Brenda* was having troubles keeping it together. She had always been someone who cried easily – her brothers teased her because tears would stream down her face during tv commercials – but now, at the age of thirty-two, she was a veritable waterworks. She often had to excuse herself from meetings at work to go into the bathroom, where she locked herself into a stall and sobbed into her hands.
Brenda’s family and friends encouraged her to see a shrink. “It’s not normal,” they told her. So she went to a psychiatrist, who did an extensive interview with her and discovered that she and her longterm boyfriend had broken up several weeks earlier. “So what you’re feeling is completely normal,” the psychiatrist told her. “You’re in mourning, just as if he had died. I’m not going to prescribe any medication for you right now, since you don’t have a history of depression, and I think this will get better. In my experience, it usually takes about six months.”
Brenda’s heart sank as he said that. She was hoping that she would start feeling better right away. She didn’t think she could handle six months of these feelings. “I know they’re painful,” the psychiatrist continued. “And I think it would help you to see someone to talk about what you’re feeling and find some ways to manage the pain.” He gave her a name and phone number and encouraged her to call right away, then added, “if you’re not feeling at least a little better in a couple of months, or if you’re feeling worse, call me right away. But even though I know I said it takes six months, I meant that’s about how long it takes for the grieving. I think with the help of a good therapist you’ll start to feel better, a little bit at a time, pretty quickly.”
How did the psychiatrist know the difference between grief and depression? Ever since Freud wrote about the difference between what he called “mourning” and “melancholy” (which today we would call depression), mental health practitioners have struggled to make this distinction. The simple rule of thumb has been that mourning is a normal, albeit painful process, and that we tend to emerge from the worst part within six months to a year after the initial crisis (although feelings of sadness and loss can and often do go on for longer than that and still be normal). Melancholy, or depression, tends to have a longer shelf-life and does not always show improvement over time.
The psychiatrist explained some of the reasons for his conclusion, including the information that Brenda had recently gone through a painful breakup, and that she did not have a history of depressive symptoms. These differences are spelled out in the DSMIV, the diagnostic and statistical manual of the American Psychiatric Association. This handbook, which is used by insurance companies for decisions about compensation, is undergoing significant and controversial revision right now. According to an article in the New York Times on January 24, 2012, one of the areas of revision is exactly the question of the difference between depression and grieving.
For my money, I’m perfectly happy for the fifth edition, or the DSMV (which is what it will be called) to include grieving under the rubric of depression, if it means that insurance companies will pay for therapy to help people cope with the stresses that often accompany loss. But I’m distressed by the idea, described by Dr. Alan Horwitz and Dr. Jerome Wakefiled in their book The Loss of Sadness, that in a society where we already run from strong feelings, we’re now going to see sadness and grief as a sickness.
The good news? Maybe this will encourage people to learn to pay a different kind of attention to our feelings. For example, Brenda went to therapy and not only found someone who would listen sympathetically to her repetitions of the pain she felt when her boyfriend suddenly announced that the relationship was over, but also found a professional who was interested in what had made this happen. As Brenda put it, “I learned to listen to thoughts I had never even spoken out loud in my own head. I discovered what I had already known for awhile – that neither one of us was really happy anymore, that I suspected that he wanted out, and that actually, I wanted out as well. I was afraid to even think those thoughts at first. They didn’t make me any happier. I was still sad that things had gone so badly. But I discovered that I had the power to make some other changes in my life. I wasn’t just a helpless victim. I mourned the loss and started to move forward.”
A year later, Brenda had found a man who she thought she could see spending the rest of her life with. “But I learned to listen to my own thoughts, and to share them with him. And to encourage him to talk to me, as well. I realized that the unspoken words were only scary because of what they meant. And that it was a lot better to have them out in the open and be able to respond to problems directly than to wait until things blew up and couldn’t be fixed.”
Feelings are often clues to what the psychoanalyst Christopher Bollas has called “the unthought known” – that is, things we know but are afraid to say aloud even inside our own heads. Putting feelings and unthought knowledge together makes it possible to move forward and, maybe a little paradoxically, to deal with the feelings in a healthy way. That may be the worst danger from the new DSMV – that it encourages us to get rid of those thoughts, to push them down with diagnoses and medications; but maybe it will do the opposite. Maybe broadening the diagnosis of depression will encourages us to go into therapy and start to think about what we are feeling. That can’t be all bad.
*names and identifying information changed to protect privacy