Recently I have become engrossed in discussions around the shifts in psychiatric research toward the brain.
This shift includes a number of different activities occurring in different disciplines and domains, most notably:
- Change in focus in mental health research from the psyche to identifying ‘biomarkers’. It is quite evident that funding is increasingly directed toward research interested in uncovering brain activity and biological causes that may underlie a mental condition, this also includes complicated grief.
- Part of this change in focus has come about due to growing criticism of the DSM and standardised modes of diagnosis based on self-reported symptoms. The director of the National Institute of Mental Health (NIMH) Tom Insel, has been openly critical of the DSM, critiquing its scientific validity. In response he has created the Research Domain Criteria (RDoC) which proposes to improve diagnosis of mental illness by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. This framework is based on the assumption that mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behaviour, and that mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment. The RDoC aims to move away from using the DSM as the gold standard and base diagnosis on emerging scientific data.
- On the level of theory there has in recent years been a flurry of interest in social and cultural theory toward affect, and thinking about neurobiology, the human nervous system and brain functions to explain the self, subjectivity, consciousness and what it means to be human (writers such as Deleuze & Guattari, Nigel Thrift, Brian Massumi, Lauren Berlant, Eve Sedgwick, are often cited as proponents of this move). However there are considerable problems with how ‘affect’ is used, and varying interpretations of what affective awareness means of implies, often supported by wrongly or selectively interpreted neuroscientific data.
What reading this literature has brought up for me is:
- How to understand the self/subject, and avoid lapsing into either essentialism (it’s all chemical) or relativism (it’s all socially constructed)
- What can we take from affect theory?
- What bearing these different explanations have for grief, and the increasing focus on defining complicated grief?
I will try to outline some of my thoughts on each point below.
i. It’s all chemical or it’s all socially constructed: Moving beyond duality
Human behaviour is increasingly explained in reference to the brain, implying that the brain fundamentally shapes who we are and our capacities and attributes. Yet the increasingly fashionable focus in psychiatric research towards finding a biological – neurological, genetic – basis for mental illness speaks of a broader move to understanding the human as a biological organism that is no longer deterministic or essentialist as it was once criticised to be, but as providing an opportunity. The idea of biology as an opportunity, not destiny is becoming a prominent explanation for mental illness (Rose, 2013a). However as even my brief foray into neuroscience has shown, the more that is known about the brain, the more we realise we don’t know (ibid). It also produces basic or crude analysis of mental states where areas of ‘activity’ are pointed out on brain scans and sections of the brain are singled out as responsible for aspects of human functioning, when these areas of the brain involve billions of synapses of which little is still known. Studies into complicated grief (CG) have sought to identify what areas of the brain are activated in people with CG compared with people with ‘normal’ grief (O’Connor, 2012). Further a study (O’Connor et.al., 2008) revealed that the areas of the brain activated in people with CG is the same as the areas of the brain activated in people with addiction, a part of the brain concerned with reward. On viewing a picture of the deceased this part of the brain would be activated, thus leading the researchers to argue that people with CG find pleasure in their distress unlike people without CG. However whilst these provide interesting explanations and interpretations, often research that seeks out specific brain activities or biological markers ignores how the human organism works as a whole and how the brain is affected by its social environment. A project headed by Nikolas Rose seeks to understand precisely how experience gets under the skin, by situating the brain in its milieu. As Rose (2013a) states:
The scientist (is required) to realize that the conditions they are dealing with, whether they be psychiatric diseases, brain diseases, physical diseases are all diseases of human beings living in their social environment and they are not things that happen with genes in petri dishes in labs and that that’s a rather important scientific thing to recognize and not just, kind of, an addendum from the social sciences or from the ethics. Recognizing how the problem feels for those on the other side, for those who are experiencing it, and therefore what the solutions may look like for those on the other side.
By acknowledging the social embeddedness of neurobiological processes, and of biological processes this research is at the forefront of a new wave in thinking about mental health that seeks to bring together the knowledge from the social sciences and the biological sciences. It is argued that biological traces are produced through the practices and ideologies of modern social life and thus the biological and sociological life of the body and brain are inseparable. Both brain, body and environment all impact upon one another. The discourse that merely seeks to identify ‘biomarkers’ or ‘cognitive biases’ glosses over the complexities of understanding the situatedness of a mental disorder; of how the outside gets in.
This then poses a problem for how to account for the subject, the self, a self that is both social and biological and further is both social and biological in a way that the biological self and social self do not exist as discrete categories. Maurice Bloch’s ‘The Blob’ still perhaps for me presents the most convincing attempt at accounting for how a human – or the blob – can be both a process, a relational being and yet also have some type of biological consistency that makes the blob identifiably human. In thinking about grief, it has always been the potentially destabilising and disorientating power of grief that has been, for me, interesting to theorise. Borrowing from Judith Butler and Lauren Berlant I have been working with a description of grief as an instance which can make a person ‘come undone’. This is a coming undone of a self that was already not the sovereign person they took themselves to be. What this means is not that grief or loss merely breaks people down before they put themselves back together again (a recovery narrative that relies upon the self as normally integrated) but rather an instance that reveals the relational nature of their sense of self; the capacity to affect and be affected. Injecting some incoherence, ambivalence, resistance into the blob then, the question is less about what makes us come undone – the impact of trauma etc – but what holds us together. Grief might be one experience that can expose our potential or capacity to be different and yet we appear or tend to stay from one day to the next more or less the same. Or to take a Deleuzian line: how do we hang together when we are multiple?
ii) What can we take from affect theory?
I got drawn into affect theory as it promises a means of describing the self that incorporates ambivalent, irrational, and contradictory behaviours. Affect theory grew out of cultural theorists borrowing from the developments in neuroscience. What binds the affect theorists and the neuroscientists is their shared anti-intentionalism (Leys, 2011). Affects can be described as a non-conscious intensity, unlike emotions they exist prior and outside consciousness. Affects are only contingently related to objects in the world; they are non-signifying forces. What the establishment of a theory of affect has provided then is to draw attention to and elucidate the gap between a person’s affects and the cognition or appraisal of the affective situation. In other words, it gives space to suggest that behaviours are not always consciously directed, or further we are not always consciously aware of what might trigger a particular pattern of behaviour or action. Affect theory’s use of neuroscience has its own problems and contradictions which have been criticised (Leys, 2011; Rose, 2013a). However despite the precarious stance of arguing for anti-intentionalism, I don’t want to dispense with the contribution of affect theory mainly for how it emphasises a radical relational model of the self. Thinking about the capacity to affect and be affected I would argue goes further than talking about embodiment or materiality in that it places more focus on the spaces in between people; how people through interaction get caught up in an energetic exchange. This also avoids relying on a model of emotions that either go from the inside out or from outside in. Rather affect theory argues for the mutual interplay; where emotions belong neither to the individual nor exist somewhere outside. It opens up space for thinking about surfaces, impressions and atmospheres.
In terms of grief I have found these ideas useful to work with as it highlights how the experience of loss is one in which the self enters a space of liminality, of non-sovereignty, which involves violating an attachment to intentionality. But further there is an object in grief, the intense yearning for the deceased as described in complicated grief diagnosis, which gives grieving an intention – but this may not be easily available for conscious deliberation. This brings us back to the continuing bonds thesis, that provides little room to think about the how the grieving person’s sense of self is composed, rather an integrated self is presumed as the norm. It also glosses over contradictory and messy feelings, ambivalence, suggestibility, resistance and how these can all exist at the same time without necessarily being pathological. To reiterate the question above then; by thinking about the self in this way, the interest lies less in how people come undone – if we alternatively assume the subject is always somewhat prone to incoherence – but rather how do they hold themselves together, and what form this holding together takes and why.
iii) What bearing do these different explanations have for grief, and the increasing focus on complicated grief?
Attending a recent talk at St Christopher’s Hospice on complicated grief brought up some interesting questions around the diagnosis of complicated grief. Whilst the shift towards brain science is starting on the level of research, psychiatric practice still remains shaped by the diagnostic categories of the DSM and ICD.
In Colin Murray Parkes’ talk he focussed on the DSM-5 and the relevant developments and associated controversies as related to grief and bereavement. His presentation was quite skeptical and he felt that the DSM had put ‘too many eggs in one basket’. He also elucidated some of the politics behind the DSM-5 and the inclusion of the proposed criteria of ‘Prolonged Complex Bereavement Disorder’ (PCBD). According to Parkes, Holly Prigerson initially proposed ‘Prolonged Grief Disorder’ to the APA for inclusion in the DSM-5. This was then countered by Katherine Shear’s description of ‘Complicated Grief’, and in the midst of the controversy over the grief exclusion and Major Depressive Disorder, the DSM backtracked and ended up with PCBD, to be considered as a ‘condition for further study’. The definition of PCBD is quite evidently a mixed combination of symptoms lacking cohesion and agreement.
Here’s some of the criteria for PCBD:
To have at least one of the following symptoms for at least 12 months after death:
– Persistent yearning/longing for deceased
– Intense sorrow
– Preoccupation with deceased
– Preoccupation with circumstances of death
At least 6 of the following symptoms persisting for 12 months or more after death:
Reactive distress to the death
– Difficulty accepting death
– Difficulty in positive reminiscing
– Bitterness and anger
– Mal-adapative appraisals about self
– Excessive avoidance of reminders
Social identity disruption
– Desire to die
– Difficulty trusting people
– Feeling alone/detached
– Feeling life is meaningless/empty
– Confusion over one’s role in life
– Difficulty planning for future
Further this disturbance has to be deemed to be causing ‘clinically significant distress’ or ‘impairment in social, occupational or other important areas of functioning’. The ‘bereavement reaction’ is considered to be ‘out of proportion to cultural, religious and age-appropriate norms’.
There is a lot to comment on here, wading through the loaded language. What is quite striking as with most psychiatric diagnosis is how a pathology is defined by the extent to which it exceeds what might normally be expected, when someone becomes unable to function. As can be seen in the list of symptoms, it is pathological to either excessively avoid or be excessively preoccupied with the deceased and/or the death. The implied norm of functioning is understood to depend on the individual social context. This appears as a way to avoid stating a general norm of functioning and grieving for all people who have been bereaved. This apparent cultural sensitivity neatly hides the contradiction of why acting in excess of a norm – which is itself variable, arbitrary, and historically context-specific – is necessarily pathological, and further not recognising how by developing a standardised criteria, specific habits and behaviours have clearly been selected as being, in any social and cultural context, somewhat problematic.
At the St Christopher’s talk, whilst there was some interest in these broader debates around diagnosis, there seemed to be a feeling amongst the attendees that this was not relevant to their daily practice. One person commented that he felt it was distracting from the main issue which is helping people (to recover, we could add). This was not exactly a surprising perspective to hear but it does speak of the disjunctures between theory and practice. The actual process of diagnosing grief as complicated, prolonged or complex might not yet be regular practice in the UK, but some practitioners did speak of how a medical diagnosis of abnormal grief can/could be useful in referring people on to other services, or as means of protecting/preventing people from more severe mental health problems. In the end there was little conclusion and there was a sense that this sort of language was ‘clinical’ and hard to understand. Grief then continues to be an ambivalent object, at times medicalised, and at other times seen as part of the natural order of things. There’s more to say here but I think there is something interesting in this management of excess or the inappropriate that produces a certain form to a person (or perhaps rather it gives a person-like form to the blob). Similarly the person who doesn’t recover isn’t formless but has their own shape too. I still remain too clueless about the brain and genetics to talk in any conclusive way about a biological core of what it might mean to be human, and so the task remains to look to the discourses that might mould the form of the grieving blob into an identifiable recovering/recovered/not recovered subject. That is to say what are the discourses, structures, norms that may impinge, limit, obstruct the capacity for flourishing or for becoming otherwise. And perhaps by exploring what holds these identities together, space can be found for thinking about relationality, the non-conscious, and how experience gets under the skin.
Fitzgerald, D., Rose, N. & Singh, I. (2014). Urban life and mental health: Re-visiting politics, society and biology, Discover Society, Issue 5 February 2014.
Leys, R. (2011). The Turn to Affect: A critique. Critical Inquiry, 37: 434-472.
O’Connor, M.-F. (2005). Bereavement and the brain: invitation to a conversation between bereavement researchers and neuroscientists. Death studies, 29(10), 905–22.
O’Connor, M.-F. (2012). Immunological and neuroimaging biomarkers of complicated grief. Dialogues in Clinical Neuroscience, 14(2), 141–148.
O’Connor, M.-F., Wellisch, D. K., Stanton, A. L., Eisenberger, N. I., Irwin, M. P., & Lieberman, M. D. (2008). Craving Love?: Enduring grief activates brains reward center. Neuroimage, 42(2), 969–972.
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., … Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS medicine, 6(8), 1–12.
Rose, N. (2013a) The Human Sciences in a Biological Age. Theory, Culture & Society, 30(10): 3-34.
Rose, N. (2013b) What Is Diagnosis For?’, Talk delivered at the Institute of Psychiatry Conference on DSM-5 and the Future of Diagnosis, Kings College London, 4th June 2013.