January 5th, 2012, by Russell Friedman
Many people have contested the validity of the stages of dying, but here we are more concerned with the supposed stages of grief which derived from the stages of dying. As professional grief recovery specialists, we contend that the theory of the stages of grief has done more harm than good to grieving people. Having co-authored three books on the impact of death, divorce, and other losses, and having worked directly with over 100,000 grieving people during the past 30 years, our reasons for disputing the stages of grief theory are predicated on the horror stories we’ve heard from thousands of grieving people who’ve told us how they’d been harmed by them.
In 1969 the psychiatrist ELISABETH KUBLER-ROSS wrote one of the most influential books in the history of psychology, On Death and Dying. It exposed the heartless treatment of terminally-ill patients prevalent at the time. On the positive side, it altered the care and treatment of dying people. On the negative side, it postulated the now infamous five stages of dying—Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), so annealed in culture that most people can recite them by heart. The stages allegedly represent what a dying person might experience upon learning he or she had a terminal illness. “Might” is the operative word, because Kübler-Ross repeatedly stipulated that a dying person might not go through all five stages, nor would they necessarily go through them in sequence. It would be reasonable to ask: if these conditions are this arbitrary, can they truly be called stages?
From Dying to Grief
Elisabeth Kubler-Ross was a fearless pioneer who openly took the medical profession to task for its callous disregard for the feelings of dying people. The subtitle of On Death and Dying explains the book’s primary focus: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families. The lessons Kubler-Ross learned from those dying people, coupled with her compassionate regard for them, became a focal point of the emergent Hospice movement. Somehow, over the years, the real virtues inspired by her work have been subordinated to the inaccurately named, largely imaginary stages.
During the 1970s, the DABDA model of stages of dying morphed into stages of grief, mostly because of their prominence in college-level sociology and psychology courses. The fact that Kubler-Ross’ theory of stages was specific to dying became obscured. Students who eventually became therapists, social workers, or doctors carried what they learned about the stages into their careers. The media also played a role in disseminating the idea that specific, inexorable stages of grief exist. When a tragedy makes the news, newscasters and alleged experts recite the DABDA model of grieving. Medical and mental health professionals and the general public accepted the theory without ever investigating its provenance or validity.
In fact, Kubler-Ross’ stage theory was not the product of scientific research. In the second chapter of On Death and Dying she laments: “How do you do research on dying, when the data is so impossible to get? When you cannot verify your data and cannot set up experiments? We [she and her students] met for a while and decided that the best possible way we could study death and dying was by asking terminally ill patients to be our teachers.” She then explains her methods: “I was to do the interview while they [her students] stood around the bed watching and observing. We would then retire to my office and discuss our own reactions and the patient’s response. We believed that by doing many interviews like this we would get a feeling for the terminally ill and their needs which in turn we were ready to gratify if possible.”
The phrase, “we would get a feeling” is especially revealing since Kubler-Ross’ feelings were processed through the filter of her life-long unresolved grief and retained anger. We know that because she went public about the anguish of her past in her final book, On Grief and Grieving, co-authored with David Kessler and published shortly after her death in 2004. In the final chapter, titled My Own Grief, she tells the gruesome story about an episode involving her father and a cherished childhood pet that caused her to make an oath never to cry again. That event, along with a host of other personal grief incidents, resulted in her bottling up a lifetime of anger that she admitted she didn’t deal with until very late in life.
When you read about Kubler-Ross’ life, you sense how much her painful past may have colored her interpretation of her interviews with dying patients. Interestingly, anger is the only stage Kubler-Ross contends is absolute for everyone in dying, or in grieving relationships with those who have died. It seems as if the palpable anger she carried for years caused her to insist we all must have anger about loss. We’re not sure why Kubler-Ross felt compelled to convert her observations from the interviews into stages. Possibly she believed that what she heard in her interviews with dying people was actually stages that needed to be quantified, or perhaps she simply attempted to put a scientific face on anecdotal evidence.
When Does Wide Acceptance Equal Scientific Fact?
On February 21, 2007, The Journal of the American Medical Association (JAMA) published the results of the Yale Bereavement Study (YBS): An Empirical Examination of the Stage Theory of Grief. The YBS evaluated a hodge-podge of alleged stages. It starts with the assumption that stages of grief exist, and then attempts to use that assumption to prove that they do. However, the existence of stages has never been established as fact. The results appeared to confirm some stages, negate others, and reposition their order and value. We cannot give any credence to the YBS because its premises and conclusions are flawed. But, since the study’s own language perpetuates the myth that stages of grief even exist, we’ll use it to make our case.
The YBS begins: “The notion that a natural psychological response to loss involves an orderly progression through distinct stages of bereavement has been widely accepted by clinicians and the general public.” It concludes: “Identification of the normal stages of grief following a death from natural causes enhances understanding of how the average person cognitively and emotionally processes the loss of a family member.” We are troubled by the assumption that stages of grief are normal and distinct and progress in a specific order. We also wonder, when does “wide acceptance” equal scientific fact?
Contrast the alleged wide acceptance of an “orderly progression of stages” with this from the inside cover of Meaning Reconstruction & the Experience of Loss, edited by Robert A. Neimeyer: “Debunking the notion that an invariant sequence of stages of grief occurs among all who experience the death of a loved one, this groundbreaking volume clearly demonstrates that highly individual processes of meaning making are at the heart of grief dynamics.” Published by the American Psychological Association in 2001, Neimeyer’s book presents 26 academicians’ and clinicians’ non-stage methods for helping grieving people. Neimeyer also addresses methodology in his introduction: “At the most obvious level, scientific studies have failed to support any discernible sequence of emotional phases of adaptation to loss or to identify any clear endpoint to grieving that would designate a state of ‘recovery.’” Although Neimeyer’s book’s was published prior to the YBS, his contributors were familiar with earlier studies that attempted and failed to quantify stages.
Dabbling in DABDA: A Stage by Any Other Name
Prior to publication of her famous book, Kubler-Ross hypothesized the Five Stages of Receiving Catastrophic News, but in the text she renamed them the Five Stages of Dying or Five Stages of Death. That led to the later, improper shift to stages of grief. Had she stuck with the phrase catastrophic news, perhaps the mythology of stages wouldn’t have emerged and grievers wouldn’t be encouraged to try to fit their emotions into non-existent stages.
Adding irony to the stages debacle, Kubler-Ross’ final book, On Grief and Grieving, is subtitled, Finding The Meaning Of Grief Through The Five Stages Of Loss. Confusingly, inside the book they’re called the Five Stages of Grief. Stages of loss conveniently fit the new book on grief and confirmed the chameleon-like capacity of the word stages to arbitrarily mean whatever Kubler-Ross or anyone else wants it to mean.
Refuting The Alleged Stages of Grief
Kubler-Ross may have been the first to advance a specific stage theory about dying, but others preceded her in the area of grief. John Bowlby, Colin Murray Parkes and several others advanced theories about grief based on stages or phases, using a variety of labels. Alternate terms for the stages they used include: Disbelief, Numbness, Yearning, Shock, and Guilt. As we refute the stages, we’ll address the most commonly used stages and point out how they have the potential to harm grieving people.
1. (a) Denial (b) Disbelief (c) Shock (d) Numbness
(a) Denial. In our thousands of interactions with grieving people we have never found one person who was in denial that a loss had occurred. We ask, “What happened?” They say, “My mother died.” There’s no denial that someone died. We’ve had a few people tell us someone died and then say, “I’m in denial.” We ask, “Do you mean the person isn’t dead?” They say, “No, but I’ve heard ‘denial’ is the first stage of grief.”
In the opening chapter of On Grief and Grieving, Kubler-Ross and Kessler state, “For a person who has lost a loved one, however, the denial is more symbolic than literal.” We have to wonder: if denial is merely symbolic rather than literal, why call it a stage?
(b) Disbelief. The YBS uses disbelief rather than denial. Disbelief, as expressed by most grievers, is rhetorical language, as in, “I still can’t believe he’s gone.” Although disbelief may reflect the emotions of a broken heart, it is really a figure of speech rather than a statement that a death didn’t happen.
(c) Shock. In cases of sudden, unexpected deaths, it’s possible that upon receiving the news, a surviving family member may go into emotional shock, during which time they’re in a suspended state, totally removed from events in the real world. This response is rare and doesn’t last very long. Most deaths are at the end of a long-term illness or of old age, and don’t produce shock in the survivors. However, there are books that maintain that shock is a standard stage of grief. There is no evidence to support that idea.
(d) Numbness. Numbness is one of the most common physiological responses to a grief-producing event. We reference numbness because the YBS coupled it with disbelief as if both are stages. Grief related numbness is the result of an overload of emotional energy in reaction to a death. Many grievers report numbness as intermittent in the immediate aftermath of a death, which usually gives way to a lack of focus or limited concentration. However, numbness is not a stage, nor is the inability to concentrate.
Potential Harm. Time can’t heal emotional wounds, but the word “stage” implies that time is a component. The suggestion to grievers that they’re in a stage of denial or disbelief can freeze them into inaction. They bury their feelings waiting for time to make that stage pass. Later they’re liable to be diagnosed with “complicated bereavement” and put on psychotropic drugs, which makes it difficult or impossible for them to access the emotions they’ve buried.
Professionally Induced Harm. Many grievers tell us that a mental or medical health professional “strongly suggested” they were in the denial stage, when all they’d said was that they were having some difficulty since Mom died. Even after reiterating they were clear that Mom had died, the therapist insisted they were in denial, which created a breach of trust and safety. The grievers terminated therapy after one or two ineffective sessions, and left their grief unattended. We believe those professionals overlooked a cardinal rule of helping grievers, which is: “Hear what your client is telling you, as opposed to having your own agenda.”
When an elderly loved one dies at the end of a long-term illness, there’s usually no anger in those left behind. Along with feelings of sadness, there may be a sense of relief that the suffering is over. Things do happen relevant to a death that can make us angry: anger at a disease or God; anger at doctors or hospitals or the drunk driver who killed our loved one; even anger at loved ones who didn’t take good care of themselves, or who took their own lives. But anger is not a universal feeling when someone important to us dies, and therefore is not a stage.
Potential Harm. When anger is perceived as a stage, there are no actions the griever can take to end it. They must stay angry as long it lasts or as long as they’re alive. As we said, stages imply that time is an element, so when time fails to end that stage, people re-create and re-live anger for years. Staying angry can have dangerous consequences, causing people to damage relationships, lose jobs, and worse, affect their health or restrict their will to live.
Professionally Induced Harm. Grievers repeatedly tell us the same scenario about anger as about denial. They report that a mental or medical health professional “planted” the idea they were in a stage of anger, when nothing they’d said would indicate that this was true.
3. (a) Bargaining and (b)Yearning
(a) Bargaining. Kubler-Ross’ bargaining stage may make sense for someone diagnosed with a terminal illness. “If you’ll just give me another chance, I’ll take better care of myself,” is a plea someone might make to whichever deity they believe in. But, it doesn’t relate to the grief people feel when someone important to them has died.
(b) Yearning. The YBS substitutes yearning for bargaining. Since 83.8% of the participants in that study were widows or widowers, most over the age of 60, we’re not surprised that many of them yearned for their lost partner. Talk to thousands of widows/widowers, as we have, and you are guaranteed to hear that most of them miss the person who died, including the surviving partners who were half of a 40-year relationship of constant bickering.
Potential Harm. The death of a long-term spouse creates an incalculable amount of emotional energy. Those feelings are often accompanied by an overwhelming sense of missing the person and wanting the familiarity of their presence back. Missing someone who has been a constant part of your life for decades is normal and to be expected. Again, calling it a stage suggests a time frame, causing them to wait for that stage to end which adds exponentially to their grief.
We’re going to address depression in greater detail than the other alleged stages because it carries with it a great deal of confusion and potential danger for grieving people. Here is a list of reactions common to grievers that are also symptoms of clinical depression:
• inability to concentrate
• disturbance of sleeping patterns
• upheaval of eating patterns
• roller coaster of emotions
• lack of energy
One list fits both, and that’s the problem. Are grievers clinically depressed? With very few exceptions, the answer is “no”, and in those few cases only if they were clinically depressed before the death that affected them. Grief is the normal reaction to loss, but clinical depression is abnormal and requires different treatment. The line between grief-related depression and clinical depression has become hopelessly blurred, in part because the medical and mental health professions have adopted the non-existent stages of grief.
Potential Harm. It is normal for grievers to experience a lowered level of emotional and physical energy, which is neither clinical depression nor a stage. But when people believe depression is a stage that defines their sad feel- ings, they become trapped by the belief that after the passage of some time the stage will magically end. While waiting for the depression to lift, they take no actions that might help them. If and when they seek professional help, they use the self-diagnosis of depression to describe themselves.
Professionally Induced Harm. When medical or psychological professionals hear grievers diagnose themselves as depressed, they often reflexively confirm that diagnosis and prescribe treatment with psychotropic drugs. The pharmaceutical companies which manufacture those drugs have a vested interest in sustaining the idea that grief-related depression is clinical, so their marketing supports the continuation of that belief.
The question of drug treatment for grief was addressed in the National Comorbidity Survey (published in the Archives of General Psychiatry, Vol. 64, April, 2007). “Criteria For Depression Are Too Broad Researchers Say—Guidelines May Encompass Many Who Are Just Sad.” That headline trumpeted the survey’s results, which observed more than 8,000 subjects and revealed that as many as 25% of grieving people diagnosed as depressed and placed on antidepressant drugs, are not clinically depressed. The study indicated they would benefit far more from supportive therapies that could keep them from developing full-blown depression.
Acceptance, as it relates to psychology or emotions, is a vague and amorphous term. Since there is almost never denial or disbelief that a death occurred, the concept of acceptance is confusing, if not moot. The YBS asked grievers to assess the level of acceptance they’d achieved about the death of someone important to them. This is an odd question, because they had to have accepted that the death occurred or else they wouldn’t have been in a bereavement study.
Potential Harm. One definition of stages cannot fit all people, or all relationships—in fact we don’t think they fit anybody. For example, an 85- year old woman whose spouse of 62 years has died reports a different emotional picture about her life and response to that death, than does a 62-year old woman whose 85-year old father has died. Both involve 62-year relationships, but the idea that there could be a stage of acceptance applicable to both is illogical.
Another Non-Stage: Not Guilty As Charged
Of all the incorrect ideas and feelings that are defined as stages of grief, guilt is undoubtedly the most unhelpful. We’ve seen it in dozens of books and heard it in hundreds of lectures. As those authors and speakers define it, guilt more accurately represents things the griever wishes had been different, better, or more in relation to the person who died; rather than a sense of having done something with intent to harm the person who died, for which the idea of guilt might make sense.
Personal Danger. Grieving parents who have had a troubled child commit suicide after years of therapy and drug and alcohol rehab, are often told, “You shouldn’t feel guilty, you did everything possible.” The problem is that they weren’t feeling guilty, they were probably feeling devastated and overwhelmed, among other feelings. Planting the word guilt on them, like planting any of the stage words, induces them to feel what others suggest. Tragically, those ideas keep them stuck and limit their access to more helpful ideas about dealing with their broken hearts.
Conclusion: The stages of grief myth
We understand that people engulfed in the aftermath of loss want to know what to expect and how long it will last. Such questions can never be satisfactorily answered. Since every griever is unique, there are no pat answers about grief.
As much effort as we’ve put in to refuting the stages, Kubler-Ross herself rebuts them better than we can in the opening paragraph of On Grief and Grieving: “The stages have evolved since their introduction, and they have been very misunderstood over the past three decades. They were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss, as there is no typical loss. Our grief is as individual as our lives. Not everyone goes through all of them or goes in a prescribed order.”
If there are no typical responses to loss and no typical losses, and not everyone goes through them or in order, how can there possibly be stages that universally represent people’s reactions to loss? The fact is, no study has ever established that stages of grief actually exist, and what are defined as such can’t be called stages. Grief is the normal and natural emotional response to loss. Stage theories put grieving people in conflict with their emotional reactions to losses that affect them. No matter how much people want to create simple, iron clad guidelines for the human emotions of grief, there are no stages of grief that fit every person or relationship.
This article was originally published in the November 2008, Volume 14, Number 2 issue of Skeptic Magazine.