The Kübler-Ross model - otherwise known as the five stages of grief - postulates a progression of emotional states experienced by both terminally ill patients after diagnosis and by loved-ones after a death. The five stages are chronologically: denial, anger, bargaining, depression and acceptance.
The model was first introduced by Swiss psychiatrist Elisabeth Kübler-Ross in her 1969 book On Death and Dying, and was inspired by her work with terminally ill patients. Motivated by the lack of instruction in medical schools on the subject of death and dying, Kübler-Ross examined death and those faced with it at the University of Chicago medical school. Kübler-Ross' project evolved into a series of seminars which, along with patient interviews and previous research, became the foundation for her book.
Kübler-Ross noted later in life that the stages are not a linear and predictable progression and that she regretted writing them in a way that was misunderstood..
Stages of dying
The stages, popularly known by the acronym DABDA, include:
- Denial – The first reaction is denial. In this stage, individuals believe the diagnosis is somehow mistaken, and cling to a false, preferable reality.
- Anger – When the individual recognizes that denial cannot continue, they become frustrated, especially at proximate individuals. Certain psychological responses of a person undergoing this phase would be: "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"; "Why would this happen?".
- Bargaining – The third stage involves the hope that the individual can avoid a cause of grief. Usually, the negotiation for an extended life is made in exchange for a reformed lifestyle. People facing less serious trauma can bargain or seek compromise. For instance: "I'd give anything to have him back." Or: "If only he'd come back to life, I'd promise to be a better person!"
- Depression – "I'm so sad, why bother with anything?"; "I'm going to die soon, so what's the point?"; "I miss my loved one, why go on?"
During the fourth stage, the individual despairs at the recognition of their mortality. In this state, the individual may become silent, refuse visitors and spend much of the time mournful and sullen.
- Acceptance – "It's going to be okay."; "I can't fight it; I may as well prepare for it."
In this last stage, individuals embrace mortality or inevitable future, or that of a loved one, or other tragic event. People dying may precede the survivors in this state, which typically comes with a calm, retrospective view for the individual, and a stable condition of emotions.
Kübler-Ross later expanded her model to include any form of personal loss, such as the death of a loved one, the loss of a job or income, major rejection, the end of a relationship or divorce, drug addiction, incarceration, the onset of a disease or an infertility diagnosis, and even minor losses, such as a loss of insurance coverage or a pet.
Criticisms of this five-stage model of grief center mainly on a lack of empirical research and empirical evidence supporting the stages as described by Kübler-Ross and, to the contrary, empirical support for other modes of the expression of grief. Moreover, Kübler-Ross' model is the product of a particular culture at a particular time and might not be applicable to people of other cultures. These points have been made by many experts,  such as Professor Robert J. Kastenbaum (1932–2013) who was a recognized expert in gerontology, aging, and death; founder and editor of two academic journals in this area (International Journal of Aging and Human Development and Omega: Journal of Death and Dying); founder of the first university-based educational and research center on death and dying (Wayne State University, 1966); and author of several relevant books (e.g., The Psychology of Death (1972); Death, Society and Human Experience (1977); and On Our Way: The Final Passage Through Life and Death (2004)). In his writings, Kastenbaum raised the following points:
- The existence of these stages as such has not been demonstrated.
- No evidence has been presented that people actually do move from Stage 1 through Stage 5.
- The limitations of the method have not been acknowledged.
- The line is blurred between description and prescription.
- The resources, pressures, and characteristics of the immediate environment, which can make a tremendous difference, are not taken into account.
A 2003 study of bereaved individuals conducted by Maciejewski at Yale University obtained some findings consistent with the five-stage hypothesis but others inconsistent with it. Several letters were also published in the same journal criticizing this research and arguing against the stage idea.
George Bonanno, Professor of Clinical Psychology at Columbia University, in his book The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss, summarizes peer-reviewed research based on thousands of subjects over two decades and concludes that a natural psychological resilience is a principal component of grief and that there are no stages of grief to pass. Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome.
The lack of support in the academic psychology literature has led to the popular and special interest press applying the labels of myth and fallacy to the notion that there are stages of grief, in publications ranging from Time magazine to Scientific American to Skeptic Magazine, the latter publishing findings of the Grief Recovery Institute that contested the concept of stages of grief as they relate to people who are dealing with the deaths of people important to them.
- Broom, Sarah M. (August 30, 2004). "Milestones". TIME.
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- Kübler-Ross, Elisabeth; Kessler, David (June 5, 2007). "On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss". Scribner. Retrieved November 27, 2016 – via Amazon.
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- Kastenbaum, Robert. Death, Society, and Human Experience, 6th edition. Boston: Allyn & Bacon, 1998.
- Corr, Charles A., Kenneth J. Doka, and Robert Kastenbaum (1999). "Dying and Its Interpreters: A Review of Selected Literature and Some Comments on the State of the Field." Omega: The Journal of Death and Dying 39(4) :239–259. doi.org/10.2190/3KGF-52BV-QTNT-UBMX
- Maciejewski, Paul K.; Zhang, Baohui; Block, Susan D.; Prigerson, Holly G. (2007). "An Empirical Examination of the Stage Theory of Grief". Journal of the American Medical Association. 297 (7): 716–23. doi:10.1001/jama.297.7.716. PMID 17312291.
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- Bonanno, George A. (January 2004). "Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events?". The American Psychologist. 59 (1): 20–8. doi:10.1037/0003-066X.59.1.20. PMID 14736317.
- "The Neuroscience of True Grit". Scientific American. 2011-03-01. doi:10.1038/scientificamerican0311-28. Retrieved 2016-12-29.
- Konigsberg, Ruth Davis (January 29, 2011). "New Ways to Think About Grief". Retrieved November 27, 2016 – via www.time.com.
- "Five Fallacies of Grief: Debunking Psychological Stages". Scientific American. 2008-11-01. Retrieved 2016-12-29.
- Friedman, Russell; James, John W. "The Myth of the Stages of Dying, Death and Grief". Skeptic Magazine. 14 (2): 37–41. Also available as: "Stages of Grief: The Myth". The Grief Recovery Institute. January 5, 2012.
- Kübler-Ross, E. (1969) On Death and Dying, Routledge, ISBN 0-415-04015-9
- Kübler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss, Simon & Schuster Ltd, ISBN 0-7432-6344-8
- Scire, P. (2007). "Applying Grief Stages to Organizational Change"
- An Attributional Analysis of Kübler-Ross' Model of Dying, Mark R Brent. Harvard University, 1981.
- An Evaluation of the Relevance of the Kübler-Ross Model to the Post-injury Responses of Competitive Athletes, Johannes Hendrikus Van der Poel, University of the Free State. Published by s.n., 2000.