Coping with the Death of a Loved One: The Seductiveness of Stages

One of the most widely held assumptions about the grieving process is that people proceed through a series of stages as they attempt to come to terms with their loss.  This view had its origins in the work of Elisabeth Kubler-Ross. In her influential book, On Death and Dying (1969), she proposed that people go through five stages as they attempt to cope with their own impending death: denial, anger, bargaining, depression, and acceptance. This model captured the imagination of professionals working in the field of bereavement, who sought to apply it to the process of grieving,.  Since that time, it’s been integrated into the curriculum of thousands of academic and professional institutions across the country. The five stages have become a mainstay in social work, and counseling, in hospitals, medical schools, nursing programs and seminaries. We see them in popular media (e.g. Frasier, Six Feet Under) as well as self-help literature for the bereaved appearing in magazines, books and influential websites. And yet, this model continues to represent one of the most firmly entrenched and widely propagated misconceptions within the field of psychology.

Is there scientific evidence in support of the stage model?  The consensus of scholars is that there is not. As Robert Neimeyer has indicated, research has failed to identify a universal or normative pattern of grieving. It turns out there is considerable variability in the kinds of emotions we experience after a loss – and the order in which we experience them.  Stage models do not help us to understand why some people are devastated by a loss, while others emerge unscathed, or even strengthened.

So if stage models aren’t quite accurate, can they have a negative impact on bereaved individuals, those in their social network, and the health care providers who treat them?  Each of these groups may use the stage model as a yardstick to assess how well the bereaved person is coping. Bereaved people may become worried if they don’t experience a particular stage, erroneously inferring that they cannot move forward until they do.  As one woman explained, “I haven’t felt much anger since my husband died. I asked my family to do things that would make me mad so that I can go through the anger stage.”  Or health care providers may make mourners feel that they are not coping correctly if they do not experience a certain stage.  A woman who lost her daughter in a drunk driving crash told her therapist that she did not feel angry.  The therapist replied, “Why aren’t you angry?  You should be angry!” In fact, bereaved people may elicit judgmental comments from others even if they are coping well following their loss. Such individuals are frequently told that they are “in denial” and that they need to get in touch with their pain.

Stage models can also lead people to dismiss legitimate emotional reactions of mourners as “just a stage.”  One woman attended a family gathering shortly after her husband’s death.  Her sister asked repeatedly about how much insurance money she would receive.  She finally rebuked her sister sharply, stating that she would not discuss the matter.  Later, she overheard her sister say to another family member, “Don’t worry about Jill.  She’s just going through the anger stage.”

Would Kubler-Ross’s stage model be more useful if it were applied to people who were dying rather than to the bereaved?   Pattison has reported that, as a result of the widely held belief in Kubler-Ross’s model, dying people who do not follow these stages are labeled “deviant,” “neurotic” or “pathological” dyers.  He said that health care providers often become angry with patients who do not move from one stage to the next, and become resentful if the dying person does not reach a state of acceptance. Such reactions on the part of health care providers are likely to interfere with the provision of compassionate care.

In fact, one of the most problematic aspects of stage models is that they have great potential to pathologize the mourner.  The majority of textbooks for doctors or nurses include a discussion of the stages of grief. Many state that the grieving process is “pathological” or “dysfunctional” if the patient does not progress through the stages to reach resolution.

Two prestigious scientific institutions have also questioned the value of stages.   The Center for the Advancement of Health concluded that grief is not divisible into distinct stages.  The Institute of Medicine recommended against using the term “stages” because it implies a more orderly progression through the grief process than typically occurs. They emphasize that grieving people should be helped to understand that there is no right or wrong way to grieve.  Ironically, some of the harshest criticisms of the stage model have been made by Kubler-Ross herself. To her credit, she noted in her book that the stages should be applied flexibly, because all people don’t grieve in the same way. Unfortunately, her followers have paid little attention to these qualifications, and have tended to view stages as a fixed sequence of responses. Shortly before her death in 2004, she stated that despite her best intentions, the stages have contributed to misunderstandings about the dying process.

Whatever the shortcomings of the stage models, it is clear that many people find the idea appealing.  Robert Neimeyer pointed out that stage models offer an apparent road map through turbulent terrains.  It may be less frightening for people to go through the grief process, or help others through it, if they know what is supposed to happen next.  Also, people may feel more comforted if their roadmap points to acceptance than if they don’t even have a roadmap.

What is your opinion of stage models?  Have the stage models helped you to cope with a loss?  What did you find helpful?  Or did these models interfere with your grieving process or make things harder for you? I hope you will share your thoughts with me.

Sources:
Bonanno, G. A. (2009).  The other side of sadness: What the new science of bereavement tells us about life after loss.  New York: Basic Book

Kubler-Ross, E. (1969).  On death and dying.  New York: Macmillan.

Maciejewski, P. K., Zhang, B., Block, S. D., & Prigerson, H. G. (2007).  An empirical examination of the stage theory of grief.  JAMA, 297, 716-723.

Neimeyer, R. A. (2001).  Meaning reconstruction & the experience of loss. Washington, DC:  American Psychological Association.

Pattison, E. M. (1977).  The experience of dying.  Englewood Cliffs, NJ: Prentice-Hall.

Silver, R. C. & Wortman, C. B. (2007).  The stage theory of grief.  JAMA, 297, 2692.

Camille Wortman Ph.D. Bio

Dr. Wortman studies grief with a special focus on sudden, tragic loss.

Learn More