research paper on the stages of grief

Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal

Affiliations.

• 1 Department of Clinical Psychology, Utrecht University, Utrecht, Netherlands.
• 2 Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, Netherlands.
• PMID: 34925174
• PMCID: PMC8675126
• DOI: 10.3389/fpsyg.2021.772696

Kübler-Ross's stage model of grief, while still extremely popular and frequently accepted, has also elicited significant criticisms against its adoption as a guideline for grieving. Inaccurate portrayal of the model may lead to bereaved individuals feeling that they are grieving incorrectly. This may also result in ineffectual support from loved ones and healthcare professionals. These harmful consequences make the presentation of the five stages model an important area of concern. The Internet provides ample resources for accessing information about grief, raising questions about portrayal of the stages model on digital resources. We therefore conducted a systematic narrative review using Google to examine how Kübler-Ross's five stages model is presented on the internet. We specifically examined the prominence of the model, whether warnings, limitations and criticisms are provided, and how positively the model is endorsed. A total of 72 websites were eligible for inclusion in the sample. Our analyses showed that 44 of these (61.1%) addressed the model, indicating its continued popularity. Evaluation scores were calculated to provide quantitative assessments of the extent to which the websites criticized and/or endorsed the model. Results indicated low criticalness of the model, with sites often neglecting evaluative commentary and including definitive statements of endorsement. We conclude that such presentation is misleading; a definitive and uncritical portrayal of the model may give the impression that experiencing the stages is the only way to grieve. This may have harmful consequences for bereaved persons. It may alienate those who do not relate to the model. Presentation of the model should be limited to acknowledging its historical significance, should include critical appraisal, and present contemporary alternative models which better-represent processes of grief and grieving.

Keywords: Kübler-Ross; bereavement; digital support; internet; online resources; psychoeducation; stages of grief; websites.

Copyright © 2021 Avis, Stroebe and Schut.

• Article Information

Top, The curves represent grief indicators as functions of time based on nonlinear regression models estimated from the data (N = 233). The data markers along the x-axis are determined by the mean value of time from loss for the individuals included in the 10 groups of observations (n = 23 observations per group for 9 groups; n = 26 observations for 1 group). The corresponding error bars indicate SDs. These 10 groups of observations were formed by ordering all of the observations used in the regression analyses (N = 233) by increasing time postloss (observations that occurred at the same time postloss were randomly assigned a position in the ordered sequence of observations for that time), and then assigning the first 23 observations on this ordered list to the first group, the next 23 observations to the second group, etc. The regression curves are based on the analysis of individual data points (N = 233) for which time from loss varies from 1.5 to 23 months. Bottom, The curves represent grief indicators as functions of time based on nonlinear regression models after the following rescaling procedure: ψ( t ) = [ Y ( t ) − Y min ]/ Y max − Y min ], where Y ( t ) is the model value for the grief indicator at time t , and Y min and Y max are the minimum and maximum model values of the grief indicator, respectively, between 1 and 24 months postloss. The 5 grief indicators achieve their respective maximum values in the exact sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the hypothesized theory of grief presented in Figure 1 .

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Maciejewski PK , Zhang B , Block SD , Prigerson HG. An Empirical Examination of the Stage Theory of Grief. JAMA. 2007;297(7):716–723. doi:10.1001/jama.297.7.716

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An Empirical Examination of the Stage Theory of Grief

Author Affiliations: Department of Psychiatry, Women's Health Research, and Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, Conn (Dr Maciejewski); Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, Boston, Mass (Ms Zhang and Drs Block and Prigerson); and Department of Psychiatry, Brigham and Women's Hospital, and Harvard Medical School Center for Palliative Care, Boston, Mass (Drs Block and Prigerson).

Context  The stage theory of grief remains a widely accepted model of bereavement adjustment still taught in medical schools, espoused by physicians, and applied in diverse contexts. Nevertheless, the stage theory of grief has previously not been tested empirically.

Objective  To examine the relative magnitudes and patterns of change over time postloss of 5 grief indicators for consistency with the stage theory of grief.

Design, Setting, and Participants  Longitudinal cohort study (Yale Bereavement Study) of 233 bereaved individuals living in Connecticut, with data collected between January 2000 and January 2003.

Main Outcome Measures  Five rater-administered items assessing disbelief, yearning, anger, depression, and acceptance of the death from 1 to 24 months postloss.

Results  Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss. In models that take into account the rise and fall of psychological responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months postloss. Acceptance increased throughout the study observation period. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief.

Conclusions  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. Given that the negative grief indicators all peak within approximately 6 months postloss, those who score high on these indicators beyond 6 months postloss might benefit from further evaluation.

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. Bowlby and Parkes 1 - 4 were the first to propose a stage theory of grief for adjustment to bereavement that included 4 stages: shock-numbness, yearning-searching, disorganization-despair, and reorganization. Kübler-Ross 5 adapted Bowlby and Parkes' theory to describe a 5-stage response of terminally ill patients to awareness of their impending death: denial-dissociation-isolation, anger, bargaining, depression, and acceptance. The stage theory of grief became well-known and accepted, and has been generalized to a wide variety of losses, including children's reactions to parental separation, 3 adults' reactions to marital separation, 6 and clinical staffs' reactions to the death of an inpatient. 7 A 1997 survey conducted by Downe-Wamboldt and Tamlyn 8 documented the heavy reliance of medical education on the Kübler-Ross model of grief. The National Cancer Institute currently maintains a Web site on loss, grief, and bereavement that describes the phases of grief. 9 As entrenched as the notion of phases of grief may be, the hypothesized sequence of grief reactions has previously not been investigated empirically.

Several bereavement scholars have investigated particular aspects of, or diagrammed changes in, grief reactions over time. 10 - 14 Bonanno et al 10 found 5 divergent grieving trajectories from preloss to 18 months postloss (common grief, chronic grief, chronic depression, improvement during bereavement, and resilience). Wortman and Silver 13 examined and disproved the necessity of 1 stage in the grief theory when they found that depression was not an inevitable response to loss. Based on Bowbly and Parkes’ 1 - 4 and Kübler-Ross’ 5 theories, Jacobs 14 synthesized and illustrated the hypothesized stage theory of grief, in which the normal response to loss progresses through the following grief stages: numbness-disbelief, separation distress (yearning-anger-anxiety), depression-mourning, and recovery. To date, no study has explicitly tested whether the normal course of adjustment to a natural death progresses through stages of disbelief, yearning, anger, depression, and acceptance.

The identification of the patterns of typical grief symptom trajectories is of clinical interest because it enhances the understanding of how individuals cognitively and emotionally process the death of someone close. Such knowledge aids in the determination of whether a specific pattern of bereavement adjustment is normal or not. Once the normal patterns of grief are known, individuals with abnormal bereavement adjustment can be identified and referred for treatment when indicated.

This study used data from a sample of community-based bereaved individuals to examine the course of disbelief, yearning, anger, depression, and acceptance as described by Jacobs 14 from 1 to 24 months postloss. Figure 1 illustrates the hypothesized sequence of stages of grief for this analysis. Because approximately 94% of US deaths result from natural causes (eg, vehicle crashes, suicide), 15 deaths from unnatural causes (eg, car crashes, suicide) were excluded thereby enabling the results to be generalized to the most common types of deaths. Individuals who met the criteria for complicated grief disorder 16 , 17 also were excluded so that the results would represent normal bereavement reactions. Although the proposed stage theory of grief 1 - 5 , 14 does not specify the precise timing of the stages, Jacobs 14 described the normal grieving process and each of its stages as being completed within 6 months following the loss of a loved one. However, in the absence of an established, empirical foundation for the length of time associated with the normal grieving process, the normal grieving process was not assumed to be limited to 6 months postloss in this study. Instead, the grief indicators were examined as functions of time up to 24 months postloss.

The Yale Bereavement Study, a longitudinal examination of grief in a community-based sample of bereaved individuals, collected data between January 2000 and January 2003, and was funded by the National Institute of Mental Health. For greater Bridgeport / Fairfield, Conn, the names of the newly bereaved (≤6 months) were obtained from the division of the American Association of Retired Persons Widowed Persons Service, a community-based outreach program. For the New Haven, Conn, metropolitan and surrounding areas, names were obtained from obituaries listed in the New Haven Register , through newspaper advertisements, fliers, personal referrals, and referrals from the chaplain's office of the St Raphael Hospital. A comparison between greater Bridgeport / Fairfield Bureau of Vital Records death certificates and the Widowed Persons Service list during the same 3-month period revealed that the Widowed Persons Service listings captured 95% of all deaths leaving behind a widowed individual, suggesting that the listing provided an unbiased and comprehensive ascertainment of recently widowed individuals in the sampled region. Participants recruited from greater New Haven (37.0%) did not differ significantly from participants recruited from greater Bridgeport / Fairfield (63.0%) with respect to sex, income, education, race / ethnicity, or quality of life. Participants recruited from greater New Haven were significantly younger (mean [SD] age, 59.7 [16.4] years) than participants from Bridgeport / Fairfield (mean [SD], 63.2 [11.5] years) ( P  = .05). The institutional review boards of all participating sites approved the research protocol.

Individuals were invited to participate in the study via a letter that described how their names were obtained, identified the investigators, outlined the aims and procedures, and noted that they would be contacted by study staff in the following week unless they informed us of their wish not to be contacted. Of the 575 persons contacted, 317 (55.1%) agreed to participate. Reasons for nonparticipation included reluctance to participate in research (n = 11; 4.3%); being too busy (n = 46; 17.8%); being too upset (n = 27; 10.5%); “doing fine” (n = 23; 8.9%); not being interested or having no reason (n = 145; 56.2%); and having other reasons (n = 6; 2.3%). Compared with participants, nonparticipants were significantly more likely to be male (25.9% vs 37.2%; P <.001) and older (mean [SD] age, 61.7 [13.1] years vs 68.8 [13.7] years) ( P <.001). Non–English-speaking persons and those considered too frail to complete the interview were ineligible. The 317 participants were interviewed at a mean (SD) of 6.3 (7.0) months after the death of a loved one. The first follow-up interview (n = 296; 93.4%) was completed at a mean (SD) of 10.9 (6.1) months postloss; second follow-up interview (n = 263; 83.0%) at a mean (SD) of 19.7 (5.8) months postloss. Written informed consent was obtained from all individuals enrolled in the study.

Of the 317 individuals identified, 58 were excluded because they met criteria for complicated grief disorder, 19 because they survived traumatic deaths, and 14 because they had missing data on examined measures. The study sample (N = 233) consisted of individuals who did not meet criteria for complicated grief disorder 16 , 17 during the study; had a family member or loved one who died from natural not traumatic causes; and had at least 1 complete assessment of the 5 grief indicators included in the stage theory of grief within 24 months postloss. The participants were significantly older (mean [SD] age, 62.9 [13.1] years; 53.5% aged ≥65 years) and more likely to be white (97.0%) than the excluded individuals (mean [SD] age, 58.5 [15.0] years; 90.4% white) but did not significantly differ with respect to sex, income, education, and relationship to the deceased. The vast majority of participants were spouses of the deceased (83.8%). The remaining participants (16.2%) were adult children, parents, or siblings of the deceased.

The data from the participants were compared with data from the 2005 US Census ( Table 1 ). 18 Compared with the US widowed population, the study participants were younger, more likely to be male, and a higher proportion were white. Compared with the US general population aged 25 years or older, the study participants were better educated and had a higher median household income.

The indicators of disbelief, yearning, anger, and acceptance of the death were assessed using single items obtained from the rater-administered version of the Inventory of Complicated Grief-Revised, formerly known as the Traumatic Grief Response to Loss. 19 Although it would have been preferable to use separate scales for the assessment of yearning, disbelief, anger, and acceptance of the death, no such scales exist for each of these grief stages. To maximize consistency across measures, single items were used for all grief phase indicators. Single-item interview screenings have proven remarkably accurate in the prediction of depression. 20 The frequency, rather than severity, of each grief indicator was used as the response format in the Inventory of Complicated Grief-Revised because frequency has proven to be a more effective means of evaluating the impact of events. 21 Grief phase indicators were measured using a 5-point Likert scale in which 1 equaled less than once per month; 2, monthly; 3, weekly; 4, daily; and 5, several times per day. These items showed moderately high correlations with the total Inventory of Complicated Grief-Revised score at baseline interview, which ranged in magnitude from 0.47 to 0.57 (all comparisons yielded P <.001). To enhance comparability in the measurement of each indicator, depression was assessed using the single-item depressed mood in the Hamilton Rating Scale for Depression. 22 The correlation between depressed mood and the total Hamilton Rating Scale for Depression score at baseline interview was 0.65 ( P <.001). To be consistent with the scale levels of other grief indicators, all levels of depressed mood were increased by 1 so that 1 indicated “absence of depressed mood” and 5 indicated “patient reports virtually only these feeling states in his spontaneous verbal and non-verbal communication.”

Individuals self-identified their racial/ethnic status according to the racial/ethnic categories defined in the US Census. 18 They also reported the cause of death for the family member or loved one. For deaths due to a terminal illness, the date of the diagnosis was recorded. Diagnoses of the terminal illness within 6 months (52/199; 26.1%) were compared with those 6 months or longer (147/199; 73.9%) prior to the death. Six months was used as the threshold because terminal diagnoses of less than 6 months resulted in smaller, less reliable groupings and elsewhere 16 , 17 it has been determined that 6 months is the time after which normal grief can be distinguished from complicated grief disorder.

Statistical analyses were conducted to test for significant differences in the magnitude of each of the 5 grief indicators within each of the 3 postloss periods (≤6 months [1-6 months category], >6 to ≤12 months [6-12 months category], and >12 to ≤24 months [12-24 months category]); to compare the pattern of changes in the absolute levels of each of the 5 grief indicators over time; and to determine when each of the 5 grief indicators achieved its maximum value.

Specifically, single-sample t tests and nonlinear, ordinary least squares regression analyses were used to examine the differences in magnitude between grief indicators at a given time postloss and changes in grief indicators as a function of time postloss. Single-sample t tests were used to examine within-person differences in magnitude between the 5 grief indicators postloss at 1 to 6 months, 6 to 12 months, and 12 to 24 months and within-person temporal changes in magnitude of each grief indicator postloss between 1 to 6 months and 6 to 12 months and between 6 to 12 months and 12 to 24 months.

Nonlinear, ordinary least squares regression analyses were used to model the trajectory of each grief indicator as a function of time postloss. Because the stage theory of grief predicts the sequential rise and fall of each of the grief indicators as a function of time postloss (ie, phase), we chose the following parametric functional form that would capture such phases:

Y  = [ A + B (− t / τ + 1)] exp (−½ t / τ ) + C

where Y represents the value of the grief indicator and the term t / τ represents time postloss with t scaled by the model parameter τ . The expression [ A + B (− t / τ + 1)] exp (−½ t / τ ) represents a linear combination of normalized (weighted) zero-order and first-order Laguarre polynomials, scaled by the model parameters A and B , respectively, included to capture the anticipated rise and fall in the data. Model parameter C represents the asymptotic value that the grief indicator approaches as time postloss increases to infinity. One observation per person (N = 233), selected randomly among those observations that contained complete data for each of the 5 grief indicators within 24 months postloss, was used to fit these regression models. For each grief indicator, the model parameters τ , A , B , and C were estimated by means of nonlinear, ordinary least squares regression implemented using PROC MODEL in SAS version 9.1 (SAS Institute Inc, Cary, NC). P  < .05 was considered significant.

A series of multivariable analyses of variance were conducted to evaluate whether demographic variables and report of diagnosis of terminal illness within 6 months of the death were significantly related to the 5 grief indicators or to the within-person differences between or temporal changes in the 5 grief indictors.

The means and SDs for the 5 grief indicators of disbelief, yearning, anger, depression, and acceptance postloss at 1 to 6 months, 6 to 12 months, and 12 to 24 months appear in Table 2 . Within each period, acceptance is greater than disbelief, yearning, anger, and depression; yearning is greater than disbelief, anger, and depression; and depression is greater than anger. Between 1 and 6 months postloss and 6 and 12 months postloss, disbelief and yearning decline and acceptance increases. From 6 to 12 months postloss and 12 to 24 months postloss, disbelief, yearning, anger, and depression decline and acceptance increases.

More specifically, acceptance is significantly greater than disbelief (1-6 months postloss: t 142  = 10.79, P <.001; 6-12 months postloss: t 208  = 23.16, P <.001; 12-24 months postloss: t 204  = 31.88, P <.001), yearning (1-6 months postloss: t 142  = 2.11, P  = .04; 6-12 months postloss: t 208  = 10.80, P <.001; 12-24 months postloss: t 204  = 19.39, P <.001), anger (1-6 months postloss: t 142  = 12.66, P <.001; 6-12 months post-loss: t 208  = 23.14, P <.001; 12-24 months postloss: t 204  = 35.24, P <.001), and depression (1-6 months postloss: t 142  = 11.64, P <.001; 6-12 months postloss: t 208  = 18.84, P <.001; 12-24 months postloss: t 204  = 29.97, P <.001).

Yearning is significantly greater than disbelief (1-6 months postloss: t 169  = 13.57, P <.001; 6-12 months postloss: t 210  = 15.57, P <.001; 12-24 months postloss: t 204  = 12.49, P <.001), anger (1-6 months postloss: t 170  = 16.43, P <.001; 6-12 months postloss: t 209  = 15.10, P <.001; 12-24 months postloss: t 204  = 12.43, P <.001), and depression (1-6 months postloss: t 170  = 14.40, P <.001; 6-12 months postloss: t 211  = 9.75, P <.001; 12-24 months postloss: t 204  = 9.41, P <.001).

Depression is significantly greater than anger (1-6 months postloss: t 173  = 3.61, P <.001; 6-12 months postloss: t 209  = 5.32, P <.001; 12-24 months postloss: t 204  = 3.16, P  = .002).

Disbelief is significantly greater than anger at 1 to 6 months postloss ( t 172  = 3.22, P  = .002); depression is significantly greater than disbelief at 6 to 12 months postloss ( t 210  = 5.22, P <.001) and at 12 to 24 months postloss ( t 204  = 2.19, P  = .03).

Between 1 and 6 months postloss and 6 and 12 months postloss, disbelief ( t 157  = 4.78, P <.001) and yearning ( t 156  = 7.89, P <.001) decline and acceptance increases ( t 130  = 3.91, P <.001). Between 6 and 12 months postloss and 12 and 24 months postloss, disbelief ( t 190  = 2.84, P  = .005), yearning ( t 191  = 5.96, P <.001), anger ( t 189  = 3.91, P <.001), and depression ( t 192  = 5.60, P <.001) decline and acceptance increases ( t 188  = 3.37, P <.001).

Figure 2 displays the results of the nonlinear regression analyses. According to the models displayed in the top part of Figure 2 , acceptance increases monotonically (uniformly in 1 direction), and is greater than each of the other grief indicators between 1 and 24 months postloss. Yearning increases between 1 and 4 months postloss, decreases between 4 and 24 months postloss, and is greater than disbelief, anger, and depression between 1 and 24 months postloss. Disbelief decreases monotonically between 1 and 24 months, is greater than anger between 1 and 6 months postloss, and is greater than depression between 1 and 4 months postloss. Depression increases between 1 and 6 months postloss, decreases between 6 and 24 months, is greater than disbelief postloss between 4 and 24 months, and is greater than anger between 1 and 24 months postloss. Anger increases between 1 and 5 months postloss and decreases between 5 and 24 months postloss. The close agreement between the models and the data in the top part of Figure 2 indicates that the phasic functional form specified in the regression models adequately represent the data.

The bottom part of Figure 2 displays the regression models following a rescaling procedure that constrains each grief indicator to fall within the interval of 0 through 1. In the top part of Figure 2 , the relative locations in time of the peaks of the grief indicators are obscured because the curves are not side by side, thereby making comparisons difficult. Those comparisons are facilitated in the bottom part of Figure 2 by placing all of the indicators on the same scale. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief. Given that there are 120 possible sequences of these 5 indicators, the probability that the observed sequence is exactly the sequence predicted by the stage theory of grief by chance alone is P  = .008.

Based on the results of the multivariable analyses of variance, the demographic factors of age, sex, race/ethnicity (white/nonwhite), education, and income and a terminal illness diagnosis reported within 6 months of the death were largely unrelated to within-person differences and temporal changes in the grief indictors throughout the study observation period (1-6, 6-12, and 12-24 months postloss). Education beyond high school was significantly associated with grief indicators 12 to 24 months postloss (Wilks λ = 0.94, F 5,199  = 2.52; P  = .03), due to its significant associations with lesser disbelief ( P  = .05) and depression ( P  = .003), and with greater acceptance ( P  = .02) during that period. Education beyond high school was also significantly associated with within-person differences in grief indicators 6 to 12 months postloss (Wilks λ = 0.95, F 4,204  = 2.51; P  = .04) and 12 to 24 months postloss (Wilks λ = 0.94, F 4,200  = 3.11; P  = .02) due to its significant associations with greater differences between acceptance and each of the other grief indicators during each of those periods. Widowhood (compared with loss of a parent, child, or sibling in this study group) was significantly associated with within-person differences in grief indicators 1 to 6 months postloss (Wilks λ = 0.93, F 4,135  = 2.51; P  = .05), due to its significant associations with a greater difference between yearning and depression ( P  = .02) and a lesser difference between acceptance and yearning ( P  = .01) during that period. Report of a terminal illness diagnosis within 6 months of the death was significantly associated with grief indicators 12 to 24 months postloss (Wilks λ = 0.93, F 5,172  = 2.62; P  = .03), due to its significant association with lower acceptance of the death ( P  = .008) during that period.

Results of this study identify normal patterns of grief processing over time following the natural death of a loved one. Given that the vast majority (94%) of deaths in the United States are the result of natural causes, 15 the findings reflect how the average person psychologically processes a typical death of a close family member. Although the temporal course of the absolute levels of the 5 grief indicators did not follow that proposed by the stage theory of grief, 14 when rescaled and examined for each indicator's peak, the data fit the hypothesized sequence exactly.

In terms of absolute frequency, and counter to the stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most often endorsed item. Evidently, a high degree of acceptance, even in the initial month postloss, is the norm in the case of natural deaths. This contrasts with individuals who survived a family member's traumatic death and those who met criteria for complicated grief disorder, 16 both groups of whom were found in preliminary analyses to have significantly lower levels of acceptance relative to the study sample. The lower frequency of acceptance of the death among participants who reported that the patient's terminal illness diagnosis was within 6 months compared with 6 months or longer prior to the death suggests that prognostic awareness may promote acceptance of the death. This result is consistent with findings reported elsewhere indicating that preparation for the death is associated with better psychological adjustment to the loss. 23 Future research that examines the effects of prospective rather than retrospective reports of prognostic awareness on the bereaved survivor's acceptance are needed before definitive conclusions can be drawn.

Yearning was the most frequent negative psychological response reported throughout the study observation period (1-6, 6-12, and 12-24 months postloss). Yearning was significantly more common than depressed mood despite the exclusive focus in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 24 bereavement section on depressive symptomatology: “As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness . . . The bereaved individual typically regards the depressed mood as ‘normal,’ . . . The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss.” 24 (p684) Findings from this report demonstrate that yearning, not depressive mood, is the salient psychological response to natural death. They indicate that depressive mood in normally bereaved individuals tends to peak at approximately 6 months postloss and does not occur prior to 2 months postloss. Findings elsewhere 25 , 26 indicate that chronically elevated levels of yearning are a cause for clinical concern. Taken together, these results imply a need for revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition with respect to bereavement.

Models that tested for phasic episodes of each grief indicator revealed that disbelief about the death is highest initially. As disbelief declined from the first month postloss, yearning rose until 4 months postloss and then declined. Anger over the death was fully expressed at 5 months postloss. After anger declines, severity of depressive mood peaks at approximately 6 months postloss and thereafter diminishes in intensity through 24 months postloss. Acceptance increased steadily through the study observation period ending at 24 months postloss. Because of the minuscule probability that by chance alone these 5 grief indicators would achieve their respective maximum values in the precise hypothesized sequence, 14 these results provide at least partial support for the stage theory of grief.

The results also offer a point of reference for distinguishing between normal and abnormal reactions to loss. Given that the negative grief indicators all peak within 6 months, those individuals who experience any of the indicators beyond 6 months postloss would appear to deviate from the normal response to loss. These findings also support the duration criterion of 6 months postloss for diagnosing complicated grief disorder, 16 , 17 , 19 , 25 or what is now referred to as prolonged grief disorder. 26 Unlike the term complicated , which is defined as “difficult to analyze, understand, explain,” 27 prolonged grief disorder accurately describes a bereavement-specific mental disorder based on symptoms of grief that persist longer than is normally the case (ie, >6 months postloss based on the results of the present study). Furthermore, prolonged grief disorder permits the recognition of other psychiatric complications of bereavement, such as major depressive disorder and posttraumatic stress disorder. Additional analyses are needed to examine grief trajectories among those meeting criteria for prolonged grief disorder.

The mode of death may be an important factor that influences the course of bereavement adjustment. In the present study, individuals bereaved by traumatic deaths (eg, vehicle crashes, suicide) were removed. Bereavement adjustment following deaths from traumatic causes may be more difficult to process and demonstrate higher degrees of disbelief and anger and lower levels of acceptance than those reported herein. A recent study found that those bereaved by traumatic vs natural deaths had greater difficulty in making sense of the loss. 28 Participants who reported that the family member or loved one's terminal illness was diagnosed within 6 months of the death did not differ significantly from other participants with respect to their level of grief indicators. However, the participants who reported the diagnosis within 6 months of the death did report acceptance of the death significantly less often. Subanalyses revealed that disbelief within 6 months postloss was also significantly higher in those for whom the patient's terminal illness diagnosis was reported to be within 6 months prior to death. Thus, the manner and forewarning of the death appear to affect the processing of grief. Studies are needed to explore the pattern of grief trajectories among the survivors bereaved by traumatic causes of death.

The results should be understood in light of several study limitations. Ideally, all individuals would have been assessed immediately after the loss rather than beginning at month 1 postloss. Due to respect for the initial mourning period and institutional review board concerns about harm to participants, we did not interview individuals within a month of the death. In addition, it would have been better to analyze data that reassessed individuals each month from 0 to 24 months postloss. However, no such data exist nor does the stage theory 1 - 5 specify in what month postloss each stage would predominate. And, although we acknowledge that other grief indicators might have been used, the various proxy measures (eg, stunned for disbelief, bitterness for anger, hopelessness for depression, quality of life scores for acceptance/recovery) all revealed remarkably similar patterns to those presented herein. We chose to present the items that fit most closely with the stage indicators illustrated in the literature. 14

It should be noted that participants were younger and less likely to be male compared with the study nonparticipants, and that the study sample may be more resilient than is typically the case given the low prevalence of depression (8.9% of the individuals had a Hamilton Rating Scale for Depression summary score of ≥17) compared with other samples of bereaved individuals. 29 - 31 Samples with more males or with older and more distressed individuals might reveal a different pattern of grief trajectories than those presented herein. Although the study sample does show some gross similarities with the US widowed population in terms of age, sex, and race / ethnicity, and with other comparable groups in terms of education and median household income, it is not directly representative of either the US widowed or US general population. Nevertheless, age, income, race / ethnicity, and sex were not significantly associated with the magnitude or course of grief and the representativeness of the Yale Bereavement Study would not appear to restrict the generalizability of the results to the US widowed population. Despite these limitations, given that the Yale Bereavement Study provides one of the most comprehensive longitudinal assessments of grief, these data are as adequate as any available for testing the stages of grief over time.

In conclusion, the results of this study provide what appears to be the first empirical examination of the stage theory of grief. They indicate that in the circumstance of natural death, the normal response involves primarily acceptance and yearning for the deceased. Each grief indicator appears to peak in the sequence proposed by the stage theory. Regardless of how the data are analyzed, all of the negative grief indicators are in decline by approximately 6 months postloss. The persistence of these negative emotions beyond 6 months is therefore likely to reflect a more difficult than average adjustment and suggests the need for further evaluation of the bereaved survivor and potential referral for treatment. The results provide an evidence base from which to educate clinicians (eg, primary and palliative care physicians, geriatricians, psychiatrists, oncologists, related hospital and hospice staff, bereavement counselors) and laypersons (eg, patients, family members, friends) about what to expect following the death of a family member or loved one.

Corresponding Author: Holly G. Prigerson, PhD, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, 44 Binney St SW, G440A, Boston, MA 02115 ( [email protected] ).

Author Contributions: Drs Maciejewski and Prigerson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design : Maciejewski, Prigerson.

Acquisition of data : Prigerson.

Analysis and interpretation of data : Maciejewski, Zhang, Block, Prigerson.

Drafting of the manuscript : Maciejewski, Zhang, Prigerson.

Critical revision of the manuscript for important intellectual content : Maciejewski, Zhang, Block, Prigerson.

Statistical analysis : Maciejewski, Zhang.

Obtained funding : Maciejewski, Prigerson.

Administrative, technical, or material support : Zhang, Prigerson.

Study supervision : Maciejewski, Block, Prigerson.

Financial Disclosures: None reported.

Funding/Support: This work was supported by grants MH56529 (awarded to Dr Prigerson) and MH63892 (awarded to Dr Prigerson) from the National Institute of Mental Health and grant CA106370 (awarded to Dr Prigerson) from the National Cancer Institute; and grant NS044316 (awarded to Dr Maciejewski) from the National Institute of Neurological Disorders and Stroke. Funding also was provided by the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, and Women's Health Research at Yale University.

Role of the Sponsors: The National Institute of Mental Health, National Cancer Institute, National Institute of Neurological Disorders and Stroke, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, and Women's Health Research at Yale University had no direct input into the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

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• The 5 Stages

How the Five Stages of Grief Can Help Process a Loss

Jodi Clarke, LPC/MHSP is a Licensed Professional Counselor in private practice. She specializes in relationships, anxiety, trauma and grief.

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

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• Next in The Stages of Grief Guide What to Know About the Denial Stage of Grief

If you or a loved one is dealing with loss , it can be helpful to learn more about the grieving process. Here we share the 5 Stages of Grief, along with a few ways to help someone who is grieving after a death or breakup.

It's important to remember that the grieving process can be complex, and it isn't the same for everyone. These steps may not be followed exactly, or other feelings may surface after you thought you were through the stages of grieving. Allowing room to experience grief in your own way can help you heal after loss.

What Are the 5 Stages of Grief?

The 5 Stages of Grief is a theory developed by psychiatrist Elisabeth Kübler-Ross. It suggests that we go through five distinct stages after the loss of a loved one. These stages are denial, anger, bargaining, depression, and finally acceptance.

In the first stage of the grieving process, denial helps us minimize the overwhelming pain of loss. As we process the reality of our loss, we are also trying to survive emotional pain. It can be hard to believe we have lost an important person in our lives, especially when we may have just spoken with them the previous week or even the previous day.

During this stage in grieving, our reality has shifted completely. It can take our minds time to adjust to our new reality. We reflect on the experiences we've shared with the person we lost, and we might find ourselves wondering how to move forward in life without this person.

This is a lot of information to explore and a lot of painful imagery to process. Denial attempts to slow this process down and take us through it one step at a time, rather than risk the potential of feeling overwhelmed by our emotions.

Denial is not only an attempt to pretend that the loss does not exist. We are also trying to absorb and understand what is happening.

The second stage in grieving is anger . We are trying to adjust to a new reality and are likely experiencing extreme emotional discomfort. There is so much to process that anger may feel like it allows us an emotional outlet.

Keep in mind that anger does not require us to be very vulnerable. However, it may feel more socially acceptable than admitting we are scared. Anger allows us to express emotion with less fear of judgment or rejection.

Anger also tends to be the first thing we feel when starting to release emotions related to loss. This can leave us feeling isolated in our experience. It can also cause us to be perceived as unapproachable by others in moments when we could benefit from comfort, connection, and reassurance.

When coping with loss, it isn't unusual to feel so desperate that you are willing to do anything to alleviate or minimize the pain. During this stage in grieving, you may try to bargain to change the situation, agreeing to do something in return for being relieved of the pain you feel.

When bargaining starts to take place, we often direct our requests to a higher power, or something bigger than us that may be able to influence a different outcome. Bargaining during the grieving process can come in the form of a variety of promises, including:

• "God, if you can heal this person, I will turn my life around."
• "I promise to be better if you will let this person live."
• "I'll never get angry again if you can stop him/her from dying or leaving me."

There is an acute awareness of our humanness in this stage of grieving; when we realize that there is nothing we can do to influence change or create a better end result.

Bargaining comes from a feeling of helplessness and gives us a perceived sense of control over something that feels so out of control. During bargaining, we tend to focus on our personal faults or regrets. We might look back at our interactions with the person we are losing and note all the times we felt disconnected or may have caused them pain.

It is common to recall times when we may have said things we did not mean and wish we could go back and behave differently. We also sometimes make the drastic assumption that if things had played out differently, we would not be in such an emotionally painful place in our lives.

During our experience of processing grief, there comes a time when our imaginations calm down and we slowly start to look at the reality of our present situation. Bargaining no longer feels like an option and we are faced with what is happening.

In this stage of grieving, we start to feel the loss of our loved one more abundantly. Our panic begins to subside, the emotional fog begins to clear, and the loss feels more present and unavoidable.

In those moments, we tend to pull inward as the sadness grows. We might find ourselves retreating, being less sociable, and reaching out less to others about what we are going through. Although this is a very natural stage in the grieving process, dealing with depression after the loss of a loved one can be extremely isolating and one of the most difficult stages.

If you or a loved one are struggling with depression, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area. For more mental health resources, see our National Helpline Database .

The last of the 5 Stages of Grief is acceptance. When we come to a place of acceptance , it is not that we no longer feel the pain of loss. Instead, we are no longer resisting the reality of our situation, and we are not struggling to make it something different.

Sadness and regret can still be present in this phase. But the emotional survival tactics of denial, bargaining, and anger are less likely to be present during this phase of the grieving process.

Click Play to Learn More About the Stages of Grief

This video has been medically reviewed by David Susman, PhD .

How Long Do Grief Stages Last?

There is no specific time period for any of these stages. One person may experience the stages quickly, such as in a matter of weeks, whereas another person may take months or even years to move through the stages of grieving. Whatever time it takes for you to move through these stages is perfectly normal.

As we consider the 5 Stages of Grief, it is important to note that people grieve differently . So, you may or may not go through each of these stages or experience them in order. The lines of the grieving process stages are often blurred. We may also move from one stage to another and possibly back again before fully moving into a new stage.

Your pain is unique to you, your relationship to the person you lost is unique, and the emotional processing can feel different to each person. Take the time you need and remove any expectations of how you should be performing as you work through the grieving process.

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Additional Grieving Process Models

Although the 5 Stages of Grief developed by Elisabeth Kübler-Ross is considered one of the most easily recognizable models of grief and bereavement, there are other models to be considered as well. Each one seeks to explain how grief may be perceived and processed.

These models can provide greater understanding to people who are hurting over the loss of a loved one. They can also be used by those in healing professions, helping them to provide effective care for grieving people who are seeking informed guidance.

Four Phases of Grief

Legendary psychologist John Bowlby focused his work on researching the emotional attachment between parent and child. From his perspective, early experiences of attachment with important people in our lives, such as caregivers, help to shape our sense of safety, security, and connections.

British psychiatrist Colin Murray Parkes developed a model of grief based on Bowlby's theory of attachment , suggesting there are four phases of mourning when experiencing the loss of a loved one:

• Shock and numbness : Loss in this phase feels impossible to accept. Most closely related to Kübler-Ross's stage of denial, we are overwhelmed when trying to cope with our emotions. Parkes suggests that there is physical distress experienced in this phase as well, which can lead to somatic or physical symptoms .
• Yearning and searching : As we process loss in this phase of grief, we may begin to look for comfort to fill the void our loved one has left. We might do this by reliving memories through pictures and looking for signs from the person to feel connected to them. In this phase, we become very preoccupied with the person we have lost.
• Despair and disorganization : We may find ourselves questioning and feeling angry in this phase. The realization that our loved one is not returning feels real, and we can have a difficult time understanding or finding hope in our future. We may feel a bit aimless during this portion of the grieving process and retreat from others as we process our pain.
• Reorganization and recovery : In this phase, we feel more hopeful that our hearts and minds can be restored. As with Kübler-Ross's acceptance stage, sadness or longing for our loved one doesn't disappear. However, we move toward healing and reconnecting with others for support, finding small ways to reestablish some normalcy in our daily lives.

7-Stage Model of Grief

Some suggest that there are seven stages in grieving instead of only four or five. This more complex model of the grieving process involves experiencing:

• Shock and denial . Whether a loss occurs suddenly or with some advanced notice, it's possible to experience shock. You feel emotionally numb and may deny the loss.
• Pain and guilt . During this stage in grieving, the pain of the loss starts to set in. You may also feel guilty for needing more from family and friends during this emotional time.
• Anger and bargaining . You may lash out at people you love or become angry with yourself. Or you might try to "strike a bargain" with a higher power, asking that the loss be taken away in exchange for something on your part.
• Depression and loneliness . As you reflect on your loss, you may start to feel depressed or lonely . It is in this stage in grieving that you begin to truly realize the reality of your loss.
• The upward turn . You begin to adjust to your new life, and the intensity of the pain you feel from the loss starts to reduce. At this point in the grieving process, you may notice that you feel calmer.
• Reconstruction and working through . This stage in grieving involves taking action to move forward. You begin to reconstruct your new normal, working through any issues created by the loss.
• Acceptance and hope . In this final stage of the grieving process, you begin to accept the loss and feel hope for what tomorrow might bring. It's not that all your other feelings are gone, just more so that you've accepted them and are ready to move on.

How to Help Someone Who Is Grieving

It can be difficult to know what to say or do when someone has experienced loss. We do our best to offer comfort, but sometimes our best efforts can feel inadequate and unhelpful.

Here are a few tips to keep in mind if someone you love is going through the stages in grieving:

• Avoid rescuing or fixing . In an attempt to be helpful, we may offer uplifting, hopeful comments or even humor to try to ease their pain or "fix them." Although the intention is good, this approach can leave people feeling as if their pain is not seen, heard, or valid.
• Don't force it . We may want so badly to help and for the person to feel better, so we believe that nudging them to talk and process their emotions before they're truly ready will help them faster. This is not necessarily true and can actually be an obstacle to their healing.
• Make yourself accessible . Offer space for people to grieve. This lets the person know we're available when they're ready. We can invite them to talk with us but remember to provide understanding and validation if they are not ready just yet. Remind them that you're there and not to hesitate to come to you.

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Resources for People in Stages of Grieving

Several organizations provide information or assistance for people going through the grieving process. Regardless of where you are in the stages in grieving, you may find help via entities such as:

• AARP , for articles on grief and loss
• Grief.com , which covers all types of grief, also providing grief workshops and access to free resources
• HOPE for Bereaved , for anyone who has experienced loss through death
• Hospice Foundation of America , grief support before, during, and after a loved one's death
• OptionB , for people who want to bounce back after a painful experience
• The Compassionate Friends , help for people who've lost a child

It is important to remember that everyone copes with loss differently. While you may experience all five stages of grief, you might also find that it is difficult to classify your feelings into any one of the stages. Have patience with yourself and your feelings in dealing with loss.

Allow yourself time to process all your emotions, and when you are ready to speak about your experiences with loved ones or a healthcare professional, do so. If you are supporting someone who has lost a loved one, such as a spouse or sibling , remember that you don't need to do anything specific. Simply allow them room to talk when they are ready.

University of Rochester Medical Center. Grief and loss: The process of healing .

Newman L. Elisabeth Kübler-Ross .  BMJ . 2004;329(7466):627.

Stroebe M, Schut H, Boerner K. Cautioning health-care professionals: Bereaved persons are misguided through the stages of grief .  Omega (Westport) . 2017;74(4):455–473. doi:10.1177/0030222817691870

Cassidy J, Jones JD, Shaver PR. Contributions of attachment theory and research: a framework for future research, translation, and policy .  Dev Psychopathol . 2013;25(4 Pt 2):1415–1434. doi:10.1017/S0954579413000692

Parkes CM. Bereavement in adult life .  BMJ . 1998;316(7134):856–859. doi:10.1136/bmj.316.7134.856

By Jodi Clarke, MA, LPC/MHSP Jodi Clarke, LPC/MHSP is a Licensed Professional Counselor in private practice. She specializes in relationships, anxiety, trauma and grief.

Can We Retrieve What’s Lost in Grief?

A critique of the "stages of grief.".

Posted April 16, 2024 | Reviewed by Abigail Fagan

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This post is a review of Grief Is For People . By Sloane Crosley. Farrar, Straus and Giroux. 191 pp. $27.

On July 27, 2019, Russell Perrault, Executive Director of Publicity at Vintage Books, Alfred A. Knopf Inc., took his dogs for a walk, checked on his beloved chickens, returned to his farmhouse in Connecticut, watched some television, walked to the barn and took his own life. According to Sloane Crosley, who worked for Perrault at Vintage Books and considered him her closest friend, the 52-year-old man had no history of depression . A year earlier, she recalls, after she had broken up with a boyfriend and a colleague at Knopf had died by suicide , Russell had texted her: “Let’s make a deal. No killing yourself without my approval first. I’ll do the same.” Crosley knew Russell had faced allegations of sexual harassment, was disillusioned with office life, and may have become estranged from his partner. She could identify no evidence, however, that he had given up on life.

In Grief Is For People , Crosley, the author of two novels and three collections of essays, provides a beautifully written, illuminating, mordant and moving meditation on her experience of loss and its aftermath.

Disgusted by “the universal truths of grief, by the platitudes,” Crosley doesn’t want to go through “its stages.” Because Russell was not her relative and she had not slept with him, Crosley learns, people she knows expect her grief to subside. Initially manageable, however, it soon “colonizes” her entire personality . She fantasizes about going to Connecticut and seeing Russell on the train platform. Therapy “seems futile, as does travel, nature, sleep, television, music, comedy, theater, art, cooking, exercise, reading, and sex.” When friends suggest she take up a hobby, she maintains she already has one: “drilling down to the core of Russell’s suicide.”

Crosley attributes her “grief overload” to a coincidence. A month before Russell killed himself, a thief broke into her apartment, stole jewelry that once belonged to her grandmother, and stole her sense of security. Put in the category of a smashed car windshield, jewelry heists, she points out, are often dismissed entirely. And unlike a suicide, a burglary has a villain and the possibility of restitution. But she tells herself that if she can get the jewelry back, she can get her friend back as well: “I would sooner be separated from this logic than from my own skin.” Nor can she ever think about the jewelry without seeing Russell holding it.

When the pandemic hit New York City, Crosley writes, she should have been prepared “to deal with the phantasmagoria of the missing. Missing objects. Missing people.” But “the catch” was that, at the outset, “nothing was actually gone. Not yet.” Anxiety , she suggests, involves “mourning what isn’t gone yet.” COVID-19 stimulated relief that Russell had been spared the experience, but also frustration at being robbed of his reaction to it. Told “no one knows how to behave,” Crosley imagines, Russell would have replied, “Have they ever?” and returned to his book.

These days, it appears, Crosley understands, with George Sand, “that we cannot tear a single page from our lives, but we can burn the whole book.” And with Albert Camus, that “there is only one liberty, to come to terms with death. After which everything is possible.” Crosley now says she has come to terms. But “the years have done nothing to dull the missing.” Nor has she completely stopped trying to treat the suicide “as a freak accident,” robbing Russell of control when she really wanted to absolve him from blame. And, perhaps, assuage resentment she may feel for his failure to confide in her. Most of all, Crosley continues to ponder “the biggest riddle of all”: how to keep her friend buried and with her at the same time.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.

Glenn C. Altschuler, Ph.D. , is the Thomas and Dorothy Litwin Professor of American Studies at Cornell University.

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7 Books on Navigating Grief

Psychologists, counselors and other experts share the titles they recommend most.

By Hope Reese

Joanna Luttrell is well acquainted with grief. The bereavement coordinator supports families that are navigating a child’s terminal illness at St. Jude’s Children’s Hospital in Memphis.

From the moment they receive a diagnosis until a year after the loss, “I send letters, resources, emails,” Ms. Luttrell said, so that families know they have support. A big part of the process, she added, involves sharing books.

If there’s a “challenging relationship or situation, I might send out a book right away,” she said. “If they’re looking to process their experience, and their emotional response to their experience, I will send one a bit later.”

While grief is universal, it’s complicated and highly individualized, Ms. Luttrell said. Reading books can provide perspective and help mourners feel less alone, she has found.

We asked Ms. Luttrell, as well as counselors, psychologists and other experts on loss, to recommend the most helpful books about grief.

1. Understanding Your Grief , Alan D. Wolfelt

Among the experts we spoke to, nearly all cited Alan Wolfelt, the founder of the Center for Loss and Life Transition, as their No. 1 author on grief.

In this book, first published in 1992, Dr. Wolfelt offers concrete steps toward healing. He helps people who have just lost someone and are having trouble thinking straight understand that “there’s nothing wrong with them,” said Audri Beugelsdijk, vice president of survivor services at the Tragedy Assistance Program for Survivors.

Dr. Wolfelt’s presentation of the material is “comprehensive, easy to read, and accessible to the general audience,” Ms. Luttrell said. “It’s easy to get overwhelmed when you are already emotionally challenged. So reading a little bit at a time can be very helpful as you work through your grief.”

2. It’s OK That You’re Not OK , by Megan Devine

In this accessible book, published in 2018, Megan Devine, a therapist and bereaved partner, offers stories, research and advice to people who are navigating grief, as well as those who support them.

She also unpacks the myth that we need to “fix” grief, said Andy McNiel, senior adviser of youth programs at Tragedy Assistance Program for Survivors. “In our society, we’re very one-dimensional in the way we talk about our experiences,” he said. “You’re either OK or you’re not OK. And the reality is, you can be OK and not OK at the same time.”

3. Man’s Search for Meaning , by Viktor E. Frankl

When the psychiatrist Viktor Frankl was imprisoned in Nazi death camps during World War II, he made a conscious effort to survive by observing, taking notes and reflecting on his higher purpose. In 1946, he published these reflections on survival in “Man’s Search for Meaning.”

This book is “truly a classic,” said Dr. David Spiegel, a medical director at the Center for Integrative Medicine at Stanford University School of Medicine. “Frankl reminds us that when we cannot change our situation, our choices still matter.”

4. A Heart That Works , by Rob Delaney

Rob Delaney’s son was diagnosed with a brain tumor as a 1-year-old and died two and a half years later. In this 2022 title, Mr. Delaney, a comedian known for his role on the Amazon Prime series “Catastrophe,” explores the full range of his emotional journey during these years and in the aftermath of the loss.

Ms. Luttrell recommends the book often to grieving families because “it’s hard to find good books from a father’s perspective,” she said. “If you’re working with a profoundly grieving father, or a man who just lost his wife, or just wants to talk to another man, having that male perspective is really, really helpful,” she said.

5. Notes on Grief , by Chimamanda Ngozi Adichie

In the summer of 2020, Chimamanda Ngozi Adichie’s father died. Less than a year later, the acclaimed novelist published this memoir, sharing her personal experience of grief.

“This book is relatable to readers who are in the depths of grief, who are trying to process their own feelings and their embodied experiences around the loss of a loved one,” said Michelle Peterie, a sociologist and researcher at the University of Sydney.

Ms. Adichie conveys that “grief is a physical experience as much as it is just an emotional experience,” Dr. Peterie said. “Adichie talks about pounding the floor with her fists and about her heart beating so fast and seeming like it’s going to run away from her. ”

“We experience grief in our bodies,” she said, “and Adichie does a really good job of capturing that.”

6. The Year of Magical Thinking , by Joan Didion

This 2005 title, from one of America’s most renowned writers is “a window into what living with grief day in, day out, is really like,” said Amber Jeffrey, host of “The Grief Gang” podcast.

“It’s really hard to quantify that first year — couple of years — after a loss, to explain the kind of delusional thoughts you have without sounding completely mad,” she said. “This book does that.”

“The Year of Magical Thinking” also helped Ms. Beugelsdijk, who now works with the families of veterans, through her own personal loss. “My version of magical thinking is that my husband is still on deployment. He’s going to come back and I’m going to be OK.”

The book also challenges the notion that the first year after a death is the hardest, Mr. McNiel said. “In reality, in the first year, there’s a lot of unknowns and sometimes just denial and struggle,” he said. “The second year sets in, and many people say that that’s when their grief is the most intense.”

7. Sad Book , by Michael Rosen, illustrated by Quentin Blake

When Michael Rosen’s 18-year-old son, Eddie, died of meningitis, he teamed up with Quentin Blake, an illustrator most known for his work with Roald Dahl, to create a picture book called the “Sad Book.” The book, published in 2004, can be illuminating for both children and adults who are grieving a loved one.

“There’s something about grief that’s really hard to articulate,” Dr. Peterie said. This book “captures something really fundamental about grief as a lived and felt experience, because it’s not purely dependent on words.” The medium allows grieving people to “have part of their experience echoed back to them,” she said.

Coping With Grief and Loss

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A New Diagnosis: Prolonged grief disorder, a new entry in the American Psychiatric Association’s diagnostic manual, applies to those who continue to struggle long after a loss .

The Biology of Grief: Grief isn’t only a psychological experience. It can affect the body too, but much about the effects remains a mystery .

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Grieving the Loss of a Pet:   Counseling. Grief-group sessions. The number of resources for coping with a pet’s death  has grown in recent years.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Kubler-ross stages of dying and subsequent models of grief.

Patrick Tyrrell ; Seneca Harberger ; Caroline Schoo ; Waquar Siddiqui .

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Last Update: February 26, 2023 .

• Continuing Education Activity

Medical professionals will work with dying patients in all disciplines, and the process is difficult as care shifts from eliminating or mitigating illness to preparing for death. This is a difficult transition for patients, their loved ones, and healthcare providers to undergo. This activity provides paradigms for the process of moving toward death as well as a discussion of how they should and should not be applied, supporting the interprofessional team to address the unique needs of their patients and guide them and their loved ones through the process.

• Describe the five stages of death, as outlined by Elisabeth Kubler-Ross.
• Describe alternative paradigms for experiencing death and grief, in addition to those introduced by Kubler-Ross.
• Explain the potential underlying process generating these outwardly demonstrated stages to provide a context for supporting patients, families, caregivers, and healthcare providers experiencing death.
• Outline interprofessional team strategies for improving care coordination and communication in a dying patient.
• Introduction

Medical professionals in all disciplines work with dying patients, and doing so effectively can be difficult. In the context of death and dying, patients, their loved ones, and the health care team must shift their goals. Where treating acute and chronic illness usually involves finding a tolerable path to eliminating or preventing the progression of a condition, treating terminal illness must involve preparing for death as well as efforts to mitigate symptoms. [1]  Understanding the experience of dying and grief allows providers to support the unique needs of patients, their loved ones, and other healthcare team members. [2] [3] [4]

Dr. Elizabeth Kubler-Ross introduced the most commonly taught model for understanding the psychological reaction to imminent death in her 1969 book, On Death and Dying. The book explored the experience of dying through interviews with terminally ill patients and outlined the five stages of dying: denial, anger, bargaining, depression, and acceptance (DABDA). This work is historically significant as it marked a cultural shift in the approach to conversations regarding death and dying. Prior to her work, the subject of death was somewhat taboo, often talked around or avoided altogether. Dying patients were not always given a voice or choices in their care plan. Some were not even explicitly told about their terminal diagnosis. Her work was popular in both the medical and lay cultures and shifted the nature of conversations around death and dying by emphasizing the experience of the dying patient. [4] [5]  This led to new approaches to working with patients through the final phase of life. She highlighted the importance of listening to and supporting their unique experiences and needs and spurred new perspectives on ways practitioners can support terminally ill patients and their family members in adjusting to the reality of impending death. [6]

Kubler-Ross and others subsequently applied her model to the experience of loss in many contexts, including grief and other significant life changes. Though the stages are frequently interpreted strictly, with an expectation that patients pass through each in sequence, Kubler-Ross noted that this was not her contention and that individual patients could manifest each stage differently, if at all. The model, which resulted from a qualitative and experiential study, was purposely personal and subjective and should not be interpreted as natural law. Rather, the stages provide a heuristic for patterns of thought, emotions, and behavior, common in the setting of terminal illness, which may otherwise seem atypical. [7]  Facility with these patterns can help health care providers provide empathy and understanding to patients, families, and team members for whom these patterns may cause confusion and frustration. [6]

Kubler-Ross's Five Stages of Dying

Denial  is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that patients would often reject the reality of the new information after the initial shock of receiving a terminal diagnosis. Patients may directly deny the diagnosis, attribute it to faulty tests or an unqualified physician, or simply avoid the topic in conversation. While persistent denial may be deleterious, a period of denial is quite normal in the context of terminal illness and could be important for processing difficult information. In some contexts, it can be challenging to distinguish denial from a lack of understanding, and this is one of many reasons that upsetting news should always be delivered clearly and directly. However, unless there is adequate reason to believe the patient truly misunderstands, providers do not need to repeatedly reeducate patients about the truth of their diagnosis, though recognizing the potential confusion can help balance a patient's right to be informed with their freedom to reconcile that information without interference.

Anger  is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed at blaming medical providers for inadequately preventing the illness, family members for contributing to risks or not being sufficiently supportive, or spiritual providers or higher powers for the diagnosis' injustice. The anger may also be generalized and undirected, manifesting as a shorter temper or a loss of patience. Recognizing anger as a natural response can help health care providers and loved ones tolerate what might otherwise feel like hurtful accusations. However, they must take care not to disregard criticism that may be warranted by attributing them solely to an emotional stage. [8]

Bargaining typically manifests as patients seeking some measure of control over their illness. The negotiation could be verbalized or internal and could be medical, social, or religious. The patients' proffered bargains could be rational, such as a commitment to adhere to treatment recommendations or accept help from their caregivers, or could represent more magical thinking, such as efforts to appease misattributed guilt they may feel is responsible for their diagnosis. While bargaining may mobilize more active participation from patients, health care providers and caregivers should take care not to mislead patients about their own power to fulfill the patients' negotiations. Again, caregivers and providers do not need to repeatedly correct bargaining behavior that seems irrational but should recognize that participating too heartily in a patient's bargains may distort their eventual understanding.

Depression is perhaps the most immediately understandable of Kubler-Ross's stages, and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain. While the patient's actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages. Consequently, caregivers may need to make a conscious effort to restore compassion that may have waned while caring for patients progressing through the first three stages.

Acceptance  describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may focus on enjoying the time they have left and reflecting on their memories. They may begin to prepare for death practically by planning their funeral or helping to provide financially or emotionally for their loved ones. It is often portrayed as the last of Kubler-Ross's stages and a sort of goal of the dying or grieving process. While caregivers and providers may find this stage less emotionally taxing, it is important to remember that it is not inherently more healthy than the other stages. As with denial, anger, bargaining, and depression, understanding the stages has less to do with promoting a fixed progression and more to do with anticipating patients' experiences to allow more empathy and support for whatever they go through. [4] [5] [6] [7]

• Issues of Concern

Criticisms of the Kubler-Ross Model 

The DABDA model has been increasingly criticized in recent years. The model has both historical and cultural significance as one of the most well-known models for understanding grief and loss. Many alternative models have been developed based at least in part on the original DABDA model. The principal criticisms of Kubler-Ross's stages of death and dying are that the stages were developed without sufficient evidence and are often applied too strictly. Kubler-Ross and her collaborators developed their ideas qualitatively through in-depth interviews with over two hundred terminally ill patients. [7]

Critics have focused on the fact that her research and use of "stages" have not been empirically validated. It is also said that the concept of "stages" is applied too rigidly and linearly. Instead, she aimed to describe a set of behaviors and emotions that may be experienced by a patient facing the end of life, and by describing them, improve understanding for both the patient and caregivers. Another important criticism of the model arises when it is viewed as prescriptive rather than descriptive, indicating that a patient must move through each stage to reach the final goal of "acceptance." This view holds many assumptions, including that progression through the stages is linear and that some stages are inherently less adaptive than others. Caregivers may view their job as helping a patient move through each stage, for example, moving through denial or anger onto more easily palatable stages such as bargaining or acceptance. Attempting to push the patient through the stages has the potential to cause harm, as they need to process their grief in their unique way. Dr. Kubler Ross and others have reminded readers that many patients will experience the stages fluidly, often exhibiting more than one at a time and moving between them in a non-linear fashion. It is also important to note that each stage can serve a protective role, and each patient will have a unique experience in their grief process. [4] [6]

Other Models of Grief

Four additional models of grief will be described below.

Bowlby and Parkes' Four Phases of  Grief

Bowlby and Parkes proposed a reformulated theory of grief based in the 1980s. Their work is based on Kubler-Ross's model and describes four phases of grief. It emphasizes that the grieving process is not linear. 

Shock and Disbelief 

The initial phase replaced the term "denial" due to negative connotations. In this phase, the reality becomes altered as the mind responds to a stressful situation by becoming unresponsive or numb to the new situation. Over time, the mind processes the new reality, and the patient moves to a new phase.

Searching and Yearning

This phase is closely related to the Anger and Bargaining stage of the DABDA model. The patient will attempt to undo the new reality and question the reason for it. 

Disorganization and Repair 

This phase closely relates to the Depression stage of the DABDA model. The patient experiences full acceptance of the new reality. They show signs of depression and apathy. 

Rebuilding and Healing 

In this phase, the patient experiences a "renewed sense of identity," which represents overcoming the sense of loss and beginning to feel in control of their destiny. They no longer show signs of depression. 

Worden's Four Basic Tasks In Adapting To Loss

Worden's model of grief does not rely on stages but instead notes that the patient must complete four tasks to complete bereavement. These tasks do not occur in any specific order. The grieving person may work on a task intermittently until it is complete. This model applies to the grief of a survivor but may also be applied to a patient facing death.

Accepting Reality of Loss

Initially, the patient may have difficulty accepting the reality of impending death. Typically, acceptance is viewed as being ready to move forward with the process of preparing for death.

Experiencing Pain of Grief 

Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel "normal" again.

Adjusting to Environment 

An all-consuming focus on impending death will cause the patient to ignore other roles in life that are important to them. The patient will typically resume daily activities such as restarting work or hobbies or becoming engaged as a spouse or parent to complete this task.

Redirecting Emotional Energy

This task is generally applicable to grieving survivors. Survivors redirect their emotional energy from suffering the loss of a loved one to engaging in new activities that bring pleasure and new experiences. Subsequent theories on grieving have transitioned from stages and tasks of grief to more experiential and narrative methods. 

Wolfelt's Companioning Approach to Grieving

Wolfelt's companioning approach views grief as a natural extension of the ability to give and receive love. As such, grief is not something to avoid but should be fully experienced and even embraced in the path to healing. The grieving person must feel their grief and learn to incorporate it into their ongoing lives. A person supporting the bereaved serves as a witness and companion alongside the bereaved as they walk through their grief journey. Wolfelt states, "Companioning is about going to the wilderness of the soul with another human being; it is not about thinking you are responsible for finding the way out." [9] [10] [9]

There are no tasks to complete, and no focus is placed on "fixing" the grief. However, he does describe six "needs of grief" or mourning that are more experiential. He acknowledges the need for grief to be both experienced and expressed, confronting the reality of the loss in tolerable doses. The bereaved must lean into or embrace the pain of the loss while focusing on self-compassion and self-care. He includes a narrative component as the bereaved transition their relationship with the departed from one of presence to one of memory and the need to explore their new identity in living without their lost beloved. They find a sense of meaning or peace with the loss and possibly confront their spiritual beliefs and framework while doing so. They also need to explore the positive aspects of their new identity after the loss. Finally, he also stresses the need to develop a support system that will encourage the bereaved toward self-compassion as grief resurges over the coming months and years. [9]  

Neimeyer's Narrative and Constructivist Model

Neimeyer views grieving as a process of meaning-making. He acknowledges that people co-construct their understanding of reality through a narrative of their own life stories, influenced by their beliefs and world views. He describes "six key realities influenced by death." In these six realities, he acknowledges that significant loss can validate or invalidate a person's framework and beliefs in life. It may require developing a new framework to heal and incorporate the loss into their worldview. Grief is simultaneously universal and unique, so the therapy for the bereaved must be tailored to each client's individual needs. The process of griefing is inherently an active rather than passive period, filled with decision-making and reconstruction both practically and existentially. 

Emotions during the grieving period are useful and can serve as guides in the process of reconstructing a sense of balance and meaning in life after the disruption caused by significant loss. Reconstructing an identity after a significant loss is an inherently social process, as the new identity is in part defined in relation to their community and social norms. And finally, adapting to loss involves finding a way to incorporate the loss into a new identity and self-narrative, giving the loss a sense of meaning, and making sense of the changes. This can enable not only survival after a loss but eventual thriving. [9] [11]  

Therapists using the narrative and constructivist model may have patients re-tell the story of their loss with visual aids exploring the thoughts and feelings that accompany the story. They may also suggest writing a goodbye letter to the deceased or exploring their feelings through metaphors. 

• Clinical Significance

The transition in care, from attempting to heal the patient to caring for them near death, can be difficult for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead patients, and their loved ones, to feel they are being abandoned as they near death. They often wish for guidance on the complex changes that the patient is going through emotionally and physically. Actions that are a normal part of the dying process, such as anger and refusing visitors, can leave loved ones confused and upset. Understanding the stages of grief allows providers to give support and guidance during the dying process. The explanations provided by medical caregivers hold particular importance for patients and family members as they seek to understand and subsequently make sense of terminal illness. These key moments of communication and connection can be pivotal in the process of making sense of and healing from significant loss. [12] [13]  Facility with the grieving process is also imperative for the healing and resiliency of medical caregivers as they navigate through grief alongside their patients. [14]

• Enhancing Healthcare Team Outcomes

For the healthcare team, caring for patients near death can be uniquely challenging for everyone involved. Healthcare providers sometimes feel as if "their job is done" as they can no longer heal the patient and "drop out" of the patient's care. This can lead to patients and their loved ones feeling abandoned by the healthcare team as they near death. [15] They often wish for guidance emotionally and physically. This is where an end-of-life interdisciplinary team can be very helpful. Physicians can provide clarity on diagnostic and prognostic information. Pharmacists participate by dispensing appropriate comfort medication in a timely fashion by working directly with the nursing staff. Hospice care providers, including social workers and nursing staff, can provide counsel, administer comfort care, deliver emotional support, and empathize with both the patient and the family. The healthcare team should possess an understanding of the models for grief, which allows providers to give support and guidance during the dying process and provides a coordinated effort to provide the patient and family with much-needed emotional support. [Level 5]

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Disclosure: Patrick Tyrrell declares no relevant financial relationships with ineligible companies.

Disclosure: Seneca Harberger declares no relevant financial relationships with ineligible companies.

Disclosure: Caroline Schoo declares no relevant financial relationships with ineligible companies.

Disclosure: Waquar Siddiqui declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Tyrrell P, Harberger S, Schoo C, et al. Kubler-Ross Stages of Dying and Subsequent Models of Grief. [Updated 2023 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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