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The Impact of the So-Called Stages of Grief

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Dangers and misinterpretations of the stages of dying by Elisabeth Kubler-Ross, by Brian Andrew Wong, Marshall University student. Friday, April 29, 2011.

Dangers and misinterpretations of the stages of dying by Elisabeth Kubler-Ross, by Brian Andrew Wong, Marshall University student. Friday, April 29, 2011.

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  • 1. STAGES OF GRIEF 1Running Head: STAGES OF GRIEF The Impact of the So-Called Stages of Grief By Brian A. Wong brian.wong@live.marshall.edu Marshall University ENG 102 – English Composition II Section 201 Instructor: Jeanne M. Hubbard Friday, April 29, 2011
  • 2. STAGES OF GRIEF 2 The Impact of the So-Called Stages of Grief Many have heard of the so-called stages of grief which a person experiences after thedeath of someone else. However, few people know about the history of the stage theory. Therehas been no valid research on this theory. Looking at grief over the death of someone as stageshas 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 aboutthem 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’scapacity for happiness. Grief is “the normal and natural reaction to loss of any kind” and “theconflicting 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 aboutrecovering from grief. Anthropologist Margaret Meade has said, “When someone is born werejoice, when someone is married we celebrate, but when someone dies, we pretend that nothinghappened” (qtd in Groves & Klauser, 2009, p. 17). When families know that their loved one isgoing 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 andthose that are occurring” (Pomeroy & Garcia, 2009, p. 28). Kubler-Ross (1969) interviewed two-hundred patients who were told by their doctors thattheir illness was no longer treatable. She came up with a stage theory of emotions experienced byone who has been diagnosed with a terminal illness. It was her theory that the dying patient goesthrough these emotional stages: Denial and Isolation, Anger, Bargaining, Depression, andAcceptance. (For this paper, Bargaining and Depression will not be discussed.)
  • 3. STAGES OF GRIEF 3 Kubler-Ross saw behaviors of patients that indicated that they were in denial of theirdiagnosis. She asserted that in every patient exists a need for denial and that for some dyingpatients their first reaction may be numbness or shock. One of the patients interviewed wasconvinced that the X-rays were mistaken for that of another patient. That patient soon left thehospital seeking a doctor who could confirm that she was not ill. Upon each diagnosis from eachdoctor the patient insisted again and again that the test results were mixed up. This denial is atemporary defense, to be replaced soon with partial acceptance and that it “functions as a bufferafter unexpected shocking news, allows the patient to collect himself and, with time, mobilizeother, less radical defenses” (Kubler-Ross, 1969, p. 35). There is a less chance of denial and useof “radical defense mechanisms” if the patient is adequately told about the illness and has thetime to “gradually acknowledge the inevitable happening” and how the patient has learned tocope with stressful situations (p. 37). She noted that for most patients, denial is not used to agreat 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 theposition of the patient to discern the origin of the anger. The anger in the patient seems, from thefamily’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 alsorationalize their anger. One patient interviewed complained about the nurses keeping the bedrailsup. The nurse was angry as well but explained to him the safety reasons for why the bedrailswere up (Kubler-Ross, 1969). For acceptance, when the dying patient received enough time to process their impendingdeath, that patient would eventually be neither angry nor depressed. The patient will then
  • 4. STAGES OF GRIEF 4experience their own form of anticipatory grief, mourning “the impending loss of so manymeaningful people and places” (Kubler-Ross, 1969, p. 99). This stage is not to be misunderstoodfor being a happy stage. The dying patient will begin to increase her or his amount of sleep andhas found acceptance and peace. Since the patient accepts her or his death, the patient might takea turn for the worse. Visitations may be limited, not desired. Communication between others andthe dying patient become nonverbal (Kubler-Ross, 1969). The stages of dying model, which has morphed into the stages of grieving, has been usedand commonly accepted by practitioners, people in academia, medical school, and television andbecome like a prescription (Friedman & James, 2008; DeSpelder & Strickland, 2005). Oftenwhen 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 forthe dying being used for the grievers after a loss occurred. When someone goes to a grief supportgroup or counseling for loss, they tell the therapist that a loss has occurred. They may say, “Mymother died.” At The Grief Recovery Institute, James and Friedman see many grievers who tellthem 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 havestrongly suggested that they were in denial even when they made it clear to the therapist that adeath has occurred (Friedman & James, 2008; James & Friedman, 2009). A griever goes throughsix 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 wouldgoing to a grief counselor indicate that a death has not happened? When the therapist does notlisten to the client, trust is breached and clients often terminate therapy soon. Anothermisperceived sign of denial is when a griever says “I still cannot believe he’s gone” and
  • 5. STAGES OF GRIEF 5“although disbelief may reflect the emotions of a broken heart, it is really a figure of speechrather than a statement that a death didn’t happen” (Friedman & James, 2008, p. 39). Oftenfeelings 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 thedentist having a tooth pulled and the dentist administers Novocain. Are you in denial that adental procedure is taking place? Kubler-Ross & Kessler (2005) wrote that “for a person who haslost 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 adeath of a loved one, when caring family members notify others within the next 24 hours that thedeath occurred, this does not show any denial that a death has occurred. There is sometimes no anger at all, according to James & Friedman (2009). Thecircumstances 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 isalways anger in grief is “both incorrect and dangerous” (James & Friedman, 2009, p. 12). Thefamily and the deceased person might not have had a chance to resolve past conflicts betweeneach 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 theemotion and feeling is a stage will make the griever wait and they will still feel the same, waitingfor time (Friedman & James, 2008). “There are no stages of grief. But people will always try tofit themselves into a defined category if one is offered to them. Sadly, this is particularly true ifthe offer comes from a powerful authority such as a therapist, clergyperson, or doctor” (James &Friedman, 2009, p. 14).
  • 6. STAGES OF GRIEF 6 An empirical research study was performed by Maciejewski, Zhang, Block, andPrigerson (2007) in Connecticut from one month to two years post-loss. Three-hundredseventeen individuals participated in this study. The Inventory of Complicated Grief Revisedwas used to measure the grief. The frequency of each grief indicator (denial, anger, etc.) wasrecorded. Periods from 1 month to 6 months, 6 months to 12 months, and 12 months to 24months were recorded. Between the 1 month to 6 months and 6 months to 12 months periodsafter the loss, denial declined while acceptance increased. Acceptance was more significant thandenial. The study found that denial was not the dominant feeling reported and that acceptancewas the feeling most often reported even during the first month after the death. In conclusion itwas found that those who scored high on the indicators beyond 6 months after the death mightbenefit from further evaluation (Maciejewski, et al, 2007). What the study did not take into account with the stages of dying by Kubler-Ross wasthat patients were notified that they were going to die while this study examined those who hadlittle to no prior knowledge of their loved one’s death; grievers grieving the death of a loved onefrom unnatural causes, such as car crashes or suicide, were examined in this study. Theparticipants could never have been in denial of the death of a family member or else they wouldnot have been in the study. It would have been effective to examine family members of dyingpatients to see if such a stage theory could apply to anticipatory grief. With the exception ofdenial, the participants in the study tended to emotionally travel back and forth from one stage toanother. With the stage theory of dying, the patient tended to go through different “stages at thesame time” (Kubler-Ross, 1969; DeSpelder & Strickland, 2005). Earlier, it was noted that the word stage will imply that there is a time component. Timedoes not heal emotional wounds. Suggesting to a griever time, will “freeze” them (Friedman &
  • 7. STAGES OF GRIEF 7James, 2009, p. 39). Stage theories for child development have more support. Frenchpsychologist, Jean Piaget developed a theory of child development. The first stage is thesensorimotor period, from about birth to two years. The second stage is the preoperationalperiod, 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 yearsto 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). ErickErikson 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). Thesetheories of child development clearly state that time is a major component, because one cannotmake a two-year-old immediately into a 10-year-old. Although these stage theories deal withaging and can be seen on the outside, there has also been research on moral development whichcannot be readily seen on the outside. Piaget also had a stage theory of moral development. Histheory has received research by MacRae (1954) and Einhorn (1971). These stage theories havegained 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 foundvariability 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,
  • 8. STAGES OF GRIEF 82009). Prolonged grief can be caused by a separation conflict that leads to incompletion of a taskof mourning (Worden, 2002), to be discussed shortly. The stage theory of grief can be harmful to post-loss grievers. Grievers can fall intocomplicated 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 toaccomplish certain tasks of grief. One way to view the process of grief is through tasks orchoices. James & Friedman (2009) state that in order for a griever to achieve grief recovery, is tocomplete tasks. “Recovery from loss is achieved by a series of small and correct choices madeby the griever” (p. 8). Worden (2002) proposes that the mourning process consists of tasks. (For this paper, thesecond task will be viewed as the first task because the first task suggests that the griever needsto accept or acknowledge the reality of the loss.) The first task is to work through the pain ofgrief. 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 ofthe griever), internal adjustments (the effect of the griever’s sense of self), and spiritualadjustments (assumptions, beliefs, and values of the world). The third task is to “emotionallyrelocate the deceased” (Worden, 2002, p. 35). Freud wrote that “mourning [is] quite a precisepsychical 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 verysimilar loss, is going through. Even if two siblings lost the same parent, they each had a differentrelationship dynamic with that deceased parent. The similarity of the loss is not an accuratepredictor on how someone will grieve (James & Friedman, 2009). This is because of the
  • 9. STAGES OF GRIEF 9Mediators of Mourning that Worden (2002) identifies: who the deceased person was, the natureof the attachment with the deceased person, how the person died, previous losses, the personalityand age of the griever, and social support. All these factors will affect how the person will grievea 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 tohelp tuck messy emotions into neat packages. They are responses to loss that many people havebut there is not a typical response to loss, as there is no typical loss” (p. 7). By using the dyingmodel of Kubler-Ross as a suggested linear sequential stage theory for grievers grieving thedeath of a loved one, people have stopped in the tracks in their grief. Each person’s grief isunique to them. There are no stages of post-loss grief. Kubler-Ross’s model for the dying cannotapply to those grieving someone who is dead.
  • 10. STAGES OF GRIEF 10 ReferencesBerk, L.E. (2009). Child development. 8th ed. (p. 21). Boston, MA: Pearson.Blau, G. (2008). Exploring antecedents of individual grieving stages during an anticipated worksite closure. Journal of Occupational & Organizational Psychology, 31(3), 530. DOI:10.1348/096317907X241560Bonanno, G.A. (2009). Grief does not come in stages and it’s not the same for everyone. Psychology Today. Mon. 26 Oct. 2009. Web. Fri. 4 March, 2011. Retrieved from: http://www.psychologytoday.com/print/34145Corey, G. (2005). Theory and practice of counseling & psychotherapy. 7th ed. (pp. 62-64). Belmont, CA: Brooks/ColeDeSpelder, L.A. & Strickland, A.L. (2005). The last dance: encountering death and dying. 7th ed. (pp. 45, 46, 190). New York, NY: McGraw-HillEinhorn, J. (1971). A test of Piaget’s theory of moral judgment. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 3(1), 102-113. Doi: 10.1037/h0082243.Friedman, R., & James, J.W. (2008). The myth of the stages of dying, death and grief. Skeptic 14(2), 37-41. Retrieved from EBSCOhost.Groves, R.F., & Klauser, H.A. (2009). The american book of living and dying: lessons in healing spiritual pain. (p. 17). New York, NY: Celestial Arts. Retrieved from Google BooksJames, J.W. & Friedman, R. (2009). The grief recovery handbook: the action program for moving beyond death, divorce, and other losses. Rev. ed (pp. 3, 7, 8, 12-14, 40). New York, NY: HarperCollinsKonigsberg, R.D. (2011). New ways to think about grief. Time 177(3), 42-46
  • 11. STAGES OF GRIEF 11Kubler-Ross, E. (1969). On death and dying. (pp. 35, 37, 44, 45, 47, 69) New York: Macmillan PublishingKubler-Ross, E. & Kessler, D (2005). On grief and grieving: finding the meaning of grief through the five stages of loss. (p. 8) New York: Simon & Schuster. Retrieved from Google BooksMaciejewski, 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(7), 716- 722MacRae, D. (1954). A test of Piaget’s theory of moral development. The Journal of Abnormal and Social Psychology, 49(1), 14-18. Doi: 10.1037/h0061606.Pellegrini, A.D. (1987). Applied child study: a developmental approach. (p. 122) Hillsdale, NJ: Lawrence EarlbaumPomeroy, E.C. & Garcia, R.C. (2009). The grief assessment and intervention workbook: a strengths perspective. (p. 28). Belmont, CA: Brooks/ColeRando, T.A. (1993). Treatment of complicated mourning. (pp. 11, 44, 45). Champaign, IL: Research PressWorden, J.W. (2002). Grief counseling and grief therapy: a handbook for the mental health practitioner. 3rd ed. (pp. 27, 30-32, 38-44). New York: Springer Publishing

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