Stages of Grief
The notion that the grief process occurs in orderly stages is widely accepted, but studied little. According to the "stage theory," the process includes stages of disbelief, followed by yearning for the lost loved one, anger, depression, and acceptance.
The new study, published in the Feb. 21 issue of TheJournal of the American MedicalAssociation, is among the first to examine whether the stage theory actually reflects normal grief patterns.
Prigerson and colleagues from Harvard Medical School and Yale University School of Medicine examined data from the Yale Bereavement Study.
The 233 study participants were followed for two years following the death of a close family member or other loved one. Eighty-four percent of the study subjects had lost a spouse, and most were in their 60s or older, Prigerson says.
Counter to the stage theory, acceptance, not disbelief, was a major early dominant grief indicator.
“Evidently, a high degree of acceptance, even in the initial month [after death], is the norm in the case of natural deaths,” the researchers wrote.
And yearning was the most commonly cited negative psychological response reported throughout the study. Feelings of longing or pining for the lost loved one tended to peak four months after the loved ones’ death and began to subside at six months.
“Yearning was seen much more often than depression,” Prigerson says. “This has important clinical implications because most of the models we use [to assess grief] focus on depression. This suggests that we are focusing on the wrong target.”
Talking About Death
Sudden death was associated with a higher degree of disbelief among survivors. While this finding is not surprising, Prigerson says it too has major implications for clinical practice.
Terminal illness was the cause of the vast majority of deaths in the study. Researchers found that having knowledge of a diagnosis for six months or longer was associated with higher levels of acceptance among survivors.
“We know that very few doctors discuss life expectancy with their terminal patients and their loved ones,” Prigerson says. “That is a hard conversation to have, but it is an important one.”
Prigerson acknowledges that the grief model may not apply to other populations, such as survivors grieving deaths from unnatural causes like car crashes and suicide, or parents grieving the loss of a child.
But the researchers point out that more than nine out of 10 deaths in the U.S. are the result of natural causes, and the vast majority of these deaths occur among middle-aged and elderly people like the ones reflected in the study.
Grief counselor David Fireman says even among this population it is difficult to characterize what it normal when it comes to reactions to the death of a loved one.
Fireman is director of the Center for Grief Recovery in Chicago.
“Grief is very personal and many variables are involved,” he says. “Grief is a process, not a condition, and from my perspective there is no correct timetable for the waves of grief that people feel.”