Grief and the New DSM

Before the newest revision to the DSM was released this summer, the DSM-IV contained a grief clause which stated that neither adjustment disorders nor depression could be diagnosed immediately following a significant death on the grounds that such symptoms were considered a normal part of the bereavement process. The “bereavement exclusion” has been removed in the updated DSM-V, meaning a person who is experiencing grief caused by the death of a significant person in their life may now be diagnosed with depression or an adjustment disorder.

In a blog post following the release of the updated DSM-V, “Grief Over New Depression Diagnosis,” New York Times blogger Paula Span explained the controversy surrounding the new definition of grief. On one hand, critics of the exclusion fear that depression may now become overdiagnosed. Span cited Allen Francis, professor emeritus at Duke, who argued that the DSM-V “medicalizing the expected and probably necessary process of mourning that people go through.” Those mourning the loss of a loved one could now legally be diagnosed with depression if they report feelings of emptiness or distraction just a few weeks after the loss of a parent, child or spouse. The trouble with this, says Francis, is that it “gives drug companies the right to peddle pills for grief,” without allowing the natural healing process that takes place over time to occur. 

Proponents of the bereavement exclusion argue that if a person may be treated for depression in the aftermath of a divorce or financial crisis, why shouldn’t one grieving the loss of a loved one be granted access to the same treatment?

The therapeutic process for helping clients cope with loss and grief is time consuming and intensive. But third-wave therapies, particularly mindfulness and acceptance-based therapies, have been proven effective in this area, and continue to show promising results.

Sameet Kumar, PhD, psychologist and author of Mindfulness for Prolonged Grief, and the best-selling Grieving Mindfully: A Compassionate and Spiritual Guide to Coping with Loss, has more than a decade of experience working with end-of-life and bereavement. 

What is prolonged grief?

Kumar’s mindfulness and compassion based approach to grief specifically addresses those suffering with prolonged grief, or grief which continues past six months following a loss. This type of grief is disabling, and is characterized by emotional numbness, role confusion, bitterness, anger, and a general avoidance of or inability to accept loss. People suffering with prolonged grief may find themselves feeling dazed, stunned, and in shock for months, even years after loss. They may find that their sorrow does not diminish with time; it may even increase. For them, grief’s pain will feel relentless, merciless, and unending.

According to Kumar’s definition, those suffering with prolonged grief will not be able to integrate their loss. In addition to the original pain of their loss, they will also struggle with the knowledge that their grief is different, which may yield secondary pain associated with a sense of failure, inadequacy, or shame stemming from their hardship.

According to Kumar, there are three main risk factors that cause and perpetuate prolonged grief. The first is related to the nature of the loss; prolonged grief frequently accompanies sudden loss, when death comes without warning or preparation. Losing a loved one to violent, traumatic death or suffering multiple losses in a short amount of time all place people at especially greater risk for prolonged grief.

The second risk factor for prolonged grief is previous difficulty managing intense emotions—what’s referred to as poor distress tolerance skills. People who experience prolonged grief are more likely to have had a previous episode of depression, or have been socially isolated.

Third, people suffering from prolonged grief are more likely to have used, and continue to use, avoidant coping skills. In the context of prolonged grief, avoidant coping can take on many forms. It could mean not disposing the belongings of a loved one, or not paying attention to emotional and physical health. Prolonged grief can put many people at risk for relapsing into addictions, or establishing new unhealthy habits such as alcoholism, legal and illegal drug addiction, or gambling.

Taking these three factors into consideration, treatment for prolonged grief should help sufferers to process traumatic loss, facilitate improved distress tolerance skills, and challenge avoidant coping. Research and clinical validation consistently place mindfulness meditation and mindfulness skills as a unique and potent facilitator of just these treatments. Mindfulness meditation empathically addresses all three of the key domains of prolonged grief; it can help individuals to process trauma, improve distress tolerance, and transform avoidance tendencies with acceptance-based strategies.

In the context of prolonged grief, mindfulness-based distress tolerance skills can also assist people in resuming the search for meaning in their loss and in grief. In this way, it strikes at the heart of the existential vacuum that is at the core of prolonged grief.  

For more on an evidence-based mindfulness program for prolonged grief, check out Kumar’s book, Mindfulness for Prolonged Grief.