For decades it has been assumed that people go through stages when confronted with a major loss such as the diagnosis of a terminal illness or the death of a loved-one.  The stage theory proposed by Elizabeth Kübler-Ross, M.D., in 1969 was particularly influential and had widespread appeal.  She proposed that people go through denial, anger, bargaining, depression, and acceptance after being diagnosed with a terminal illness.  Similar stage models have been applied to many other major stressful events such as the death of a loved one or the loss of a limb. 

Even though Kübler-Ross did not believe people necessarily go through all of these stages, or go through them in a particular order, it has become commonly accepted, even among psychotherapists, that a progression through the stages is typical, normal, and reflects adaptive, effective coping.  For example, as psychologists Camille Wortman, Ph.D., and Roxanne Silver, Ph.D., reported, it is often assumed that depression is normal or even inevitable after a major loss such as the death of a loved-one, and that distress and depression are necessary in order to work through the loss successfully.  Clinical lore suggests that that there must be something awry with one’s coping process if one does not show evidence of going through the stages. 

Wortman and Silver challenged these assumptions back in the 1980s.  They completed an extensive review of the published literature that was related to coping with loss, although back then there had been no published studies that tested stage models explicitly (in spite of, or perhaps as a result of, the widespread acceptance of stage models).  Among their many compelling revelations, they found that depression is not inevitable after loss, some people do not even experience major distress, and failure to experience depression or significant distress is not particularly indicative of a failure to work through the loss.  Their review, in short, challenged the stage models as well as some of the more general and widely accepted assumptions about coping with loss noted above. 

A recent study published in JAMA by Paul Maciejewski, Ph.D., and his colleagues appears to be the first empirical investigation designed explicitly to assess whether there is a normal progression through stages after a major loss.  They examined whether bereaved individuals progress through disbelief, yearning, anger, depression, and acceptance.  They studied 233 individuals who had lost a loved one to natural causes.  The authors assert that their results support a stage model, and base their interpretation on the fact that the five emotional responses they examined “peaked” in the order predicted by the theory.  Specifically, disbelief peaked soon after the death (within two months), followed by a peak in yearning, then anger, depression, and finally acceptance (at 20-24 months after the loss).   

But the JAMA study yielded data that are also inconsistent with stage models of coping with loss.  For example, although disbelief peaked soon after the death of a loved-one as stage theory would suggest, the most frequent response to the death of a loved one was, by far, acceptance.  Even though acceptance peaked later on in the coping process, and disbelief peaked early on, people reported experiencing acceptance early in the coping process (soon after their loss) much more frequently than any of the other emotions (stages) assessed.  Participants reported a greater frequency of acceptance than all other responses, including disbelief, at all of the time points assessed in this study.  In short, most people accepted the death, and did so fairly quickly.  This directly contradicts stage theories and the common assumption that acceptance emerges as the final stage of coping with loss, after one experiences feelings such as disbelief, anger, and depression. 

So, what about the other stages?  The second most frequently occurring response was yearning (we miss our loved ones after they die).  Beyond that, the bereaved participants in the JAMA study reported feeling disbelief, anger, and depression pretty infrequently (e.g. once per month).  This does not mean that people are not sad or upset when their loved ones die; rather, it means that most people are able to accept their loss without frequently feeling (or even going through a significant period of) disbelief, anger, and depression.  Perhaps people would feel more of these emotions (i.e., go through these “stages”) if their loved ones died from unexpected, non-natural causes (e.g. auto accidents), but this remains speculation as there are no published data akin to the JAMA study. 

Overall the data are inconclusive at best with respect to stage models, and even incompatible with models that suggest denial, anger, and depression are typical, normal responses to loss.  In fact, the study suggests that these responses are atypical in response to natural loss and perhaps indicative of less effective coping.

Most people yearn for their deceased loved ones and apparently are able to accept the loss fairly quickly.  But it seems there are probably as many ways to cope effectively with major loss as there are people.  There are many adaptive, effective ways of coping that may or may not fit neatly within a stage model.  Some people even have positive emotional experiences as part of their grieving process (think reminiscence).  Some people use humor.  Others get angry, but apparently not everyone.  In short, this clinician is not ready to endorse stage models of coping with loss.   

Related References

Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.

Maciejewski, P. K., Zhang, B., Block, S. D., & Prigerson, H. G. (2007). An empirical examination of the stage theory of grief. Journal of the American Medical Association, 297, 716-723.

Wortman, C. B. & Silver, R.C. (1989). The myths of coping with loss. Journal of Consulting and Clinical Psychology, 57, 349-357.