is ‘normal grief’ a mental disorder?

IS ‘NORMAL GRIEF’ A MENTAL DISORDER?

B S W

INTRODUCTION

First of all, something needs to be said about the meaning of ‘normal grief ’and of ‘mental disorder’. I use ‘disorder’ throughout the paper as a generalterm for ‘negative health state’ or ‘state of unhealth’. Hence ‘disorder’, inthis sense, covers not only those things which we normally call disorders, butalso such things as (for example) allergies, diseases, injuries and phobias.Other general terms such as ‘disease’ or ‘malady’ would have been equallygood, and I have chosen the term ‘disorder’ only because it is commonplacein such documents as the fourth edition of the Diagnostic and Statistical Manualof Mental Disorders (henceforth DSM: American Psychiatric Association,), not because I am advocating a particular distinction between (forexample) disorders and diseases.

Where it is possible I shall try to remain neutral about the general ques-tion ‘What is a disorder?’, so that my arguments do not become too depend-ent on a particular theory of health. I shall assume, however, that we have aprima facie reason for believing that a condition is a disorder if it is a stateof persons which causes them to be harmed (e.g., through death or pain)and/or causes impairment (by which I mean, roughly, subnormal func-tioning of one or more of their parts or systems). In so far as I make thisassumption, then, I am in agreement with at least part of DSM’s suggesteddefinition (p. xxi) of (mental) disorder:

A behavioural or psychological syndrome or pattern that occurs in an individual andthat is associated with present distress (e.g., a painful symptom) or disability (i.e.,

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impairment in one or more important areas of functioning) or with a significantlyincreased risk of suffering death, pain, disability, or an important loss of freedom.

The other key term used in this paper is ‘normal grief ’. I shall notattempt to give a detailed account of grief here, except to say that someoneis grieving only if the emotional response to a real or perceived loss (usually,though not necessarily, of another person) involves some degree of distressor suffering. By ‘normal’ I mean statistically normal, rather than ‘good’ or‘healthy’, and so to grieve ‘normally’ (in this sense) is to react emotionally toloss in ways which are within the normal range for the relevant group(which may be taken to be humanity in general, or may be narrowed downin respect of such factors as age, culture and sex).

The distinction between normal and abnormal grief that I have in mindmirrors in some respects DSM’s distinction between normal grief reactions andmajor depressive episodes (which one might also call ‘abnormal’ or ‘pathological’grief, when the immediate cause is bereavement). These states have similarsymptoms, the main difference being (p. ) that those of the latter aremore extreme in duration and/or intensity:

after the loss of a loved one, the symptoms persist for longer than two months or arecharacterized by marked functional impairment, morbid preoccupation with worth-lessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

What makes questions about the health status of normal grief theoreticallyinteresting is precisely this distinction, and DSM’s attempt to excludenormal grief from the category ‘mental disorder’, even though in itssymptoms it is strikingly similar to disorders such as depressive episodes.Indeed, it is notable that immediately after DSM’s definition of ‘mentaldisorder’ (p. xxi, quoted above) a specific caveat has to be added in order tostop normal grief and similar conditions from being classed as disorders:

In addition, this syndrome or pattern must not be merely an expectable and culturallysanctioned response to a particular event, for example, the death of a loved one.

What I aim to do in this paper is to contribute to the debate about thenature of mental disorder by showing that the specific exclusion of normalgrief, and therefore also the more general exclusion of ‘expectable andculturally sanctioned responses’, from the category ‘mental disorder’ is arbi-trary and unjustified. If my arguments are successful, those who proposedefinitions of mental disorder like that contained in DSM are faced with adifficult choice. Either they must bite the bullet and admit that normal griefis a disorder, or, if they think that it is obviously not a disorder, they mustadmit that I have provided a powerful counter-example to their generalposition. Hence there are two rather different ways of reading this paper.

STEPHEN WILKINSON

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The first is to take it simply as an argument for the view that normal grief isa disorder. But alternatively one might take it as attacking ‘orthodox’ defini-tions of mental health, by providing an extended discussion of one particularcounter-example.

GRIEF IS A MENTAL DISORDER: THE CASE IN FAVOUR

The prima facie case in favour of the view that grief (by which from now on Imean ‘normal grief ’ unless otherwise indicated) is a disorder is simple, and iswell expressed by Engel:

[grief] involves suffering and an impairment of the capacity to function, which maylast for days, weeks and even months. We can identify a constant etiologic factor,namely, real, threatened, or even fantasied object loss. It fulfils all the criteria of a dis-crete syndrome, with relatively predictable symptomatology and course. The grievingperson is often manifestly distressed and disabled.1

Engel correctly identifies here the main reasons for viewing grief as adisorder. In particular, there are two important features that it shares withmany (other) disorders. First, it involves pain or suffering. Secondly, it in-volves some kind of incapacity, or interruption of normal functioning.2 Sothe case in favour of viewing grief as a disorder is just that it is a state whichnormally involves distress and/or impairment. And this case (leaving thespecific exclusion of normal grief reactions aside) is supported by the ac-count of ‘mental disorder’ offered in DSM, which, as we saw earlier, tellsus (p. xxi) that mental disorders are syndromes or patterns which are ‘associ-ated with’ either ‘present distress’ or ‘an impairment in one or more im-portant areas of functioning’, or which cause ‘a significantly increased risk ofsuffering death, pain, disability, or an important loss of freedom’.

My initial contention therefore is that there is clearly a prima facie case forregarding grief as a disorder, not least because grief seems to meet the cri-teria suggested in DSM. The issue for the rest of this paper is whether thevarious arguments for not viewing grief as a disorder are powerful enough tooverturn this prima facie case. In what follows, I shall assess critically each ofthe following objections to the view that grief is a disorder:

. Grief is an entirely normal response to loss. Grief is positively healthy, since failing to grieve (when appropriate) is

unhealthy. Grief involves cognitive good



1 G. Engel, ‘Is Grief a Disease?’, Psychosomatic Medicine, (), pp. –, at p. .2 See also L. Kopelman, ‘Normal Grief: Good or Bad? Health or Disease?’, Philosophy,

Psychiatry and Psychology, (), pp. –, esp. p. .

. Grief is a rational response to loss. Grief ought not to be treated or ‘medicalized’. Grief has a ‘distinct sustaining cause’.

OBJECTION (): NORMALITY

That normal grief cannot be a disorder, precisely because it is normal, is themost obvious objection, and is presumably what the authors of DSM havein mind when they suggest (p. xxi) that grief is not a disorder because it is‘merely an expectable and culturally sanctioned response to a particularevent’. Of course there is one sense in which grief is not normal: it is (for-tunately) not true that most people are presently grieving. However, it isnormal both in that it is something that the vast majority of peopleexperience at some time in their lives and (more importantly) in that it is anormal response to loss.

However, grief ’s normality is really no reason not to regard it as a dis-order, since lots of disorders (e.g., influenza) are similarly normal. This pointis well made by both Engel and Reznek:

Is not grief simply a natural reaction to a life experience? How can one [therefore]put it into the same category as the pathological states we call disease? To this weanswer that it is ‘natural’ or ‘normal’ in the same sense that a wound or a burn are thenatural or normal responses to physical trauma (Engel, p. ).

It would be a mistake ... to argue that because it is normal (in the empirical sense) torespond to emotional loss with grief, grief is not a disease. It is normal (in this sense)to respond with measles and mumps to the appropriate virus, but this does not meanthat they are not diseases.3

These arguments provided by Engel, Reznek and others are sufficientgrounds to reject immediately the claim that ordinary grief cannot be adisorder because it is normal – quite simply because many disorders arenormal responses.

OBJECTION (): GRIEVING IS HEALTHY

A more serious objection is that grief is a positive and healthy response toloss. Grief, it is argued, ought not to be classified as a disorder, since it

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3 L. Reznek, The Nature of Disease (London: Routledge, ), p. ; cf. also A. Flew,‘Disease and Mental Disease’, in A. Caplan et al. (eds), Concepts of Health and Disease (Reading:Addison-Wesley, ), pp. –, esp. p. .

represents the most healthy of three possible kinds of reaction to loss, theothers being ‘under-response’ (e.g., the complete absence of emotion) and‘excessive grief ’ (e.g., a ‘major depressive episode’).

There are two main reasons for regarding grief as positively healthy. Thefirst is that it makes a positive causal contribution to mental health by (forexample) enabling people to ‘come to terms with’ their loss: as Kopelman(p. ) puts it, ‘normal grief seems good because it enables people to over-come loss and form new attachments’. The second is that grief is healthy inthat failing to grieve would itself be symptomatic of an unhealthy lack ofemotional engagement, a general failure to respond emotionally to theworld in ways which are valuable:

Grief is a consequence of our capacity for attachment to things that we may lose.Thus, it is a necessary concomitant of many things that contribute to a good life,including empathy, family, and a sense of community (ibid.).

The objection then is that grief is not really a disorder because, all thingsconsidered, it is healthy in one or both of these ways.

This objection, however, is unsuccessful, not because these claims aboutthe ‘healthiness’ of grieving are false (on the contrary, I find them highly be-lievable), but because they do not show what they are supposed to: they failto show that grief is not a disorder. There are two related reasons for this.First, it is possible for a condition X to be a disorder for a person A even if Ais (all things considered) healthier with X than without X. Secondly, it ispossible for particular episodes of X to be disorders, even if being disposed tosuffer from X (in specified circumstances) is healthier than not being sodisposed.

Taking the first of these points, how could a condition like grief be both adisorder and healthy? The answer is that particular disorders may some-times be healthy, all things considered, because of their positive side-effects.For example, if a young boy has mumps, we should regard him as having adisorder, even if it is in his interests to have this disease now in order toprevent him from having it as an adult (when it could cause sterility). Or if aman manages to avoid military combat by shooting himself in the foot,thereby saving his own life (because his unit is subsequently wiped out inbattle), we should view his foot-wound as a genuine injury even thoughit has benefited him (and his health) greatly. What examples like this show isthat although disorders normally contain intrinsic ‘evils’ such as pain, theyare sometimes good for people’s health overall because of their good effects.And so even if grieving has substantial beneficial effects on grievers’ mentaland/or physical health, this is not a sufficient reason to view it as not adisorder.



The second point is similar in some ways to the first. Could a conditionlike grief be a disorder, even though having a disposition to grieve (in appro-priate circumstances) is healthier than not having that disposition? It seemsto me that the answer to this is ‘Yes’, because, in general, a particularresponse φ to a set of circumstances C can be a disorder even if beingdisposed to φ in C is itself more healthy than not being so disposed. Minorburns, for example, are clearly injuries (and therefore disorders in my broadsense), but only in so far as they are painful conditions: i.e., they do notinvolve any other evils such as disability or increased risk of death. Ourdisposition to suffer painful minor burns in appropriate circumstances (i.e.,when exposed to heat), however, is a healthy one, since if it was removed wewould probably be less healthy in general than we now are. For people whopreviously recoiled when their hand was placed in a flame for just one ortwo seconds would not then notice that they were being burnt until they sawor smelt their burning flesh, and would as a result suffer much more severeinjuries than they would have if their pain receptors were in full workingorder.

What this shows is that although minor burns are injuries, the capacity tosuffer them (in particular the disposition to feel pain in response to them) is ahealthy capacity, chiefly because it helps us to avoid other more seriousinjuries. And so dispositions to be injured can (surprisingly, perhaps) behealthy if we are overall more healthy with them than without them.

In some respects, then, grief is structurally similar to minor burns.Particular ‘grievings’ are disorders which we might call ‘mental injuries’. Butthe capacity to respond to loss with these mental injuries is healthy, since, allthings considered, our mental health is probably better with it than withoutit. And so any attempt to render people immune to grief by eliminating thatcapacity and all that goes with it would be inadvisable, just as it would beinadvisable to render people completely insensitive to physical pain in orderto make them immune to (say) minor burns.

We can, then, reconcile the view that grief is a disorder with the view thatit is a healthy response. In spite of its being a disorder, it can be healthy inone or both of the following ways. First, it can be symptomatic of somegeneral capacity (e.g., emotional sensitivity and engagement) which is itself agood capacity to have (in mental health terms). Secondly, it can beinstrumentally good in so far as the experience of grief and the relatedgrieving processes are effective means of preventing the individual fromsuffering more serious disorders later on. Hence the plausible view that griefis, in these senses, healthy does not in fact pose a threat to the view that it isa disorder.

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OBJECTION (): GRIEVING IS COGNITIVELY GOOD

Like the previous objection, this one is based on the idea that there is some-thing good about grief. But whereas the previous objection focused ongrief ’s positive contribution to mental health, this one focuses instead on itshaving some cognitive value; the main claim is that states which involve cog-nitive goods, like grief, cannot be disorders. It seems to me that grief maywell be cognitively good in a variety of ways. It may be that grief helps oneto acquire a deeper understanding of the lost person, of oneself, and of ‘thehuman condition’. Furthermore both Gubbins and Kopelman plausiblyargue that grief may provide moral knowledge and/or play an importantrole in our moral lives.4 Accepting this, however, need not lead to our aban-doning the view that grief is a disorder; it only has this implication if we alsoaccept (which I do not) that something cannot be a disorder if it involvescognitive good.

The main reason for not accepting this is an appeal to counter-examples.Someone with terminal cancer clearly has a very serious disorder. However,someone in this state may well say, and many do, that being in this con-dition has allowed them to have a much richer understanding of themselves,of the ‘meaning’ of their lives, of death and dying, and of their relationshipswith others. Now of course that is not to say that many (if any) people in thatcondition would think that these cognitive goods outweighed the many evilsinvolved. But it does seem clear that suffering conditions like this can lead toone’s having kinds of understanding and knowledge that one would nototherwise have. What follows from this is that we ought not to refuse toclassify a condition as a disorder just because it involves cognitive good,since terminal cancer is obviously a disorder, even when it carries with it arange of cognitive goods. (I should however add that it certainly does notcarry these with it as a matter of necessity.)

I conclude, therefore, that although grief may well enhance one’s under-standing of various important things, that is not a reason for refusing toclassify it as a disorder. For, in general, disorders can make one a betterperson, in cognitive or moral terms, and this should be unsurprising, giventhat to say that someone has a disorder is to provide an assessment in healthterms, not in cognitive or moral terms.



4 J. Gubbins, ‘Grief ’s Lesson in Moral Epistemology’, Annual of the Society of Christian Ethics, (), pp. –; Kopelman, pp. –.

OBJECTION (): GRIEF IS A RATIONAL RESPONSE

Advocates of objection () (‘Grieving is cognitively good’) may, with goodreason, feel unsatisfied by the response in the previous section, since itfocused solely on grief ’s positive effects on grievers’ knowledge-states, andfailed to consider that grief might itself be an epistemically or rationallyassessable state. In this section, I consider the view that grief is (or can be) arational response to loss, and examine whether this poses a serious threat tothe view that it is a disorder.

I shall call the following principle the ‘rational state principle’: if X is anintrinsically rational state then it is not a disorder.5 If (a) the rational state principleand (b) the claim that normal grief is rational can both be shown to be true,then normal grief will have been shown not to be a disorder. We thereforeneed answers to the following questions. Is the rational state principle true?And is grief a rational state?

For the present, I am quite happy to accept the rational state principle(though I shall not argue for it, since it is part of an objection, not part of myview), and so I shall assume its truth. I shall spend the remainder of thissection therefore discussing whether or not grief is a rational response toloss. If it is, then it cannot be a disorder. If not, then it can be. This is a com-plex issue, not least because there is much philosophical dispute about thenature of rationality and of the emotions, and I cannot hope to do fulljustice to this here. I shall, however, offer one argument for grief ’s not beingrational in the relevant sense.

Two women, A and B, are faced with exactly similar losses. A goesthrough normal grief ; B does not. B’s failure to grieve is not based on ir-rational beliefs or desires. She has an accurate picture of her situation (asdoes A). All that differentiates her from A is that she fails to have a normalemotional response. In particular, she fails to undergo the kind of mentalsuffering usually associated with grief. Is B less rational than A?

A common response to this kind of thought-experiment (one which hasbeen suggested to me by several psychiatrists and other mental healthprofessionals) is just to insist that A and B in fact have different beliefs, evenif there is nothing in their verbal behaviour to indicate this and even if Bclaims to have the very same beliefs as A. Hence B (it is sometimes said)must be ‘in denial’, because otherwise she would be producing the same

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5 Something similar to the rational state principle is proposed by K. Clouser, C. Culverand B. Gert, ‘Malady’, in J. Humber and R. Almeder (eds), What is Disease? (Totowa: HumanaPress, ), and by Culver and Gert, Philosophy in Medicine (Oxford UP, ).

emotional responses as A. And so we might say that B is less rational than Abecause being ‘in denial’ is (arguably) less rational than fully grasping thetruth. In practice, this does admittedly seem like a sensible response to suchsituations. But as a response to this hypothetical thought-experiment itmisses the point entirely, since ex hypothesi A and B have the same beliefs, andthe only point of difference is in their emotional response.

With this in mind, let us return to the question ‘Is B less rational than A?’.It seems to me that the answer to this is in fact ‘No’. We may certainly havevarious concerns about B’s failure to grieve. Perhaps it is unhealthy, orsymptomatic of a lack of emotional engagement (either in general or inrelation to the lost person), or liable to upset others (who are disturbed byB’s failure to grieve). But would we really be concerned at B’s (supposed) lackof rationality? Would we really want to regard B’s failure to grieve as a failureto be sufficiently rational? Again I think that the answer to this is ‘No’. Ourconcerns and criticism would not be about B’s (lack of ) rationality, butabout B’s mental health, or about the kinds of undesirable character traitthat B’s failing to grieve reveals. Opinions may differ about this kind of case(tracking to a large extent people’s differing views of rationality) and in so faras these differ then this argument is indecisive. However, I suggest that it isat least odd to call irrational someone’s failure to grieve, in the circum-stances described. And if it is accepted that not to grieve should not be seenas a failure in terms of rationality, it seems reasonable to suppose, con-versely, that to grieve should not be seen as a success in terms of rationality.In other words, if non-grieving ought not to be criticized for its lack ofrationality, then grieving cannot be a positively rational response.

Although that concludes the argument against grief ’s being a rationalresponse, two further clarificatory points need to be made. The first is that Iam not suggesting that grief is an irrational response. Rather it is (consideredin itself ) non-rational, not assessable in terms of rationality. The second(related) point is that there are some senses in which grief can be rational orirrational. The most obvious of these relates to the kinds of beliefs on whichgrief is based. We could, for example, quite properly speak of a failure togrieve as irrational if that failure was caused by an irrational belief (e.g., thatthe loved one will come back to life). Alternatively, we might legitimately saythat it is rational to grieve in so far as grieving is in one’s interests (assum-ing that it is healthy in normal circumstances).

Although these two claims seem at first glance to be inconsistent, they arein fact compatible. My suggestion is that grief is intrinsically non-rational. Butthis is quite compatible with our making assessments of its extrinsic ration-ality, either in terms of the epistemic rationality of the mental states thatcause it (e.g., beliefs), or in terms of the desirability to rational agents of its



effects (e.g., on health). To say that grief is extrinsically rational in one ofthese senses is really to make a rational assessment of its causes and effects,not of the grief itself. Hence even though grief can be (and often is) extrin-sically rational in various ways, it is not itself a rational state and hence is notexcluded from the category ‘mental disorder’.

OBJECTION (): TREATMENT AND MEDICALIZATION

The fifth objection is that we ought not to classify grief as a disorder becauseit would be wrong to treat or medicalize it. There are two versions of theobjection. The first says that we ought not to classify grief as a disorder, be-cause to do so would have bad consequences. The second says that suit-ability for medical treatment is a necessary condition for being a disorder;hence, given that (arguably) medical treatment for grief is inappropriate, it isnot a disorder.

Version of the argument can be found in the work of Kopelman (seealso Reznek, p. ). Views about grief, Kopelman says (pp. –),

would, if consistently adopted, affect how people are viewed or treated. If normal griefis generally good or adaptive, we should encourage people who lose treasured objectsto grieve. If it is an illness or disease, however, arguably we should treat it medicallyor marginalize the requests or claims of grieving people.... The view that normal griefis a disease predisposes physicians, nurses, and others to view [the griever’s] choice asimpaired by his disease of grief, or to treat it medically.

I do not wish to deny that classifying grief as a disorder might have thesebad effects. What is questionable, though, is whether this sort of moralconsideration is relevant to the issue of whether or not it is a disorder. Itcould only be relevant if some principle like the following were true:

P. For any type of condition X, X is a disorder only if classifying it as adisorder has no significantly harmful effects.

But (P) is false. Imagine a world w in which there is widespread extremeand irrational fear of others’ ill-health, coupled with the false belief that allunhealthy states are highly infectious. In w, the standard practice for dealingwith illness is to kill those who are ill by burning them, thereby (it isbelieved) destroying the relevant infection and preventing it from spreading.In w there will be no (or very few) conditions which meet (P), since classi-fying a condition as a disorder will almost always significantly harm peoplewith that condition (by causing them to be killed). So if we accept (P), thenwe must conclude that there are very few disorders in w, certainly far fewerthan in the real world (where having one’s condition classified as a disorder

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can often be beneficial). But this is clearly the wrong conclusion. There is noreason whatever to believe that there are fewer disorders in w than in theactual world (except in so far as people with disorders in w are executedand, as it were, take their illnesses to the grave with them). So in order toavoid this absurd conclusion we must reject (P). Whether a condition is adisorder or not does not depend on what consequences classifying it as a dis-order would have for those with that condition.

The most that version of the objection establishes, then, is one or bothof the following: (a) if grief is a disorder, we should conceal this fact; (b) evenif grief is a disorder, mental health practitioners should act as if it were not.I concede that one or both of these might be true, but neither (a) nor (b) isincompatible with the view that grief is a disorder.

Reznek is one writer who might endorse version of this objection, sincehe believes that something can only be a negative health state (what heterms a ‘pathological condition’, p. ) if both (i) it requires medical inter-vention, and (ii) medical intervention is appropriate. My own view is thatReznek’s theory is wrong in this respect. However, even if it were not, ver-sion of the objection would still fail, since it is far from clear that medicaltreatment for grief is unrequired and inappropriate.

First, we should ask what exactly ‘medical intervention’ means, as itoccurs in Reznek’s theory. In saying that something is a disorder only ifmedical intervention is appropriate and required, do we mean (a) that someexisting medical treatment is appropriate and required, or (b) that some poss-ible medical treatment (as yet undiscovered) is appropriate and required?

Clearly (a) is a non-starter, since it would imply that conditions becomedisorders only when there is a treatment for them. And so the claim must bethat something is a disorder only if there is some possible medical interven-tion that is appropriate and required.

But if that is what the theory says, then it is far from clear that grief failsto meet the relevant condition. What if there were some side-effect-free,non-addictive drug which made grief more bearable (and perhaps less long-lasting) without in any way cognitively impairing the griever? Would it notbe appropriate to offer such a drug to grievers? Or what if there were someremarkably successful ‘talking cure’ – some new form of counselling thathad effects not unlike the previously mentioned drug? Would that be in-appropriate? Given such possibilities, there are no grounds for ruling out apriori the discovery of an intervention which would be an entirely appro-priate treatment for grief. If there were a treatment which benefited grieverswithout cognitively impairing them and without adversely affecting thirdparties, it would be hard to resist the conclusion that this ought to beoffered.



Reznek’s theory, though, gives us two conditions to meet: medicalintervention must be both appropriate and required. So even if it were acceptedthat medical intervention might be appropriate, he may still argue that it isnot required. There are two main reasons for thinking that medicalintervention is not required. The first is that grief is too minor, in the sensethat the level of suffering is not sufficient to warrant medical attention. Thesecond is that it is a condition from which the agent will recover (for themost part) without assistance from health care professionals. However, itseems that neither reason is good enough.

The first reason is that grief does not require medical attention because itdoes not involve enough suffering. But there are lots of conditions (such asminor back pain, headaches, influenza and warts) which (a) are widelybelieved sometimes to require medical intervention, (b) are disorders, but (c)involve much less suffering than grief. So if we are to determine whichconditions require medical intervention (and so determine which conditionscan be disorders) by setting some minimum level of suffering, then either wehave to admit that grief requires medical intervention and could be adisorder, or we have to deny that the minor physical ailments listed aboverequire medical intervention and in so doing deny that they are disorders.And since they clearly are disorders, the much more plausible option is toallow that grief could be a disorder too.

The second point is that grief does not require medical attention becauseit will ‘cure itself ’. Similar problems arise with this line of argument,however. Normal colds, influenza, etc., do not normally require medicalattention in so far as they will (usually) disappear without it. But clearly theyare disorders. So again there is a choice between either allowing that griefrequires medical intervention and can be a disorder, or denying that suchthings as influenza are disorders. And again of the two options it seemsmuch more plausible to allow that grief could be a disorder.

As was mentioned earlier, my own view is that the best way of dealingwith these issues is to reject Reznek’s view and deny that there is anynecessary connection between a condition’s being a disorder and itsrequiring medical intervention. However, I believe that the precedingarguments have shown that even someone who accepts Reznek’s positionshould allow that grief could be a disorder.

OBJECTION (): DISTINCT SUSTAINING CAUSES

The final objection I shall consider arises from Clouser, Culver and Gert’sexcellent work on the definition of health. One of their main contributions

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to this field is the claim that a condition cannot be a disorder (what they calla ‘malady’) if it has a distinct sustaining cause. They use this idea to draw adistinction between those harmful and/or painful states which are what wemight call environmental, or external, or social, such as being maderedundant, having one’s wallet stolen or being too cold, and those harmfuland/or painful states which are diseases or disorders, such as depression, mal-nutrition and hypothermia. The thought here is that the former havedistinct sustaining causes, while the latter have not.

In what follows, I shall not be challenging their general views aboutdistinct sustaining causes. This is first because it is not necessary for me to doso in order to deal with the objection that I am about to describe, andsecondly because my own view in any case is that their theory of health(though not the way they apply it to grief ) is highly plausible.

First, though, what exactly is a distinct sustaining cause? In brief, x is adistinct sustaining cause of a condition c if and only if:

(a) x is a cause of c(b) x is not part of (i.e., is distinct from) the person with c(c) If x were removed, c would cease to exist almost immediately, i.e., x is

necessary for sustaining c.

For example, I am subjected to very loud music. This causes me pain,discomfort, distress, etc. Do I have a disorder? Assuming that my symptomsdisappear shortly after the music ceases, then there is no disorder, accordingto Clouser, Culver and Gert’s theory. The reason for this is that the cause ofmy symptoms (the music) was both distinct (it is clearly not part of me) andsustaining (because my symptoms were sustained only by the continuedpresence of the music and disappeared when the music disappeared). If, onthe other hand, my hearing was permanently damaged, or if I suffered fromheadaches for years after the incident, then I probably would have adisorder, according to the theory, because my symptoms persisted long aftertheir cause stopped. In this second case, then, we should say that althoughthe cause is distinct, it is not sustaining, because its continued presence is notrequired in order to keep my symptoms in existence.

In an earlier work (this time without Clouser) Culver and Gert apply theiraccount of health to grief in the following way. According to them (Philosophyin Medicine, p. ), grief is not a disorder because it has a distinct sustainingcause, normally the death of a loved person:

We believe that Engel’s lack of the concept of a distinct sustaining cause leads himastray in classifying grief as a disease.... If a man is grieving over the death of his wife(what DSM rd edn calls ‘uncomplicated bereavement’ ... ), is her death a distinctsustaining cause? We believe it is.



One obvious objection to this analysis is that although loss is undoubtedly adistinct cause, it seems not to be sustaining, since the loss itself is not an on-going process but a one-off past event. Their response to this claims that

when one grieves for the loss of a loved one, the loss remains for the whole period ofthe grief and beyond.

So Culver and Gert are thinking of the loss (of a loved person) as analogousto the loud noise in the example I used earlier. In the noise case, I do nothave a disorder if the following is true: if the noise disappeared, then so(more or less immediately) would my symptoms. Similarly, in the grief case,I do not have a disorder if the following is true: if the loss disappeared thenso (more or less immediately) would my symptoms. Culver and Gert plaus-ibly think that this conditional is true in almost all cases of grief – because if,miraculously, my loved one was brought back from the dead, then my grief-symptoms would disappear. Hence normal grief is not a disorder because ithas a distinct sustaining cause: ‘the loss of a loved one’.

Although this seems reasonable enough at first glance (‘of course’, onemight think, ‘losses like this persist, i.e., they never go away’), it begins tolook problematic when subjected to critical scrutiny. For what exactly doesit mean to say that the loss persists? It must mean one of two things:

(a) The griever’s sense of loss of A persists throughout the period of grief, or(b) The fact that A is dead persists throughout the period of the grief.

If it means (a) then the loss will fail to be a distinct cause, since the sense ofloss is an internal mental state, not distinct from the griever.

Option (b), then, is the best for Culver and Gert. What persists is the factthat A is dead. Now, though, they are faced with a new problem. For whatexactly does it mean to say that this fact persists? What they must have inmind here is something like the following. At the moment at which A died,the proposition ‘A died at time t ’ became true and will remain true for ever.Further, this proposition causally explains the state of the grieving person.So what seems to be going on here is that Culver and Gert are allowing thetruth (the ‘continuing truth’, so to speak) of some causally explanatory pro-position to count as a sustaining cause.

This, though, implies a terribly permissive conception of what can beallowed to count as a sustaining cause – a conception which will generatehighly counter-intuitive results elsewhere. What is the cause of a burn?Normally, the fact that heat was applied at time t. Another way of describingthis is as follows. The proposition ‘Heat was applied at time t ’ became trueat time t and will remain true forever. Hence it looks as if burns are just likegrief in this respect. There is a distinct sustaining cause in the sense thatthe fact that heat was applied at time t persists throughout the lifetime of

STEPHEN WILKINSON


the burn and beyond. So the conception of ‘sustaining cause’ which stops usfrom classifying grief as a disorder also stops us from classifying burns (andprobably all injuries) as disorders too. And this I take to be a reductio of thisconception of ‘sustaining cause’.

There are two styles of answer to the question ‘What is the cause of theseburn-symptoms?’:

(a) We can cite an event – the event of being exposed to heat at time t(b) We can cite a fact – the fact that B was exposed to heat at time t.

Similarly, there are two styles of answer to the question ‘What is the cause ofthis grief?’:

(a) We can cite an event – the event of A’s dying at time t(b) We can cite a fact – the fact that A died at time t.

The reason why Culver and Gert run into difficulty is that they illicitly movefrom talking about ‘event-causation’ (talking of events being the causes ofthings) to talking about ‘fact-causation’ (talking in terms of things beingcaused by the fact that p). I do not claim that there is in general anythingwrong with either of these ways of thinking and talking about causation. ButCulver and Gert face two problems. First, they are inconsistent. Theyshould either analyse all cases in terms of event-causation or analyse all casesin terms of fact-causation, since the two different styles of analysis generateconflicting results. Secondly, if they were to opt in general for ‘fact-causation’ analyses (as they do in the case of grief ) they would end up com-mitted to the view that all distinct causes are distinct sustaining causes. Andthis cannot be an acceptable view, since (for the reasons given earlier) itimplies that such things as burns, broken bones, etc., are not disorders.

So although Clouser, Culver and Gert’s general theory of health is plaus-ible, Culver and Gert’s attempt to use the theory to show that grief is not adisorder is unsuccessful. The reason for this is that their argument for grief ’snot being a disorder proves too much. It requires the use of fact-causationanalyses, and the use of these, if generalized, would lead to our failing toclassify even central cases of disease or injury as disorders. Therefore this useof fact-causation analyses, and with it Culver and Gert’s argument, shouldbe rejected.

CONCLUSION

The structure of this paper is straightforward. I presented the prima facie casefor grief ’s being a disorder. That case is that grief, like most other disorders,



involves (in varying degrees) pain and/or incapacity. Then I considered sixobjections to the view that grief is a disorder, rejecting each. I concludetherefore that there is a strong case for viewing grief as a disorder. Thisconclusion may have both theoretical and practical implications.

On the theoretical side, establishing that normal grief is a disorder mightform one part of an attack on the ‘orthodox’ view that ‘expectable andculturally sanctioned responses’ cannot be mental disorders (DSM, p. xxi).Similarly, it might encourage us more generally to think of ‘normal’ episodesof distress and sadness (e.g., in response to disappointment or loss) as, quiteliterally, mental injuries (mental injury being one sort of mental disorder).Alternatively, as I suggested at the outset, the argument presented in thispaper may be taken as a reductio of the DSM view of mental disorder (andother similar accounts), and rather than persuading us that grief is a dis-order, may instead encourage us to find a different and better general theoryof mental disorders.

More practically, establishing that normal grief is a disorder may havevarious effects, some positive, some negative. On the positive side, it mightlead us to think that, as people with mental health problems, grievers haverights to special mental health services, and/or rights to compensation fortheir ‘mental injuries’, rights which they would not have if they were notinjured, but ‘merely distressed’. However, on the negative side, as Kopel-man suggests (p. ), viewing grief as a disorder might encourage people to‘marginalize the requests or claims of grieving people’. My own view (onefor which there is not space here to argue) is that answers to questions suchas ‘What services, or compensation arrangements, should there be for griev-ing people?’ ought not to be determined by the health status of grief, butrather by the needs and the suffering of grieving people. However, whetherthe claim that grief is a mental disorder would in fact be viewed as ‘ethicallyneutral’ in practice is far from clear.6

Keele University

STEPHEN WILKINSON


6 I would like to thank everyone who has provided comments on previous oral or writtenversions. The list (which may not be complete) includes Piers Benn, Bob Brecher, John Cox,Angus Dawson, Eve Garrard, André Gallois, Bob Lockie, David McNaughton, RichardNorman, Sally Sheldon and Philip Stratton-Lake.

is ‘normal grief’ a mental disorder?

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