politics of the hap


Recovery as a process of normalisation: what is normal grief?
February 11, 2014, 3:58 pm
Filed under: Uncategorized

Theorisations of grief serve not only to capture grief but define the appropriate ways it is approached and performed. The theories that currently dominate the way grief is understood and managed are theories and studies of a largely psychological nature. As Granek (Granek, 2013) has argued, grief theory has been over-psychologised, with on over-emphasis on identifying the dysfunctional aspects of grief. This has produced a contemporary understanding of grief that tends to cohere around the idea that grief is an experience that impacts on the psychological well-being of a person and needs to be recovered from through processes of detachment from the deceased. Successfully detaching from the deceased will enable the reintegration of the grieving person back to ‘normal’ functioning through adjustment and acceptance and help them relearn healthy patterns of attachments to the deceased (Kubler-Ross, 1970; Lindemann, 1979b; Parkes & Weiss, 1983). Currently neuroscientific data is shaping present understandings of grief by exploring how grief affects the brain (O’Connor, 2005, 2012). This is opening up new avenues for viewing grief not only as a matter of the psyche but also as possessing biological and somatic markers.

Whether as a matter of chemical imbalance or a disorientated psyche, grief, despite the many claims to its ‘natural’ occurrence, is posited as an experience that requires reorganisation. Though the stages of grief so famously outlined by Kubler-Ross (Kubler-Ross, 1970) have been critiqued following empirical enquiry (Konigsberg, 2011; Maciejewski, Zhang, Block, & Prigerson, 2007) the continual search to capture grief in scientific terms and the proliferation of self-help literature on grieving suggests grief is still considered as something to be ‘worked through’(Worden, 1991), and significantly an activity for which individuals are responsible. Studies that have explored the social constructions of grief have highlighted the social structures and contexts that shape perceptions of grief (Jakoby, 2012; Lofland, 1985; Walter, 1999; Wambach, 1985). This work has illuminated how grief can be understood as a social emotion and not only as an individual psychological experience. Sociological explorations of grief have also discussed how hierarchies of grief exist that demarcate appropriate presentations of grieving (Robson & Walter, 2013) and can act to ‘disenfranchise’ certain types of grief (Doka, 1989). For example, the relationship with the deceased, the type of death, and the age of the deceased all factor in to how much or little grieving is appropriate. This is to argue that not all losses can be understood as being equal and further that different social settings or structures demand different responses (Charmaz & Milligan, 2006). Grieving then becomes not only an internal psychological task to work through but an active presentation of self.

But where and how do these norms, these ‘feeling rules’ (Hochschild, 1983), emerge? In my research I will be exploring how factors such as the impact of government policy on healthcare practices as well as empirical data on grief patterns and behaviour, shifts in counselling practices (for example the shift in popularity to cognitive behavioural therapy) and changes in psychiatric diagnostic manuals all contribute to how the norms on grief in contemporary Western societies are shaped and interpreted. The norms that ‘police’ and regulate grief (Walter, 2010) in a modern neo-liberal society that has witnessed the ‘secularisation of death’ (Mellor & Shilling, 1993) are arguably far more fluid where the priority is individual choice and autonomy. This is reflected in healthcare services where patients are increasingly viewed as consumers of what is claimed to be a democratic system in which the voice of the service user is far more central. In particular, policies concerning recovery are becoming progressively more popular (Department of Health, 2001; McPherson, Evans, & Richardson, 2009). Recovery began as a radical movement, drawn from a melange of beliefs and values that emerged from anti-psychiatry, the psychiatric survivors movement, and the consumer rights movement, that critiqued the paternalistic nature of health care and sought to reclaim power back to the patient or service user (Braslow, 2013; Roberts & Wolfson, 2004; Travis, 2009).  The introduction of recovery into health care policy, the growth of narrative approaches to health care, and the growth of online user directed forums are all attempts to remedy what is considered to be the ‘epistemic injustice’ at the heart of the way health care services have been administered (Carel, 2013).

Though the initial move towards recovery sought to bring acceptance to living with an illness and to broaden the notion of recovery outside of medical requirements, as recovery has been co-opted and incorporated into mainstream practices the radical demands have gradually coincided with, or indeed diluted by, a government agenda of autonomy and individual responsibility (Braslow, 2013). This is perhaps a result of the ‘plastic’ nature of recovery which originally was designed to be inclusionary rather than the exclusionary nature of the healthcare of the past. Indeed for grief, what recovery means and entails has been contested (Balk, 2008; Paletti, 2008; Rosenblatt, 2008; Sandler et al., 2008; Shapiro, 2008) and the divergent conceptualisations have done little to dent the belief in the stages and phases of grief in wider culture. A possible cause for the failure of recovery to bring about the radical demands it set out to achieve is that in trying to expand what was viewed as normality, it became incorporated by the norm itself, without that norm experiencing dramatic change.

Recovery has come to rely on assumed notions of what it means to be a functional citizen yet the criteria of what is deemed to bring quality of life are rarely questioned. A Department of Health policy document entitled ‘The Journey to Recovery’ (2001) describes recovery from mental illness as including the following: having an acceptable place to live, a meaningful occupation, access to further education and training, access to information on entitlements and benefits, and engaging in ‘ordinary social activities’. This vague list of components of the happy recovered life (an ‘acceptable’ place according to whom? What are ‘ordinary social activities’?) appear to point towards an ideal life, a normality to which everyone should live by or strive for. In grief literature there are similar notions found as Shear (2012) describes the aims of successful mourning are: to be re-engaged with daily life, to be reconnected to others, to be able to experience hope for the future, for grief to be transformed and integrated, and to ‘effectively regulate’ emotions. As Arnason & Hafsteinsson (Arnason & Hafsteinsson, 2003) argue, the way in which grief is dealt with can be linked to permutations in government rationality. The types of bereavement therapies offered, mainly versions of cognitive behavioural therapy and increasingly mindfulness therapy, are part of broader government interests in well-being and happiness. These types of choices that are made available to a person following bereavement can be seen as processes of subjectification (Foucault, 1975). That is to say the adoption of behavioural therapies or mindfulness within the NHS in UK healthcare to treat grief both shapes how grief is defined but also shapes the subjectivity of the person who is grieving. This process of subjectification is not a simple process of disciplining from above, but as the incorporation of the recovery movement has shown, it is a process composed of two vectors where individuals are encouraged to undertake activities of self-governance, just as they are being encouraged to treat or work through their grief with the help of external services and interventions (Hacking, 1986).

Increasingly the resilience of people in the face of loss has become a popular focus in grief as well as across healthcare research (Bonanno, Moskowitz, Papa, & Folkman, 2005; Bonanno, 2009; Edward, 2005; Mancini & Bonanno, 2009; Miller, 2002; Richardson, 2002; Stokes, 2009; White, Driver, & Warren, 2008). George Bonanno and colleagues (2005) argue that most people tend to remain resilient in the event of losing a loved one. Bonanno (2009) dismisses the idea that people go through stages instead proposing that for most people grieving does not become a serious problem, and that if there is no real devastating sense of loss there are no stages to go through. This argument also brings into question the focus in grief theory on attachments and bonds to the deceased. Whereas the continuing bonds thesis (Klass et al., 1996) promoted the idea that ‘getting over it’ did not mean having to ‘let go’, an emphasis on resilience rather enforces an idea of our self-sufficiency; the belief that our autonomy remains intact even after losing a close family member or friend. The growth of research into resiliency also sits neatly within the broader emphasis in health care on recovery, where recovery is defined as an individual self-determined process. Yet the acknowledgement of the complicity between how people report themselves as resilient, and the wider societal discourses that promote and favour resiliency and rapid recovery from grief is notably absent in studies promoting the power of resiliency.

Seen through this lens then, resilience appears a simple gloss that ignores the complexity in how agency is formed and obtained. Resilience and recovery rely on an autonomous subject, and therefore the inability to ‘bounce back’ can only be a failure of the individual. So while grief is construed as a potentially problematic occasion, it is equally one where an individual is seen to be capable of rising above their suffering, using it productively to transform their lives. The transformative potential of grief has been highlighted (Balk, 1999) and stories of dramatic fighting against adversity proliferate in self-help books and memoirs (Dennis, 2008, 2012). When autonomy and choice are promoted as desirable qualities and when recovery from grief is depicted as something that is the responsibility of the individual, recovery becomes an obligation and a normative requirement. The failure to perform recovery thus becomes a moral failure of will.

Yet this presumption of autonomy gets confused in the instance of grief where commonly people who are grieving are considered not to know what is best for them; they cannot be autonomous (Parkes, 1972). As Butler (1997) highlights, subjects come into being through recognition, through being interpellated by language. If a subject is deemed vulnerable – and that is in contrast to the desired autonomy – then the very viability of the subject is questioned. It is in this instance when the person who is grieving is seen as requiring intervention to get them ‘back on track’. The grieving person is a ‘risky’ individual who needs managing (Rose, 2007). Yet to be deemed a risk there needs to be a normality from which abnormality is identified. The knowledge of the normal mind that the psychological disciplines claim to possess (Rose, 1985) provides the condition and basis for the application of techniques and measures such as diagnosing complicated grief. Complicated grief or prolonged grief disorder are categories that seek to explain and treat the 7% who do not cope ‘effectively’ with bereavement (Shear, 2012). Complicated grief is what occurs when the natural healing process is ‘impeded’ ‘derailed’ ‘delayed’ due to ‘interference’ and complicating factors (ibid). Some of the symptoms of complicated grief are intense yearning for the deceased, numbness, detachment, avoidance, trouble accepting loss as real, intrusive/preoccupying thoughts, sense of loss of meaning in life, and ruminating. Yet who decides what is sanctioned in grief and what is not? Shear describes the intention behind treating complicated grief is to stop ‘unnecessary suffering’ but often it would seem this more a matter of easing the suffering or discomfort of others around the person who is grieving. After all, it is family members who tend to be the ones who refer their grieving relatives for treatment (Shear, 2010).

What is interesting in this search for the pathological is the ambiguity of what makes up normal patterns of grief. Complicated grief is described as something that ‘derails’ the ‘normal healing process’ (Shear, 2012), yet what the ‘normal healing process’ actually entails remains vague. Studies that focus on the meanings the bereaved make about their grief and the deceased are widespread and narrative approaches to studying grief have sought to tackle the idea that there is only one or right way to grieve (Bury, 2001; Charmaz, 1999; Gilbert, 2002; Neimeyer, 2005; Valentine, 2008). In these narrative explorations, grief is depicted as a unique and individual experience. Telling stories about grief is seen to help bring voice to the multifaceted and varied nature of grieving. Yet this seems to fit uneasily with a preoccupation to identify the biological and psychological markers of grief, where bereaved people can be slotted into typologies and composed of lists of symptoms.

Furthermore there is an odd contradiction in that the aim of complicated grief treatment to promote ‘natural healing’ neglects to see how external intervention automatically undermines the possibility of a natural order of grieving. Perhaps rather this failure to perform natural recovery or tap into resilience reserves is in fact the ‘natural’ state of grief insofar as it is an equally valid manifestation of a state that is still undefined. Perhaps it is the norms through which grief is defined that need expanding; the definition needs to shift to fit the person, not the person to fit the definition. This is evermore salient for grief where the state of normality is constantly in flux, it is only by delineating failed performances can the desirable norms be selected and reinforced. As Maciejewski et.al. tellingly note:

The identification of the patterns of typical grief symptom trajectories is of clinical interest because it enhances the understanding of how individuals cognitively and emotionally process the death of someone close. Such knowledge aids in the determination of whether a specific pattern of bereavement adjustment is normal or not. Once the normal patterns of grief are known, individuals with abnormal bereavement adjustment can be identified and referred for treatment when indicated (2007, p.717).

But of course individuals are identified and referred for treatment without the normal patterns of grief being known. This suggests then that the norms through which grief are guided are not so much a way to stay faithful to a natural mourning or healing process, for this process is not known or at least cannot be identified. Rather then the norms of grief do something else; they prevent against and constrain the possibility of not recovering. ‘No recovery’ is chaotic and open-ended; there is no transformation of self or resolutions available in this experience of grief (Kauffman, 2007). The risk of no recovery is not just to the person who is grieving; it is a risk to the very idea of the vision of the good life the recovery narrative promotes. According to the diagnostic criteria of prolonged grief disorder, showing symptoms of grief for six months or more can potentially be cause for intervention (Prigerson et. al., 2009). The popularity of research into resilience further fosters the idea that grief is something to be recovered from quickly (Balk, 2008). Time then becomes one of the key indicators in managing grieving. ‘Technologies of temporalisation’ (Binkley, 2009) is one of the strategies Foucault (Foucault, 1975) argued institutions use to produce docility in its workforce. Borrowing Foucault’s concept, the experience of grieving has become something framed by time, by an imperative to recover within socially acceptable parameters, which thus may induce a sense of docile adherence to guidance promoting the ‘natural’ healing process. There are clear and immediate incentives and obligations for a grieving person to recover in order to get back to work and to re-engage with ‘ordinary social activities’ which all take place within a routinised daily pattern. To refuse to conduct oneself in this way, or to fail to conduct oneself in this way, is to willingly or forcibly enter into the unfamiliar space of no recovery.

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