the impact of the so-called stages of grief
DESCRIPTION
Dangers and misinterpretations of the stages of dying by Elisabeth Kubler-Ross, by Brian Andrew Wong, Marshall University student. Friday, April 29, 2011.TRANSCRIPT
1 STAGES OF GRIEF
Running Head: STAGES OF GRIEF
The Impact of the So-Called Stages of Grief
By
Brian A. Wong
Marshall University
ENG 102 – English Composition II
Section 201
Instructor: Jeanne M. Hubbard
Friday, April 29, 2011
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The Impact of the So-Called Stages of Grief
Many have heard of the so-called stages of grief which a person experiences after the
death of someone else. However, few people know about the history of the stage theory. There
has been no valid research on this theory. Looking at grief over the death of someone as stages
has caused grievers to think that time will heal their emotions and can lead to further issues;
there are no stages of post-loss grief.
Death and grief are universal experiences that we all face, yet many neglect to talk about
them until the loss occurs and they become overwhelmed. According to James & Friedman
(2009) very little is known about grief recovery and unresolved grief can impact a griever’s
capacity for happiness. Grief is “the normal and natural reaction to loss of any kind” and “the
conflicting feelings caused by the end of or change in a familiar pattern of behavior” (p. 3).
Given that definition, we are all grievers. Despite the universality of grief, we know little about
recovering from grief. Anthropologist Margaret Meade has said, “When someone is born we
rejoice, when someone is married we celebrate, but when someone dies, we pretend that nothing
happened” (qtd in Groves & Klauser, 2009, p. 17). When families know that their loved one is
going to die, for example in hospice or palliative care, they experience anticipatory grief.
Anticipatory grief is grief for “losses that have already occurred as a result of the illness and
those that are occurring” (Pomeroy & Garcia, 2009, p. 28).
Kubler-Ross (1969) interviewed two-hundred patients who were told by their doctors that
their illness was no longer treatable. She came up with a stage theory of emotions experienced by
one who has been diagnosed with a terminal illness. It was her theory that the dying patient goes
through these emotional stages: Denial and Isolation, Anger, Bargaining, Depression, and
Acceptance. (For this paper, Bargaining and Depression will not be discussed.)
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Kubler-Ross saw behaviors of patients that indicated that they were in denial of their
diagnosis. She asserted that in every patient exists a need for denial and that for some dying
patients their first reaction may be numbness or shock. One of the patients interviewed was
convinced that the X-rays were mistaken for that of another patient. That patient soon left the
hospital seeking a doctor who could confirm that she was not ill. Upon each diagnosis from each
doctor the patient insisted again and again that the test results were mixed up. This denial is a
temporary defense, to be replaced soon with partial acceptance and that it “functions as a buffer
after unexpected shocking news, allows the patient to collect himself and, with time, mobilize
other, less radical defenses” (Kubler-Ross, 1969, p. 35). There is a less chance of denial and use
of “radical defense mechanisms” if the patient is adequately told about the illness and has the
time to “gradually acknowledge the inevitable happening” and how the patient has learned to
cope with stressful situations (p. 37). She noted that for most patients, denial is not used to a
great extent; the dying patients may “talk about the reality of their situation” (p. 37).
With anger, the patient is unable to remain in denial. Denial is replaced by anger, envy,
rage, and resentment. Not many of those around the dying person place themselves in the
position of the patient to discern the origin of the anger. The anger in the patient seems, from the
family’s point of view, difficult to cope with. The patients then get angry at the hospital staff;
their wishes are not respected or they are in the hospital for too long. The patient can also
rationalize their anger. One patient interviewed complained about the nurses keeping the bedrails
up. The nurse was angry as well but explained to him the safety reasons for why the bedrails
were up (Kubler-Ross, 1969).
For acceptance, when the dying patient received enough time to process their impending
death, that patient would eventually be neither angry nor depressed. The patient will then
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experience their own form of anticipatory grief, mourning “the impending loss of so many
meaningful people and places” (Kubler-Ross, 1969, p. 99). This stage is not to be misunderstood
for being a happy stage. The dying patient will begin to increase her or his amount of sleep and
has found acceptance and peace. Since the patient accepts her or his death, the patient might take
a turn for the worse. Visitations may be limited, not desired. Communication between others and
the dying patient become nonverbal (Kubler-Ross, 1969).
The stages of dying model, which has morphed into the stages of grieving, has been used
and commonly accepted by practitioners, people in academia, medical school, and television and
become like a prescription (Friedman & James, 2008; DeSpelder & Strickland, 2005). Often
when a tragic event occurs, many often hear of Kubler-Ross’s stages (Konigsberg, 2011;
Friedman & James, 2008). James & Friedman talk about the dangers of Kubler-Ross’s stages for
the dying being used for the grievers after a loss occurred. When someone goes to a grief support
group or counseling for loss, they tell the therapist that a loss has occurred. They may say, “My
mother died.” At The Grief Recovery Institute, James and Friedman see many grievers who tell
them that a death occurred. There is no sign of denial if the griever said this (Friedman & James,
2008; James & Friedman, 2009). Grievers have been to mental health professionals who have
strongly suggested that they were in denial even when they made it clear to the therapist that a
death has occurred (Friedman & James, 2008; James & Friedman, 2009). A griever goes through
six processes through three phases. The first phase and process is to acknowledge the death
(Rando, 1993; Worden, 2002). Often, the therapist sees the griever after the funeral. So would
going to a grief counselor indicate that a death has not happened? When the therapist does not
listen to the client, trust is breached and clients often terminate therapy soon. Another
misperceived sign of denial is when a griever says “I still cannot believe he’s gone” and
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“although disbelief may reflect the emotions of a broken heart, it is really a figure of speech
rather than a statement that a death didn’t happen” (Friedman & James, 2008, p. 39). Often
feelings of numbness are mistaken for denial (James & Friedman, 2009). It is normal to express,
“I can’t believe…” (Blau, 2008, p. 530). One way I like to think of this is when you are at the
dentist having a tooth pulled and the dentist administers Novocain. Are you in denial that a
dental procedure is taking place? Kubler-Ross & Kessler (2005) wrote that “for a person who has
lost a loved one, however, the denial is more symbolic than literal” (p. 8). Friedman & James
(2008) ask, “If denial is merely symbolic rather than literal, why call it a stage?” (p. 39). After a
death of a loved one, when caring family members notify others within the next 24 hours that the
death occurred, this does not show any denial that a death has occurred.
There is sometimes no anger at all, according to James & Friedman (2009). The
circumstances surrounding the death are often the source of the griever’s anger. Anger is often a
“factor in our difficult relationships” with the person who died and presuming that there is
always anger in grief is “both incorrect and dangerous” (James & Friedman, 2009, p. 12). The
family and the deceased person might not have had a chance to resolve past conflicts between
each other. Often there is unfinished business, especially with sudden deaths (James & Friedman,
2009; Worden, 2002). When viewed as a stage, the griever is at a standstill. Implying that the
emotion and feeling is a stage will make the griever wait and they will still feel the same, waiting
for time (Friedman & James, 2008). “There are no stages of grief. But people will always try to
fit themselves into a defined category if one is offered to them. Sadly, this is particularly true if
the offer comes from a powerful authority such as a therapist, clergyperson, or doctor” (James &
Friedman, 2009, p. 14).
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An empirical research study was performed by Maciejewski, Zhang, Block, and
Prigerson (2007) in Connecticut from one month to two years post-loss. Three-hundred
seventeen individuals participated in this study. The Inventory of Complicated Grief Revised
was used to measure the grief. The frequency of each grief indicator (denial, anger, etc.) was
recorded. Periods from 1 month to 6 months, 6 months to 12 months, and 12 months to 24
months were recorded. Between the 1 month to 6 months and 6 months to 12 months periods
after the loss, denial declined while acceptance increased. Acceptance was more significant than
denial. The study found that denial was not the dominant feeling reported and that acceptance
was the feeling most often reported even during the first month after the death. In conclusion it
was found that those who scored high on the indicators beyond 6 months after the death might
benefit from further evaluation (Maciejewski, et al, 2007).
What the study did not take into account with the stages of dying by Kubler-Ross was
that patients were notified that they were going to die while this study examined those who had
little to no prior knowledge of their loved one’s death; grievers grieving the death of a loved one
from unnatural causes, such as car crashes or suicide, were examined in this study. The
participants could never have been in denial of the death of a family member or else they would
not have been in the study. It would have been effective to examine family members of dying
patients to see if such a stage theory could apply to anticipatory grief. With the exception of
denial, the participants in the study tended to emotionally travel back and forth from one stage to
another. With the stage theory of dying, the patient tended to go through different “stages at the
same time” (Kubler-Ross, 1969; DeSpelder & Strickland, 2005).
Earlier, it was noted that the word stage will imply that there is a time component. Time
does not heal emotional wounds. Suggesting to a griever time, will “freeze” them (Friedman &
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James, 2009, p. 39). Stage theories for child development have more support. French
psychologist, Jean Piaget developed a theory of child development. The first stage is the
sensorimotor period, from about birth to two years. The second stage is the preoperational
period, from about two to seven years of age. The third stage is the concrete operational stage,
from about 7 to 11 years of age. The last stage is the formal operation stage, from about 11 years
to 15 years of age and beyond (Berk, 2009; DeSpelder & Strickland, 2005; Pellegrini, 1987).
Viennese psychoanalyst Sigmund Freud had his theory of Psychosexual Stages of development:
oral stage, anal stage, phallic stage, latency stage, and genital stages (Corey, 2005). Erick
Erikson also had stages of development: trust vs. mistrust, autonomy vs. shame, initiative vs.
guilt, industry vs. inferiority, identity vs. role confusion, intimacy vs. isolation, generativity vs.
stagnation, and integrity vs. despair (Corey, 2005; DeSpelder & Strickland, 2005). These
theories of child development clearly state that time is a major component, because one cannot
make a two-year-old immediately into a 10-year-old. Although these stage theories deal with
aging and can be seen on the outside, there has also been research on moral development which
cannot be readily seen on the outside. Piaget also had a stage theory of moral development. His
theory has received research by MacRae (1954) and Einhorn (1971). These stage theories have
gained more credibility than Kubler-Ross’s theory. Her theory has been commonly accepted.
Friedman & James (2008) ask, “When does wide acceptance equal scientific fact?” (p. 38).
There are not stages to grief. Bonanno (2009) has observed many grievers and found
variability in people’s reaction to loss. A pattern he found with his colleagues is prolonged grief,
an enduring grief reaction. Those with prolonged grief can struggle for years and to the grievers,
“grief is one long horrible experience and it only seems to get worse over time” (Bonanno,
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2009). Prolonged grief can be caused by a separation conflict that leads to incompletion of a task
of mourning (Worden, 2002), to be discussed shortly.
The stage theory of grief can be harmful to post-loss grievers. Grievers can fall into
complicated mourning. There is difficulty in finding a definition of complicated mourning
(Rando, 1993). For this paper complicated mourning is defined as when a griever has trouble to
accomplish certain tasks of grief. One way to view the process of grief is through tasks or
choices. James & Friedman (2009) state that in order for a griever to achieve grief recovery, is to
complete tasks. “Recovery from loss is achieved by a series of small and correct choices made
by the griever” (p. 8).
Worden (2002) proposes that the mourning process consists of tasks. (For this paper, the
second task will be viewed as the first task because the first task suggests that the griever needs
to accept or acknowledge the reality of the loss.) The first task is to work through the pain of
grief. The next task is to adapt “to an environment in which the deceased is missing”;
adjustments include external adjustments (the effect of the death on the everyday functioning of
the griever), internal adjustments (the effect of the griever’s sense of self), and spiritual
adjustments (assumptions, beliefs, and values of the world). The third task is to “emotionally
relocate the deceased” (Worden, 2002, p. 35). Freud wrote that “mourning [is] quite a precise
psychical task to perform” (qtd by Worden, 2002, p. 35).
A stage theory of grief would suggest that everyone will grieve the same way, in order.
No two people will grieve the same way and will not know what another griever, even of a very
similar loss, is going through. Even if two siblings lost the same parent, they each had a different
relationship dynamic with that deceased parent. The similarity of the loss is not an accurate
predictor on how someone will grieve (James & Friedman, 2009). This is because of the
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Mediators of Mourning that Worden (2002) identifies: who the deceased person was, the nature
of the attachment with the deceased person, how the person died, previous losses, the personality
and age of the griever, and social support. All these factors will affect how the person will grieve
a loss.
Kubler-Ross’s model for the dying person has been misunderstood. Kubler-Ross &
Kessler (2005) said that the stages “have been very misunderstood…They were never meant to
help tuck messy emotions into neat packages. They are responses to loss that many people have
but there is not a typical response to loss, as there is no typical loss” (p. 7). By using the dying
model of Kubler-Ross as a suggested linear sequential stage theory for grievers grieving the
death of a loved one, people have stopped in the tracks in their grief. Each person’s grief is
unique to them. There are no stages of post-loss grief. Kubler-Ross’s model for the dying cannot
apply to those grieving someone who is dead.
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