The Five Stages of Grief

Transcript

Welcome to this video about Elisabeth Kübler-Ross and the Five Stages of Grief.

Origins of the Five Stages

Elisabeth Kübler-Ross was a Swiss psychiatrist who immigrated to the United States in 1958. As part of her practice, she began sitting with dying patients, whom she saw were often left to die alone. She found that over 90% of doctors at that time did not tell dying patients that they were dying, so no one provided these patients with the opportunity to talk about their feelings or fears.

When Kübler-Ross began to teach in 1965, she interviewed dying patients and encouraged them to share their feelings while medical students observed from another room. This brought attention to the needs of the dying. Initially, Kübler-Ross was ostracized by other physicians who felt that her approach was completely inappropriate and unprofessional.

However, after the publication of her best-selling book, On Death and Dying, in 1969, Kübler-Ross and her theories about dying became widely known and appreciated. In this book, Kübler-Ross described a number of stages that dying patients go through. While she noted in the text that there were additional stages, such as preparatory or anticipatory grieving and shock, there were separate chapters for the five primary stages, which included:

Denial
Anger
Bargaining
Depression
Acceptance

These five stages then became the focus of her theory as interpreted by others.

To be clear, Kübler-Ross was writing about the stages dying patients go through, not about the bereaved, and her stages were meant as guidelines rather than prescriptive stages. Kübler-Ross pointed out that not everyone goes through all stages and that the stages are not necessarily sequential.

However, these five stages took on a life of their own, and people started to apply them to many different scenarios, including grief.

Thus, what began as the five stages of dying became the five stages of grief even though no research had been carried out about grief. In fact, no empirical studies were carried out about dying either as Kübler-Ross based her conclusions on interviews and anecdotal evidence.

That does not mean, of course, that the observations were false, just that the conclusions may not apply to everyone as people have come to expect. Too often, people are expected to go through these stages in order to “heal” and people may feel there is something wrong with them if they don’t.

It’s good to remember that the five stages were always intended by Kübler-Ross to help us recognize what people are going through when they are dying, so that we can support them.

The 5 Stages

Let’s look at these five stages and how they are interpreted in more detail.

The first stage is denial, although keep in mind that labeling it “first” does not mean it occurs first, or even at all, for a bereaved individual. During this stage, the person may feel overwhelmed and numb and may have difficulty coping and dealing with responsibilities.

As part of the stages of dying, an individual may simply deny a diagnosis or the reality that death is approaching, but for those who are bereaved, denial may serve as a defense system to suppress feelings in order to help them manage their grief.

When someone is in denial, the most important intervention is to just be patient and supportive. Do not try to force them to deal with reality. They generally know what the reality is, and need time to process all that comes with that reality.

The next stage is anger, which may be directed at the deceased, God, healthcare providers, family, friends, or at anyone or anything. A recent study reports that anger is, in fact, the most common emotion that the bereaved experience and it’s a common response in those who are dying as well, but that doesn’t mean it’s a necessary stage or that people are in denial if they don’t express anger, as some suggest.

Anger is often expressed by people asking, “Why did this happen to me?” or “Why am I being punished?”

Dealing with someone’s anger can be difficult, but remember that the anger is an expression of grief, not really a personal attack. Don’t argue or try to defend the situation, but acknowledge the feelings, by responding with statements such as, “I can see how upset you are.”

The third stage is bargaining. When anticipating an event, such as dying or illness, this is the stage where people may make promises: “If I get well, I will go to church every week.” During the grieving process, people are more likely to dwell on the “what if’s.” For instance, “What if my husband had stayed home instead of driving to work?” or “What if I volunteer at the Cancer Society? Maybe that will make me feel better.”

This stage is often accompanied by feelings of guilt, particularly in the bereaved parties. For instance, the parent of a sick child may think, “I should have noticed there was something wrong with my child.”

There’s little point in telling people not to torture themselves with these kinds of thoughts, so avoid reassurances and listen rather than talk.

The fourth stage is depression. People may feel deeply sad and grief-stricken as they cope with their loss. Depression is the most common emotion we’ve come to expect from grief. This is true in the dying as well as the bereaved. In fact, if people don’t appear depressed, sometimes others assume that they are in denial.

The depression associated with grief is not necessarily one that requires treatment because it’s not an abnormal state for many people.

However, grief can differ. Acute grief often occurs suddenly at the time of loss, leaving the person overwhelmed and often inconsolable. Over time, the acute phase subsides somewhat. Some people may experience some relief by 6 to 8 weeks, but it is more common for grief to peak at about 4 to 6 months. However, for others, it can persist for years.

Some people experience anticipatory grief before a loss. They may experience fear, anxiety, and exhaustion. This is a common experience of the spouse, child, or parent of a person who is dying of a chronic disease.

Prolonged/chronic grief, on the other hand, can occur if a person is unable to come to terms with loss. This type of grief may be prolonged for months or years and may pose a risk to the individual who is experiencing it. The depression experienced in prolonged grief is unrelenting and debilitating. People sometimes try to cope with chronic grief through substance abuse and may experience anorexia, insomnia, and panic attacks. Some may become suicidal, so chronic grief may require treatment, such as antidepressants and counseling.

When people are in the stage of depression, allow them to express their feelings without being judgmental. Don’t try to cheer them up or use meaningless clichés, such as “He’s in a better place.” Don’t ask open-ended questions, like “how can I help” but rather offer concrete help, such as, “I’m bringing dinner tonight,” or do something useful, such as mowing the lawn or washing their dishes.

If the stage of depression has persisted for an extended time, such as months, and a person is clearly coping poorly, this is the time to suggest grief therapy. This may be gently recommended by saying something such as, “I can see how difficult your life is and how sad you are. Perhaps grief therapy might help you.”

The fifth and last stage is acceptance. This does not mean that people have fully recovered or that their lives are back to normal, but it does mean that they have learned to live with their new normal and can see a life beyond their grief. For people who are dying, acceptance can bring a sense of peace and help to alleviate fear.

It’s also important to remember that people may experience periods of acceptance and then cycle back to an earlier stage. They may, for example, function well for a few days and then have periods of depression and anger.

When people reach the stage of acceptance, continue to provide support because this doesn’t mean that their grief has ended. People who are dying are still facing death and all the suffering that can entail.

For the bereaved, ask them to engage in activities, like going for a walk or out to lunch, but avoid pushing them to do things or telling them to move on. They may not be ready.

Most of all, let the bereaved talk about their loss. Too often people think that it’s better to just ignore the loss, so they talk about everything else, but people who have lost a loved one often want to talk about that person, to share memories of the person they’ve lost.

Throughout Kübler-Ross’s career, she wrote about death and dying and during the 1970s and 1980s promoted the development of hospices throughout the United States and in other countries. She was immensely influential. The five stages of death and dying and of grief remain embedded in our culture and help us to understand and support those who are grieving.

Thanks for watching and happy studying.

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