News Special Report

‘Like Being in an Ocean’: The Many Stages of Grief

photo of Christina and family

July 11, 2019 -- Around 2 a.m. on April 28, 2016, Cathy Semeria made a call no mother should ever have to make.

Her son Nick had been awoken by a friend with troubling news of a fatal crash the night before that involved five University of Georgia students -- possibly including his sister Christina. Nick urged his parents to call Athens Regional Medical Center near where she went to school. Hands shaking, Cathy dialed the number.

“I said, ‘You just need to let me know that my daughter is OK,’” she recalls. “There was total silence on the other end.”

She threw the phone at her husband and collapsed in disbelief.

In the coming days, as news unfolded about the accident that killed 19-year-old Christina Semeria and three friends and left another critically injured, Cathy waded through waves of shock and daze. At first, she couldn’t cry. “Was that normal?” she asked herself. Six weeks later, she started crying and couldn’t stop.

A year later, she still bristled when well-meaning friends suggested her daughter “would want her to be happy.” And she often replayed the details of the accident in her mind: No drugs. No alcohol. No speeding. Yet their car drifted across the center line. Why?

Today, she has found solace in her community, and through carrying on “Tini’s” legacy via social media. But when a friend of her daughter -- the youngest of her four children -- gets married or graduates from college, the pain pulls Cathy under again.

“Grief is like being in an ocean and you don’t know when a wave is going to hit you, or how high it is going to be, or how long you are going to get caught in the riptide,” she says.

While Cathy’s journey may sound familiar to some, it is -- new research suggests -- wholly her own.

Fifty years after psychiatrist Elisabeth Kubler-Ross introduced the now iconic five stages of grief -- denial, anger, bargaining, depression, and acceptance -- scientists in the growing field of bereavement research say it’s not so simple.

 

Men grieve differently than women. Soldiers grieve differently. More than 60% of people, recent research has shown, bounce back surprisingly quickly. But about a quarter take a year or two, and one in 10 have what is known as “complicated grief” -- a persistent, debilitating yearning that can last years.

Grief changes the body in different ways, too: People who grieve longer have different brain activity, different hormone patterns, and a higher risk of bereavement-related health problems.

“There has been this idea in the past that grief proceeds in the same somewhat lockstep sequence for everyone,” says  David Feldman, PhD, a professor of counseling psychology at Santa Clara University in California. “We now know it just doesn’t work that way. People often attack themselves for doing grief wrong when, really, we are all entitled to our own way.”

The Truth About the Five Stages

David Kessler, who co-authored several books with Kubler-Ross, says her work has been “widely misunderstood.”

He says that when she introduced the stages in the 1969 book On Death and Dying, they were intended to describe the emotional process of a dying person at the end of life.

In 2004, On Grief and Grieving, by Kessler and the late Kubler-Ross, was published. The book formally adapted the stages to the bereaved, and the authors included an often overlooked notice on Page 1.

“We explained that they are tools to help us frame and identify what we may be feeling, but they are not stops on some linear timeline,” Kessler says.

That said, he still uses the stages in his workshops and on his website, grief.com, to describe what many go through.

Denial, which sometimes shows up as shock, helps us pace our grief, he says, letting in only as much pain as we can handle. Anger is “pain’s bodyguard,” letting have connections without being too vulnerable.

“A connection made through the strength of anger feels better than nothing,” he says.

Bargaining helps us make a plan to climb out of grief -- we’ll volunteer in our loved one’s name or vow to live our own lives more fully. Depression is a given, he says, once we let the reality of the loss sink in.  Then there is acceptance.

“Not everyone goes through all the stages, and they are not in any prescribed order,” he stresses.

The Broad Spectrum of Grief

George Bonanno, PhD, a professor of clinical psychology at Teachers College at Columbia University, says he has seen no evidence that these stages are universal among the grieving and, in fact, the five-stages theory has in some ways done more harm than good.

“In the ’90s, the idea was that everyone must go through this painful, elaborate working-through process, and if they didn’t, either they didn’t care about the person or they were in denial and needed treatment,” he says. “A lot of people were getting treatment when they really didn’t need it.”

In one groundbreaking study of 205 widows and widowers, he found 46% showed little depression, intense yearning, or longing in the 18 months after the death of their spouse. Ten percent actually had improved mental health, as the chronic stress of caregiving subsided. Another 2015 study -- of 2,512 people who had lost spouses or children -- found that 69% were “resilient,” having little depression at three follow-up time points.

As Bonanno writes, “These individuals are not cold and unfeeling or lacking in attachment but, rather, are capable of genuine resilience in the face of loss.”

On the other end of the spectrum is complicated grief, also known as prolonged grief disorder.

“Imagine feeling the way you felt in the early days after a friend or family member died, only it is years later,” says Katherine Shear, MD, founding director of the Center for Complicated Grief at the Columbia School of Social Work.

About 7% to 10% of the bereaved struggle with it, but it’s more common among those who have lost a loved one to homicide, suicide, or other violent incident. About 24% of parents who have lost children and 23% of military families have it.

They often rearrange their lives to avoid reminders of the deceased -- a park a child used to play in; a spouse’s favorite restaurant.

“All of a sudden there are a ton of places they can’t go,” says Shear, recalling one patient who -- 4 years after the death of her son -- seldom left the house because she was afraid she’d run across something that would trigger her grief.

Over time, people who once offered support start to fall off, says Shear. “Then people start to say things like ‘I know this is really hard, but it’s time to get over it.’”

Research also suggests that men and women differ in their grief, with women grieving more chronically and men grieving more acutely.

“In the beginning, I felt like I had been dismembered -- like half of my body was missing,” recalls Sam Feldman, of Martha’s Vineyard, MA, whose wife of 53 years, Gretchen, died of cancer in 2008.

Four weeks after her death, he attended a dinner party with friends and was struck by the fact that no one brought up her name.  He finally got up and left.

“In retrospect, I realize that they were uncomfortable bringing her up,” he recalls. “But I wanted to talk about her. Sometimes I don’t think people realize that.”

Because husbands tend to rely heavily on their wives for social plans and have more trouble sharing their feelings, he says widowers are often struck with profound loneliness.

“We have a lot of acquaintances but sometimes not a lot of intimacy, so it’s hard to find people to talk to,” says Feldman.

But when he attended a support group, he walked in to discover it was all women and they, as he puts it, seemed to be on a different path than he was.

He ended up founding his own all-men’s group, now known as the National Widowers Organization, to help fill that gap. And he has since remained strongly involved in the arts community, of which Gretchen (a painter) was a part.

At age 90, he has a new partner and is happy.

But he still drives by Gretchen’s nearby grave almost daily and thinks of her often.

“It’s not a negative thing. She’s just a part of who I am now,” he says.

Your Brain on Grief

While the research is young, studies have begun to shed light on what happens in the brain and body during grief.

In the days after a loved one’s death, the bereaved’s body pumps out stress hormones like epinephrine and cortisol, boosts blood pressure, and weakens immune response, studies show. In fact, in the first 3 months after the death of a spouse, the odds of dying are twice as high for men and 1.5 times as high for women.

In most cases, those changes fade over time.

But in people with prolonged or complicated grief, things are different.

Studies show they continue to have higher levels of the stress hormone cortisol and may also have an imbalance of the hormone oxytocin, a.k.a. “the mothering hormone,” which helps people form bonds with one another.

Meanwhile, brain imaging studies show that when healthy people are shown a photo of the deceased many months later, it still activates those regions associated with physical pain.  But in people with prolonged grief, a reward center called the nucleus accumbens -- which is also linked to yearning for food or drugs -- also lights up.

“In a way, people who lose a loved one and can’t get over it are like drug addicts,” says Bonanno. “Their reward system is in hyperdrive, and they are in a constant state of yearning for a person who is not there and is not going to be there.”

A New Way to Manage Grief

While it may help some people, in many cases, the bereaved do not require long-term therapy or medication, says Bonanno, author of The Other Side of Sadness. What the New Science of Bereavement Tells Us About Life After Loss.

“Most people recover pretty quickly,” he says. “It’s not that they aren’t sad. But they can work and continue with their lives and experience joy and pleasure, sometimes even in the early days after a loss.”

But for those with complicated grief, professional counseling is recommended.

Shear has come up with a 16-week program in which people explore when and how to face their grief and when it’s appropriate to set it aside. In one exercise, they are asked to recount the story of when and how they first learned of the death. In others, they’re encouraged to return to the places they’ve been avoiding, take steps to strengthen relationships with the living, and plan for the future.

They also develop healthy ways to stay connected with their lost loved ones.

“Grief is not all bad,” says Shear. “It is not something we need to make go away or get rid of or not talk about. We need to allow it a place in our lives and our communities.”

The Sixth Stage

In November, Kessler will publish a follow-up to the book he authored with Kubler-Ross, adding a sixth stage, which he has come to understand better since the death of his own 21-year-old son.

“I was devastated, and I tried to do what I told everyone else to do,” he says, recalling how he sat in grief counseling groups, his book on the table, where no one knew he’d written it. The stages rang true to him. But one was missing: Meaning.

“We are not a generation that is just OK with finding acceptance,” he says. “We want to transform our grief into something more meaningful.”

Cathy Semeria says that of all the stages of grief she’s heard about, she identifies with this one the most.

Despite the occasional comment that she’s being too vocal on Facebook, or that her grief is lingering too long, she continues to post candidly and speak publicly about her grief process, has started a support group for grieving parents, is more active than ever in her church, and intends to write a book.

“Even in the deepest of grief, I continue to live my life with purpose and meaning and share my story,” she says.

Is she over the grief? No, she says. There is no climbing over it.

But she has gained the strength to walk through it.

WebMD News Special Report Reviewed by Neha Pathak, MD on July 11, 2019

Sources

George Bonanno, professor of clinical psychology, Teachers College, Columbia University, New York; author, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss.

David Feldman, PhD, professor of counseling psychology, Santa Clara University, California.

David Kessler, death and grieving expert, grief.com; co-author, On Grief and Grieving.

Katherine Shear, MD, professor of psychiatry, Columbia School of Social Work; founder, Center for Complicated Grief.

Psychology of Aging: “Prospective Patterns of Resilience and Maladjustment During Widowhood.”

Dialogues in Clinical Neuroscience: “Immunological and neuroimaging biomarkers of complicated grief.”

Journal of Psychiatric Research: “Trajectories of depression following spousal and child bereavement: A comparison of the heterogeneity in outcomes.”

Australian Critical Care: “What is normal in grief?”

Mary-Frances O’Connor, PhD, associate professor of psychology, University of Arizona.

Cathy Semeria.

Sam Feldman.

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