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February 5, 2013
“Pleasure puts you to sleep and pain wakes you up,” an Indian sage once said, yet in the United States we live in a culture that prizes painlessness far more than wakefulness. Indeed, we are increasingly being encouraged to pathologize pain at moments when we would otherwise be called to wrestle with life’s meaning.
The latest edition of the DSM, the Diagnostic and Statistical Manual of Mental Disorders (due for publication in May) which is the bible of psychiatry, regards grief as a disease.
Following the death of a loved one, depression occurring within a few weeks can be treated as an illness in need of a pharmaceutical cure. The pain of loss can and supposedly should be chemically dissolved.
All too predictably, the support that was once provided by other people is coming instead to be provided by pills.
Instead of recognizing grief as an appropriate response to death and the profoundly difficult transitions that come in its wake, a human experience is being turned into a neurotransmitter imbalance and in the process a huge business opportunity is being opened up for companies like GlaxoSmithKline.
Late last year, the business section of the Washington Post reported:
For years, the official handbook of psychiatry, issued by the American Psychiatric Association, advised against diagnosing major depression when the distress is “better accounted for by bereavement.” Such grief, experts said, was better left to nature.
But that may be changing.
In what some prominent critics have called a bonanza for the drug companies, the American Psychiatric Association this month voted to drop the old warning against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression — and thus, treated with antidepressants.
The change in the handbook, which could have significant financial implications for the $10 billion U.S. antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows.
The association itself depends in part on industry funding, and the majority of experts on the committee that drafted the new diagnostic guideline have either received research grants from the drug companies, held stock in them, or served them as speakers or consultants.
In March, 2011, my wife died and I experienced the physiology of grief. I felt greatly sad and yearned for her. I didn’t sleep well. When I returned to a now empty house, I became agitated. I also felt fatigued and had difficulty concentrating on my academic work. My weight declined owing to a newly indifferent appetite. This dark experience lightened over the months, so that the feelings became much less acute by around 6 months. But after 46 years of marriage, it will come as no surprise to most people that as I approach the first anniversary of my loss, I still feel sadness at times and harbour the sense that a part of me is gone forever. I’m not even sure my caregiving for my wife, who died of Alzheimer’s disease, ended with her death. I am still caring for our memories. Is there anything wrong (or pathological) with that?
Experience, including the experience of loss, is never neat: that is, out of context. It is always framed by meanings and values, which themselves are affected by all sorts of things like one’s age, health, financial and work conditions, and what is happening in one’s life and in the wider world. The collective and personal process we usually refer to as culture is one sort of framing: a kind of master framing. Historically, widows in many patriarchal societies were culturally framed as grieving for a lifetime or at least, a long time. The globalisation of our era has brought in its wake an expectation of serial marriages with much shorter periods of bereavement. Still, DSM-IV’s framing of normal grief as lasting only 2 months must stand out in global perspective as a shocking expectation. We can say the same about the APA’s [American Psychiatric Association] proposal for treating any grief as depressive disorder, which must be seen as a radical cultural framing peculiar to American academic psychiatric research.
Inasmuch as there is no compelling evidence that antidepressant drugs improve mood in normal people, the APA, if it wanted to authorise treatment for normal grief, had to make it over into a disease — ie, depression. Then psychiatrists could, as a routine practice, prescribe antidepressants for bereavement. This phenomenon of reframing a previously normal experience as a disease is called medicalisation and is quite far advanced in psychiatric practice, which already labels shyness as anxiety disorder and puts some people who are unskilled in negotiating social relationships in the Asperger’s syndrome end of the autism spectrum. These framings represent a cultural shift, now well along its way, to remake experiences formerly regarded as morally bad, religiously sinful, disturbing, or just different as medical issues of illness and disablement. The upshot is that unprecedented numbers of people with what was earlier regarded as the ordinary distress of living are taking psychotropic medication.
The increasing secularisation of our age with the dominance of biotechnology is one factor behind this shift to a new cultural frame, just as much as the political economy of the pharmaceutical industry, the transformation of American medicine into big business, and the infiltration of bureaucratic standards and regulations ever more deeply into ordinary life. All of which brings me back to the experience of grieving. Why not medicalise it? Why not deprive death of its sting for the survivors and make the experience of loss as painless as possible? Given the parlous state of global capitalism at the moment, maybe this would also help to fund health-care systems. Professor David J Kupfer, who chairs the DSM-5 Task Force making the revisions, is reported to have told The New York Times that making grief into a disease would allow psychiatrists to treat people who were suffering so that they would get the treatment they need for being depressed. And that’s the rub really. Is grief something that we can or should no longer tolerate? Is this existential source of suffering like any dental or back pain unwanted and unneeded?
My own experience, together with my reading of the literature, suggests caution is needed before we answer yes and turn ordinary grieving into a suitable target of therapeutic intervention. My grief, like that of millions of others, signalled the loss of something truly vital in my life. This pain was part of the remembering and maybe also the remaking. It punctuated the end of a time and a form of living, and marked the transition to a new time and a different way of living. The suffering pushed me out of my ordinary day-to-day existence and called into question the meanings and values that animated our life. The cultural reframing — at once subjective and shared with others in my life-world—held moral and religious significance. What would it mean to reframe that significance as medical? For me and my family, and I intuit for many, many others such a cultural reframing would seem inappropriate or even a technological interference with what matters most in our lives.
Before his wife’s death, Kleinman gave the following interview in which he talks about his experience of caregiving: