I find this interesting. What I wonder about is whether some losses are pathological in themselves, and whether putting the emphasis on how that person responds is appropriate. I have also treated someone who had traumatically lost a daughter two years earlier. At the time, my own daughter was young. Even now, as a parent, it seems to me the loss of a child is wrong, unexpected, unacceptable, and can only be imagined to cause pathological suffering. Maybe it doesn't matter what the label is, but there are some losses from which people cannot return to baseline.
I think some losses are *pathological within a given context*. Loss of a child, especially a small child, used to be absolutely run of the mill part of life (something like 20% of children died before reaching 5 yo in 1900, for example), and while OBVIOUSLY it could be traumatic and even if not traumatic, extremely sad, it was also NORMAL. So there was both an expectation that it might happen, and societal/cultural ways to handle it. And nowadays it's indeed unexpected, very rare and thus, perhaps necessarily, metabolised socially and processed individually very differently -- as wrong and unacceptable -- the vast majority of mothers never have to face this kind of loss.
And I think this applies to other cases too. My partner died unexpectedly and suddenly in his early 50s and while the shock of it led to (pretty spectacular and still not gone 6 years on) trauma response on my side, the grief itself was "normal" (in the sense of not being pathological). But I also think that living in a community where relatively many men die in middle age (remote, physical labour, booze, dangerous work at sea etc) made the grief easier to socially process, even tho he wasn't a fisherman. As the undertaker said to me "people here still understand death", and what he meant I think was "death that's not at 83 of degenerative conditions of old age".
I do think that response matters *in a given cultural context* --we would likely all see certain deaths as "justifying" heavier or longer grief and conversely, certain reactions that would feel like ENTIRELY REASONABLE to a death of a child, suicide of a close friend or a loss of a spouse at 30yo would seem "excessive" to a loss of a 90 year old parent. Yet all of those could progress to some kind of acceptance or adjustment and as the OP states, it's the *stuckness in prolonged suffering (and to some extent dysfunction tho I personally hate that argument)* that matters.
To your point of pathological within a given context, the NYT today has an article about a 20-yo young man who visited the ER twice and died due to medical error:
The parents are described as still acutely grieving and angry two years later, and are suing for wrongful death.
I agree that context with loss is crucial, and am sorry for your own loss. So many things contribute to context: death of a twin might mean more than that of a much older sibling, preventable loss is much harder than say loss that is anticipated or unavoidable. The larger question you raise is whether many of our DSM diagnoses are culturally and temporally specific.
I do respect your and Awais' contention that, no matter the loss, a lack of some degree of adjustment may constitute "disorder."
Thanks for this post, Awais. Grief is so awful! And it is so misunderstood by scientists who try to make it more consistent than it is.
I spent three years getting funding and recruiting grief expert collaborators to analyze of one of the best prospective studies of grief ever conducted in hopes of understanding how low mood is useful. (the CLOC study https://www.icpsr.umich.edu/web/ICPSR/studies/3370)
I concluded that there is no way to define "normal" grief, its variations are manifold. A third of our subjects had little or no grief; in contrast to my hypothesis, most of them seemed to have good relationships and stable lives. A third had regular grief with all its variations in symptoms and sequence. A third had a harder time and longer symptoms, but still lots of variation. The best predictor was previous low mood and depression. We found no evidence that delayed grief led to bad outcomes, and what I was taught in psychiatry residency-that prolonged grief was a product of an ambivalent relationship-was just plain wrong. Surviving spouses with ambivalent relationships had less grief than others.
As for evolution and grief, I remain uncertain if it is an adaptation or an epiphenomenon of attachment and the broader capacity for sadness. More work is needed.
I"ve worked with survivors of sucide loss, both individually and in groups, for about 25 years. It's pretty rare for survivors to be "done" with their intense grief after a year; in fact, many describe the 2nd year to be "harder," noting the the pain of the loss feels "sharper," whereas in the first year survivors are often more pre-occupied with attempts to make sense of the nature of the "suicide" itself. In addition, for many, the surprising loss of support and implicit and explicit blame of survivors (pretty well documented in research) serves to intensify the duration of the grief process. In contrast to Freud and others who emphasize the "relinquishment" of the intense bond with the lost love one as the goal of "successful" grief, I prefer the "Continuuing Bonds" theory (Klass, Silverman, and Nickman) which emphasizes the internalized connections that remain and are continuously re-worked throughout the lifespan.
I have such strong feelings of grief (of any variety) being labeled “disordered.” My daughter died almost 10 years ago and the first 8 years following were excruciating. I am doing better now but why do we have such firm beliefs that grief needs to look a certain way? I did seek treatment and my first psychiatrist told me that while it was tragic that my daughter died, this sort of thing happens every day and I needed to move on. If we’re going to medicalize my grief then I think we can also say her “treatment” was malpractice. Of course, I’m being facetious but it illustrates my frustration. I don’t pretend to know what “normal” looks like after this kind of loss. I am skeptical of the medical community that thinks it has better answers.
Strong feelings are understandable given the topic! I've had them myself. I don't think we are obliged to look at grief a certain way. I have mixed feelings about what your psychiatrist told me, but I am also not your physician and don't know the clinical details, so I don't know how I would've responded, but I do think many psychiatrists also dismiss or ignore the clinical framing of grief. I imagine you do agree that certain forms of grief can be maladaptive and destructive for the person? If so, I am curious what conceptualization and language you'd prefer for those cases.
Thanks for your comment. I do agree that grief can be maladaptive but don’t we already have ways to define that occurrence? In my case, I’m sure I met the criteria for major depression. Is another label necessary? Especially one that may overwhelmingly be used to label women experiencing severe grief as doing it wrong? That concerns me.
Not everyone with complicated grief meets depression criteria and even when people have both depression and complicated grief, it is common for people's depression to get better with depression treatment but for complicated grief to remain (it requires specialized grief-focused therapy). Since complicated grief has distinctive clinical features and distinctive treatment, it isn't quite accurate - clinically or scientifically - to conflate it with depression.
In theory, this makes sense. But in practice, is this what actually happens? Does the psychiatric profession treat prolonged grief with this specialized therapy? My psychiatrist treated my complicated grief with the same antidepressants that she uses to treat major depression. In the several years following my daughter’s death, I never once heard a professional discuss specialized therapy for what I was experiencing. In my experience, professionals were quick to use the label “complicated grief” but never went beyond treating as they might depression. Maybe that explains my 8 years of severe symptoms.
I appreciated this very much, I have been thinking/writing about grief recently too, albeit in a more angry-personal and less clinical-thoughtful context. This is a very useful balancing of "normal vs abnormal" that honours the immensity of loss and the intensity of responses ... while stressing that living safely and well matters, and the griever is deserving of this.
Absolutely agree. Spent much of my career working to help people with prolonged grief who desperately wanted help. It exists but not everyone seeks assistance. People find ways through it. My personal experience after losing my father needed therapy.
When I think of complicated grief, I think of Queen Victoria. Her story has always struck me a such a tragedy, not only for her own personal suffering and despair throughout 40 years of widowhood, but also for the suffering her family and household endured due to her insistence on their complying fully with her rituals of remembrance. I like to think that, if she had been willing, good psychotherapy and medication management might have relieved her (and her children and staff) of some of that suffering, and opened up opportunities for life beyond Albert.
What if I said that I just don't agree with your opening thesis. Melancholia is closer to diabetes than prediabetes. You diagnose it by recognising it. You know it when you see it and it looks nothing remotely like grief, at least not any more than indigestion resembles a heart attack.
Over the last 8 months, I have been quite struck by some people's inability to recognise it. I think the most parsimonious explanation is that the ability to recognise melancholia comes down largely to innate talent. Just as some people are very socially competent, able to recognise subtle cues, others are socially awkward and have to concentrated much harder to pick up on things. The same basic ability seems to operate in clinicians, some of them can recognise melancholia at 20 paces, others cannot no matter how hard they try. To those who lack the perceptual ability, melancholia is confusing and they confabulate explanations such as suggesting it is difficult to distinguish from say grief.
This results in a split, people who can spot it and can't understand the problem and people who can't spot it and can't understand the problem. Melancholia is as self evident to those who can see it as any visible disease. Imagine a would where half of all clinicians couldn't recognise the facial expressions and body langauge associated with pain. That's actually real life, so imagine it's 80%. The ones who can't see it would be naturally perplexed and wonder if their colleagues were conflating pain with hunger or some other expression.
Of course it's frustrating because when the blind ask the sighted what is it they are seeing, the sighted reply "you know it when you see it".
I find this interesting. What I wonder about is whether some losses are pathological in themselves, and whether putting the emphasis on how that person responds is appropriate. I have also treated someone who had traumatically lost a daughter two years earlier. At the time, my own daughter was young. Even now, as a parent, it seems to me the loss of a child is wrong, unexpected, unacceptable, and can only be imagined to cause pathological suffering. Maybe it doesn't matter what the label is, but there are some losses from which people cannot return to baseline.
I think some losses are *pathological within a given context*. Loss of a child, especially a small child, used to be absolutely run of the mill part of life (something like 20% of children died before reaching 5 yo in 1900, for example), and while OBVIOUSLY it could be traumatic and even if not traumatic, extremely sad, it was also NORMAL. So there was both an expectation that it might happen, and societal/cultural ways to handle it. And nowadays it's indeed unexpected, very rare and thus, perhaps necessarily, metabolised socially and processed individually very differently -- as wrong and unacceptable -- the vast majority of mothers never have to face this kind of loss.
And I think this applies to other cases too. My partner died unexpectedly and suddenly in his early 50s and while the shock of it led to (pretty spectacular and still not gone 6 years on) trauma response on my side, the grief itself was "normal" (in the sense of not being pathological). But I also think that living in a community where relatively many men die in middle age (remote, physical labour, booze, dangerous work at sea etc) made the grief easier to socially process, even tho he wasn't a fisherman. As the undertaker said to me "people here still understand death", and what he meant I think was "death that's not at 83 of degenerative conditions of old age".
I do think that response matters *in a given cultural context* --we would likely all see certain deaths as "justifying" heavier or longer grief and conversely, certain reactions that would feel like ENTIRELY REASONABLE to a death of a child, suicide of a close friend or a loss of a spouse at 30yo would seem "excessive" to a loss of a 90 year old parent. Yet all of those could progress to some kind of acceptance or adjustment and as the OP states, it's the *stuckness in prolonged suffering (and to some extent dysfunction tho I personally hate that argument)* that matters.
To your point of pathological within a given context, the NYT today has an article about a 20-yo young man who visited the ER twice and died due to medical error:
https://www.nytimes.com/2025/10/05/well/sam-terblanche-virus-death-columbia.html?searchResultPosition=2
The parents are described as still acutely grieving and angry two years later, and are suing for wrongful death.
I agree that context with loss is crucial, and am sorry for your own loss. So many things contribute to context: death of a twin might mean more than that of a much older sibling, preventable loss is much harder than say loss that is anticipated or unavoidable. The larger question you raise is whether many of our DSM diagnoses are culturally and temporally specific.
I do respect your and Awais' contention that, no matter the loss, a lack of some degree of adjustment may constitute "disorder."
Thanks for this post, Awais. Grief is so awful! And it is so misunderstood by scientists who try to make it more consistent than it is.
I spent three years getting funding and recruiting grief expert collaborators to analyze of one of the best prospective studies of grief ever conducted in hopes of understanding how low mood is useful. (the CLOC study https://www.icpsr.umich.edu/web/ICPSR/studies/3370)
I concluded that there is no way to define "normal" grief, its variations are manifold. A third of our subjects had little or no grief; in contrast to my hypothesis, most of them seemed to have good relationships and stable lives. A third had regular grief with all its variations in symptoms and sequence. A third had a harder time and longer symptoms, but still lots of variation. The best predictor was previous low mood and depression. We found no evidence that delayed grief led to bad outcomes, and what I was taught in psychiatry residency-that prolonged grief was a product of an ambivalent relationship-was just plain wrong. Surviving spouses with ambivalent relationships had less grief than others.
As for evolution and grief, I remain uncertain if it is an adaptation or an epiphenomenon of attachment and the broader capacity for sadness. More work is needed.
Details available at https://www.randolphnesse.com/articles/grief
I"ve worked with survivors of sucide loss, both individually and in groups, for about 25 years. It's pretty rare for survivors to be "done" with their intense grief after a year; in fact, many describe the 2nd year to be "harder," noting the the pain of the loss feels "sharper," whereas in the first year survivors are often more pre-occupied with attempts to make sense of the nature of the "suicide" itself. In addition, for many, the surprising loss of support and implicit and explicit blame of survivors (pretty well documented in research) serves to intensify the duration of the grief process. In contrast to Freud and others who emphasize the "relinquishment" of the intense bond with the lost love one as the goal of "successful" grief, I prefer the "Continuuing Bonds" theory (Klass, Silverman, and Nickman) which emphasizes the internalized connections that remain and are continuously re-worked throughout the lifespan.
Thank you for bringing this up!
I have such strong feelings of grief (of any variety) being labeled “disordered.” My daughter died almost 10 years ago and the first 8 years following were excruciating. I am doing better now but why do we have such firm beliefs that grief needs to look a certain way? I did seek treatment and my first psychiatrist told me that while it was tragic that my daughter died, this sort of thing happens every day and I needed to move on. If we’re going to medicalize my grief then I think we can also say her “treatment” was malpractice. Of course, I’m being facetious but it illustrates my frustration. I don’t pretend to know what “normal” looks like after this kind of loss. I am skeptical of the medical community that thinks it has better answers.
Strong feelings are understandable given the topic! I've had them myself. I don't think we are obliged to look at grief a certain way. I have mixed feelings about what your psychiatrist told me, but I am also not your physician and don't know the clinical details, so I don't know how I would've responded, but I do think many psychiatrists also dismiss or ignore the clinical framing of grief. I imagine you do agree that certain forms of grief can be maladaptive and destructive for the person? If so, I am curious what conceptualization and language you'd prefer for those cases.
Thanks for your comment. I do agree that grief can be maladaptive but don’t we already have ways to define that occurrence? In my case, I’m sure I met the criteria for major depression. Is another label necessary? Especially one that may overwhelmingly be used to label women experiencing severe grief as doing it wrong? That concerns me.
Not everyone with complicated grief meets depression criteria and even when people have both depression and complicated grief, it is common for people's depression to get better with depression treatment but for complicated grief to remain (it requires specialized grief-focused therapy). Since complicated grief has distinctive clinical features and distinctive treatment, it isn't quite accurate - clinically or scientifically - to conflate it with depression.
In theory, this makes sense. But in practice, is this what actually happens? Does the psychiatric profession treat prolonged grief with this specialized therapy? My psychiatrist treated my complicated grief with the same antidepressants that she uses to treat major depression. In the several years following my daughter’s death, I never once heard a professional discuss specialized therapy for what I was experiencing. In my experience, professionals were quick to use the label “complicated grief” but never went beyond treating as they might depression. Maybe that explains my 8 years of severe symptoms.
I appreciated this very much, I have been thinking/writing about grief recently too, albeit in a more angry-personal and less clinical-thoughtful context. This is a very useful balancing of "normal vs abnormal" that honours the immensity of loss and the intensity of responses ... while stressing that living safely and well matters, and the griever is deserving of this.
Absolutely agree. Spent much of my career working to help people with prolonged grief who desperately wanted help. It exists but not everyone seeks assistance. People find ways through it. My personal experience after losing my father needed therapy.
When I think of complicated grief, I think of Queen Victoria. Her story has always struck me a such a tragedy, not only for her own personal suffering and despair throughout 40 years of widowhood, but also for the suffering her family and household endured due to her insistence on their complying fully with her rituals of remembrance. I like to think that, if she had been willing, good psychotherapy and medication management might have relieved her (and her children and staff) of some of that suffering, and opened up opportunities for life beyond Albert.
What if I said that I just don't agree with your opening thesis. Melancholia is closer to diabetes than prediabetes. You diagnose it by recognising it. You know it when you see it and it looks nothing remotely like grief, at least not any more than indigestion resembles a heart attack.
Over the last 8 months, I have been quite struck by some people's inability to recognise it. I think the most parsimonious explanation is that the ability to recognise melancholia comes down largely to innate talent. Just as some people are very socially competent, able to recognise subtle cues, others are socially awkward and have to concentrated much harder to pick up on things. The same basic ability seems to operate in clinicians, some of them can recognise melancholia at 20 paces, others cannot no matter how hard they try. To those who lack the perceptual ability, melancholia is confusing and they confabulate explanations such as suggesting it is difficult to distinguish from say grief.
This results in a split, people who can spot it and can't understand the problem and people who can't spot it and can't understand the problem. Melancholia is as self evident to those who can see it as any visible disease. Imagine a would where half of all clinicians couldn't recognise the facial expressions and body langauge associated with pain. That's actually real life, so imagine it's 80%. The ones who can't see it would be naturally perplexed and wonder if their colleagues were conflating pain with hunger or some other expression.
Of course it's frustrating because when the blind ask the sighted what is it they are seeing, the sighted reply "you know it when you see it".