This statement was developed by a workgroup at the meeting of the International Work Group on Death, Dying and Bereavement in Victoria, British Columbia on April 28 – May 3, 2013. You have full permission to translate the document into other languages, and to distribute it via websites, blogs, the media, and other venues. It is our intention that the message be shared widely.
When does a broken heart become a mental disorder?
Rarely, if ever.
But don’t tell that to the American Psychiatric Association, which has just released its fifth version of the
Diagnostic and Statistical Manual of Mental Disorders. The DSM is a catalogue of mental disorders,
hundreds of them, each trailing a listing of symptoms. The manual informs selection of a diagnosis,
which is required by U.S. insurance companies for reimbursement for mental health care.
There’s a major change in the newest version, DSM-5, with serious implications for the millions of
people who are coping with the death of a child, spouse, parent, friend, or other loved one.
But first, a quick glimpse at the history of this publication, often referred to as the bible of psychiatry.
The very first edition, published in 1952, didn’t even refer to grief, considering it an accepted and
normal reaction to the death of a loved one. The third edition added an exclusion statement under
Major Depressive Disorder, referred to as the “bereavement exclusion.” Under this exclusion, a
diagnosis of Major Depressive Disorder could not be made for a full year after a death. They recognized
that normal and common reactions to the death of a loved one could look like symptoms of depressive
disorder, for example, sadness, disturbed sleep, lack of concentration, changes in eating, and loss of
interest in things that were once pleasurable.
In 1994 the 4th version of the DSM reduced the bereavement exclusion to two months after a death, and
this new version removes the bereavement exclusion completely, meaning in effect that anyone can
receive a diagnosis of Major Depressive Disorder two weeks after the death of a child, parent, spouse,
friend, or anyone.
Why does this matter? For at least three reasons:
First, normal reactions to the death of a loved one will be easily misclassified as the mental disorder
depression. Grief is not the same experience as major depressive disorder. It is not an illness to be
treated or cured. It is a healthy response to a painful reality that one’s world is forever altered, and will
never be the same. Absorbing this loss, and adapting to all the changes it unleashes, has its own unique
course for every person, and will not be stilled or stopped by quick fixes or simple solutions. Death is a
life-altering event, but grief is not a pathological condition.
Second, antidepressants are commonly and frequently prescribed. There is a strong likelihood that
newly bereaved people will qualify for a diagnosis of Major Depressive Disorder just two weeks after a
death even though their reactions are normal. Antidepressants have not been shown to be helpful with
grief-related depressive symptoms, and there is accumulating evidence of long-term negative effects of
being on antidepressants. We need to ask why psychiatry is pathologizing grief and therefore making
inappropriate pharmacological treatment easier. And we should not overlook the self-interest of
pharmaceutical companies who see a new and substantial market for antidepressants, currently a
multibillion dollar industry.
Third, about 80% of prescriptions for antidepressants are written by primary care physicians, not
psychiatrists. We have the expectation that physicians, as well as psychologists, social workers, and
clergy, to whom many of us turn for help after losses of all kinds, have professional training, solid
research backing, and supervised experience to guide them. Some do, but in fact, a considerable
majority of practitioners with these degrees have no professional training at all in responding to the
The caution here? Be wary of physicians or other medical professionals who rush to prescibe antidepressants to address your grief.
Here’s a better prescription: Mourn the death of your loved one in your own way. There is no prescribed
formula. You may cry; you may not. Your reactions will be shaped by many things: the relationship you
had with the deceased, your personality style, and the support or lack of support you receive from
others. Push aside those who tell you to move on, that every cloud has a silver lining. What one person
finds comforting might not work for another. Find friends and family who understand, and with whom
you can share your experience. If they won’t listen or help, or if their help is not enough, search for
support groups through your local hospital, hospice or community organizations. Don’t be afraid to seek
professional help, but if you do, ask about the person’s training, qualifications, and experience with
grief, loss, and bereavement.
We grieve as deeply as we love. We can get off track with love, and we can respond to our grief in ways
that aren’t healthy, or don’t serve us well. But let’s not make love, or grief, a mental disorder.
This document was written by a group of concerned professionals in response to the release of the
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( DSM-5).
Thomas Attig, PhD, Professor Emeritus in Philosophy, Bowling Green State University
Inge B.Corless, RN, PhD, FAAN, Professor, MGH Institute of Health Professions, Boston, MA
Kathleen R. Gilbert, PhD, Executive Associate Dean, Indiana University School of Public Health, Bloomington, IN
Dale G.Larson, PhD, Professor, Department of Counseling Psychology, Santa Clara University, CA
Mal McKissock, OAM, Director of Clinical Services, Bereavement Care Centre, Sydney, Australia
David Roth, Executive Director, Puetz-Roth Funerals and Grief Companions, Bergisch Gladbach, Germany
Donna Schuurman, EdD, FT, Executive Director, The Dougy Center for Grieving Children & Families,
Phyllis R. Silverman, PhD, Scholar-in-Residence, Women’s Studies Research Center, Brandeis University, Waltham, MA
J. William Worden, PhD, ABPP, Psychologist, Laguna Niguel, CA
We would like to acknowledge the International Work Group on Death, Dying and Bereavement (IWG)
for the opportunity to develop these ideas. This statement represents the opinions of the authors, not
the opinions of the Board or membership of the IWG.
Understanding Children's Grief
The way in which children experience and express grief after a significant loss in their lives is influenced by many things; the nature of the loss, the manner in which the loss occurs; their previous relationship with the lost person or object; personality; previous life experience including other losses; their physical and emotional health; developmental 'stage'; the familial and social environment in which the loss occurs; behaviour modelled by adults in their environment; and most importantly, the availability or otherwise of understanding and loving support.
The impact of loss affects children in very similar ways to those of adults, but their expressions of grief are often different, and therefore easily missed or misunderstood.
Whatever their age at the time the loss occurs, children may cry initially and later remain dry eyed even when adults around them are crying. Visually, the comparison between an expressive adult's grief and that of a child or adolescent may appear dramatically different, making it easy for adults to make sweeping pronouncements that 'children are resilient and get over things easily; they soon forget'. Remarks like this are inaccurate and often make children and young people angry. They feel as if their grief is minimised at best, believed to be non-existent at worst.
Children and young people frequently cry on the inside. Tears outwardly expressed make them feel embarrassed, different, and vulnerable. They desperately need to remain part of the group, no different to their peers; and they need to convince themselves that life will continue in a positive way despite their loss experience.
In grief, children and young people, like adults, tend to become an exaggerated version of their former selves. If they were socially outgoing before, they may become even more social and appear 'shallow' to adults who find the idea of social activities abhorrent. If they were previously shy or withdrawn, they may become more so in grief and concern adults who believe it is important to 'let go of the past and get on with life'. They may act out in anger at the world for destroying their hopes and illusions; at parents and other significant adults for not being able to prevent the event that is causing them pain. For example, four-year-old Timothy felt very angry with his parents for not saving the life of his little sister who died in fairly traumatic circumstances. Before this event he had seen them as wise and all-powerful, able to fix everything, able to make his world safe, manageable and predictable.
Sometimes children's anger is an attempt to invite their parents or other caregivers back into a parenting role. When parents grieve, the child or young person may feel abandoned or unimportant, as if they have lost not only the person who died, but those who grieve as well. Or they may fear that everything in their world is out of control and unconsciously try to challenge someone to restore order and predictability.
One of the most common and significant indicators of the distress experienced by grieving children manifests itself in SLEEP DISTURBANCES. The underlying emotion that results in sleep disturbances is usually fear, a pronounced aspect of children's grief. They may have difficulty going off to sleep, fear being in the dark, or wake from dreams that may be violent or traumatic. They may call out for comfort and reassurance, or seek safety and security in the warmth of someone else's bed. Whatever the story content of the dream, fears are usually about the possibility of their own death, or the death of someone else that is important to them. Almost every grieving child we have worked with has eventually expressed the belief that if they stay awake, or sleep with the person whose death they fear, they will notice changes in breathing, notice anything that might be wrong, and be able to save their life. If they go to sleep, maybe they too won't wake up again; if they leave a bereaved parent to sleep alone, maybe the parent will be tempted to invite someone else into their bed and the deceased parent will be forgotten.
Allowing a grieving child to find comfort in the bed of another, however close the relationship is not a good long-term solution, even though it is an understandable one. After all, who in a grieving household is likely to have the energy to take the child back to bed, listen to their fears, provide reassurance, make the child's bedroom feel safe again, and stay until they are once again enveloped in sleep? It is much easier to allow the child to slip under the blankets and receive comfort from a wordless hug , especially if the parent or sibling also experiences comfort from the exchange. Many grieving families in these circumstances need understanding support and some creative suggestions so that children's anxieties can be addressed in ways that are helpful in the long term. It may be useful to read section 4 in 'The Grief of Our Children' (ABC Books, 1998), especially pages 158-159.
A heavy sense of responsibility is another common childhood grief reaction. If a sibling has died, the remaining child or children may feel as if they have to be of such value to their parents that they can fill the void left by the child who has died, that they can make the parents happy again, and give them a reason for living. So much to worry about; so much responsibility for life, death and other people.
We are happy to answer questions or make suggestions. Children are welcome to do the same. We hope in the near future to create a 'chat room' on our web site so that those who grieve or who care for grieving children can share experiences and helpful suggestions. We will also develop a 'chat room' for grieving children which we hope will feel empowering at a time of great vulnerability in their lives.
Items of Interest - Letter to a Dead Parent/Letter to Living Parent
At one of the group meetings children aged 7-11 who had been attending a group at ‘A Friend’s Place’, were asked what they would put in a letter a) to their parent who died and b) their living parent. Following is a list of things they would say...
Letter to a Dead Parent
I think about them everyday.
I would like to tell them about our achievements, athletics, and school activities
I would like to tell them I love them
I miss them heaps.
I still care for them
I wish you were still alive
I wish you could come back
I wish we could have a cup of tea together
I wish you could go mad at me again.
I wish I could talk to you about problems
I wish I would have spent more time with you when you were alive doing things like Playing cricket, go shopping having another kick with the footy in the park.
I wish I could go to work with dad.
I wish I could still help mum clean the house.
I wish you could be here for mum’s birthday.
I wish I had known when you were going to die, I could have done something
I wish I had learned more about you when you were alive
I wish I could ride my bike in the house like you used to let me
I wish I could still tell you stuff
I wish I could have said goodbye
When it happened it was a dream and I felt dizzy
I wish I could have learned all the stuff I have without you dying.
The moment you died I felt sadder than I have ever in my whole life.
There are no words to describe the sadness, sadness is not nearly strong enough
Thank you for everything you’ve done.
I wish I could say thank you for giving me a great life.
Thank you for giving me life.
Letter to Living Parent
Thank you for looking after me and doing it so well.
Thank you for helping me get through this.
Thank you for supporting me
Thank you for bringing me here.
Thank you for being my mum
Thank you for letting me do things, I know this is tough for you
Thank you for finding the time for me
Thank you for being a taxi
Thank you for your patience
I wish you wouldn’t have to be a mother and a father
I love you
Thanks for learning all the new things you have.
Even though you are a male you can cook
Thank you for giving me a little sister
It would be OK to find someone else; I don’t want you to be alone for ever.
It doesn’t have to be the same
Thank you for giving me a stepmother who loves me.
I think you spend more time with me even though you’re busier
I don’t want anything to happen to you.
Sorry for being so naughty
Its OK you’re mad more often
Sorry for stressing you out so much
I hope you can help my brother remember dad the way I do.
Sorry for treating you like I love dad more than you.
Thank you for being brave enough to get out of bed in the morning
Thank you for always being there for me
I wish it wasn’t so hard for you.
It’s OK to cry
To order The Magic of Memories CD (stories to help adults understand and facilitate childhood grief) or the Kids Grief: A Handbook for Group Leaders, please click here.