Beyond the five stages of grief
The bereavement process is seldom linear and varies from one person to the next.
D
r. Elisabeth Kübler-Ross devel-
oped a frequently cited model
of bereavement, the “stages of
grief,” in her landmark book On Death
and Dying. She described a linear five-
step process—consisting of denial,
anger, bargaining, depression, and
acceptance—as terminally ill patients
became aware of impending death. Dr.
Kübler-Ross’ work helped legitimize
the wide variety of emotions in people
who are dying. The five-stage theory
was later altered and adapted to cover
the reaction to other losses, such as di-
vorce or the death of a loved one.
Today, however, many experts no
longer embrace the concept of sequen-
tial stages of grief and have proposed a
number of alternatives.
For example, Dr. Colin Murray
Parkes, who has written extensively
on bereavement, proposed that people
who have experienced a loss undergo
several prolonged and overlapping
phases—numb disbelief, yearning
for the deceased, disorganization and
des­pair, and finally reorganization—
during which they carve out a new life.
The road to this new life may be long.
According to Dr. Parkes, people must
go through a painful period of search-
ing for what has been lost before they
can release their attachment to the
person who died and move forward.
When enmeshed in disorganization
and despair, people find themselves
repeatedly going over the events pre-
ceding the death as if to set them right.
Dr. J. William Worden suggested a
model of grieving that includes certain
tasks. The first three tasks are to accept
the loss, to experience the resulting
pain, and to put the loss in some per-
spective and adjust to a changed world
without the person who has died. The
fourth and final task is for people to al-
ter ties with the deceased enough that
they are able to invest their love and en-
ergy in others. People may shuttle back
www.health.harvard.edu December 2011
and forth among these tasks. However,
Dr. Worden suggests that leaving some
of the tasks undone is like healing only
partially from a wound.
Some experts combine elements
of several grief models. Dr. Margaret
Stroebe and Dr. Henk Schut note that
early in grieving, the emphasis is on
“loss-oriented coping,” such as focusing
on the person who died, the circum-
stances of the death, and painful feel-
ings like yearning and despair. Later,
people invest more in “restoration-
oriented coping,” focusing on managing
practical issues that arise, such as loneli-
ness or challenging new circumstances.
Rather than grieving continually, people
seek occasional periods of respite. Time
away from grief might take the form
of a weekend with friends or a day of
social activities.
A new way of grieving
Most recently, two psychologists make
the case that advances in diagnosis and
treatment—which have enabled peo-
ple to live longer with life-threatening
illnesses, such as cancers and heart
disease—have significantly changed
the grieving process.
In their book Saying Goodbye: How
Families Can Find Renewal Through
Loss, Dr. Barbara Okun and Dr. Joseph
Nowinski identify a pattern of grief
commonly encountered by families
who face the loss of a loved one to pro-
tracted illness. The book includes the
following stages, which begin long be-
fore a person actually dies.
Crisis. Family life is disrupted by the
diagnosis. People are upset, saddened,
and anxious. Other, unexpected feelings—
resentment, anger, or guilt—may also
emerge but often go unexpressed in the
interest of rallying around the patient.
Unity. The patient’s needs are para­
mount. Activities include managing
medical treatment, lining up social and
support services, gathering insurance
and other information, and attending
to legal matters such as wills.
Upheaval. The patient may be in
remission or doing relatively well. But
for others, unity and patience may have
worn thin as protracted illness buffets
their lives, relationships, and routines.
At this stage, it’s important—though
often difficult—for family members to
communicate honestly about the up-
heaval they’re experiencing.
Resolution. As the patient’s health de-
teriorates, everyone comes to accept that
the end is near. Decisions about hospice
and other end-of-life matters have been
made. Now is the chance for resolving
old issues, healing wounds, and address-
ing resentments and jealousies—factors
that can undermine family members’
ability to come together and support
one another.
Renewal. This final stage begins
with the funeral and continues for a
long time, as individuals adjust to the
loss and to their changed roles.
Navigating the process
Every person—and every family—
grieves differently. Some people may
feel anxious, or others worry on their
behalf, if they don’t follow a particu-
lar path. However, grief is not a tidy,
orderly process, and there is no sin-
gle “right” way to grieve. It’s normal
for emotions to collide and overlap.
Each person grieves uniquely, taking
as much time as necessary, finding a
meaningful way to come to terms with
a loss.
Kübler-Ross E. On Death and Dying (Rout-
ledge, 1969).
Okun B, et al. Saying Goodbye: How Families
Can Find Renewal Through Loss (Berkley, 2011).
Parkes C. Bereavement: Studies of Grief in
Adult Life (Routledge, 2010).
Worden J. Grief Counseling and Grief Therapy:
A Handbook for the Mental Health Practitioner
(Springer Publishing Company, 1991).
| Harvard Mental Health Letter | 3
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