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There Are No 'Five Stages' of Grief

There Are No 'Five Stages' of Grief

By Hilda Bastian

It was early springtime here in Australia when my son died. I took jasmine and dark-red sweet peas from my garden to his funeral and laid them carefully beside him, wondering how I could even keep breathing through the pain.

His name was Adam. He was 38, and more than six feet tall, but he was still my baby. His birth, as my first child, brought me to the most joyous life turn I’ve ever gone through; his death, the most shattering. I’d spent the first weeks of his existence obsessing over him around the clock, preoccupied with the basics of survival and longing for a snatch of sleep. Now, in the first weeks after his death, I reeled through a twisted mirror image of the same experience. It left me buckled over my kitchen sink, an awful, primal sound tearing from deep in my lungs. That sound—of keening—was one I’d heard just twice before: once from an animal, and then from a friend at her 12-year-old’s funeral. I hope to never hear it again.

The news of Adam’s death arrived by phone, in the middle of the night. The shock was so intense that when I tried to email people to let them know what had happened, my cold and shaking fingers made an eerie sound as they clattered on my keyboard in the dark.

In the weeks that followed, over many other nights, I’d come back to that keyboard, searching the internet for solace. I hoped that I might click on something, anything, that could help me get through my intolerable emotions, or make sense of my collapse. But as I read through grief websites and other information meant for those in my position, I couldn’t help but sit in judgment. I’m a meta-scientist—my expertise is in assessing the strength of scientific evidence and writing patient information—and my professional self was always right beside me, peering at the screen.

Having that perspective made the process heavy going. The internet of grief is crammed with conflicting theories and advice. Even a quick scan of the scientific literature told me that, for several reasons, I was at very high risk of becoming the sort of person who makes others say, sadly, “She was never the same …” But I could also see that my fate wasn’t sealed. I knew that people could find a way to carry infinite sadness and still have a joyful life. I couldn’t envisage that, but I set out to try, for my sake and my family’s.

So I groped my way, as best I could, through the competing claims of grief experts. There’s been a huge amount of research on bereavement—a search of just one biomedical database turns up about 10,000 papers published in the past 10 years—but I found it rife with unreliable results from tiny, problematic studies. As is true in many areas of psychology and medicine, a mass of studies has formed into a giant smorgasbord from which one can pick and choose results to fit any narrative, even when the weight of the evidence points another way. Theories based on the flimsiest data—or on none at all—have shaped how people think about their own and others’ grief.

In those early days, I decided that I’d have to come back to this research later on, when I was in better shape, so I could work through the evidence more thoroughly. Some studies had already helped me make important decisions. Among the confusing swirl of data, I knew there would be research that could help me more, and others too. The joy of my son’s birth had set me on the path to childbirth activism and epidemiology. It seemed fitting that I’d work on the science of grieving because of his death.

There are many things i want to understand. Some are quite specific: Do open caskets at funerals help more people than they traumatize? How is grief after sudden, unexpected deaths like Adam’s different from grieving after losses that come with weeks or months of warning? Other topics are broader: Might I have suffered more, or less, if I’d gone about my grieving differently, or would that have made no difference? What can communities do to reduce severe, prolonged grief? But I thought I’d start my journey with a look at how the path of grieving is described. For this article I’ve delved into the so-called stages of grief.

Denial, anger, bargaining, depression, acceptance. Before Adam died, I’d had a vague recollection that this whole idea had been debunked. But I quickly found that it was thriving. Indeed, when I turned to the internet of grief, I came across the stages everywhere, in versions that had sometimes been rejiggered or remixed.

The five-stage model wasn’t generated from data. It’s a theory, developed by the psychiatrist Elisabeth Kübler-Ross and published in 1969, that explains how people come to terms with their own impending death. I remember watching Kübler-Ross on television when I was a young teenager, absolutely enthralled, and later buying some of her books. By the time her second one was published, in 1974, Kübler-Ross had expanded her claims, such that the five stages would apply to the grieving process too. Families go through them once while their loved one faces death, she argued—and then they may again when that person has died.

Though I’d been a fan of Kübler-Ross’s work, mentions of this theory caused me stress when I was in extreme grief. Was my denial “stage” over yet? If not, how long did I have before I’d turn into a rage monster and scare my grandkids? Some grief websites warned that people can move backward and forward through the stages as they grieve—an idea that made me worry that the all-consuming despair could return. That possibility nipped at any sense of hope and encouragement I could muster: My anxiety would ebb, but then the internet whispered, It won’t last.

The five stages, so the theory goes, aren’t simply bidirectional either; they can also come on out of sequence, or with stages skipped over. “Keep in mind that these stages are meant to be descriptive and don’t necessarily apply to everyone or happen in the order presented,” Cleveland Clinic says. But other sources seem to argue just the opposite, suggesting that certain stages might be central to the grieving process: Depression may be overwhelming, told me, but “this stage is a necessary part of your healing journey.” And the time we spend in any stage, I learned from, “can last for minutes or hours as we flip in and out of one and then another.” If the five-stage model does not describe predictable steps along a typical path, then why even call them “stages” at all?

Some writers retrofit the substance of each stage to make them match up better to the reality of grieving. None of Kübler-Ross’s original stages, for example, seem to capture one of grief’s most common features: yearning for the person lost. But cramming new emotions and ideas willy-nilly into the model’s elements is nothing more than tinkering. The last straw for me came at the website for Cake, an end-of-life start-up that boasts of being “founded by MIT and Harvard alumni” and has raised $7 million in venture funding. At Cake, the “bargaining” stage has been rebranded as “bargaining and guilt,” in which you could be “feeling desperation, helplessness, and lose [sic] of hope.” The “depression” stage? Well, that could leave you “feeling overwhelming sadness, despair, and loneliness.” Meanwhile, the University of Washington suggests that bargaining means “ruminating on the future or past, over-thinking and worrying, comparing self to others”—none of which has anything to do with bargaining, either as Kübler-Ross originally described it or as the word is generally defined.

I learned that my doubts were well founded. Plenty of researchers, practicing psychologists, and expert panels have given up on Kübler-Ross’s theory; some have called for it to be “relegated to the realms of history.” Already by the early 1980s, a U.S. Institute of Medicine committee cautioned “against the use of the word ‘stages’ to describe the bereavement process,” as it might “result in inappropriate behavior toward the bereaved, including hasty assessments of where individuals are or ought to be in the grieving process.” And a few years after that report, the research psychologists Camille Wortman and Roxane Silver thoroughly debunked the five-stage model, noting, for example, that most people don’t experience depression after bereavement. What’s more, when a grieving person does become clinically depressed, they might be at risk of long-lasting suffering rather than in the middle stage of a steady advance toward “acceptance.”

Yet despite decades of attempts by scholars and professionals to let the five stages die, the model remains dominant. Research surveys of its spread confirmed my own experience: The stages appeared in roughly 60 percent of English- and Dutch-language websites about grieving that were evaluated in 2020. Another recent study asked roughly 60 mental-health professionals and 150 people from the general public whether they believed that the grieving process “can be expected to progress through a predictable series of stages, starting with denial and ending with acceptance.” Nearly half of the clinicians and more than two-thirds of the other adults rated that statement as being “definitely” or “probably” true.

Even if the five-stage model were (finally) to give up ground, other unsupported theories of grieving are poised to take its place. A couple of months after Adam died, I watched a doctor’s tweet go viral with the caption, “I’ve never seen a better graphical depiction of grief.” The attached diagram suggests that grief doesn’t diminish over time but rather stays the same size as “life begins to grow bigger around it.” That idea was first written up by a grief counselor named Lois Tonkin in a half-page article for the journal Bereavement Care in 1996. The basis for her theory? She’d heard a grieving mother describe her personal experience that way at a workshop, and the model “made sense of grief for me in a way that others had not.”

The Tonkin “growing around grief” model will surely be read, by some, as a beautiful, encouraging sentiment that honors the depth of our love for those we have lost. But if I’d happened to see it just a few weeks earlier, in the immediate aftermath of Adam’s death, it would have been another, demoralizing whisper to my hyper-anxious mind: This agony is permanent. No amount of life could dwarf the savage pain that I was feeling at that point; my grief would have to shrink if I could ever hope to flourish.

If you’re like me and don’t take to the Kübler-Ross or Tonkin models, there are plenty of others—too many to unpack here—each with its own advocates and critics. They all have the same purpose: By diagramming suffering and its relief, the models give a sense of structure to a tumult of scary, new emotion. That can feel like a shelter. But what if it’s built on a false foundation?

I’ve never felt as hopeless as I did when I lost my son. I didn’t need a vague theory. Facing grief that felt unbearable, I needed to know: When might the very worst be over?

Most grief websites won’t even try to give an answer to that question. They might describe a process of grieving—with reference to the five-stage model, or otherwise—while noting that you can’t put a timeline to that process, because there is no typical experience. Some sites make hand-waving reference to a point at which the distress of losing someone close will have eased. “Most people start to feel better at the 12-month mark,” I read in one particularly unhelpful formulation from Cake. Only start to?!

As a medical-evidence expert, I found this frustrating. We can provide people with information about the prognosis of complicated and life-shattering diseases, so surely we can do it for grieving too. Indeed, I’ve spent the past few months on the hunt for scientific studies that offer better information on the course of grief. (I’ve provided details and limitations at a blog I’ve started for collecting and assessing evidence on grief.) The 103 studies in my analysis include data drawn from more than 38,000 bereaved people, the bulk of them living in the U.S. or in European countries; the rest live in Asia, Australia, and Canada. Most of the studies were based on occasional interviews or questionnaires; a few compared data on medical care for entire populations of grieving people with similar groups of non-bereaved people. Though the methods of these studies vary, their findings converge on a similar broad pattern: For most people, after most deaths, grief starts to ease after a few weeks and continues to reduce from there. There can still be tough times ahead, but in most circumstances, by the time you reach six months, you’re unlikely to be in a constant state of severe grief.

Although most people will experience grief when they lose someone close to them, they won’t be overwhelmed by it. For roughly half of the bereaved, grief is mild or moderate and then subsides. Among those who experience high levels of grief at the outset, distress will usually begin to ease in a few weeks or months too. It’s not a straight line, where each day is better than the one before, but the overall level of suffering does go down over time.

Some bereaved people, though—about 10 percent, according to the research—will be in severe grief for six months or longer. The risk of remaining in deep grief for more than a year is higher for those under socioeconomic stress or who experienced the loss of a spouse, and it’s higher still after the loss of a child, or a sudden death via accident, suicide, or homicide.

Adults who face this long-running, severe distress are experiencing what many clinicians and researchers term “prolonged” or “complicated grief.” That increases their chances of having serious mental and physical health problems, including premature death and suicidal thoughts. Even if we don’t personally know someone who died within a couple of years of a major loss, we’ve probably all heard stories of it.

Our relationship with complicated grief, though, is itself pretty complicated. The diagnosis is relatively new, and still controversial—especially when it’s made at six months, and when it’s applied to those who are more likely to experience particularly severe grief in the first place. Quite a few people who meet the criteria at six months won’t still be suffering at that level by 12 months, for example. (I’m one of them.) The one-year cutoff has critics, too, as does the practice of ever calling grief a medical condition at all. “If grief is love,” a recent Washington Post op-ed argued, “why set expectations on its pace or texture? Why pathologize love?”

But expectations matter quite a bit. While pathologizing the normal can be harmful, so too can its reverse: We don’t always know for ourselves, or recognize for others, when help is needed. And the science shows that being locked in long-term, unrelenting grief can take a heavy toll.

When Adam died, I needed hope that a vibrant life was within my reach. The science showed me that it might be closer than I could imagine. So I tried to look forward. As I did so, I held on to a thought about my boy that helped me face a future without him: He had loved me his whole life. That love is precious, and it’s for keeps. I will not waste it.

By Hilda Bastian Hilda Bastian is a scientist, writer, and founding member of the Cochrane Collaboration. She was formerly the editor of the PubMed Health project at the National Library of Medicine.

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