Filed under: Grief, Recovery | Tags: complicated grief, grief, happiness, positive psychology, recovery
31st January 2013
As a way into thinking about the current debates surrounding recovery I have been quite drawn by the debates around the omission of the grief exclusion in the DSM-5’s definition of major depressive disorder and how that has raised issues surrounding the normative boundaries of grief. Complimenting this is the establishment of a category of ‘complicated grief’, or sometimes referred to as prolonged grief disorder. The proponents of the establishment of a ‘complicated grief’ diagnosis include Katherine Shear and Holly Prigerson and colleagues who have outlined a ‘scale’ or ‘inventory’ of complicated grief. The boundaries of what constitutes CG however seem to still be in flux, yet its supporters argue a concrete category is necessary in order to separate those that have ‘difficulty in progressing through the natural healing process’. The implication here is that there is a natural and instinctive healing process that is impeded in some way and thus requires correcting in order to reach the appropriate recovery.
Omega also dedicated a journal issue in 2006 discussing CG which highlighted some interesting points. Neimeyer in his article interestingly commented how the existence of grief as a real phenomenon is not the issue but rather the ways in which it is constructed by various groups. His argument was thus that ‘complicated grief’ was not a thing to be essentialised but a social construct reified in discourse. Whilst in agreement with viewing grief and complicated grief as a socially constructed, or at least socially manipulated emotion, Neimeyer’s argument that CG is comparable to abstract concepts such as ‘democracy’ or ‘power’ I found unconvincing. For while Neimeyer seems to admit that CG does not exist as a ‘real’ thing, diagnosing individuals with CG does become a real thing in terms of a labelled, categorised aspect of someone’s personality or emotional landscape; it becomes something to overcome. In the same Omega issue, Walter made some poignant points in asking ‘What is complicated grief?’ and listed some of the key contributing factors that have brought about the idea of CG. One point he made that I thought was salient was how the only thing that separates CG from ‘normal’ grief or from mourners in general is the time period in which feelings of grief last. As Walter remarks:
This reflects popular notions that grief is something one should get over quickly, and that it is embarrassing and/or inconvenient if colleagues or family members’ functioning is impaired by grief for extended periods. Indeed, it reflects a widespread duty in American culture for its members to be self-determining individuals and, moreover, happy.
Further Walter put forward an argument for the usefulness of complicated grief as a political tool and thus not something to be ‘therapied away’ but something that may lead to a more just society. I feel this is a particularly neglected line of enquiry and reminded me of Sara Ahmed and how she demonstrates the political and emotional uses and benefits of unhappiness in her book ‘The Promise of Happiness’. The way in which Walter linked the obligation to recover from grief with a wider sense of duty to be happy also paves a way for my own research.
The shifting boundaries of CG also provides a rich basis to explore the ranging definitions of what constitutes abnormal and normal grief. As Arnar Arnason also highlighted in his work, bereavement counselling exists as a way to make ‘visible’ feelings that ‘already exist’ but remain incomprehensible to the mourning individual. Bereavement counselling and the increasing medicalisation of grief can be seen therefore as a way of re-ordering the chaos of grief into tangible categories. This clearly brings up thoughts of Foucault and the medical gaze as well as Nikolas Rose’s work on psychotherapy and the normalising role of medicine. Intervention is made on the basis of the correct naming of things. The questions that arise for me so far from beginning to read the literature around CG, is to ask why does grief need to be defined or categorised in this particular way. CG is an example of how boundaries can be placed on grief and certain grief experiences can be labelled as pathological, which in turn assumes a normative healthy grieving process. In this act of naming CG – which as Neimeyer remarked does not exist as a ‘real’ thing – there is the sense that something is being created; grief is being ‘made-up’, or performed, in a certain way. Throughout some of the literature there is also a – I feel problematic – assumption of grief and feelings of grief as something that already exists out there, the process of naming and categorising thus becomes a way to capture them and act upon them. Yet I am interested in posing the question: Rather than identifying what is ‘already out there’ are we not creating categories, symptoms and pathologies where they do not exist? For how do we know things exist if we cannot name them and why do we think these categories, say CG for example, are the best means to capture them?
13th February 2013
I have been tentatively exploring the historical contexts of the contemporary conception of recovery. There are a few intersected factors that have emerged from some very preliminary readings, those being the impact of WW1 and WW2, the creation and proliferation of cognitive behavioural therapies and increased experimentation with psychiatric disciplines. One of the key impacts of war was the prevalence of ‘shellshock’. Shellshock as a non-physical injury posed an interesting problem to the medical profession that allowed what was arguably the first wide-scale intervention into the mental health of the population. The treatment of shellshock is a key instance of mental illness becoming a matter of ‘social hygiene’ (Rose, 1989). The sheer quantity of cases of shellshock shifted the perception of madness from something that was dependent on individual personal history and childhood trauma to something less discriminating and capable of affecting all individuals. Viewing shellshock as a treatable disorder promoted the idea that the individual was open for intervention and further that intervening into individual mental health was a matter both of public health and individual autonomy and freedom. This perspective has its legacy in contemporary healthcare as displayed in the Foresight report (2008) – a government directed project into ways to create ‘positive mental capital’ and well-being:
Positive mental health has an important societal value, contributing to the functions of society, including overall productivity. It is an important resource for individuals, and nations, contributing to human, social and economic capital.
Indeed another recent document published by the Department of Health was entitled: ‘No health without mental health’ (2011). It could be argued that following the world wars emerged an opportunity for mental health to become far more central to the understanding of what it means to be well, and further that positive mental health became a requirement for a productive and efficient workforce. Mental disorders such as shellshock thus became something that needed to be treated and to be overcome, which stimulated the experimentation with new behavioural therapies at places such as the Maudsley hospital (Marks, 2012). The indiscriminate nature of shellshock – the fact it was a mental disturbance produced from the experience of war rather than an internal trauma based in family history – complemented the rise of CBT that dispensed with Freudian heavy psychoanalytical approaches while retaining the element of the unconscious and unconscious drives.
This in some ways mirrors the view of positive psychology. Positive psychology believes the potential for happiness lies in our own hands and is something that can be achieved through correct training and adjustment. In the UK, Action for Happiness is an organisation that established itself with the aim to promote the way to achieve happiness. One of its slogans found on its website (http://www.actionforhappiness.org/) is quite instructive of the idea that positive mental health is a individual choice: ‘If you can’t change it, change the way you think about it’. I can’t help but draw parallels with the NHS website and their slogan: ‘Your health, your choices’. The emphasis on individual choice and the fostering of the idea of autonomy frames the way recovery is understood. Recovery from unhappiness or illness becomes a matter of making the right choices; unhappiness is a product (or defect) of the individual not the social context. For if you can’t change it you can at least change how you think about it. Unhappiness becomes synonymous with the inability to act on ones own and take responsibility for ones own life (Binkley, 2011). To fail in taking steps towards attaining happiness is a shunning of responsibility but also autonomy – making ones self happy becomes a matter of individual freedom.
Positive psychology reaffirms its status by claiming it has scientific measurable techniques that are proven to make you happy. The idea of happiness as a measurable entity is now widely assumed with the first national well-being measure carried out last year. Recently the department of health also put forward its support for a scheme that would promote 30 self-help book titles in GP surgeries and libraries. The idea is that when an individual turns up at the doctors showing signs of depression they will be directed to these titles which include much of the ‘Overcoming…’ series and self-help classics such as ‘Feel the fear and do it anyway’. This promotion of self-help books is seemingly an extension to the IAPT scheme which a government initiative to increase access to talking therapies throughout the UK.
What is interesting is how recovery became something individually directed to something guided by experts. Perhaps this is a bigger question that directs us to much bigger shifts in healthcare. To return back to positive psychology, the conception of the self is an interesting one. As mentioned above, positive psychology rejects psychoanalytic models that emphasis the unconscious or early childhood, employing in Binkley’s words ‘a strikingly truncated view of the human psyche’ (2011, p384). Yet positive psychology and the happiness proponents centre their belief in the need to guide and advice people about happiness by claiming we don’t always do the things we ought. We are prone to making mistakes about our happiness, says Paul Dolan (2011) and so we need our attention redirected to the right (happy) objects. Positive psychology thus seems to imply we have an unconscious that leads us to unhappiness and needs redirecting but this is something we need to be helped with – in the name of autonomy. I also feel this conception of the self and emotions echoes how bereavement counsellors and psychiatrists seem to work on the idea that feelings are already existent in the grieving individual, but simply need a language through which to articulate them.
With the ‘happiness agenda’ the problem occurs when the promotion of certain ways of living a life are at the expense of other ways of living, of being free to be unhappy, resulting in a decrease in the toleration of the different ways people live their lives. Indeed the pursuit of happiness can in itself mean happiness is decreased through failing to attain the objects that are designated as creating happiness. This is an argument put forward by Pascal Bruckner in which he attacks the ‘duty to be happy’. His argument also draws interesting parallels with Lauren Berlant’s idea of ‘cruel optimism’. Cruel optimism is when something you desire is actually an obstacle to your flourishing. The attachment to the desire (say to be happy, or to recover) becomes cruel only because the object that draws your attachment impedes the aim that brought you to it initially. These objects come in to represent happiness or freedom but ultimately by becoming attached to them they get in way of any chance we have of sensing freedom or happiness.
This has lead me to think more about emotions, and return to Sara Ahmed’s work on happiness and emotions (2004, 2010) and sociological explorations into emotions, in order to reflect on the understanding of grief I am assuming in my own analysis.
Ahmed, S. (2004). The Cultural Politics of Emotion. Edinburgh: EdinburghUniversity Press.
Ahmed, S. (2010). The Promise of Happiness. Durham and London: Duke University Press.
Berlant, L. (2011). Cruel Optimism.Durham and London: Duke University Press.
Bruckner, P. (2010). Perpetual Euphoria: On the duty to be happy. Oxfordshire: PrincetonUniversity Press.
Department of Health (2011a). No health without mental health: a cross-government mental health outcomes strategy for people of all ages, London: Department of Health.
Dolan, P. (2011, 8th February). ‘Absolute beginners: Behavioural economics and human happiness’. Department of Social Policy Inaugural Lecture delivered at the London School of Economics. Video of talk available here: http://www2.lse.ac.uk/publicEvents/events/2011/20110208t1830vSZT.aspx
Foresight Mental Capital and Wellbeing Project (2008). Mental Capital and Wellbeing: Making the most of ourselves in the 21st century. Final Project report – Executive summary. The Government Office for Science, London.
Marks, S. (2012) ‘Cognitive behaviour therapies in Britain: The historical context and present situation’ in Dryden, W (ed) Cognitive Behaviour Therapies. London: Sage.
Rose, N. (1989) Governing the Soul: The Shaping of the Private Self. Second Edition. London: Free Associations Books.
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