The Impact of the So-Called Stages of Grief more

STAGES OF GRIEF 1 Running 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 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 the death of someone else. However, few people know about the history of the stage theory. There has been no valid research on this theory. Looking at grief over the death of someone as stages has 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 about them 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’s capacity for happiness. Grief is “the normal and natural reaction to loss of any kind” and “the conflicting 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 about recovering from grief. Anthropologist Margaret Meade has said, “When someone is born we rejoice, when someone is married we celebrate, but when someone dies, we pretend that nothing happened” (qtd in Groves & Klauser, 2009, p. 17). When families know that their loved one is going 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 and those that are occurring” (Pomeroy & Garcia, 2009, p. 28). Kubler-Ross (1969) interviewed two-hundred patients who were told by their doctors that their illness was no longer treatable. She came up with a stage theory of emotions experienced by one who has been diagnosed with a terminal illness. It was her theory that the dying patient goes through these emotional stages: Denial and Isolation, Anger, Bargaining, Depression, and Acceptance. (For this paper, Bargaining and Depression will not be discussed.) STAGES OF GRIEF 3 Kubler-Ross saw behaviors of patients that indicated that they were in denial of their diagnosis. She asserted that in every patient exists a need for denial and that for some dying patients their first reaction may be numbness or shock. One of the patients interviewed was convinced that the X-rays were mistaken for that of another patient. That patient soon left the hospital seeking a doctor who could confirm that she was not ill. Upon each diagnosis from each doctor the patient insisted again and again that the test results were mixed up. This denial is a temporary defense, to be replaced soon with partial acceptance and that it “functions as a buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less radical defenses” (Kubler-Ross, 1969, p. 35). There is a less chance of denial and use of “radical defense mechanisms” if the patient is adequately told about the illness and has the time to “gradually acknowledge the inevitable happening” and how the patient has learned to cope with stressful situations (p. 37). She noted that for most patients, denial is not used to a great 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 the position of the patient to discern the origin of the anger. The anger in the patient seems, from the family’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 also rationalize their anger. One patient interviewed complained about the nurses keeping the bedrails up. The nurse was angry as well but explained to him the safety reasons for why the bedrails were up (Kubler-Ross, 1969). For acceptance, when the dying patient received enough time to process their impending death, that patient would eventually be neither angry nor depressed. The patient will then STAGES OF GRIEF experience their own form of anticipatory grief, mourning “the impending loss of so many meaningful people and places” (Kubler-Ross, 1969, p. 99). This stage is not to be misunderstood for being a happy stage. The dying patient will begin to increase her or his amount of sleep and has found acceptance and peace. Since the patient accepts her or his death, the patient might take a turn for the worse. Visitations may be limited, not desired. Communication between others and the dying patient become nonverbal (Kubler-Ross, 1969). The stages of dying model, which has morphed into the stages of grieving, has been used and commonly accepted by practitioners, people in academia, medical school, and television and become like a prescription (Friedman & James, 2008; DeSpelder & Strickland, 2005). Often when 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 for the dying being used for the grievers after a loss occurred. When someone goes to a grief support group or counseling for loss, they tell the therapist that a loss has occurred. They may say, “My mother died.” At The Grief Recovery Institute, James and Friedman see many grievers who tell them 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 have strongly suggested that they were in denial even when they made it clear to the therapist that a death has occurred (Friedman & James, 2008; James & Friedman, 2009). A griever goes through six 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 would going to a grief counselor indicate that a death has not happened? When the therapist does not listen to the client, trust is breached and clients often terminate therapy soon. Another misperceived sign of denial is when a griever says “I still cannot believe he’s gone” and 4 STAGES OF GRIEF “although disbelief may reflect the emotions of a broken heart, it is really a figure of speech rather than a statement that a death didn’t happen” (Friedman & James, 2008, p. 39). Often feelings 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 the dentist having a tooth pulled and the dentist administers Novocain. Are you in denial that a dental procedure is taking place? Kubler-Ross & Kessler (2005) wrote that “for a person who has lost 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 a death of a loved one, when caring family members notify others within the next 24 hours that the death occurred, this does not show any denial that a death has occurred. There is sometimes no anger at all, according to James & Friedman (2009). The circumstances 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 is always anger in grief is “both incorrect and dangerous” (James & Friedman, 2009, p. 12). The family and the deceased person might not have had a chance to resolve past conflicts between each 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 the emotion and feeling is a stage will make the griever wait and they will still feel the same, waiting for time (Friedman & James, 2008). “There are no stages of grief. But people will always try to fit themselves into a defined category if one is offered to them. Sadly, this is particularly true if the offer comes from a powerful authority such as a therapist, clergyperson, or doctor” (James & Friedman, 2009, p. 14). 5 STAGES OF GRIEF 6 An empirical research study was performed by Maciejewski, Zhang, Block, and Prigerson (2007) in Connecticut from one month to two years post-loss. Three-hundred seventeen individuals participated in this study. The Inventory of Complicated Grief Revised was used to measure the grief. The frequency of each grief indicator (denial, anger, etc.) was recorded. Periods from 1 month to 6 months, 6 months to 12 months, and 12 months to 24 months were recorded. Between the 1 month to 6 months and 6 months to 12 months periods after the loss, denial declined while acceptance increased. Acceptance was more significant than denial. The study found that denial was not the dominant feeling reported and that acceptance was the feeling most often reported even during the first month after the death. In conclusion it was found that those who scored high on the indicators beyond 6 months after the death might benefit from further evaluation (Maciejewski, et al, 2007). What the study did not take into account with the stages of dying by Kubler-Ross was that patients were notified that they were going to die while this study examined those who had little to no prior knowledge of their loved one’s death; grievers grieving the death of a loved one from unnatural causes, such as car crashes or suicide, were examined in this study. The participants could never have been in denial of the death of a family member or else they would not have been in the study. It would have been effective to examine family members of dying patients to see if such a stage theory could apply to anticipatory grief. With the exception of denial, the participants in the study tended to emotionally travel back and forth from one stage to another. With the stage theory of dying, the patient tended to go through different “stages at the same time” (Kubler-Ross, 1969; DeSpelder & Strickland, 2005). Earlier, it was noted that the word stage will imply that there is a time component. Time does not heal emotional wounds. Suggesting to a griever time, will “freeze” them (Friedman & STAGES OF GRIEF 7 James, 2009, p. 39). Stage theories for child development have more support. French psychologist, Jean Piaget developed a theory of child development. The first stage is the sensorimotor period, from about birth to two years. The second stage is the preoperational period, 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 years to 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). Erick Erikson 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). These theories of child development clearly state that time is a major component, because one cannot make a two-year-old immediately into a 10-year-old. Although these stage theories deal with aging and can be seen on the outside, there has also been research on moral development which cannot be readily seen on the outside. Piaget also had a stage theory of moral development. His theory has received research by MacRae (1954) and Einhorn (1971). These stage theories have gained 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 found variability 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, STAGES OF GRIEF 8 2009). Prolonged grief can be caused by a separation conflict that leads to incompletion of a task of mourning (Worden, 2002), to be discussed shortly. The stage theory of grief can be harmful to post-loss grievers. Grievers can fall into complicated 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 to accomplish certain tasks of grief. One way to view the process of grief is through tasks or choices. James & Friedman (2009) state that in order for a griever to achieve grief recovery, is to complete tasks. “Recovery from loss is achieved by a series of small and correct choices made by the griever” (p. 8). Worden (2002) proposes that the mourning process consists of tasks. (For this paper, the second task will be viewed as the first task because the first task suggests that the griever needs to accept or acknowledge the reality of the loss.) The first task is to work through the pain of grief. 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 of the griever), internal adjustments (the effect of the griever’s sense of self), and spiritual adjustments (assumptions, beliefs, and values of the world). The third task is to “emotionally relocate the deceased” (Worden, 2002, p. 35). Freud wrote that “mourning [is] quite a precise psychical 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 very similar loss, is going through. Even if two siblings lost the same parent, they each had a different relationship dynamic with that deceased parent. The similarity of the loss is not an accurate predictor on how someone will grieve (James & Friedman, 2009). This is because of the STAGES OF GRIEF 9 Mediators of Mourning that Worden (2002) identifies: who the deceased person was, the nature of the attachment with the deceased person, how the person died, previous losses, the personality and age of the griever, and social support. All these factors will affect how the person will grieve a 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 to help tuck messy emotions into neat packages. They are responses to loss that many people have but there is not a typical response to loss, as there is no typical loss” (p. 7). By using the dying model of Kubler-Ross as a suggested linear sequential stage theory for grievers grieving the death of a loved one, people have stopped in the tracks in their grief. Each person’s grief is unique to them. There are no stages of post-loss grief. Kubler-Ross’s model for the dying cannot apply to those grieving someone who is dead. STAGES OF GRIEF 10 References Berk, 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:10.1348/096317907X241560 Bonanno, 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/34145 Corey, G. (2005). Theory and practice of counseling & psychotherapy. 7th ed. (pp. 62-64). Belmont, CA: Brooks/Cole DeSpelder, L.A. & Strickland, A.L. (2005). The last dance: encountering death and dying. 7th ed. (pp. 45, 46, 190). New York, NY: McGraw-Hill Einhorn, J. (1971). A test of Piaget’s theory of moral judgment. 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