THE CAGE OF THE STAGES
One morning in 2007, glancing at my local newspaper before work, I was stunned to come across this headline: “Study Confirms Five Stages of Grief.” The accompanying article began, “When a loved one dies, people go through five stages of grieving, according to accepted wisdom . . . Now the first large-scale study to examine the five stages shows not only that they are accurate, but also that people who have not reached the acceptance stage by six months may need professional help.”1
As I read, disbelief washed over me — then anger. I knew better by then, because of my own clinical experience with more than a thousand grieving people for nearly three decades. I had believed in the stages once and had attempted to use them to diagnose my own grief and the grief of bereaved people who sought me out. But in case after case, I looked for so-called denial in my clients and found none. Time after time, grieving people sat in my office and told me they were perplexed by their lack of “anger.” Me, too. After Ryan’s death, I felt a lot of things, but anger wasn’t one of them. “Bargaining” — what was that? Most of the grieving people I saw weren’t “depressed”; they were just deeply and understandably sad. And “acceptance”? If that meant clients eventually returned to feeling as they had before their loss, that was not what I observed.
That’s why, by 2007, like an increasing number of others in my field, I had been encouraging my clients to not feel confined by the stages of grief. I did not believe that those stages conformed to real life, at least not in the rigid, lockstep way in which they were commonly understood.
I also came to learn another important lesson from my experience — theories like the stages were actually damaging to the bereaved. They placed people like Mary from the introduction in a box; they established an artificial and unreasonable timeline for suffering. In addition to the original pain of loss, the bereaved suffered from self-doubt, self-criticism, and shame when their experiences did not comply with the accepted wisdom.
On that morning in 2007, I saw that flawed and damaging orthodoxy seemingly being endorsed and legitimized at the highest levels of my profession. The newspaper story — a version of which was printed in papers across the nation — was based on an article in the esteemed Journal of the American Medical Association. That article, in turn, was based on results of research at Yale University.
I immediately put down my paper and went to my computer. I found the journal article and other published accounts of the study and tried to figure out just how the researchers had reached their conclusions. As it turned out, the article was based on a study of 233 grieving people, a significant enough number. But to my mind, many problems were immediately evident.
First, the studied population was dominated by one subgroup: elderly people who had lost a spouse. Thus, it was misleading to suggest that the study represented a broader grieving population. Others, such as those who had suffered a traumatic loss, were eliminated as subjects, though why was never made clear. I knew firsthand that the experiences of people in that category tended to be much more complicated and less predictable.
Second, and most important in my mind, the research did not aspire to test the validity of the stages model. In fact, the study assumed the stages to be true. The purpose of the research was to study the stages in the subjects over time, not to challenge the stages themselves. It was another misguided attempt to quantify the unquantifiable, which was the problem with the stages of grief to start with.
But the damage was done. Forty years after Elisabeth Kübler-Ross introduced the stages of grief in On Death and Dying, grievers were again being told how they should feel and for how long. If they didn’t follow the stages, then the experts said they might be suffering from a mental health disorder that should be treated by a professional.
Over the years, my grieving clients have come to see me for two reasons above all. First, given our death-phobic society, they felt like they had no other safe place to share the true feelings about their loss. Second, they were worried that they were going crazy. That concern was largely the by-product of theories like the stages of grief, which attempt to take a phenomenon that is natural, wholly unique, and unpredictable and make it into something diagnosable, like tonsillitis.
Hard as it is to conceive now, there was a time when humans lived without the benefit of mental health professionals to pronounce whether they were grieving correctly. The idea of “grieving correctly” would have seemed a ludicrous notion centuries ago, in the days before antibiotics and vaccines, when death was so much a part of everyday life. Most people lived on farms or in small towns and relied on their neighbors for consoling food and emotional support. The corpse was laid out in the family living room before the procession to church and cemetery. I have no doubt that the sorrow of those times was as deep as anything we experience today, but I also think there may have been something more natural about it all.
Then came the Industrial Revolution and the migration from country to city. People left behind their tight-knit communities and found themselves increasingly isolated in the anonymous crush of urban life. The assembly line did not stop for grief. Funeral homes came into being to provide living rooms for rent. With advances in medicine, we started living longer. With each passing decade, death became more foreign and unnatural.
The same thing happened with grieving. Community life and associated rituals of support for the bereaved began to disappear. In the past few decades, with the decline of organized religion as a unifying center of the community and a source of comfort, the isolation has grown ever more pronounced.
Psychology stepped into this profound human void, attempting to fill what the absence of the community and religion left for the individual to manage alone. If, to a significant degree, a goal of my profession is to alleviate suffering, what was a more universally painful experience than loss? But a person’s grief experience gradually became a data point, something to be studied and dissected. We tried to put mourning under a figurative microscope, tried to fit it into a “medical model” as an illness to treat, not as a normal and inevitable phenomenon of life.
Sigmund Freud was among the first to weigh in on this phenomenon. In his famous 1917 paper “Mourning and Melancholia,” the father of modern psychology attempted to make the distinction between mourning and depression (or what he called melancholia).2 Though the symptoms were similar, Freud held that mourning, triggered by the loss of a loved one, was normal, healthy, and temporary. He theorized that when mourning was done, the bereaved person would be free from the emotional attachment to the deceased. “[W]hen the work of mourning is completed the ego becomes free and uninhibited again,” he wrote.3
Two words in Freud’s statement — work and completed — laid the foundation for so much of what was to come in the following decades of grief theory. His paper was also the birth of the notion of grieving as a process — with a beginning, a middle, and an end.
But even Freud’s own experience did not seem to bear this theory out. Nine years after the death of his daughter, on what would have been her thirty-sixth birthday, Freud wrote to his friend Ludwig Binswanger, who had just lost his own son:
Although we know that after such a loss the acute state of mourning will subside, we also know we shall remain inconsolable and will never find a substitute. No matter what may fill the gap, even if it be filled completely, it nevertheless remains something else. And actually this is how it should be. It is the only way of perpetuating the love we do not want to relinquish.4
Another milestone in the study of grief came during World War II, with the work of a psychiatrist named Erich Lindemann. In 1942, nearly five hundred people perished in a fire at Boston’s Cocoanut Grove nightclub, the worst disaster of its kind in American history. In the aftermath, Lindemann, chief of psychiatry at Boston General Hospital, undertook the first systematic study of grief by interviewing the survivors of the dead.
Taking a page from Freud, Lindemann coined the term grief work. His work tracked Freud’s in other important ways, particularly with regards to the notion that the outcome of completed grief work was detachment, or a withdrawal of emotion, energy, and feelings for the deceased. He wrote, “The duration of a grief reaction seems to depend upon the success with which a person does the grief work, namely, emancipation from the bondage to the deceased, readjustment to the environment in which the deceased is missing, and the formation of new relationships.”5
Lindemann, who influenced many theorists to come, was also the first to put grief on a strict timeline. He wrote that eight to ten sessions with a psychiatrist over a period of four to six weeks was sufficient to manage most cases of grieving. This idea still makes me cringe.
As the twentieth century unfolded, other psychological theories and schools of thought, which were created to treat maladies such as family dysfunction, addiction, and anxiety disorders, were retrofitted to tackle grief. A prominent example is a school of psychology in which I was trained, Gestalt. The goal of Gestalt theory and therapy, which came to prominence in the 1950s and 1960s, was to help a client resolve “unfinished business” from past relationships and traumas. Gestalt therapists were trained to put their clients through rituals and exercises, such as the empty chair and letter writing, to access and resolve old emotional wounds. But once again, the purpose was an end to pain, a completion of it, a task completed. Gestalt and other emerging schools offered techniques that endorsed more or less the same objectives — completion, detachment, and acceptance.
The grieving person who did not move beyond the pain of loss had failed somehow or was pathological, which is exactly how I felt for a long time after Ryan’s death — as if something was wrong with me. The Gestalt therapist who had me talk to the empty chair assumed that I had gotten bogged down in my mission of letting go and that, consequently, I was “stuck” in my grief. In the excruciating months and years after Ryan’s death, I assumed the same. I was determined to break through and achieve this Gestalt “closure.”
The following story is an example of my commitment.
A few months after our loss, I attended a fall retreat with my colleagues. At the time, I was sleep deprived and weepy and thus clearly “behind” in my mourning. On the first afternoon of the retreat, after we had finished our work, I struck off alone on a path into the woods. A gurgling stream seemed to offer me an opportunity for resolution.
I picked up a small stick at the side of the water and decided that the twig would represent my son. I silently chanted that it was time to let go of Ryan, that it was time to accept his death. After some reflection and deep breathing, I bent and set the twig into the water, watching as it floated down the stream and finally out of sight. I stood by the water for several minutes, desiring catharsis, wishing for resolution. Nothing happened.
Elisabeth Kübler-Ross was a psychiatrist and a native of Switzerland. She married an American and moved to the United States in 1958. During her psychiatry residency in New York in the 1960s, she became interested in the treatment of the terminally ill in Western societies. Her groundbreaking study of the dying was the basis of her 1969 book, On Death and Dying.
“It is not meant to be a textbook on how to manage dying patients, nor is it intended as a complete study of the psychology of dying,” she wrote in the book’s preface. “It is simply an account of a new and challenging opportunity to refocus on the patient as a human being . . . We have asked him to be our teacher so that we may learn more about the final stages of life with all its anxieties, fears, and hopes.”6 Despite this opening caveat, Kübler-Ross went on to introduce the stages in authoritative, declarative sentences, as if they were fact, not an interesting theory:
“Denial functions as a buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less radical defenses.”7
“When the first stage of denial cannot be maintained any longer, it is replaced by feelings of anger, rage, envy, and resentment. The logical next question becomes: ‘Why me?’”8
“The third stage, the stage of bargaining, is less well known but equally helpful to the patient, though only for brief periods of time. If we have been unable to face the sad facts in the first period and have been angry at people and God in the second phase, maybe we can succeed in entering into some sort of an agreement which may postpone the inevitable happening.”9
“When the terminally ill patient can no longer deny his illness, when he is forced to undergo more surgery or hospitalization, when he begins to have more symptoms or becomes weaker and thinner, he cannot smile it off any more. His numbness or stoicism, his anger and rage will soon be replaced with a sense of great loss.”10
“If a patient has had enough time . . . and has been given some help in working through the previously described stages, he will reach a stage during which he is neither depressed nor angry about his ‘fate’ . . . Acceptance should not be mistaken for a happy stage. It is almost void of feelings. It is as if the pain had gone, the struggle is over, and there comes a time for ‘the final rest before the long journey’ as one patient phrased it.”11
Often lost is the fact that the aforementioned stages — even as they applied to dying people, not the bereaved — were met with skepticism.
In fact, three criticisms are summarized in the online reference Encyclopedia of Death and Dying. Chief among them is the relative flimsiness of Kübler-Ross’s research, which “offered nothing beyond the authority of her clinical impressions and illustrations from selected examples to sustain this theory in its initial appearance.”12 Critics also argued that the stages were overly broad and thus could not adequately describe a complex emotional event like dying. Finally, the stages implied a sequential order to the emotional reality of dying, though even Kübler-Ross conceded that a person might move back and forth between stages.
Over the years, however, the skeptics were largely ignored. Because of their simplicity and apparent logic, the stages became a phenomenon. In my profession, it was only a small leap to apply them more broadly to those who were grieving the loss of another, in addition to those who were dying. We were eager to latch onto anything that might demystify the messy, confusing, and painful experience of mourning. It didn’t hurt that Kübler-Ross seemed to endorse applying the stages more broadly. “Any natural, normal human being, when faced with any kind of loss, will go from shock all the way through acceptance,” she said in 1981. “You could say the same about divorce, losing a job, a maid, a parakeet.”13
With every passing year, as the stages became more ingrained as gospel, their application to the bereaved became more and more rigid. In the experience of mourning, the stages were not viewed as optional. “If you ignored or repressed the stages, you risked getting stuck with unresolved and painful emotions,” Ruth Davis Konigsberg wrote in The Truth About Grief: The Myth of Its Five Stages and the New Science of Loss. “But if you plunged yourself through them, you would eventually emerge on the other side stronger and wiser, a reward that was particularly appealing in the 1970s as the self-help movement with its promise of personal transformation was sweeping the country.”14
The stages of grief still remain the cultural orthodoxy. No psychological model has been imbedded as deeply in the popular culture as this one continues to be. Konigsberg called the Kübler-Ross model “the idea that wouldn’t die.” She described how the stages have permeated our culture, from politics to literature, and have become “a stock reference in popular entertainment, turning up in episodes of Frasier and The Simpsons, and more recently The Office, Grey’s Anatomy, Scrubs, and House.”15
The stages are so prevalent that their mention tends to go in one ear and out the other — until we lose someone. For the bereaved, every reference to the five stages of grief on television or in the media can seem like a referendum on their own sorrow.
Take Suzanne, a young woman who came to see me a year after her brother-in-law had been killed in a workplace accident. Not only was Billy the man who had married her sister, but he and Suzanne had also been close friends since childhood. She was devastated by his death.
“He was like a brother to me,” she told me.
But that was not what brought Suzanne to my office. A few weeks before we met, she had come across an article in a popular women’s magazine that featured the stages of grief. In the article, several well-known therapists, citing the stages, suggested that a person should be concerned if their mourning had not begun to abate after six or seven months. The experts even had a term for it — pathological grief — and said it should be treated by a mental health professional.
It wasn’t enough that Suzanne felt profound sorrow. She now wondered if she was pathological — sick, crazy — as well.
Another client, Nan, had recently lost her mother to cancer. She came to see me at a time when the stages had become accepted wisdom and self-diagnosis among grievers was epidemic. She got straight to the point on her first visit to my office: “I need closure,” she said.
But she took her self-diagnosis to an even deeper level. Nan felt like she knew why she had not been able to achieve closure. It was the “repressed” anger she felt toward her dead mother.
“Tell me more about that,” I said. “Do you know what you might be angry about?”
It turned out that Nan and her mother had had a highly complex and often painful relationship. The daughter had wanted to clear the air before her mother died but was repeatedly rebuffed by the dying woman.
“We had so much unfinished business,” Nan told me, unknowingly using the old Gestalt term. “Now I have nowhere to go with these feelings. I’ll live with this forever. My chance for closure is gone.”
By the time I saw Nan, I thought differently about “unfinished business” and “closure” than I had in years past.
“You couldn’t change your mother,” I said. “Just like you can’t change what you’re feeling now.”
“So what am I supposed to do?” she said. “I don’t want to feel this way the rest of my life.”
“Maybe it will help to know that almost no one achieves closure, at least not in the way you’d expect,” I said. “Everyone’s grief is different, but it’s safe to say there is no finish line.”
When I said that, there was an immediate change in her. She settled more deeply into her chair and sighed. Liberated from the rules and expectations of society, she could begin to relax. The biggest problem wasn’t the complicated pain of her loss; it was the expectations society had placed on her and that she had placed on herself.
Multiply the experiences of Mary, Suzanne, and Nan by the millions. So much damage has been done by the theories and therapies promoting the ideas of finishing unfinished business and closure, the five stages chief among them. The words of this recent blog by Emily Eaton, a young mother whose son died from leukemia, are too familiar:
[O]ne of the first things I did after I came out of my initial shock was ask a friend, “What are the 5 stages of grief, again?” I wanted a roadmap for my future. I wanted a to-do list. Then, I learned that the theory . . . is based neither on bereavement nor scientific research . . .
I wasn’t just surprised. I was disappointed when I learned the facts about Kübler-Ross’s five stages. I was mostly disappointed because I liked the idea of having a map or path through this process, which I could follow and track my progress through a journey that by definition (I assumed) had a beginning, middle, and end. But I was also disappointed to learn that these five stages had become conventional wisdom in the field of psychology and mental health without any scientific research to back it up.16
Megan Devine, a grief counselor and prominent advocate for the bereaved, pointed out the flaws of the Kübler-Ross model in a 2013 essay in the Huffington Post:
[Kübler-Ross] identified five common experiences, not five required experiences. Her stages, whether applied to the dying or those left living, were meant to normalize and validate what someone might experience in the swirl of insanity that is loss and death and grief.
The stages of grief were not meant to tell you what you feel, what you should feel, and when exactly you should feel it. They were not meant to dictate whether you are doing your grief “correctly” or not. They were meant to normalize a deeply not-normal time. They were meant to give comfort. Dr. Ross’ work was meant as a kindness, not a cage.17
But a cage they have become.
Strange as it seems today, my graduate counseling programs in the late 1970s didn’t offer a single class on working with the bereaved. The grief research and theories I mentioned earlier remained obscure. That might be why Kübler-Ross’s stages became such a phenomenon — they didn’t have much competition.
I had only a casual knowledge of the stages at the time of Ryan’s death, but I studied them much more deeply afterward. I had always been drawn to such models as they seemed to offer a formula for relieving pain. In the early 1980s, I still subscribed to the notion that with grief, resolution and closure were the goals, as they were for other psychological diagnoses. Resolution and closure were what the stages of grief seemed to promise.
I also needed a strategy for working with the bereaved, because after word got out about my own loss, I became known in my town as a grief expert, deservedly or not. A larger and larger percentage of my practice consisted of bereaved people, and the stages became the diagnostic lens through which I evaluated them.
Janie came to see me about two years after Ryan’s death and six months after she had lost her own four-year-old son, Marcus. She had devoted her life to caring for the boy, who had suffered from a degenerative lung disease (though it was an unrelated infection from a hospital stay that had taken his life).
“I feel like I should be better by now,” she told me in our first session. “I’m still depressed.”
“That’s a stage of grief,” I told her.
I encouraged her to read Kübler-Ross. She did, finishing On Death and Dying by our next session and eager to discuss the stages. We went through them one by one.
“I guess I was in denial,” she told me. “I always knew that Marcus could die from his lung condition, but for a long time I couldn’t believe that it was something else entirely that caused his death.”
Bargaining was never an issue, she said; nor was anger. In fact, Janie worried that there was something wrong with her because she wasn’t angrier.
“That’s just not my way,” she said.
The one stage she could really relate to was depression — the lack of energy and constant tearfulness. That was what we focused on as I tried to move her along to acceptance. I employed the old Gestalt exercises: She talked to Marcus in the empty chair. She wrote her little boy beautiful, heartbreaking letters. In the six months that I saw her, almost every session was deeply emotional.
I have no doubt that Janie benefited from our time together. As is typical, by the time she came to see me, she wasn’t comfortable talking about Marcus with her friends, many of whom were young mothers themselves. My office was a safe place for her. I also helped Janie and her husband understand the stresses that grief imposes on a marriage, and I suggested healthy ways for them to communicate about their loss.
But, after our last session, she was still deeply bereaved. I believed that my task had been to help her achieve some measurable change in her emotional state, some sense of resolution, and, in that regard, I seemed to have failed.
“Am I doing something wrong?” she asked me on one of our last visits.
I assured her that she was not.
“So how long will this take?”
I fumbled for a reply.
“Try to be patient,” I said.
Then I confessed, “I don’t think I’ve gotten there either.”
Looking back, I don’t know if I would have come to doubt the stages had I not been a grieving person myself and seen that they did not match up with my own experience. I was increasingly haunted by the notion that I was promoting a theory about loss that wasn’t true in my own life. The words of my mentor echoed in my mind: “You should never expect something of a client you would not expect of yourself.” I was caught in a curious limbo between doubting myself and doubting the ever-popular grief model.
I hoped that the answer could be found in more study or another theory. By the mid-1980s, there was no shortage of literature, because grief counseling was becoming an increasingly popular subspecialty of psychology. So, I read everything I could find.
Although the terms were often interchangeable, everything I found was a variation on the same theme — grief as work to reach an emotional conclusion. William Worden’s Grief Counseling and Grief Therapy, the bible in my field, was a prominent example.18 Worden described the four “tasks” of grieving: “Accept the Reality of the Loss,” “Experience the Pain of the Loss,” “Adjust to an Environment in Which the Deceased Is Missing,” and “Withdraw Emotional Energy and Reinvest It in Another Relationship.” (Worden has since changed the wording of his last task, but this is how it was stated when I learned it.)
The echoes of Freud, Lindemann, and Kübler-Ross were unmistakable. Grieving was predictable, the theorists said. Grievers could feel better if they just worked hard enough. There was something wrong with those who continued to suffer.
Most modern grief theories continue to promote the idea that pain of loss should come to an end. That is what is implied by the words closure, acceptance, recovery, and resolution. Closure advocates accuse those of us in the other camp of being enablers who encourage people to remain “stuck” in their grief or to “wallow.” But we know what we have observed in the real world, and we have seen the pain that arbitrary models have caused in so many grieving people. And yet the stages and other resolution-based models still dominate our culture.
In the mid- to late-1980s, I realized it was time for me to find a new way — a new way to grieve and to help others who were grieving.