The RCPsych Article of the Month for March is ‘The mourning process and its importance in mental illness: a psychoanalytic understanding of psychiatric diagnosis and classification‘ written by author Rachel Gibbons and published in BJPsych Advances.

At the heart of human experience lies a universal truth eloquently captured by Nick Cave in 2022:

‘What it is to be human. It seems to me that the common agent that binds us all together is loss, and so the point in life must be measured in relation to that loss. Our individual losses can be small or large. They can be accumulations of losses barely registered on a singular level, or full-scale cataclysms. Loss is absorbed into our bodies from the moment we are cast from the womb until we end our days, subsumed by it to become the essence of loss itself.’

Cave, 2022

Have you ever wondered what underlies psychiatric illness? Why can two people experiencing similar life events react so differently, with one navigating through relatively unscathed and the other developing a psychiatric disorder? And when someone does become ill, why is the illness manifests in different ways—such as anxiety, depression, or psychosis? These questions preoccupied me when I started working as an adult consultant psychiatrist in an inpatient unit, and I spent 10 years working on a straightforward answer, which is now published in BJPsych Advances.

This paper brings together the fields of psychiatry and psychoanalysis, offering a model to understand the complex nature of mental illness in a simple way. As psychiatrists, we often look from the outside at symptoms and think about diagnosis. Psychoanalysts, on the other hand, look from the inside of the mind at the unifying human psychodynamics, where mental illness is understood to arise from difficulties in responding to the human experience of loss and grief, as described by Nick Cave above. This paper argues that mental illnesses are not just random collections of symptoms but are rooted in the universal human experiences of loss and mourning.

This model put forward suggests that all mental illnesses is a response to life’s loss events and that the symptoms arise from a disruption in the natural process of grieving- ‘pathological mourning’. Through this lens, the symptoms of psychiatric disorders are seen as manifestations of the mind’s attempt to defend itself against the pain of loss. Everyone experiences loss, but it’s the way we process the feeling that emerge that can profoundly affect our mental health.

By examining how individuals get “stuck” at certain points in the mourning process, we can begin to see psychiatric disorders in a new light. Each disorder, with its unique symptoms, reflects a different point of arrest in the journey of mourning.

Why is this important? Because it shifts our perspective from viewing mental illness as a static condition to understanding it as a dynamic process related to our most fundamental human experiences.

This approach empowers psychiatrists and psychoanalysts alike to identify the loss event that underpins the disorder, clarifying treatment pathways and advocating for a more empathetic and comprehensive approach to psychiatric care—one that acknowledges the inner turmoil of loss and the individual paths we tread in our journey through grief.

What Nick Cave reminds us is that loss is not just a part of life; it is a defining element of our humanity. By shedding light on the internal struggles behind psychiatric symptoms, we open the door to more personalised, holistic, compassionate, and effective treatments, helping individuals navigate their unique paths through loss and towards recovery.

‘Dr Rachel Gibbons’ article titled ‘The mourning process and its importance in mental illness: a psychoanalytic understanding of psychiatric diagnosis and classification’ is chosen as the article of the month. This article brings together our understanding of the mourning process, the role of psychological defence mechanisms & processing of loss events through life and how they influence presentation of mental illness and treatment response. A few case vignettes are provided, aptly explaining how psychological defence mechanisms processing the grief, may play a role in precipitating and/or maintaining symptoms of mental illness, thereby enhancing our understanding of mental illness. This calls for re-considering and reviewing treatment plans, goals and time-scales for management in some of our patients, and also warding off thoughts of therapeutic nihilism that may sometimes set in.’

Professor Asit Biswas
Editor-in-Chief, BJPsych Advances