinical utility. The second question we raise with Østergaard et al.’s (2019) study is that it lacks cultural sensitivity. This is because their approach to grief as being mainly pathological in the Greenlandic context contributes to a psychologization of the term in a context plagued by collective challenges, such as suicide. These problems are namely structural and located outside of the individual. Østergaard et al. (2019) are sympathetically aiming to map the need for interventions in pathological grief, but their framing of grief as mainly psychopathological may contribute to a problematic focus on interventions aimed at individual mourners at the expense of necessary societal changes in preventing suicides and accidents. The above-mentioned case is an example of the need for adequate knowledge of cultural norms and social relations.
If PGD is used without cultural sensitivity, there is a real risk of psychologizing factual societal problems by treating them individually and symptomatically (see Kofod & Brinkmann, 2021; Madsen, 2018). PGD thus has potential to blur out societal problems, as the case of Greenland illustrates. One could argue that the defining feature of individual suffering in and of itself is reason enough to warrant treatment, however, the kind of ubiquitous grief seen in Greenland reminds us that structural problems are to be seriously considered in the context of psychiatric practice. Structural problems do not call for individual treatment, but for interventions on a larger cultural scale. This emphasizes the need for theoretical critique of diagnostic cultures and psychologization, as the grief diagnosis might distort our view of where interventions are most prudent. In the following, we will discuss the implications of the previously mentioned critiques and address how the debate about PGD introduces important considerations to the political handling of psychiatric illness.
Discussion
As noted, the debate about the grief diagnosis is driven in part by (a) health psychological researchers who, with the diagnosis, aim to manage and accommodate a tormented minority, and in part by (b) cultural psychological researchers, who use PGD as means to a problematization of contemporary tendencies to psychologize and pathologize common phenomena. In light of this debate, we wonder how two fundamentally sympathetic viewpoints can be performed as contraries. Currently, there exists an array of literature highlighting the necessity of the PGD diagnosis, but there are also numerous well-meaning arguments against it. The fact that this debate continues—years after the enactment—leads us to question why the controversy surrounding grief diagnosing continues, and why the two perspectives seem so irreconcilable.
We believe that the irreconcilable character of the debate relates to a fundamental issue about the societal function of psychiatric diagnoses. That is, the way we deal with mental disorders in today’s society is based on diagnoses, and that we consequently need these in order to help people who suffer (Bergsmark, 2021). To be more precise: the diagnosis of PGD is an expression of a meaningful and necessary development in psychiatric nosology, but at the same time, it underlines the fact that there are significant problems with psychiatric diagnoses which are not limited to the discussion of grief (see Aftab, 2021). This dilemma raises the question: Can one be a psychological therapist and at the same time maintain and engage in what are significant problems associated with psychiatric diagnoses?
Advancing our appreciation of pathological grief
There is no doubt that mental illnesses exist in what can be called pathological variants, although this is theoretically difficult to ascertain (see section Critique 1). The assessment that a disorder requires treatment is not always given. We believe that the need to treat depends primarily on political assumptions and interests in accordance with cultural psychology’s critique of contemporary diagnostic cultures (see section Critique 2). However, our critical analysis suggests that psychiatric diagnoses are not in and of themselves illegitimate, but should be understood as pragmatic tools for therapists, patients, and society, and which at the same time serve a variety of interests which preferably should be mapped out and explicated (see Perkins et al., 2018; Smail, 2005). The role of psychologists must thus be to treat individuals who can be said to be in need of professional interventions, while simultaneously considering what has led to a phenomenon, such as grief, now being formulated, relatively unproblematically, as a psychological and potentially disturbed phenomenon.
This kind of practice will involve being critical of the conceptual basis and problems of psychiatric diagnoses, while concurrently maintaining our clinical mandate as therapists. A way of approaching this is to address what has been termed conceptual competence (Aftab & Waterman, 2021). This competence, which is deemed unprioritzed or lacking in current formal education, stresses awareness of conceptual assumptions in psychiatric practice. Some of these assumptions and challenges have been illustrated throughout this article, and their relevance has been underlined. A lack of focus on conceptual issues in psychiatry leaves a gap between the theoretical critique and hands-on practice, which possibly fuels the problematic two-way monologue between cultural and health psychologists—at least apparent in the Nordic debate about pathological grief. Conceptual competence introduces a possible solution and way of integrating insights from health psychology and cultural psychology, and thus has the potential to further our handling of mental suffering.
In the context of grief, the PGD diagnosis should presumably be seen as a tool to alleviate individual suffering, and consequently it operates by situating the conflict within the individual, and thereafter treated by individual psychological solutions. The critique of PGD seems to reflect and problematize this general function of psychiatric diagnoses, where mental disorders are handled on the basis of the individual, rather than taking a stand against problematic societal tendencies. This is, in our view, a very welcome perspective. However, this important problematization drowns in a somewhat tabloid discussion about grief as an existential basic condition. The narrow focus on grief is inappropriate, but points to a real question: Are mental disorders so fundamentally socially rooted that meaningful interventions must first and foremost be political (Parker & Pavón-Cuéllar, 2021)?
Currently, diagnoses and psychiatry as a whole handle acute suffering in a functional and pragmatic way, and the people who we intend to help with the upcoming diagnosis of PGD are certainly those who will most likely benefit from treatment. But this must not steer focus away from the fact that the diagnosis serves a societal function that can be problematized and politicized. In the case of grief, there is a concern that contemporary societies value the medical diagnosis as the sole legitimate way of handling suffering (see Bergsmark, 2021), and as such the enactment of the PGD diagnosis may express a lack of political investment in adjusting increased demands on performance and productivity (Kofod, 2017). While this individual–psychological way of treating mental suffering handles the acute individual dysfunction, it simultaneously does suggest the need for more complex, politically founded responses—exemplified and reflected in the Greenlandic situation.
Moving forward, we ask how psychologists may handle acute suffering and, at the same time, be politically aware. Our analysis indicates conceptual competence as a possible solution and way of integrating insights from cultural psychology in health psychology and psychiatric care. The engagement of professionals in the political discussion on how to handle mental suffering is wanted, as being theoretically minded does not hinder therapeutic practice (see Bergsmark, 2023).
Fundamentally, the criticisms of the grief diagnosis seem to concern more rudimentary psychiatric issues, and the debate should take this into account in order to be more transparent about the potentials and problems of diagnostics. This has the potential to guide political ways of approaching mental suffering and its contextual factors related to increased societal pressures and acute needs of treating suffering (e.g., with regard to the increased rates of depression, see Bergsmark, 2023). These considerations are already suggested in the Nordic debate about grief pathologization but are rarely explicated. The continued effort to improve the psychiatric handling of mental suffering should seriously consider these critiques and make this the starting point of formulating possible solutions.
Conclusion
In this critical analysis, we have examined which considerations are lost during debates about the upcoming diagnosis of Prolonged Grief Disorder in the Nordic countries. First, we have shown how PGD illustrates a larger theory problem in psychology, in which the phenomena constructed is not robust nor validated. Second, we have shown that the introduction of PGD in ICD-11 (WHO, 2019) reflects what has been termed “diagnostic cultures,” and how the pathological concept of grief is negotiable. However, while being legitimate concerns, this criticism is directed at larger discussions than pathologization of grief. We believe that the debate must recognize and address this.
Accordingly, we have discussed how health psychology can benefit from cultural psychological considerations, and vice versa, through conceptual competence. We believe that the pragmatic value of psychiatric diagnoses should be questioned, which cultural psychology tends to do. At the same time, it should be acknowledged that diagnoses facilitate the treatment of psychological disorders, and thus that health psychological initiatives are legitimate. The political guidelines for identifying something as deserving treatment are uncertain, and therefore we should problematize when a disorder warrants individualized treatment, and when the problem reflects a structural, cultural issue.
To summarize, our analysis indicates that the implementation of PGD raises very few grief-specific issues, but illustrates some pervasive and serious problems with psychiatric diagnostics as a whole. This accentuates the need for dialogue and conceptual competence between mental health professionals, and for political engagement in handling mental suffering. In the Nordic debate about the psychiatrization of grief, we see these considerations suggested, but unfortunately rarely explicitly discussed. By virtue of our professionalism, we should engage in these debates, but it is important that this does not end up in a sensationalist and contradictory quarrel about the grief phenomenon. This is especially important to prevent people from confusing clinical or disorderly grief with common or universal grief. As such, clarification in the debate may lead to fruitful theoretical discussions of psychiatric concepts and the way we handle mental suffering in contemporary societies, with grief as an exceptional example.
Footnotes
Acknowledgements
A special thank you to Ester Holte Kofod (“The Culture of Grief”) and Maja O’Connor (The Danish National Center of Grief) who have read and commented on the draft article. The article is translated from Danish by Niels Busch and the first author.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
