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The Myth of the Stages of Dying, Death and Grief

By: Russell Friedman and John W. James

IN 1969 THE PSYCHIATRIST ELIZABETH KÜBLER-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

During the 1970s, the DABDA model of stages of dying morphed into stages of grief, mostly because oftheir prominence in college-level sociology and psychologycourses. The fact that Kübler-Ross’ theory of stageswas 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, Kübler-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 Kübler-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, coauthored 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.

Wide Acceptance vs. Scientific Fact:

On February 21, 2007, The Journal of the American Medical Association (JAMA) publishedthe results of the Yale Bereavement Study (YBS):An Empirical Examination of the Stage Theory of Grief. The YBS evaluated a hodge-podge ofalleged stages. It starts with the assumption that stages of grief exist, and then attempts to use thatassumption to prove that they do. However, theexistence of stages has never been established asfact. The results appeared to confirm somestages, negate others, and reposition their orderand value. We cannot give any credence to the YBS because its premises and conclusions areflawed. But, since the study’s own language perpetuatesthe 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?

Refuting The Alleged Stages

Kübler-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
Denial.In our thousands of interactions withgrieving people we have never found one personwho was in denial that a loss had occurred. Weask, “What happened?” They say, “My motherdied.” There’s no denial that someone died. We’vehad a few people tell us someone died and thensay, “I’m in denial.” We ask, “Do you mean theperson 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, Kübler-Ross and Kessler state, “For aperson who has lost a loved one, however, thedenial is more symbolic than literal.” We have towonder: if denial is merely symbolic rather thanliteral, why call it a stage?
Disbelief. The YBS uses disbelief ratherthan denial. Disbelief, as expressed by mostgrievers, is rhetorical language, as in, “I still can’tbelieve he’s gone.” Although disbelief may reflectthe emotions of a broken heart, it is really a figureof speech rather than a statement that adeath didn’t happen.
Shock. In cases of sudden, unexpecteddeaths, it’s possible that upon receiving the news,a surviving family member may go into emotionalshock, during which time they’re in a suspendedstate, totally removed from events in the realworld. This response is rare and doesn’t last verylong. Most deaths are at the end of a long-termillness or of old age, and don’t produce shock inthe survivors. However, there are books thatmaintain that shock is a standard stage of grief.There is no evidence to support that idea.
Numbness.Numbness is one of the mostcommon physiological responses to a grief-producingevent. We reference numbness becausethe YBS coupled it with disbelief as if both arestages. Grief related numbness is the result of anoverload of emotional energy in reaction to adeath. Many grievers report numbness as intermittentin the immediate aftermath of a death,which usually gives way to a lack of focus orlimited concentration. However, numbness is nota stage, nor is the inability to concentrate.
Potential Harm.Time can’t heal emotionalwounds, but the word “stage” implies that time isa component. The suggestion to grievers thatthey’re in a stage of denial or disbelief can freezethem into inaction. They bury their feelings waitingfor time to make that stage pass. Later they’reliable to be diagnosed with “complicatedbereavement” and put on psychotropic drugs,which make it difficult or impossible for them toaccess the emotions they’ve buried.

2. Anger
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.

3. (a) Bargaining and (b)Yearning
Bargaining. Kübler-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.
Yearning.The YBS substitutes yearning for bargaining. Since 83.8% of the participants inthat study were widows or widowers, most overthe age of 60, we’re not surprised that many ofthem yearned for their lost partner. Talk to thousandsof widows/widowers, as we have, andyou are guaranteed to hear that most of themmiss the person who died, including the survivingpartners who were half of a 40-year relationshipof 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.

4. Depression
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 haveadopted 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 feelings, they become trapped by the belief that after the passage of sometime 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.
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.

5. Acceptance
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.

Conclusion
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, Kübler-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