Philosophy, Psychiatry, & Psychology

Loretta Kopelman argues that "normal" grief is adaptive rather than nonmorally bad and hence best not considered a disease. If grief is not bad, then is it good? Adaptive, as Kopelman makes clear, is not synonymous with good. Clearly some individuals are able to transcend the pain of grief and bereavement to reach a new level of functioning or personal perception. This is commonly seen in individuals who survive a physical illness. Following a myocardial infarction, the hard-driving executive may reevaluate his priorities and begin to enjoy life in a different manner, but it would be wrong to suggest that the myocardial infarction was "good" for him. Some HIV patients report that their illness experience has brought out areas of support from family and friends which were previously unknown. Nevertheless, this deadly virus could never be considered "good." Kopelman's point, then, is that, in and of itself, grief may be adpative and, to this extent, good. On this model, failure to mourn may be as abnormal as prolonged or unresolved grief (Zisook and Schochter 1993).

From a practical point of view, it is helpful to consider the various perspectives on grief (McHugh and Slavney 1983). Both Freud and Pollack viewed grief from the perspective of an individual's life history. This hermeneutic interpretation of subjective experience offers one explanation of how grief may be adaptive or maladaptive. It utilizes an introspective psychology linking meaningful associations with patients' narratives. A second and quite distinct perspective is that of the disease model. This attempts to develop reliable, identifiable syndromes as a basis for establishing the course, prognosis, and possible treatments for distinct diseases. In physical medicine, diseases may be further defined by biological correlates or even specific causes. Comparable disease concepts are more problematic in psychiatry, mostly because the boundaries of mental syndromes seem less circumscribed and more value laden, partly because well defined anatomical and physiological correlates have, in general, not yet been identified. To circumvent such difficulties, DSM-III, III-R, and IV utilize the term disorder rather than disease(APA 1994).

Engel and Hofer advocate viewing grief as a disease, not for reasons of general theory, but for the pragmatic reason that grief is best understood by the medical model (Engel 1961; Hofer 1984). This means, first, that syndromes must be reliably defined and demarcated from other disorders, such as depression. Second, the identification of such syndromes allows us to understand their course and eventual prognoses, as well as [End Page 223] the development of soundly based treatments. Hofer's paper underscores the neurobiology of separation and grief in both animal and human models. It also provides the beginnings of a causal explanation of health-related problems that may occur in bereaved individuals. Psychoimmunological changes in both stress and bereavement have also been found and suggest a physiological underpinning to the subjective psychological experience of grief (Calabrese 1987).

A third perspective is that of personality differences. Which personality styles allow the bereaved to mourn and return to normal functioning? Elevated neuroticism, for example, correlated with vulnerability to depression, and thus might be a personality marker for abnormal grief states (Kendler et al. 1993). Clearly this is a perspective that merits further study.

The diagnosis of uncomplicated grief is made after the fact. The exact resolution of this mourning process differs from individual to individual and needs to be better defined. But it is clear, at least, that grief is a condition that leaves us vulnerable to other conditions such as major mood disorders or anxiety states. In this respect grief is similar to pregnancy, which also produces biological changes leading to vulnerability. When uncomplicated grief ceases to be an after-the-fact designation, when we are able to predict in advance who will experience grief in an uncomplicated manner and who will develop bereavement syndromes that evolve into other psychiatric disorders, then we may be able to dispense with the disease model (Zisook, Schochter, and Lyons 1987). Until then, whatever the philosophical arguments, it may well be useful to consider grief a syndrome, and to utilize the medical model to explore the limits between...