The Kübler-Ross model, or the five stages of grief, postulates a series of emotions experienced by terminally ill patients prior to death, or people who have lost a loved one, wherein the five stages are: denial, anger, bargaining, depression and acceptance. Although commonly referenced in popular media, the existence of these stages has not been demonstrated and the model is not considered helpful in explaining the grieving process.
The model was first introduced by Swiss-American 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. Although Kübler-Ross is commonly credited with creating stage models, earlier bereavement theorists and clinicians such as Erich Lindemann, Collin Murray Parkes, and John Bowlby used similar models of stages of phases as early as the 1940s.
Later in her life, Kübler-Ross noted that the stages are not a linear and predictable progression and that she regretted writing them in a way that was misunderstood. "Kübler-Ross originally saw these stages as reflecting how people cope with illness and dying," observed grief researcher Kenneth J. Doka, "not as reflections of how people grieve."
Stages of grief in terminal illness
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. Examples include the terminally ill person who "negotiates with God" to attend a daughter's wedding or an attempt to bargain for more time to live in exchange for a reformed lifestyle.
- 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.
In a book co-authored with David Kessler and published posthumously, Kübler-Ross 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.
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. 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 and colleagues 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 peer-reviewed research or objective clinical observation by many practitioners in the field has led to the labels of myth and fallacy in the notion that there are stages of grief. Nevertheless, the model's use has persisted in popular news and entertainment media including the animated sitcom The Simpsons.
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