11 Conclusions 291
will soon be mislabeled as psychiatrically sick” (italics added; Frances, 2010).
Indeed, Wakefield (2013) expresses similar concerns that we share: Normal
grievers may be diagnosed and medicated rather than supported in their grief.
The decision not to include complicated grief or prolonged grief in the
DSM-5 also causes consternation for those who provide grief therapy. Nearly
all clinicians recognize the constellation of symptoms described as prolonged
grief (Holland, Neimeyer, Boelen, & Prigerson, 2009) or complicated grief
(Shear, 2015) and the tendency of these mourners to remain stuck in their
grief, often with intrusive thoughts, intense yearning for the deceased, and
ongoing avoidance of discussion of the death or the deceased. The International
Classification of Diseases 11 (ICD-11) purportedly will include either compli-
cated grief or prolonged grief in recognition that mourners benefit from diag-
nosis and treatment when they experience on-going debilitating grief. The
continuing tension between avoiding pathologizing normal grief and allow-
ing treatment for debilitating grief ensures that these diagnostic issues will
remain thorny.
Structured approaches to treating these mourners—using exposure
therapies (especially telling the story of the death) and cognitive behavioral
methods to reappraise negative cognitions—have been empirically tested and
exhibit good efficacy using many of the interventions discussed previously
in this text (Bryant et al., 2014; Shear, Boelen, & Neimeyer, 2011). Shear (2015)
identified the core components of such treatment as (a) establishing the lay
of the land; (b) promoting self-regulation; (c) building connections; (d) set-
ting aspirational goals; (e) revisiting the world; (f) storytelling; and (g) using
memory.
Grief is painful, messy, and temporarily debilitating—and the myth that
the pain can be avoided is seductive. Yet, many of the lessons of grief have to
do with what one is able to bear and live through—lessons only learned when
one must do so. Our inclination is to help grievers attend to their physical
well-being, to allow for as much emotional expression as fits the individual
within a dual-process model context, and to support grievers in coping with
their pain. If a griever is suicidal, still quite debilitated after 4 to 6 months, has
strong feelings of worthlessness, or is unable to begin to eat and sleep more
normally after several weeks, then a referral for psychiatric evaluation makes
sense.
Maturational Losses as Disenfranchised Losses
We have demonstrated that children and adults experience various matura-
tional losses, some as a direct result of normal growth and aging, and some
related indirectly to the maturational stage an individual inhabits. These losses
are common in each age group but often receive little support from others
precisely because they are considered “fairly normal.” In effect, these losses
and the grief that individuals experience are not validated by society in the
ways that allow people to grieve losses deemed legitimate (worthy of sympa-
thy or support). Although not included in Doka’s (1989, 2002) five categories
of disenfranchised loss, we assert that many maturational losses are indeed
disenfranchised.
