I get asked this question repeatedly and often from those who are reaching out when struggling with grief and loss. The search for answers and meaning. The sense of disbelief that is sitting with them creates a desire to better understand what recovery will look like and how long it may take.
I’ll open this Blog with a few caveats:
- The grief and healing journey is deeply personal
- Everyone processes and manages grief differently
- There is no grief treatment model that “fits all”
- The five stages of Grief model and theories must therefore be considered a guide: they may not help or resonate with those in grief or after experiencing loss
- When reaching out for help, those affected should receive an empathetic response from practitioners that includes advice on the range of grief support options available
The Kubler-Ross Model
In a classic text, On Death and Dying, Elisabeth Kübler-Ross (1969) identified five distinct stages of grief that she observed in her patient conversations with terminal illness:
- Denial and isolation
A prevention and overwhelm mechanism used by patients during all stages of their illness. This allows the patient time to develop other coping mechanisms.
- Anger
A behaviour directed at others, again, as sufferers struggle to develop coping strategies and come to their plight. Friends, family and carers struggle to respond; if a defensive or angry response is directed to the affected, further escalation is likely.
- Bargaining
An attempt to postpone death, bargaining can take many forms: directed at a higher power or the treating staff. Patients will impose deadlines to bargain for more time in a similar fashion to a child bargaining with an adult.
- Depression
Once bargaining is exhausted, feelings of grief and loss prevail. A preparatory depression sets in as the patient begins to accept separation from their life. Reactive depression is common: increasing fear and anxiety are common.
- Acceptance
The patient appears to have given up the struggle for life. Social withdrawal is common.
These five stages have been widely adopted by both the general public and some grief and loss counsellors as a ‘template’ for expected grief experiences, despite having been developed in the context of adjustment to a terminal diagnosis. Much criticism has been levelled against Kübler-Ross’s stage-like descriptions, which have been interpreted by many to indicate a necessary progression to resolution or acceptance of a loss.
Although the model has received much criticism for its assumptions about the ‘stage-like’ progression of grief, it was never intended to prescribe a ‘normal’ or universal grieving process.
Does the grief unfold in stages?
The assumption that the grief process unfolds in stages has been held by many mental health practitioners.
- The stages are merely descriptive categories that have been artificially isolated and separated for simplicity and clarity. Kübler-Ross noted that the ‘stages’ may overlap, occur simultaneously or may not occur at all in some individuals.
- The original book was never intended or designed as a research study, but rather as a collection of descriptions, observations and reflections based on conversations with the terminally ill.
- The central message of Kübler-Ross’s model and work is about the importance of listening to the needs of dying individuals.
Although Kϋbler-Ross’s model is widely recognised, contemporary use in the context of grief and loss is limited to the recognition of the emotional states of anger, denial, depression and acceptance that may (or may not) accompany a significant loss. There have been widespread misinterpretations surrounding this model. An effective counsellor will take the time to explain to clients that they may not experience the emotional responses described in Kübler-Ross’ model or progress through the described phases.
Bowlby’s Attachment Model
Another theoretical model that has had a significant impact on the conceptualisation of the grief process is Bowlby’s attachment theory. Attachment theory suggests that attachments (i.e., strong connections) develop between infants and their primary caregiver to ensure survival. When this attachment bond is threatened (e.g., through separation), a response characterised by distress, anxiety, and attempts to re-establish connection is activated (Tedeschi & Calhoun, 2004).
One of Bowlby’s key observations was that the grief responses of bereaved individuals echo the separation responses and behaviours of infants as they attempt to re-establish contact with their primary caregiver. Bowlby suggested the following stages (or phases):
- Phase of numbing. Numbness and disbelief, which can last from a few hours up to a week, may be punctuated by outbursts of extremely intense distress and/or anger.
- The phase of yearning and searching for the deceased can last for months and sometimes years.
- Phase of disorganisation and despair: Feelings of depression and apathy occur when old patterns have been discarded.
- Phase of greater or lesser degree of reorganisation: This represents recovery from grief and acceptance of what has taken place.
More current approaches focus on key aspects and attachment rather than these phases.
Rando’s Six “R’s”
Another influential stage-based theory was proposed by Rando (1993), who argued that individuals move through similar phases or processes that are fairly universal. She identified these as the ‘Six “R” processes’ – a blend of phase and task-centred models leading to a “healthy resolution of grief”. Rando proposed that these are interrelated and build upon each other; however, some may occur simultaneously, and the course of grieving can fluctuate, taking the individual back and forth through the process. Rando’s (1993) ‘Six Rs’ mourning processes are shown in the table below:
Avoidance phase
- Recognising the loss (e.g., acknowledging and understanding the death).
Confrontation phase
- Reacting to the separation (which includes experiencing the pain, expressing the psychological reactions to the loss, and identifying and mourning secondary losses).
- Recollecting and re-experiencing the deceased and the relationship (including cognitive and affective dimensions).
- Relinquishing the old attachments to the deceased and the old assumptive world.
Accommodation phase
- Readjusting to move adaptively into the new world without forgetting the old.
- Reinvesting in new relationships.
The idea that grief occurs in a progressive set of predictable, identifiable and sequential stages, although a more restrictive conceptualisation than probably originally intended, became part of the way many people think about grief. While both task and stage/process theories highlight important aspects of the grieving process and provide bereaved individuals with some realistic expectation of the grieving process, more recent research has disputed some of the assumptions behind these theories.
Current trends in grief counselling
Contemporary theories of grief differ from the traditional approaches above and tend to reflect changes in society. There is now a focus on the following themes:
- Recognition of the uniqueness of the griever
- Questioning the grief work hypothesis
- Continuing bonds with the deceased
- Recognition of social context and culture
- Adaptive grieving styles
Individual differences in grieving
Current approaches to grief and loss acknowledge the complex and highly individualised nature of the grieving process. There is growing recognition that although grief and loss are universal experiences, there is a range of healthy and ‘normal’ responses to loss. The grieving process is highly individual and is influenced by a unique interaction of personal factors, the loss event itself, and the many contexts in which loss and grief occur. Contemporary theories recognise that grief is also more than an emotional response, but is expressed through cognitive, physical pain and guilt, spiritual, and social changes.
Recognition of the different stages of Grieving
One recent development is the recognition of different styles of grieving. Many individuals use different cognitive, behavioural, and emotional strategies in their grieving process. Three patterns of grieving are generally recognised: intuitive grieving, instrumental grieving, and blended grieving:
- Intuitive grieving. The intuitive style is marked by a heightened experience and expression of emotional responses and a desire to talk about the loss.
- Instrumental grieving. This style is characterised by a more cognitive approach, the desire to control emotion, and a focus on performing tasks and problem-solving. Instrumental grievers show far less emotional responses than intuitive grievers, and it is theorised that their emotions may even be less intense than those of intuitive grievers.
- Blended grieving: Most people are blended grievers, meaning they utilise both intuitive and instrumental grieving styles, usually with one style more dominant than the other.
The key differences between intuitive and instrumental grieving are summarised in the table below:
| Intuitive | Instrumental |
| Bereavement is experienced effectively. | Bereavement experienced cognitively. |
| Outwardly express feelings and symptoms of grief. | Focus on mastering one’s situation. |
| Share with others one’s feelings on their mental health. | General reluctance to discuss feelings. |
| Primary strategy: experience the distress that bereavement produces. | The primary strategy is to problem-solve and conceptualise. |
| Secondary strategy: care for others and fulfil responsibilities. | Secondary strategy allows for expressing feelings in private. |
| Prolonged periods of Lindemann’s acute grief syndrome [this refers to physical symptoms including fatigue and digestive symptoms, cognitive disturbances such as a sense of unreality and distance from others, preoccupation with the deceased and feelings such as guilt, irritability, anger, the primary as well as a tendency to self-isolate] also, known as prolonged grief disorder. | Intermittent, brief periods of cognitive confusion. |
Conclusion
The 5 Stages of Grief are a guide only. The complicated grief and healing journey is personal to the individual. All of the models outlined above cannot be considered “linear”. Many of those in grieving stages will relate to the stages of grief theory, but most will experience what I describe as “oscillation”. Simply put, many of us may get “stuck” in a stage or bounce between stages. If we place too much belief in these models and stage theories, we may feel a sense of greater helplessness during a “stuck” period (“why am I not getting better/ why am I not moving to the next stage”).
My approach as a Grief Counsellor is to first work to understand the affected individual’s personal experience. History and context disclosures then help me select the appropriate type of support systems and therapy. This ranges from defining the meaning of the loss to memorialisation to Acceptance and Commitment Therapy (ACT) principles.
Please reach out today for support. You will be met with Compassion and Empathy.
