Context is everything

Is prolonged grief following the death of a loved one an illness? Who decides? And how?

In the first scene of “Hitchcock Loves Bikinis” (see YouTube), a young mum is happily playing with her baby. Next comes a close-up shot of Alfred Hitchcock, the late movie director, smiling. Clearly, he is a man whose heart is warmed by this sweet glimpse of maternal love. In the next scene, we see a bikini-clad woman sunbathing, followed by the same shot of Hitchcock smiling. Instead of a benign grandfatherly figure, this time we see a lecherous old man. The moral of the story is simple: when it comes to understanding human behaviour, context is everything. 

Consider, for example, a certain Mr M. Several times each month, he has visions that he claims are sent to him directly from God. These holy messages contain recommendations about how people should live their lives. Mr M feels compelled to convey this advice to anyone who will listen. His speech is normally intelligible, but he occasionally produces a strange babble that he claims to be the voice of a holy spirit that periodically occupies his body. He can tell when the spirit departs because, exhausted by its heavenly labours, Mr M faints dead away.

Is Mr M’s behaviour abnormal? Is he mentally ill? There are no easy answers to these questions. Abnormal behaviour and mental illness are widely used terms, but they have no universally accepted definition. The same behaviour may be judged “normal” at some times and “abnormal” at others, depending on who is doing the judging and the circumstances in which the behaviour occurs. Mr M’s visions, babble, and fainting are common among Pentecostals and Charismatics who speak in “tongues” and fall into trances. The participants at one of their prayer meetings would not consider Mr M mentally ill. They may see his behaviour as exemplary.

In contrast, Mr M’s visions and babbling would be viewed as exceedingly odd if they occurred in a movie theatre, business meeting, or restaurant. Again, context is everything. As the late psychiatrist, Thomas Szasz, famously quipped, “If you talk to God, you are praying. If God talks to you, you have schizophrenia.”

To professionals who work in mental health, the existence of mental illness appears self-evident, and the controversy surrounding the term seems puzzling. But there is a crucial difference between psychological and physical illnesses. Mental illnesses are context-dependent, while physical illnesses are not. A person with a cough, a cloudy chest x-ray, and a bacterial infection has pneumonia. The social context is irrelevant. 

Mental illness is almost always defined in relation to social norms. Homosexuality was once considered a personality disorder (a medical diagnosis endorsed by the psychiatric profession). At its 1973 annual meeting, the American Psychiatric Association (APA) voted to remove homosexuality from its manual of recognised diagnoses. From that day forward, homosexuality was no longer a personality disorder; indeed, it was no longer an illness at all. The APA’s action was not based on new scientific discoveries about human sexual behaviour. It simply acknowledged society’s increased tolerance for alternative sexual preferences. Try to imagine a meeting of doctors voting to declare that diabetes is no longer an illness. It would be ludicrous. But, in the field of mental health, old diagnoses are often revised, and new ones are continuously invented. 

In a recent example, the APA decided in 2022 that prolonged grief following the death of a loved one is a mental illness that clinicians can treat (for a price, of course). Given that Hitchcock has been dead for years and the APA’s homosexuality vote took place almost 50 years ago, you might think that today’s APA would be alert to the importance of context. Alas, it is not. The new illness of grief is conceived as context-free—identical across cultures, genders, age groups, and nationalities.

In The Myth of Mental Illness, published 50 years ago, Thomas Szasz warned against making illnesses out of the slings and arrows of life. “Classifying thoughts, feelings and behaviours as diseases is a logical and semantic error.” Grief is nothing like diabetes or pneumonia; it is a normal human response to loss. There is no “right way” to grieve. Societies differ significantly in what they regard as normal. Some engage in short periods of formal mourning; others grieve for more extended periods. Queen Victoria mourned for Albert for the rest of her life.

Critics of psychiatry believe that creating new mental illnesses, such as prolonged grief, is a business decision designed to produce more patients for clinicians to treat. They are right to be suspicious. After all, we all lose loved ones at some point in our lives, so we are all potential patients. Other critics point out that the diagnostic criteria for grief disorder do not include how long mourning needs to last to be considered “prolonged.” Clinicians could suggest “treatment” within a few weeks of a loved one’s death.

Grief is a normal and healthy response to loss. Calling it an illness could convince perfectly well people that they are unable to control their own lives. Intervening in the grieving process may keep bereaved people from learning to adapt to adversity.

One point is crystal clear. History, culture, government, social norms, political systems, economics, and family dynamics shape our lives and determine our behaviour. Before we attempt to help human beings in distress, we must take special care to understand their specific circumstances—one size does not fit all. Context is everything.