CHAPTER 2.................................................................................................................................................... 10
2.8 Grief diagnosis and classification
When confronted with death, faith and belief are challenged. There is confusion and a sense of betrayal, and such a state paves way to the experiencing of either spiritual struggle, spiritual crisis, complicated grief, or complicated spiritual grief of the bereaved (Burke et al., 2014). In line with this view, Rando et al. (2012) recommend that clinicians and researchers should assess the ways that cultural and spiritual/philosophical factors complicate and facilitate the grieving process. For instance, themes such as resentment and doubt towards God, dissatisfaction with the spiritual support received, and substantial changes in the bereaved person‘s spiritual beliefs and behaviours can lead to complicated spiritual grief and call for different treatment protocols (Burke et al., 2014). The specific cause of death, such as natural anticipated death, natural sudden death, homicide, suicide and/or fatal accident deferentially also predicts levels of CG and CSG (Burke & Neimeyer, 2014).
Individuals who have suffered atrocities, such as homicide, might be more prone to feeling or expressing extreme anger towards God (Neimeyer & Burke, 2014). The CSG is a relatively new area in bereavement studies and it is gaining more attention.
The DSM-IV-TR included a bereavement exclusion criteria denoting that bereavement was seen to be a normal human reaction, with its behavioural repertoires being culturally determined (Bonanno & Kaltman, 2001). However, the DSM-5 has dealt away with the exclusion criteria, making it to be diagnosable as a mental disorder. Several scholars (Fox & Jones, 2013; Frances, 2013; Wakefield, 2013) stand opposed to the elimination of the exclusion criteria for a variety of reasons. For instance Frances (2013) argued that such a consideration may not only lead to the medicalization of normal grief, but also exacerbate health costs because of over-diagnosis of major depression. On the other hand, diagnosing bereavement as depression may run the risk of pathologising the cultural norms established for individuals who grieve the death of a loved one (Fox & Jones, 2013). Fox and Jones goes on to highlight that the diagnosis of bereavement as a mood disorder have implications for how counsellors conceptualize and treat both bereavement and major depression.
Further arguments were that as much as there are similarities between bereavement and depression, there are differences such as in bereavement, the bereft often are able to feel an intimate connection to the people around them, and experience mixed negative and positive emotions. When compared to those suffering from depression, the affected tend to feel socially exiled or isolated, are characterized by significant difficulty in experiencing self-validating positive feelings (Wakefield, Schmitz, First, &
Horwitz, 2007; Frances, 2013). In addition, depression is composed of a recognizable and stable cluster of debilitating symptoms accompanied by a protracted enduring mood‖ (Zisook & Shear, 2009). In other words, grief should not be diagnosed as a form of depression or an abnormal reaction despite its potential of becoming severe enough to cause depression (Fox & Jones, 2013).
Those in support of eliminating the exclusion criteria held that held that individuals who suffer other severe life stressors, such as illness, divorce, physical assault, rape, and job-loss, are as likely to develop major depression as those suffering bereavement, yet these stressors are not grounds for exclusion of a major depression diagnosis (Kendler, 2010). In a nutshell, most quantitative grief studies
held a strong view that grief should be classified as pathological on the basis of it sharing a similar quantifiable syndrome with major depressive disorder (Kendler, 2010; Zisook, Shear, & Kendler, 2007; Kessing, Bukh, Bock, Vinberg, & Gether, 2010). This sentiment is captured by Stetka, Christoph and Correll (2013), by highlighting that the proponents of the elimination of the bereavement exclusion criteria argued that grief does not preclude the development of full-blown depression, and that grief predisposes the bereft to major depressive disorder. The overarching argument was that, a clinician evaluating a bereaved person was at a risk for both over-and-under-diagnosing the patient, either pathologising a normal condition or neglecting to treat an impairing disorder (Shear et al., 2011).
With the DSM-5, the argument that the bereavement exclusion criteria should be eliminated, rather than retained has finally been laid to rest, despite ongoing arguments and fierce criticisms from many groups and organisations (Wakefield, 2013; Pies, n.d.). Bereavement is now classifiable as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one (Stetka, Christoph & Correll, 2013). Wakefield contends that the reasons provided for this change, varied over time, and ranged from fear of missing genuine cases of depression and fear of missing suicidal cases to the effectiveness of medication with the excluded group and the fear that clinicians would misapply the exclusion. In light of this contentious debate, the American Psychiatry Association (APA, 2013) reckons that the aim of the DSM-5 is to provide an accurate diagnosis for people who need professional help, and as a result, there are several proposed strategies put forth to help clinicians to differentiate a major depression, ―normal‖
bereavement and pathological bereavement. It is within the context of these arguments that Fox and Jones (2013) highlighted that a balance between cultural sensitivity and accurate diagnosis is an ethical dilemma that counsellors will continue to face in the publication of the DSM-5.