Historical influences and modern descriptions
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GRIEF AS PATHOLOGY: The Evolution of Grief Theory in Psychology From Freud
to the Present
Leeat Granek Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
The emergence of grief as a topic worthy of psychological study is an early 20th century invention. Freud published his influential essay on mourning and melan- cholia in 1917. Since he proposed the concept of “grief work,” contemporary psychologists have examined his theory empirically and have claimed that grief is a pathology that should be included within the psychological domain. How, and why, has grief theory evolved within the discipline of psychology in this way? In what ways do these changes in the understanding of grief coincide with other historical developments within the discipline? In this article, I trace the development of grief, originally conceived by Freud within a psychoanalytic and nonpathological framework, to the current conceptualization of grief within the disease model. I show how grief theory has evolved within the discipline of psychology to become (a) an object worthy of scientific study within the discipline, and subsequently, (b) a pathology to be privatized, specialized, and treated by mental health professionals.
Keywords: grief, history of psychology, pathology
In the 19th century, grief was a condition of the human spirit or soul. It might sometimes be viewed as a cause of insanity, but it was not itself a mental illness. (Walter, 2005–2006, p. 73)
How did grief become an object worthy of scientific study? When did it enter into the psychological domain? Why has grief become one of the newest areas of psychological research? While anthropologists, sociologists, and psychologists have contended that grieving is one of the few rites of passage that is cross- culturally and cross-historically consistent (Archer, 1999; Gilbert, 2006; Parkes, 2001; Rosenblatt, 1993, 2001), the emergence of grief as a topic worthy of psychological study is an early 20th century invention (Archer, 1999). Freud (1915/1966/1989) published his influential essay on mourning and melancholia in 1917. Prior to this publication, there were few researchers devoted to exploring the phenomenon of grief.
Grief as a psychological concept, and grieving as a reaction to the loss of someone who has died, are different entities. When I speak of grieving as a universal phenomenon, I am referring to the experience of a person who is responding to the death of another human being whom he, or she, has loved. One definition offered by contemporary psychologists is that “bereavement refers
I am grateful to Michelle Leve for her careful reading of an earlier version of this article. I am thankful to Dr. Alexandra Rutherford for her feedback in developing, and editing earlier drafts of this article and for her continued mentorship and support in all academic pursuits.
Correspondence concerning this article should be addressed to Leeat Granek, Department of Pediatrics, McMaster Children’s Hospital, Hamilton Health Sciences, 1200 Main Street West, HSC 3A, Hamilton, Ontario, Canada, L8N 3Z5. E-mail: [email protected]
History of Psychology 2010, Vol. 13, No. 1, 46 –73
© 2010 American Psychological Association 1093-4510/10/$12.00 DOI: 10.1037/a0016991
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to the loss of a loved one by death, and grief refers to the distress resulting from bereavement” (Genevro, Marshall, Miller, & Center for the Advance- ment of Health, 2004, p. 498). Mourning is another closely related term and is frequently used as a synonym for grief. While some researchers make a distinction between defining grief as “a reaction to loss” (DeSpelder & Strickland, 2005, p. 268), and mourning as the “process by which a bereaved person integrates the loss into his or her ongoing life” (DeSpelder & Strick- land, 2005, p. 269), I use the terms interchangeably in this article to refer to the emotional reaction to the loss of a loved one that can include sadness, longing, sorrow, despair, and anguish. The modern, psychological conception of grief will be further distilled as I begin to show how the term and the concept of what constitutes grief has evolved since it was first introduced into the psychological domain.
Human versus Natural Kinds: The Development of the Psychological Concept of Grief
Ian Hacking (1995) referred to this kind of distinction as categorical differ- ences between natural kinds and human kinds of classifications in the social sciences. He defined human kinds as conceptual categories that meet the following criteria: they must be relevant to some groups of people, they must be studied in the social sciences, they must primarily sort people, their actions, and behaviors in various categories, and lastly they must primarily classify people as opposed to objects. He further articulated that cutting edge human kinds are those studied by at least one professional society of experts; regular conferences, one of which is major, and a number of others which are more specialized; at least one recently established professional journal to which the authorities of the discipline contrib- ute; and in general the intention of intervening, helping, and/or improving the human kind that is the object of their study (Hacking, 1995). The concept of grief within the discipline of psychology is a clear example of a cutting edge human kind as described by Hacking (1995).
A natural kind, according to Hacking (1995), is one that is found in nature, but that often is transformed into a human kind. Hacking used the example of teenage pregnancy to make his point. There have always been young women who have been pregnant; however the classification of what constitutes “young women,” “teenager,” or the stigma associated with “early parenting” is a human kind that was constructed by the social sciences (Hacking, 1995). These human kinds can only be developed within a social context that has invented the concept of adolescence and the social mores that stipulate pregnancy should happen when one is older.
The same can be said of the distinction between grief as a natural kind and grief as a human kind. Some have argued that grieving, or the reaction to the death of a loved one, is a natural kind that has always existed in some form (Archer, 1999; Gilbert, 2006; Parkes, 2001; Rosenblatt, 1993, 2001). While this is an intriguing contention to examine, this article focuses on the conception of grief in the 21st century within the realm of psychology as a constructed human kind, or what I have termed a psychological kind. Another way to think about the concept of a psychological kind is to take Danziger’s (2003) definition of scientific objects
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as “things scientists confront as material to be explored, worked on, manipulated, and understood” (p. 20 –21).
While volumes have been written about the ways in which people have grieved historically (both in North America and cross-culturally; see Metcalf & Huntington, 1991; Parkes, Laungani, & Young, 1997; Rosenblatt, 1993), in this article, I trace the development of grief as a psychological construct as it has historically evolved within the discipline. Before delving into this trajectory, it is necessary to situate contemporary grief research within the field as it is under- stood today.
The main tenets of modernism are an emphasis on scientific rationality, reason, observation, and a belief in continuous progress (Gergen, 1991, 1992). Modern life emphasizes goal directedness, functionality, rationality, and effi- ciency in all areas of living (Gergen, 1991, 1992).
Stroebe, Gergen, Gergen, and Strobe (1992) wrote that when applied to grief, the modernist paradigm suggests that people need to recover from their state of intense emotionality and return to normal functioning and effectiveness as quickly and efficiently as possible. Modernist theories of grief and related therapeutic inter- ventions encourage people who have experienced loss to respond in just this way. Grieving, a debilitating emotional response, is seen as a troublesome interference with daily routines, and should be “worked through.” Such grief work typically consists of a number of tasks that have to be confronted and systematically attended to before normality is reinstated. Reducing attention to the loss is critical, and good adjustment is often viewed as breaking of ties between the bereaved and the dead (Stroebe et al. 1992, p. 1206).
This description of grief research and theory is an accurate picture of how grieving is understood in the field of modern psychology today. Grief has been constructed as a pathological condition necessitating psychological intervention in order for people to heal as quickly as possible (Engel, 1995; Green et al., 2001; Raphael, 1983; Zisook & Shuchter, 2001). The goal is to get people functioning and back to work in a timely and cost efficient manner. How has grief, an emotion that was once considered to be a normal human reaction to loss, come to be understood as potentially pathogenic and in need of professional psychological intervention? Why is it important to trace this history, and what can it teach us about the way we understand grief today?
While some mainstream psychologists dismiss the historical trajectory of the discipline (and its knowledge products) because they believe in the principle of scientific progress, or the idea that our current knowledge is an improvement over discoveries of the past, I begin with the assumption that the “essence of psycho- logical categories (insofar as they have one) lies in their status as historically constructed objects” (Danziger, 1997, p. 12).
In Naming the Mind, Danziger (1997) distinguished between psychological subject matter (i.e., sadness or anxiety), and constructed psychological categories (i.e., MDD or panic disorder). He noted:
The only part of history of psychology that has a relatively unproblematical subject matter is the part that is defined by the modern discipline of Psychol- ogy. Once texts and institutional structures of that discipline appear on the scene we have a clearly identifiable field with relatively sharp boundaries. This
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field is characterized by certain categories of discourse whose history can be investigated in a relatively straightforward way. (p. 15)
Following Danziger’s (1997) model, this article enters the narrative around grief when the concept was first introduced into the lexicon of contemporary psychologists working in the established discipline of psychology. It is the most rational starting point for an endeavor such as this one because it illuminates a clear historical trajectory from the point when grief is first introduced as a psychological object, to the present, where it has become a pathology to be monitored, managed, and treated by mental health professionals. By going back to the origin of the category within the discipline, it will be possible to examine why, and how, grief became a psychological object, and to study the metamor- phosis of today’s taken-for-granted knowledge about how we adjust to the loss of a loved one.
Psychoanalytic Conceptualizations of Grief
While Freud (1856 –1939) was the first to introduce the concept of grief into the psychological lexicon, there were a few researchers who came before him. When I say researchers, I am referring to people who have studied the phenom- enon of grief within a relatively close paradigm to the social sciences. While other texts can be found on the topic of grief prior to the 17th century, the ones I focus on here attempted in some way to systematically or empirically document the process of grieving.
Burton (1577–1640) wrote about bereavement and other forms of loss briefly in his book, The Anatomy of Melancholy, published posthumously in 1651 (Burton, 1651/1938). Burton argued that grief is a kind of transitory melancholy that affects everyone at some point in their lives. While Burton referred to grief as a “cruel torture of the soul” (p. 259), he also emphasized the distinction between melancholy as a disease, and melancholy as a normal reaction to everyday events such as death of a loved one. He proposed that melancholy could either be found in disposition or in habit, the former referring to context specific melancholy, and the latter referring to a person who is habitually melancholic in character. “In disposition, is that transitory melancholy which goes and comes upon every small occasion of sorrow, need, sickness, trouble, fear, grief, passion or perturbation of mind . . . and from these melancholy dispositions, no man living is free” (p. 143).
Perhaps ironically, Burton is used by contemporary psychologists to argue that the concept of depression has a historical continuity with the contemporary psychological definition of major depressive disorder (MDD). A careful reading of Burton, however, can leave no doubt that his concept of melancholy was always context specific, while contemporary definitions of MDD are usually symptom-based and do not provide an explanatory framework as to why the depression developed (Horwitz & Wakefield, 2007). Similarly, some psycholo- gists (e.g., Archer, 1999) have suggested that Burton was the first theorist to define the concept of grief in psychological terms. While Burton did acknowledge grief, he did so in the context of describing a specific kind of melancholia, which as will shortly be illustrated, has little in common with the contemporary psy- chological definition of grief. While Burton (1651) did contribute to the
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foundation on which grief as a psychological kind developed, in the sense that he included it as part of the domain of medicine, he did not define it in the same way it is conceptualized today.
In the 17th century, grief was often viewed as potentially fatal, and it was widely believed that grief could make you mad and even lead to premature death (Cressy, 1997; Laurence, 1989). Benjamin Rush (1745–1813), an American physician, included grief in his book The Diseases of the Mind (Rush, 1812/1947), although he did not think that grieving people were necessarily sick. Rush described a list of emotional and physical symptoms characteristic of grieving people such as aphasia, fever, sighing, loss of memory, and the development of gray hair. Rush offered a variety of remedies to “heal grief” that included using opium, crying, and in intense cases, bloodletting and purges (Rush, 1812/1947).
Darwin (1809 –1882) also briefly touched upon grief in his book on emotional expression published in 1872. He described in detail the expressions of depression and grief, including the mechanical aspects of crying and the accompanying facial expressions. Darwin also made a distinction between an active, frantic form of grief, and a passive, more depressive form, which he claimed had different etiologies. In addition to describing the physical characteristic of grief in people, Darwin noted that animals such as monkeys and apes also display and experience grief (Darwin & Ekman, 1872/1972/1998).
The first thorough study of the psychology of grief was written by A. F. Shand (1858 –1936) in a book on instincts and emotions, in which he referred to grief as “the laws of sorrow” (Shand, 1914/1920). He described four types of grief reactions: the first was active and directed aggressively to the outside world; the second was depressive and lacking in energy; the third suppressed through self-control; and the fourth involved frenzied and frantic activity. Shand (1914/ 1920) also spoke about other aspects of grief, including the need for social support, the continued relationship with the deceased, and the trauma associated with sudden death.
It was Freud’s psychoanalytic theories, however, that have had the most impact on contemporary grief research within the discipline of psychology. There were two simultaneous trajectories happening within the psy-disciplines in the 20th century that helped introduce and popularize psychoanalytic thought in North America.
The first trajectory had to do with the introduction of Freudian theories in the United States, the expansion of psychiatry in the 20th century, and the develop- ment of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that would become an organizing artifact for the discipline (American Psychiatric Association, 1994, 2000). The second trajectory that coincided and developed in relationship to psychiatry was the expansion of psychological expertise into the domain of the everyday. To understand how the construct of grief has evolved within the psychological domain, it is necessary to understand the background context of what was happening historically within the disciplines at the time.
In 1909, Freud embarked on his first professional trip to America and gave five lectures at Clark University (Freud, 1909/1990). His seminal book, Introduc- tory Lectures on Psychoanalysis (Freud, 1915/1966/1989) was later published in 1915. Since it is beyond the scope of this article to elaborate extensively on
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Freudian thought, my emphasis here is to explore the general impact of Freud’s ideas on American culture in relation to psychological classification and its impact on the development of grief as a psychological construct.1
In his Clark lectures, Freud introduced two new ideas that were foundational for the establishment of grief as a psychological kind.2 The first was the focus on everyday life as sources of interest for psychoanalysis; these included themes such as slips of the tongue, dreams, infantile sexuality, and the power of the uncon- scious in affecting people’s everyday behaviors (Freud, 1909/1990).
Illouz (2008) noted that the inclusion of these seemingly insignificant human behaviors as central to analysis consisted of “making the unmeaningful, the trivial, the ordinary full of meaning for the formation of the self” (p. 38). The emphasis on everyday life as a realm worthy of investigation and analysis was a revolutionary new epistemological stance that was inclusive and broad enough to encompass almost everyone and everything. It set the stage for including emotions such as grief that were once considered beyond the scope of psychology as legitimate objects of study.
The second, and related idea introduced by Freud, was the link he made between the realm of the everyday and the health of ordinary and dysfunctional people. According to Freud, health and pathology were on a continuum, and there was no clear boundary between them. Freud, therefore, effectively managed to blur the distinction between normality and abnormality, as well as what he conceived to be the symptoms that could distinguish among these categories.
The epistemological stance of evaluating behavior on a normal versus abnor- mal continuum became popularized with the dissemination of Freudian ideas in the United States. What is significant about this paradigmatic shift is not the specific criteria that constitute a pathology, but the very notion that one could evaluate a behavior or a condition on this continuum at all. While Freud was less interested in classification and distinguishing pathology, (i.e., he believed in a dynamic continuum between normality and abnormality that everyone moved along), he popularized the idea that everyday occurrences and situations could be included in the psychological realm. It was on this foundation that the construct of grief as a psychological object of study was born.
In 1912, Freud published Totem and Taboo (Freud, 1912/1938), in which he outlined his main ideas on grief that he later expanded in Mourning and Melan- cholia (Freud, 1917/1963). Freud (1917/1963) proposed that the mourner had the task of detaching their libido/emotional energy from the deceased and sublimating it into other areas of their lives. Freud’s essay has often been interpreted to mean that those who failed to do their “grief work,” a term that has evolved into an ingrained Western psychological concept, could end up with a psychiatric illness that resulted from their pathological grieving (i.e., Genevro et al., 2004).
1 For a thorough review of Freudian theories, see Brunner (1995) and Rieff (1979); for a historical account of the development of psychoanalysis and Freudian thought, see Roazen (1973/ 1987) and Manning (2005); for a more elaborate discussion of the impact of Freudian ideas on epistemological narratives of the self, see Illouz (2008).
2 For a commentary on the significance of the Clark Lectures, see Fancher (no year available) The Origin and Development of Psychoanalysis and Sigmund Freud (1910), available online at http://psychclassics.yorku.ca/Freud/Origin/commentary.htm. A hard copy text of this is also avail- able. Also see Freud (1909/1990).
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Emerging from this view are several Western assumptions that have remained central to psychological research on grief, including the idea that grief is an active process that involves an intense struggle to give up the emotional attachment to the person who has been lost, and that this struggle is a process that involves time and energy on the part of those mourning. It is somewhat ironic that Freud’s work is used by later psychologists to justify the concept of “grief work” and “patho- logical mourning” (i.e., Archer, 1999; Stroebe et al., 1992) since Freud (1917/ 1963) never intended to pathologize grief and, in fact, he clearly stated in his famous essay that:
although mourning involves grave departures from the normal attitude to life, it never occurs to us to regard it as a pathological condition and to refer it to medical treatment. We rely on it being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful (p. 252).
Freud’s (1917/1963) essay was a watershed in the history of the conceptual- ization of grief within the discipline and was crucial to the development of grief as a psychological kind. Notably, while it is true that this text was the seed from which grief as a psychological kind emerged, it was in some sense, grossly misunderstood. The idea that grief should ever be pathologized, or that one could ever do one’s “grief work” so thoroughly as to completely sublimate the emo- tional energy into something or someone else (as the process is understood by many in contemporary psychology today), was alien to Freud. While Freud advocated that the person grieving had to detach their libido or their emotional energy from the deceased and sublimate it into other areas of their lives, he also argued that this is a slow and laborious process and that it is never completely resolved (Freud, 1917/1963).
Another aspect of Freud’s essay that is often misrepresented is the conflation of grief as a result of becoming bereaved (which Freud called mourning) and grief that came from other losses (which Freud called melancholia), including loss of a relationship because of separation. Repeatedly, Freud emphasized that although mourning and melancholia may look the same symptomatically, they are distinc- tive because they are context-specific. While Freud believed that mourning, or grieving the loss of a loved one who has died, was a normal and time-consuming process, it was not pathological. Melancholia, on the other hand—to which most of the paper was devoted— had the potential to become a disease because it was a reaction that occurred out of any understandable context (Freud, 1917/1963). He argued:
In mourning we found that the inhibition and loss of interest are fully accounted for by the work of mourning in which the ego is absorbed. In melancholia, the unknown loss will result in a similar internal work and will therefore, be respon- sible for the melancholic inhibition. The difference is that the inhibition of the melancholic seems puzzling to us because we cannot see what it is that is absorbing him so entirely. (p. 254)
Finally, it is worthy noting that, although Freud (1917/1963) did briefly mention the possibility of pathological mourning, defined as the inability to introject or sublimate the lost love object into something more constructive, he
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argued that this rarely happened in the case of bereavement and that further, mourning takes time and is a long and drawn out process.
Many early 20th-century studies of grief followed from Freud’s theoretical analysis (Abraham, 1924; Deutsch, 1937; Klein, 1940). Abraham published a paper dealing with the subject in 1924. Like Freud (1917/1963), Abraham (1924) argued that mourning and melancholia are related conditions but are indisputably distinct. “In the normal person,” wrote Abraham (1924), grieving was:
set in motion by real loss (death); and its main purpose is to preserve the persons’ relations to the dead object, or—what comes to the same thing—to compensate for his loss. Furthermore, the conscious knowledge of his loss will never leave the normal person, as it does the melancholic (p. 438).
Whereas Freud (1917/1963) focused on sublimation of cathartic energy, Abraham (1924) focused on the process of introjection of the lost object while mourning. In Abraham’s (1924) conceptualization, the grieving person’s “grief work” involved taking in the dead person to oneself in order to heal from the loss. He stated, “the process of mourning thus brings with it the consolation; ‘My loved object is not gone, for now, I carry it within myself and can never lose it’” (p. 437).
Perhaps the most interesting insight offered by Abraham (1924), and the one most often taken up by contemporary psychologists, is the point he made about “normal mourning” in the first place. In this paper, he argued several times that psychoanalysis does not really know what “normal mourning” looks like in a healthy person other than Freud’s conjecture that the prime aspect of melancholia is ambivalence toward the lost object, whereas in “real mourning,” it is grieving over the loss of a dead person where there is no ambivalence. While suggesting that pathological mourning is a construction of contemporary psychology, it is interesting to note that from the beginning of its entry into the discipline, grieving was regarded as an explicitly problematic concept because there was no protocol to distinguish the “normal” from the “pathological.”
While Freud (1917/1963) and Abraham (1924) set the tone for the patholo- gization of grief, the first person to truly conceptualize it in this way was Helene Deutsch (1884 –1982). In her essay, The Absence of Grief (Deutsch, 1937), she wrote, “It is well recognized that the work of mourning does not always follow a normal course. It may be excessively intense, even violent, or the process may be unduly prolonged to the point of chronicity” (p. 12). It is unclear on what basis Deutsch drew her conclusions. She does not cite anyone when claiming that it “is well recognized that the work of mourning does not always follow a normal course,” and while she may have been drawing on her clinical experience in making these claims, there are no known theorists that came before her to support these statements. In fact, the notion of a “normal course of mourning” is unclear even to founding theorists of the concepts of “grief work.” It is more likely that Deutsch was using these statements rhetorically to support her argument that the death of a loved person must produce a reaction in the bereaved, and that the absence of such grief is as much pathology as is extensive mourning in time and intensity (Deutsch, 1937).
Deutsch’s (1937) work is essential in tracing the chronology of the contemporary understanding of grief within the discipline. Even though Deutsch’s work appeared to
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be based on little referenced evidence, her theoretical formulations were foundational on several accounts. Her idea that unmanifested grief is as pathological as chronic grief is one of the underlying assumptions driving contemporary psychological research on the topic. While Freud (1917/1963) never claimed that grief becomes pathological if it goes on “too long” or “too intensely,” Deutsch legitimized the concept of pathological grief by claiming that another type of dysfunctional grief is the kind that is absent or unexpressed (Deutsch, 1937). She thereby introduced both concepts into the psychological discourse.
The second major theory she introduced that has become so widespread today it appears to be almost common sense is that unmanifested energy, in this case unmanifested or repressed grief, will resurface in other ways if not brought into consciousness and treated (Deutsch, 1937). She stated:
the process of mourning as a reaction to the real loss of a loved person must be carried to completion. As long as the early libidinal or aggressive attachments persist, the painful affect continues to flourish, or vice versa, the attachments are unresolved as long as the affective process of mourning has not been accomplished (p. 21).
Deutsch’s (1937) ideas were pivotal in the process of grief becoming a psychological kind. In this short paper, she set the foundation for much of contemporary grief research. Her idea that pathological grieving can manifest in either intensity and chronicity or in the absence of any symptoms introduced the concept that all grieving people are potentially ill and need to be monitored for the process of their “grief work.” Second, the notion that “grief work” must be done or else it will resurface somewhere else puts the onus of responsibility on the grieving person to self-monitor or risk becoming ill or psychologically unbalanced.
By 1940, psychoanalysts such as Melanie Klein (1882–1960) were openly referring to grief as a disease, albeit in different ways than one might think about it today. Klein (1940) argued that infants separating from their mothers in the form of weaning from the breast or actual physical separation from their maternal figures could be compared with adults mourning in later life. In her view, normal mourning involved the activation of early psychotic anxieties involving separation from the mother. She stated:
the mourner is in fact ill, but because this state of mind is common and seems so natural to us, we do not call mourning an illness. (For similar reasons, until recent years, the infantile neurosis of the normal child was not recognized as such). To put my conclusions more precisely: I should say that in mourning the subject goes through a modified and transitory manic-depressive state and overcomes it, thus repeating, though in different circumstances and with different manifestations, the process which the child normally goes through in early development (p. 322).
While contemporary psychologists cite Klein’s work to justify modern un- derstandings of “grief as illness” or “grief as a disease,” Klein (1940) clearly meant something else in her conceptualization. The quoted paragraph is often cited as proof that there is continuity between contemporary notions of patholog- ical grief and early psychoanalytic work. While Klein does refer to grief as an illness, several other caveats appear in her essay, including the comparison of the
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mourning process to normal infantile neurosis and normal developmental pro- cesses of the child, and the notion that it is transitory, not a permanent state of disease. It is likely that Klein, writing in the context of psychoanalysis where psychopathology and mental health were on a continuum, believed that the “ill mourner” was in a temporary state that was part of the normal process of grieving, and not literally ill or diseased as conceptualized by later psychologists (Engel, 1995; Green et al., 2001; Parkes & Weiss, 1983; Raphael, 1983; Zisook & Shuchter, 2001).
Klein’s (1940) theory of mourning is complex, and layered, and in many ways is more about child development than about grief. In her view, adult mourning and grief was a replay of earlier losses in childhood where the infant went through a transitory depressive phase in coping with losses associated with the mother. It is important to note that Klein (1940) believed that this phase of mourning for both the infant and the adult was transitory, normal, and part of healthy development.
Klein’s solution to the problem of adult grief included shedding of tears and the realization that grief and suffering can have positive effects. Klein’s (1940) essay was more theoretical than practical, and while Deutsch (1937) advocated (albeit subtly) for the intervention of psychoanalysis, it is not obvious from reading Klein (1940) that she intended any kind of intervention at all. In fact, she appeared more inclined toward realizing the growth potential in the grief process than in trying to treat it. This theoretical approach to understanding grief changed radically with the shift from psychoanalytic conceptualizations to psychiatric ones.3
Psychiatric Conceptualizations of Grief
To understand how grief evolved from a psychoanalytic to a psychiatric construct, it is necessary to begin by briefly examining the historical context in which the psy-disciplines developed. Emil Kraepelin (1856 –1926) often dubbed, the “father of psychiatry,” had different ideas than Freud about the etiology of pathology but shared the view that psychological pathology was an area worthy of scientific attention. In contrast to Freud, Kraepelin wanted to prove that psychiatric disorders were hereditary and attempted to classify all mental disor- ders into common patterns. Kraepelin’s goal was to establish that all psycholog- ical symptoms were unambiguous and had “physical foundations” (Kraepelin, 1902/1921, p. 115).
Shorter (1997), a historian of psychiatry, described Kraepelin’s contributions to psychiatry as a major revolution in the history of the discipline. The essence of the change was the shift from thinking of pathology on a continuum to differen- tiating distinct diseases by looking at their outcomes in psychiatric patients and creating a system in which psychiatrists could reliably diagnose pathology.
In addition to providing a new way of classifying illness, Kraepelin’s system insisted that there was a number of discrete psychiatric illnesses, or diseases, each
3 The development of grief as a psychological kind was also impacted by World War I and World War II. It is beyond the scope of this article to trace the social history of grief vis-a vis the wars. For two recent excellent books on the subject, see: Evans (2007); Gilbert (2006; especially chap. 7), Acton (2007), and Faust (2008).
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separate from the next; being “Kraepelinian” meant that one operated within medical model, rather than a biopsychosocial model, as the battle lines later became drawn. A medically oriented psychiatrist believed in approaching psychi- atric illness just as a cardiologist would approach heart disease (Shorter, 1997, p. 108).
Kraepelin’s “new way of classifying illness” became the foundation for the development of the DSM (Lane, 2007). The first diagnostic manual was called the Statistical Manual for the Use of Hospitals for Mental Diseases (1918). It was based on Kraepelin’s classifications and was primarily intended for use in mental hospitals, because that is where most psychiatrists were working at the time. The Statistical Manual was used exclusively by psychiatrists to classify mental dis- orders from this first edition to its tenth edition published in 1942 (Horwitz & Wakefield, 2007).
By the early 1950s, however, the field of psychiatry was radically changing (Scull, 1989). The role of psychiatry shifted from state hospitals, which focused primarily on psychiatric disorders, to outpatient therapy, with less severe patients that required more psychotherapy. Many of these changes had to do with the explosion of patients that resulted from World War II and the soldiers, which as a result of the Veteran’s Administration (VA) bill, were now entitled to psychi- atric “treatment” (Grob, 1991; Pickren & Schneider, 2005).4
As an illustration of how popular the psy-disciplines became around this time, one could look at the rising rates of employment for psychiatrists. The percentage of American psychiatrists working in independent practice rose from 8% in 1917 to close to 30% in 1941. By 1970, almost 70% of psychiatrists were working in independent practice to meet the demands of clients (Herman, 1995). Because the Statistics Manual was less relevant to the majority of patients that the psychiatrists were now treating (because it focused heavily on severe psychosis), in 1952, the American Psychiatric Association codified and produced the first edition of the DSM that was intended to better reflect the nature of the psychiatry’s changing role and changing population of patients (Horwitz & Wakefield, 2007).
The development and use of the DSM and the focus on the scientific status of psychology both contributed to the shift of thinking about grief as a psychoana- lytic concept on a continuum to a more distinct diagnostic pathology to be treated by mental health professionals. This conceptual shift was part of a larger
4 The VA) Bill, or what is called the GI Bill of Rights, was legislated by the U.S. Congress and signed into law by President Franklin Delano Roosevelt in 1944. It was a bill guaranteeing soldiers returning from war access to education, training programs, loans on houses, and health services that included psychological diagnosis and treatment (see http://www.gibill.va.gov/). The passing of this bill was a boon for the psy-disciplines because it provided them a deluge of new patients. The GI Bill Web site set up by the U.S. Department of Veteran Affairs noted that by the mid-1950s, over ten million people had used services that were funded by the VA. Barber (2008) noted that World War II “produced an unprecedented stream of new patients for psychiatry: an endless supply of . . . ‘battle fatigued’ soldiers suffering from guilt, anxiety and terrifying flashbacks. There were a remarkable 1.1 million admissions for psychiatric disorders in military hospitals over the course of the war” (p. 71; also see Moore, 1992). The central role of the psy-disciplines in the army continues to this day. A recent article in Time Magazine (June 2008), entitled America’s Medicated Army, reported on the heavy use of antidepressants and therapists by the soldier’s in the field, and by returning veterans (see Thompson, 2008).
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movement within the field of psychology to be seen as more scientific by using the empirical, quantitative methods that were typical of medical studies. From the beginning of the discipline’s history, psychology sought to establish itself in a league with other fields that used this aspect of the scientific method (Teo, 2005). Psychologists wanted to model themselves after the prestigious natural sciences, and indeed, by the 1930s, it was established that psychology “was to join with the natural sciences and utilize their methods, epistemology, and experimental appa- ratuses” (Ward, 2002, p. 43).
The use of these quantitative methods, epistemologies, and experimental apparatuses were pivotal in transforming grief from a psychoanalytic concept to a psychiatric one. Because psychologists wanted to model themselves on the hard sciences, they wholeheartedly embraced everything about the scientific episte- mology. This included the idea that mental disorders like grief could be catego- rized into discrete, distinct entities, and that one could use the experimental methods of science to diagnose mental disorders (Scull, 1989). While the quest to be scientific was present from the very inception of psychology, the influence of the discipline and its standardized tests began to spread rapidly at around the same time psychiatry began to take off. World War II was a major catalyst in bringing psychology’s presence into the academy, the hospitals, and into the realm of everything therapeutic (Capshew, 1999). Grief as a psychiatric concept enters into this narrative in the mid-1940s with Lindemann’s work on mourning.
While Freud put grief on the map, Lindemann (1944) charted the territory. Lindemann’s publication Symptomatology and the Management of Acute Grief was a pivotal, transitional point in the development of grief as a psychological kind. During the early 20th century as psychology was solidifying as a discipline, the field of psychiatry was also seeking to expand its domain and influence (Capshew, 1999). While psychiatry was mostly relegated to the asylums in the 19th century (Burnham, 1996; Shorter, 1997), by the middle of the 20th century the profession was beginning to expand into public settings and advocating psychotherapy as a cure for everyday ills (Ward, 2002). Building on their work treating veterans in the First World War, psychiatrists were gaining control over the emerging “mental hygiene movement.”5 As psychotherapy began to infiltrate the collective psyche and become more popular among the middle class, psychi- atry began to shift its emphasis from psychosis, found exclusively in hospitalized settings, to the general well-being of the lay public (Capshew, 1999). One of the
5 The Mental Hygiene Movement began in 1908 in response to Clifford Beers’ (1907/1953) autobiography entitled A Mind That Found Itself, which criticized the state of mental institutions at the time. Beers founded the Connecticut Society for Mental Hygiene and the National Committee for Mental Hygiene, which would later become the group to organize the National Association for Mental Health in 1950. These groups advocated better quality care for the mentally ill based on scientific research and methods and included prevention of mental illness and knowledge dissem- ination in their mandate. The National Institute of Mental Health (NIMH) took over this role in 1949 in the United States. The Mental Hygiene Movement had a major role in reforming institutional care, expanding public education about mental health and the development of clinics throughout the States. In many ways, the movement was about the promotion and dissemination of scientific, psychiatric, and psychological knowledge, and it was thus a pivotal area for psychiatrists to gain control over in an attempt to professionalize their discipline (see Grob, 1983).
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newly coopted concepts in the field of psychiatry was grief and it began with Lindemann’s study.
Lindemann (1944) offered a rationale for psychologizing grief in the very first sentence of his article.
At first glance, acute grief would not seem to be a medical or psychiatric disorder in the strict sense of the word, but rather a normal reaction to a distressing situation. However, the understandings of reactions to traumatic experiences whether or not they represent clear cut neuroses has become of ever increasing importance to the psychiatrist. (p. 141)
Lindemann’s (1944) paper was the first to present an empirical study of bereaved patients. Its cachet and its novelty were in its “scientific” and “objective” approach in documenting the grieving process. By interviewing 101 subjects who had recently been bereaved, Lindemann claimed to produce a systematic, objec- tive, and accurate representation of what the grieving process entailed and, further, argued that psychiatrists could, and should play a role in aiding the mourner in their grief work (Lindemann, 1944).
Lindemann’s (1944) study revolutionized the concept of grief within the field by establishing several assumptions about the nature of the grieving process that have remained central to psychology today. First, he established that grief was a medical disease (or in contemporary terms, a psychiatric/psychological disorder) that fell into the purview of psychiatry (and subsequently modern clinical psy- chology). The first point he made in his treatise is that “grief is a definite syndrome with psychological and somatic symptomatology” (p. 141).
The second significant point is the development of a list of normal and abnormal grief symptoms in a systematic way. On this he wrote, “this [grief] syndrome may appear immediately after a crisis; it may be delayed; it may be exaggerated or apparently absent” and that further, “in place of the typical syndrome there may appear distorted pictures, each of which represent one special aspect of the grief syndrome” (p. 143).
By listing normal and abnormal symptoms and patterns of grief in his paper, Lindemann described the process of grief as a disease with an etiology that could be predicted, managed, and subsequently treated by professionals.
Lindemann’s third major achievement in this paper was his argument that psychiatrists could, and should, be involved in the management of grief since they were experts in the field and knew the right techniques to help the patient with their grief work. He stated:
Proper management of grief reactions may prevent prolonged and serious alter- ations in the patient’s social adjustment, as well as potential medical disease. The essential task facing the psychiatrist is that of sharing the patient’s grief work, namely, his efforts at extricating himself from the bondage to the deceased and finding new patterns of rewarding interaction. It is of great importance to notice that not only overreaction, but under reaction of the bereaved must be given attention, because delayed responses may occur at an unpredictable moment and the dangerous distortions of the grief reaction, not conspicuous at first, be quite disturbed later on. (p. 147)
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Thus, Lindemann argued for the explicit intervention of psychiatrists in the grief process. He believed that psychiatrists should not only treat grief like a medical and psychological disease, but that patients should also be monitored for normal grief reactions to see if they were doing their “grief work” properly. Furthermore, patients should also be monitored for not showing enough grief. Indeed, Lindemann went on to propose that psychiatrists should be involved in almost all cases of grief since patients will need psychiatric intervention to make sure they stay on course with their grief work, and if they are too grief stricken, and if they are not showing enough grief.
Lindemann goes as far as to claim that while it was once the case that ministers and religious institutions used to deal with the grief stricken, “comfort alone” from these people “does not provide adequate assistance in the patient’s grief work.” It is only a psychiatrist that can be of help to the bereaved and the use of social workers, ministers, and family members should be for the purposes of “urge[ing] the patient to . . . see a psychiatrist” (p. 147). This approach of criticizing other resources for the grieving person including religious ministers, family, and friends became a recurring theme throughout the development of grief as a psychological construct. Destabilizing other institutions and resources for the mourner in order to step in and take over the role of expert and therapist parallels psychology’s approach to professionalizing the discipline where everyday expe- riences became coopted by psychologists and other mental health professionals as problems for them to solve (Daniels, 1967).
Finally, Lindemann implied a distribution of responsibility to the mourner to do their grief work properly. Lindemann emphasized the idea that the duration of the grief reaction depends on the success with which a person does their grief work. This work involved the emancipation from the bondage of the deceased, a readjustment to the new environment in which the deceased was missing, and the formation of new relationships. Success for the mourner could only come from working on themselves and slugging through their grief work, which could be done properly only with the guidance of a psychiatrist. In this way, Lindemann set up a paradigm of success or failure for the mourner. This view later become popularized in mainstream culture resulting in a new kind of self-consciousness for the griever. On this, Gilbert (2006) noted that in addition to the universal question of whether one is honoring the dead properly, “twentieth-century West- ern society has added another, distinctively clinical anxiety: Am I recovering from the illness of grief at a proper rate?” (p. 257). The genesis of this clinical anxiety is rooted in Lindemann’s study.
In the years immediately following Lindemann’s paper, there were few large- scale empirical studies of bereavement. Brewster, writing in 1950, reiterated Lindemann’s ideas about grief work and described a clinical case study of a bereaved woman going through the phases of the grief process. Stern, Williams, and Prados (1951) followed shortly after with an article on the etiology of grief, describing the symptoms in the same manner as one would describe a disease in the medical field. These authors repeated Lindemann’s (1944) warning that the grief work must be done in order to avoid pathology and described their small sample as disturbed, but none were “psychotic, nor was the depression of such a degree that electric shock treatment or hospitalization was necessary” (Stern et al., 1951, p. 261). While these articles were readily available in the public domain
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(i.e., Stern et al.’s paper was published in the American Journal of Psychiatry), they did not appear to have a profound impact on the field (as is evidenced by their rare citation in subsequent grief texts). The next major turning point for grief within the domain of psychology came with publications by Marris (1958); Hobson (1964); Gorer (1967) and Parkes (1964a, 1964b, 1965, 1971) in the United Kingdom.
Grief Studies in the United Kingdom
As with the United States, psychology and psychiatry experienced a surge of popularity in the United Kingdom in the 20th century (Moncrieff & Crawford, 2001). Similar to the trajectory in America, the British psychological disciplines went through various explanatory paradigms for mental illness (Moncrieff & Crawford, 2001). While psychoanalytic theory was popular from the mid-1940s to the mid-1960s, it was increasingly replaced by a more empirical, quantitative approach with a focus on a biological orientation for understanding and treating mental illness (Bennett, 1991; Hale, 1995; Healy, 1996; Shorter, 1997).6
In tandem to what was happening in the United States, British psychiatrists and psychologists began to heavily emphasize empiricism and psychopharmaco- logical experiments during the 1950s and 60s to professionalize their disciplines. Moreover, the emphasis increasingly began to shift from severe cases of psychotic patients to the mental health of normal people in the community in order to expand their reach and services (Moncrieff & Crawford, 2001). It was in this context that grief research began to emerge in the United Kingdom.
Although Marris’ (1958) study was the first empirical examination of be- reavement in the United Kingdom, as a psychologist, he had a substantially different view on the process than did Lindemann (1944). Marris (1958) inter- viewed 72 widowed women whose husbands had died within the previous two years. Like Lindemann (1944), he presented a systematic description of the typical patterns of grief. However, he also asked questions about the widows’ social contexts, including their financial situations, if they had remarried, and their social support networks. Despite his emphasis on community, Marris’ focus was mostly empirical and was a strictly quantitative study whose main purpose was to list the symptoms of grief.
Hobson (1964) interviewed widows from a small town in the Midlands of England, and like Marris (1958), found that physical symptoms in the grief process involved migraines, ulcers, asthma, chest pains, and skin complaints as particularly prevalent as well as a general feeling of fatigue, and a sense of being removed from reality.
Gorer (1905–1985) interviewed a sample of 80 bereaved people ranging in age from 18 to 80 years living throughout the United Kingdom (Gorer, 1967). While Gorer described the process of grief and offered novel concepts to describe two particular types of intense and permanent grief reactions (mummification and
6 The shift in explanatory paradigms for mental illness was also influenced by other historical movements within the psy-disciplines that included, but were not limited too, spiritism, behavior- ism, and cognitive psychology. For a thorough review of each of these movements and their impact on psychological explanatory paradigms, see Capshew (1999), Freedheim (1992), and Daniels (1967).
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despair), his contribution to the field is most notable in his critical analysis of the state of mourning in North America and Britain. Ironically, when Gorer is referenced in contemporary psychology texts, he is described as a qualitative researcher who should be taken with caution or summarily dismissed for his methodological limitations (i.e., Archer, 1999). What is rarely noted is the main point of his compelling book; that “the social denial and the individual repudiation of mourning” was becoming widespread in the United Kingdom and America (p. x). Starting out as an anthropologist/sociologist, Gorer’s intent was to identify the sociological and cultural implications of bereavement, which he argued, was increasingly being treated “as exclusively or predominantly private and psycho- logical” (p. viii).
Other insights included the idea that the disavowal of mourning may have to do with the pressure to have a “fun-morality” or what he described as the ethical duty to enjoy oneself and appear to be well adjusted. He suggested that perhaps “the right to the pursuit of happiness has been turned into an obligation. Public and private mourning maybe felt as contravening this ethic” (p. x). While Gorer’s project involved looking at the actual grief process, the main purpose of his study was to deconstruct the social context in which these grief reactions occurred. As with other examples within the discipline (i.e., Wundt and his Volkerpsychologie7), only part of this thesis was “translated” for public consumption within North America. While some of his empirical concepts came into the psychological lexicon (e.g., mummifi- cation), his critical theory remained opaque to most psychologists and psychiatrists working in North America.
Collin Murray Parkes, however, has a different legacy. Parkes, a psychiatrist, working under the supervision of Bowlby, produced a series of articles about grief that were published within the same decade. While Bowlby’s theories were largely psychoanalytic in their theoretical orientation, Parkes was heavily steeped in the empirical, scientistic rhetoric of the time, and it was ultimately his ideas that were assimilated into contemporary psychological culture. Parkes’ clinical studies (1964a, 1964b, 1965, 1971, 1964b, 1965, 1971), which are credited as the “beginning of a sounder empirical basis for the description of grief” (Archer, 1999, p. 21), were largely concerned with atypical patterns of grief. In these studies, he interviewed bereaved patients in psychiatric hospitals (1964a, 1964b, 1965, 1971, 1964b, 1965, 1971) and bereaved widows in the general community (Parkes, 1970). These studies provided detailed descriptions of the grief process that were “empirically sound” and grounded in science (Archer, 1999; Genevro et al., 2004). His contributions were significant for a number of reasons that parallel Lindemann’s (1944) work.
First, he provided a further rationale for the pathologization of grief and set in motion what was about to become an explosion of research into the “illness of
7 Danziger (1979) noted that only part of Wundt’s prolific writings were translated from German to English, thereby, ignoring a large part of his philosophy and research. While the natural science component of Wundt’s philosophy was consumed and disseminated among North American psychologists, his “softer sciences” approach, which he called “voelkerpsychologie” and that included language, art, mythology and religion, was excluded. As a result, North American psychology developed more along the lines of natural sciences than social sciences. Gorer wrote in English, so when I use the term “translation,” I mean that only the scientific or empirical parts of his work were adapted in North America (also see Smith, 2005).
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grief.” In his 1964 publication, Parkes stated, “the claim that grief is itself an illness, which has been defended by Engel is supported by the finding that 28/29 bereaved psychiatric patients interviewed by me were found to be suffering from variants of typical grief” (Parkes, 1964a, p. 180).
His second major contribution to the field was in justifying the use of psychiatry to treat this illness. In the same paper cited above, Parkes concluded that “it is time that the psychology of bereavement and the means by which help can be given to the bereaved were made part of the medical curriculum” (Parkes, 1964a, p. 279).
The third major achievement had less to do with content and more to do with methods. Parkes’ studies were considered by the psychological and psychiatric communities as sound description of grief based on hard evidence. As such, he provided not only information about the processes of grief, but also an empirical method in which future psychologists could begin to study the phenomena. He published his articles largely in medical journals - the majority in the prestigious British Medical Journal and included numerous scientific charts and statistics to make his points. He also focused heavily on the somatic aspects of grief in his studies and was the first to suggest that the bereaved had higher morality rates and physical problems, thereby, turning grief into a physical and mental disorder to be treated by medical doctors (Parkes, Benjamin, & Fitzgerald, 1969).
Finally, in all his articles, Parkes referred to grief as a complex process requiring professional intervention. In this way, he firmly established grief as a psychological kind within the discipline by offering both the “problem” (patho- logical grief) and the “solution” (psychiatric intervention).
The Synergy of Psychology and Psychiatry
Parkes’ work had a profound influence on the burgeoning field of clinical psychology that was gaining momentum midcentury. World War II was a signif- icant turning point in the history of psychology. The VA in the United States mandated that all members of the armed forces were eligible for psychiatric and/or psychological treatment. The war dramatically increased the number of available patients because veterans were returning from war with debilitating psychiatric casualties and began seeking care. Psychiatrists could no longer handle the load of cases it had previously treated, and recruited psychologists to help manage the shortage of mental health professionals (Grob, 1983; Pickren & Schneider, 2005). The VA soon became the largest employer of psychologists. As a result of this shift, research being conducted in psychiatry was infiltrating into the exploding field of psychology, and along with co-opting the concepts came the coopting of epistemologies and methods.
While Parkes favored qualitative interviews, he often used quantitative out- comes in his studies, citing charts and crude statistics to make his points. North American clinical psychologists who were working at staking their claim as a scientific discipline comparable to psychiatry endeavored to follow the clinical tradition but opted for additional “scientific measures” to test their concepts (Capshew, 1999; Napoli, 1981).
In the introduction, I outlined Hacking’s (1995) criteria for a human kind to become a cutting edge human kind. The transformation must include the following:
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at least one professional society of experts studying it; regular conferences, one of which is major and a number of others which are more specialized; one recently established professional journal to which the authorities of the discipline contrib- ute to; and in general the intention of interfering, intervening, helping and/or improving the human kind that is their object of their study (Hacking, 1995). The first and last of these criteria were fulfilled by the steady stream of psychoanalysts, psychiatrists, and a few psychologists who became increasingly interested in the construct of grief after Freud’s (1917/1963) original publication. These professionals were both a “society of experts” studying the same phenomena and all had the intention of helping and/or improving their object of study. The rest of Hacking’s (1995) criteria for becoming a cutting edge human kind, or what I have called a psychological kind, were fulfilled simultaneously and almost immediately follow- ing Parkes’ studies.
In 1970, Omega: The Journal for Death and Dying was established. Death Studies followed on its heels with its first edition coming out in 1971. In addition to these journals, a slew of standardized questionnaires appeared. These included scales that measured physical and psychological health (Clayton, Halikes, & Maurice, 1971, 1972; Maddison & Viola, 1968; Maddison & Walker, 1967), as well as scales for depression, anxiety, and psychological well-being (Vachon, 1982; Zisook, 1987).
A decade later, more questionnaires were produced which claimed to measure bereavement (Jacobs, Kasl, Ostfeld, & Berkman, 1986a, 1986b; Jacobs, Kosten, Kasl, & Ostfeld, 1987–1988; Raphael & Martinek, 1997). The Texas Inventory of Grief (Faschingbauer, Devaul, & Zisook, 1977) was introduced in 1977 and was followed with several revisions including a shortened version of the questionnaire (Zisook, Devaul, & Click, 1982). The Grief Experience Inventory was published in 1985 and is one of the most widely used scales today to measure grief (Sanders, 1980 –1981). Other scales include the Response to Loss Instrument (Deutsch, 1982), The Revised Grief Experience Inventory (Lev, Munro, & McCorkle, 1993), The Inventory of Complicated Grief (Prigerson et al., 1995), The Core Bereave- ment Items (Middleton, Burnett, Raphael, & Martinek, 1996), and the Perinatal Grief Scale (Toedter, Lasker, & Alhadeff, 1988).
The explosion of these questionnaires is indicative of the scientific and quantitative ethos of psychology at the time. While it used to be the case that psychological laboratories symbolized the serious nature of psychological sci- ence, the development of diagnostic instruments such as the questionnaires described above came to take over the physical space of the lab (Cohen, 1992). The statistical standardization provided by these measures situated grief as a scientific construct that could be evaluated for its degree of pathology. The study of grief as a psychological construct had transitioned from a psychoanalytic, to a psychiatric, to a mostly quantitative, empirical endeavor in less than 30 years within North America and Britain.
In 1988, a special issue of the Journal of Social Issues on the study of grief was published. I note this publication in particular because it sits at the midpoint between Parkes’ influential studies that came out in the late 1960s and early 1970s and today’s contemporary research on grief. What is striking about reading the introduction of this issue written by Stroebe, Stroebe, and Hansson (1988) (three pivotal figures in the field), is that while some of the theories of grief had changed
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since Parkes’ work, little about the structure or approach of these studies had been modified. By this point, grief theory had become decontextualized from experi- ence and had been psychologized completely. The focus was entirely on symp- toms, and the ability to measure, diagnose, and manage grief. The language of the authors is jargon-filled, scientific, and inundated with references to the progress psychologists were making in treating grief. In their review of the grief literature, the authors pointed out two main themes, the first being the “health consequences of mental and physical health and life expectancy of mourners”; and the second being “pathological forms of grief” (Stroebe et al., 1988). By the early 1990s, the focus on grief was almost entirely on its dysfunctional nature. Phrases like “predictors of abnormal grieving and poor outcome” and the “effectiveness of intervention programs” were liberally sprinkled throughout this introduction. Contributions in this issue included articles on the biological correlates of loss in humans and nonhumans, high-risk groups for pathological grief, and the role of counseling and therapy in helping grievers heal from their losses (Stroebe et al., 1988). Having defined the pathological griever, and created questionnaires to identify him/her, the psychologist could now study the griever in new ways, and create even more categories of pathological grief to address, including those “at risk” for the condition.
It is worth noting that Stroebe et al. (1988) used typical scientistic strategies to validate their own concept of grief and discredit previous theories. They critiqued Freud (1917/1963) for being “nonempirical” and psychoanalytic, and cite Lindemann (1944) as the founder of the study of grief because of his empirical approach to studying the phenomenon. Indeed, they follow in his footsteps by emphasizing “that it is well established that bereavement can be detrimental to mental health and the effect of the loss can be so severe as to create or (exacerbate existing) emotional problems of clinical magnitude” (p. 6). While it would seem fitting to most people that bereavement would cause “detrimental mental health” (at least for a short while), by this point what could be considered a normal process of grieving for a lost loved one had become a dysfunction within the discipline.
Following Hacking’s (1995) criteria for cutting edge human kinds almost to the letter, the last point the authors emphasize, and which lies at the foundation of the psychological imperative to study grief, is the conclusion that (a) grief may be a pathology; (b) that it needs the help of the experts to solve the problem; (c) that grief should be studied by the experts, using expert methods that are based on an empirically sound foundation; and, (d) that psychologists will be doing a great service to their clients by helping them with their grief work (Stroebe et al., 1988). They stated that the work of these psychologists is:
guided by a concern for the bereaved, and by the belief that to be effective in helping, we have to proceed from a sound base of theoretically oriented and empirically derived knowledge . . . It is not enough for us to stay close and to open our hearts to another person’s suffering: valuable though this sympathy may sometimes be, we must have some way of stepping aside from the maze of emotion and sensation if we are to make sense of it (p. 15).
By this point, grief had become so completely ingrained into the psycholog- ical purview it no longer required a justification to be studied or treated like a
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psychological object. The majority of psychologists researching grief today are entirely empirical in their orientation. Contemporary psychologists studying grief have focused on the phenomenology and measurement of grief with an emphasis on scale development (Jacobs et al., 1986a, 1986b; Prigerson et al., 1995; Shuchter & Zisook, 1993; Steeves, 2002; Stroebe, Stroebe, & Schut, 2003; Toedter et al., 1988; Tomita & Kitamura, 2002).
Other psychologists have proposed the cognitive/experimental theory of grieving that looks at the cognitive “impairments” and processes during the phases of bereavement (Cohen, Mannarino, & Staron, 2006; Epstein, 1993; Folkman, 2001; Stubenbort & Cohen, 2006). Another related area of research looks at the physiological changes that come with grief including endocrine disturbances, increased mortality risk, and physical ailments like heart troubles (Laudenslager, Boccia, & Reite, 1993; Ott, 2003; Prigerson, Bierhals, Kasl, & Reynolds, 1997; Stroebe & Stroebe, 1987).
The “grief as trauma” perspective looks at the violent circumstances in which people die and how they impact the grieving process for the survivors (Cohen, Mannarino, & Deblinger, 2006; Jacobs, 1999; Prigerson, Shear, Frank, & Beery, 1997; Prigerson & Jacobs, 2001; Raphael, 1997; Raphael & Martinek, 1997; Rubin, Malkinson, & Witztum, 2003), while the “stage model” of grieving, or the idea that grieving progresses in a set of orderly stages examines the sequence in which people move through the mourning process (Bowlby, 1980; Maciejewski, Zhang, Block, & Prigerson, 2007; Raphael, 1983; Volkan, 1981).
The grief and adaptation perspective looks at personality and gender differ- ence in how people cope and adapt to grief (Bonanno & Kaltman, 2001; Bonanno et al., 2002; Dutton & Zisook, 2005), while grief and attachment theories focus on the relationship between early development and grieving in later life (Bowlby, 1980, 1983; Field, 2006; Field, Gao, & Paderna, 2005; Jacobs et al., 1987–1988; Shaver & Tancredy, 2001; Stroebe, Schut, & Stroebe, 2005a; Weiss, 2001).
One of newest areas of research is grief within the disease model, or com- plicated grief (Avrill & Nunley, 1988; Bonanno, 2006; Brewster, 1950; Engel, 1995; Hardison, Neimeyer, & Lichstein, 2005; Neimeyer, 2005–2006; Ott, 2003; Parkes, 2005–2006; Prigerson et al., 2002; Raphael & Middleton, 1990; Vander- werker, Jacobs, Parkes, & Prigerson, 2006; Volkan, 1984 –1985; Zisook & DeVaul, 1985, 1983).
In response to the growing trend of seeing grief as a disease, counseling psychologists have now begun to focus on developing grieving interventions and examining their efficacy (Cohen, Mannarino, & Deblinger, 2006; Cohen, Man- narino, & Staron, 2006; Larson & Hoyt, 2007; Neimeyer, 2000, 2001a, 2001b; Stroebe, Schut, & Stroebe, 2005b; Stroebe, Zech, Stroebe, & Abakoumkin, 2005).
In addition to an explosion of articles on these subjects, several comprehen- sive reviews and books have been published including the Handbook of Bereave- ment (Stroebe, Stroebe, & Hansson, 1993) and the Handbook of Bereavement Research in 2001 (Stroebe, Hansson, Stroebe, & Schut, 2001).
In the introduction, I explained that the modern view of grief proposes that grieving “is a debilitating emotional response,” that is seen as a troublesome interference with daily routines, and should be “worked through” as quickly and efficiently as possible. As is evident by the description of contemporary grief research in psychology, this view is widely held. The belief that grief is
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intrinsically traumatic and causally pathogenic is generally accepted among psychologists who study grief today.
Conclusion
By tracing the development of grief theory, originally conceived by Freud within a psychoanalytic framework, to the current concretization of grief within the disease model, I have shown how grief theory has evolved within the discipline of psychology to become a psychological kind, or an object worthy of scientific study within the discipline. The evolution of grief from a psychoana- lytic, to a psychiatric, to a pathological entity within the discipline coincided with the changing social, cultural and historical changes happening within the disci- plines of psychology and psychiatry in North America and the United Kingdom.
While contemporary psychologists, situated within a modernist paradigm, argue that contemporary psychological notions of grief are situated within, and build upon previous research in the field (i.e., Freud, Deutch, and Klein), reading the primary sources suggests otherwise.
Modern grief researchers claim that grief is a psychological problem neces- sitating extensive study and intervention by trained professionals. However, the early psychoanalytic researchers did not make this claim, or believe that normal grief was a problem to be solved by psychologists or psychiatrists. In fact, they stated the opposite. Freud (1917/1963), in particular, was clear that grief should not be considered a disorder, and that intervening with a mourner could even cause psychological damage.
By tracing the historical biography of grief as a psychological kind, it becomes increasingly evident that grief, at least as a psychological object, is transient and its definition is contingent on the changing cultural, historical, and social context. On this Danziger (2003) has noted, “The coming and going of such categories is not the story of a “mirror to nature” that yields ever-more accurate reflections but a much more mundane story of social interests, everyday practices, and human preoccupations” (p. 28).
It is beyond the scope of this article to assess the implications of these developments on contemporary notions of grief and its impact on mourners in North America. In a forthcoming article, I take up the consequences of grief as a psychological kind and describe the rhetorical strategies used by contemporary psychologists to formalize the category of grief to include it in the next version of the DSM set to be published in 2012 (Granek, 2009).
What is worth noting in the conclusion of this article is that the pathologi- zation of grief is part of the widespread phenomena of turning everyday problems into psychological disorders to be managed and treated by mental health profes- sionals (Lunbeck, 1994). Grief is certainly not the only natural kind turned into a psychological kind in recent years. Some clear examples include the transfor- mation of mild malaise and general unhappiness into MDD (Horwitz & Wake- field, 2007), or the shift in thinking of shyness and introversion, as social anxiety disorder (SAD) (Lane, 2008). As with MDD and SAD, grief is slowly morphing from a difficult, but necessary condition of living, into a psychological disorder that can be observed, diagnosed, and treated.
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In this article, I traced the trajectory of how this shift in conceptualizing grief as a psychological kind has happened. The next step which I take up elsewhere (see: Granek, 2009), is to argue that the evolution of grief into a psychological object of study is not a neutral, or purely theoretical development, but rather, has changed the very experience of what it means to be mourner living in North America today.
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Received April 1, 2009 Revision received June 18, 2009
Accepted June 21, 2009 yy
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