Pathologizing the pathological and the place for grief: Reply to Brinkmann

Clarifying the premises

First and foremost, hopefully accommodating Brinkmann’s (2023) “bafflement” (p. 874), we could not agree more: professional disagreement and debate is necessary, enlightening, and in many ways truly scientific. It provides possibilities for interdisciplinary development and prevents professional hegemony, and we certainly advocate for such.

The Nordic debate about PGD, however, is plagued by a persistence of arguments on the (il)legitimacy of the diagnosis, with few openings for constructive dialogue and real cooperative development. We do not see this form of principal two-way monologuing as fruitful or productive, and we are alarmed at what at times comes across as a disregard for the very real suffering of bereaved people in clear need of help. It is not obvious to us that disregarding the diagnosis on principle (Brinkmann, 2023, p. 874) is a thoughtful response to the work being done to reduce immense suffering in the population in question.

That said, it should be addressed that, yes, it is thought-provoking that a phenomenon such as grief is to be included in the psychiatric nomenclature. On this matter, we fully agree. Although we do not share Brinkmann’s (2023) experience of a “broad opposition from medical doctors” (p. 874), and furthermore most certainly believe that “public disbelief” is influenced by the ways in which one chooses to portray the forthcoming diagnosis for pathological grief, we do believe that the PGD diagnosis should lead professional attention toward theoretical issues in nosology. One might say that we, along with Brinkmann, agree on the questions and puzzles that PGD provokes but arrive at different conclusions: Brinkmann ending up oppositional and us remaining agnostic.

Brinkmann (2023) argues: “With the pathologization of grief, there is hardly any form of deep suffering left in human life that is outside a diagnostic frame” (p. 875). We sympathize with his unease. In fact, Brinkmann (2014) has elaborated on this topic in an excellent article. His worries are indeed relevant—that alternative “languages of suffering” are losing ground to a far too overused diagnostic frame of reference, and that normal painful experiences too uncritically are being talked about as medical issues.

However, Brinkmann’s argument does not account for, or simply deliberately diverges from, the very central premise that PGD does not, in fact, refer to typical, generic, nonpathological, universal grief; it is not reflective of a normal human experience. It is quite the opposite—it is what one assumes to be pathological, in the same way that, for example, clinical depression does not reflect generic sadness and thus is well worthy of a diagnostic frame and language. The very argument that PGD pathologizes normal grief responses is faulty unless one also believes that other mental disorders constitute invalid categories—which is a radical and provocative, but intriguing, statement, typically associated with what is sometimes described as antipsychiatric literature (see also Chapman, 2023).

Furthermore, to add nuance to Brinkmann’s unease, we need to underline that it is incorrect to propose that 10% of the general population is expected to receive a diagnosis of PGD. To give a diagnosis, a structured clinical interview must be performed. PGD was only very recently officially included in the diagnostic manuals as a mental disorder, and no such validated interview is yet available. Instead, the often-cited 10% estimate is based on self-report measures, which estimate the overall intensity of PGD symptoms. These studies estimate how many in a sample of bereaved people are likely to have clinically relevant symptom levels. This refers to people who have PGD symptoms that are severe enough to be likely to benefit from evidence-based treatment for PGD. Thus, the 10% refers to cases with clinically relevant or probable PGD. It identifies a subsample that includes significantly more people than those with the full PGD diagnosis as identified with a structured clinical interview. Through these clinician-administered interviews (i.e., actual diagnosing), newer estimations arrive at 2%–4% PGD prevalence (Rosner et al., 2021), which is on a par with other psychiatric diagnoses. In our opinion, this should raise awareness of the significant proportion of citizens currently experiencing clinically significant distress without proper treatment, not that normal grief is being illegitimately pathologized.

To be clear, we do not read Brinkmann’s commentary as antipsychiatric as such, but rather as thoughtfully skeptical of an uncritical broadening pathologization of human life. As he states:

The reason why the introduction of PGD has caused such a stir is . . . that it was probably the last example of a human experience that was at the same time intensely painful and yet resisted pathologization due to the inherent meaningfulness of reacting with grief to bereavement. (Brinkmann, 2023, p. 875)

Brinkmann argues that the problems of pathologization (of which he describes four) actualize why diagnosing unproportionally distressing responses to loss in the absence of a valid theory of mental disorders is “problematic, bordering on the unscientific” (p. 876). These problems are well formulated but only partially apply to the case of PGD, as we will elaborate in the following.

Pathologizing the pathological

Brinkmann leads our attention to the worrying trend that more and more people are being seen by psychiatric services, and that the necessary resources do not adequately follow (Issue 1). This development is indeed worrying, and there has been great debate on how to understand and handle this politically.

In the context of PGD, however, the very problematic side of Brinkmann’s (2023) argument is the claim that by broadening the concept of diagnosis (in this case, we assume, by the introduction of the diagnosis), fewer resources are made available for “the most severe problems” (p. 875). While we agree with the general concern regarding limited resources, we are provoked by the lack of understanding that the population at risk of being diagnosed with PGD is exactly what one would call “the most severe.” As we argue in our original article as well, the conflation of pathological grief with normal and subclinical grief is confusing and misguides focus on the need for more resources for individuals at risk of the most severe grief reactions, as seen in PGD.

The second issue described by Brinkmann—the indiscriminate consumption of psychiatric diagnoses—raises greater concerns. It is true, as Brinkmann argues, that medical language has gained prominence in contemporary society, and that this may have undesirable consequences—we are fond of the psychologist Kofod’s (2017) work on this subject. This will surely influence how one also looks at so-called “normal grief,” and, as we argue in our original article, tackling the subclinical group will be a challenge, as it is with all mental disorders, in part due to the risks of medicalization from below.

It is, however, important to note that diagnoses can also have the opposite effect: they can be empowering and indeed create possibilities and hope where this is due. We believe that the issue Brinkmann describes more broadly stems from the democratization of psychiatric diagnoses. The difficulties of keeping diagnoses to their intended area of expertise are, in our opinion, a timely discussion, but not at all limited to the discussion on PGD. It is quite the opposite—we would argue that framing grief as a stand-alone example removes an important focus on problems in nosology at large.

The individualization of suffering that Brinkmann describes in the third issue is indeed very problematic. Brinkmann points out that diagnosing the individual risks undermining societal issues that may have driven the individual suffering, in which experiences could be viewed as natural in unnatural/pathological circumstances. In fact, we elaborate a great deal on this in our discussion and section on the Greenland context (Bergsmark & Ramsing, 2023, p. 865). We strongly believe that societal issues and contextual factors in general need to be taken seriously with regard to their contribution to individual suffering. However, in the context of pathologization and more specifically PGD, at least two aspects need to be addressed.

First, we need to acknowledge that individual treatment is still warranted in cases of treatment-demanding grief, as the suffering experienced is indeed very real and debilitating. We believe that individual treatment does not hinder political awareness and actively participating in the work toward bettering mental health as a political issue. As we argue in our original article, this kind of reflexive practice is needed in psychiatry and is a field to be further acknowledged and developed, which is not impossible.

Second, it is possible to reassure Brinkmann with regard to his concrete worries about social intervention not being researched when the diagnosis is in place. It is quite the opposite—the current directions of grief research work around a “stepped-care model” that explicitly seeks to provide appropriate support. This means that individual psychotherapy is not assumed when grief is evaluated as nonpathological, partly because treating ordinary grief is acknowledged as counterproductive. Institutionalized approaches will in theory not be involved until the condition is considered treatment-demanding, which gives room for communal, social, and cultural contributions.

In general, we argue that the problem of individualization is first and foremost dangerous when it becomes an issue of social and political injustice. Brinkmann’s fourth issue argues on an existentialist basis that alternative languages of human suffering are being eroded in favor of the medical. We do believe that there is value in maintaining the existential language of suffering as “part of being alive as embodied, mortal beings” (Brinkmann, 2023, p. 876), but are certain that people with agonizing mental problems as seen in psychiatric patients are interested in medical takes to alleviate their condition, and that existentialism makes a poor diagnostic tool in relation to treatment. There seems to be an important distinction between general discussions of normal or expected human suffering, such as grieving the loss of a loved one, and the lived experience of painful pathological states.

Nonetheless, there are important political discussions to be had also with regard to pathological states. Brinkmann mentions and concludes that poverty and marginalization are painful but nonmedical states. In our view, injustices such as poverty and marginalization can very well lead to mental disorders (in the same manner as losses can lead to pathological grief responses). Such mental disorders would not just be sociopolitical issues, but also conditions in need of healing. A general concern we have with the debate around PGD, as well as broader discussions in the field of critical psychology, is that it seems to be impossible for many professionals to appreciate and incorporate both perspectives in practice. A colleague once described it as follows: if the drinking water is contaminated, one needs to both clean the water and resolve the issue leading to the contamination. In the case of grief, we see the need for research into the contributions of unjust social conditions to developing pathological grief specifically, as well as clinical interventions for those afflicted.

The question of what a mental disorder is

Brinkmann’s commentary mainly addresses the consequences of pathologization, but a central part of the text is also about the question of what a mental disorder is. Brinkmann argues that the operationalized way of conceptualizing mental disorder has equaled pathology with its symptoms, which, in his opinion, is problematic at the very least. In reality, however, there are far more problems with psychiatric diagnostics than this alone (as wonderfully formulated by Aftab & Ryznar, 2021) and, correspondingly, there are many exciting developments in the field. These theoretical discussions of psychopathology are very timely, but with regard to the concrete case of grief, we still believe the main question that needs to be asked is: By today’s standards, can the concept of mental disorders also incorporate grief? Indeed, this does not make it impossible to have theoretical criticism—in fact, we encouraged this in our original article.

What Brinkmann (2023) describes as “absurd” is rather a disregard for what psychiatric nosologies in their current form are intended to be. The function of psychiatric diagnoses is certainly welcome in clinical care, but from both a practical and a theoretical perspective, new directions for psychiatry are nonetheless in need of continuing discussion. In the final section of this response, we would therefore very briefly like to address three standpoints for what we believe are fruitful developments for psychiatry, incorporating the important contributions of critical cultural psychology while maintaining the ability to identify and treat serious suffering:

These standpoints are all in line with establishing PGD as a psychiatric diagnosis, assuming that professionals are considerate of the conceptual shortcomings of psychiatric diagnoses at large. Therefore, it is more a question of whether people are favorably disposed to seeking cooperative developments, including a strong critical stance as well as clinical knowledge. The Nordic debate on PGD has shown that this is not obvious. We hope that this short response has made clear the necessity for common ground going forward.