An Empirical Examination of Grief

We received an interesting e-mail not long ago from a gentleman asking if there had been much empirical work done on grief and mourning. His wife had died and he found that he recovered quite readily, but that many others in his situation were severely affected by their grief, to the point that they couldn’t really function in their jobs.

I had previously poked around in this subject a bit but hadn’t come up with anything very interesting. There was this Wall Street Journal article called “Putting a Price Tag on Workplace Grief,” which included a reference to the Grief Recovery Institute, both of which left a lot of interesting questions unasked.

So I was interested to see that the Journal of the American Medical Association has just published a paper called “An Empirical Examination of the Stage Theory of Grief” (link is to the abstract only), a longitudinal study of 233 bereaved people in Connecticut. The stage theory of grief was pioneered by the psychiatrist Elisabeth Kubler-Ross, most famous for writing On Death and Dying. There has been considerable controversy and confusion over the application of Kubler-Ross’s stage theory: e.g., does it apply to a bereaved person as well as a person who is dying himself/herself? Does it apply in the case of, say, divorce as well as death?

Anyway … a commonly accepted premise is that there are five sequential stages of grief: denial, anger, bargaining, depression, acceptance. Here is a summary of the JAMA study, which supports some of the stage theory while contradicting perhaps the most essential argument:

Counter to stage theory, disbelief was not the initial, dominant grief indicator. Acceptance was the most frequently endorsed item and yearning was the dominant negative grief indicator from 1 to 24 months postloss. In models that take into account the rise and fall of psychological responses, once rescaled, disbelief decreased from an initial high at 1 month postloss, yearning peaked at 4 months postloss, anger peaked at 5 months postloss, and depression peaked at 6 months postloss. Acceptance increased throughout the study observation period. The 5 grief indicators achieved their respective maximum values in the sequence (disbelief, yearning, anger, depression, and acceptance) predicted by the stage theory of grief.

Even though there isn’t much meat here, I am happy to see that a subject as essential as grief is being put to some empirical testing. I would like to think that we are on our way to a less childish, or child-like, view of death in this country, although there isn’t yet much evidence to support my hope. At the very least, the hospice movement continues to grow, with roughly one-third of all U.S. deaths now within a hospice program. As someone whose mother died under hospice care — as good a death as any of us could have imagined — I consider this a hopeful sign.


pkimelma

You did not indicate if the JAMA article was looking at the dying, the survivor, and/or if it included divorce as well. Kubler-Ross was focused on the person dying (how they come to deal with being told they are dying) and how Hospices could assist in that. Yearning implies a focus on the survivor after the death.

valpodoc

As someone who takes care of terminally ill patients and their families, I am of the opinion that this subject is much more difficult than it initially appears. Observations include: 1.Grief may be subjective, i.e. the surviving spouse may function quite well at work, but be completely socially withdrawn otherwise. This might indicate that people could potentially be in various stages of grief depending on the activity they are pursuing. 2.Grief/resolution may be confounded by social/ethnic mismatches. 3.Grief is dependant on social support. One of the reasons I believe Hospice works is it becomes a surrogut support group (one with experience).

stuart

The five stages idea seems way too cookie cutter for me. I have been through two grieving situations in the relatively recent past (mother and wife) and have not identified any real similarities between my processing of the two events or between the process and the five stages. Is there any real evidence for the five stages idea?

meomaxy

I wish I could remember where I saw it, but I remember seeing an article about a study not exactly about grief, but I think about trauma and PTSD. The question was who does better, those who suppress their emotions or those who went through some sort of grief counseling where they were encouraged to talk about the traumatic event over and over. The finding was that the suppressers did better, which was counter to what the whole grief counseling industry was supposed to be about.

I have no opinion about the stages of grief, but I have to think that one's response would have to vary from person to person, not just because of psychological variations but also due to one's attitude about life's expectations.

Just a few generations ago, it was typical for children to die, wives to die in childbirth, infections to strike down young men and women. If people then grieved the way you would expect people to grieve today, it would be hard to imagine how society could have functioned.

Read more...

sharonbkatz

I am a psychologist and nurse who has specialized in the areas of grief and loss for the past 27 years. I am the author of the American Counseling Association's on-line countinuing education course on Grief Counseling. While the medical profession still may use Kubler-Ross' stage model, grief professionals have moved beyond the use of that model because (1) there is little clinical support for stage models; (2) stage models give the false impression of an orderly grief process; (3) stage models give a false impression of the commonality of the grief experience; and (4) stage models propagate the view of a 'normal' vs 'abnormal' grieving process. An excellent example of a more useful and current model is Therese Rando's Six "R"s, a process model which is very comprehensive and useful in understanding grief. Another example of more current thinking beyond stage models is William Worden's Task Model.

Read more...

Pallimed1

Stephen, I agree that it is nice to see such difficult to grasp topics such as grief looked at in a more scientific way. While grief and other subjects like it can be very complex and may never be boiled down to a simple explanation, I think we all learn a bit more by asking these tough questions.

As a hospice physician, I found this study insightful and helpful. I write about the JAMA grief article from a MD perspective more on my blog Pallimed. To answer/reply to a few of the comments:
1) pkimelma: this study looked at a group of people who had a death of a loved one in the past year. Mostly white elderly females who lost a spouse.
2) valpodoc, I agree that hospice workers often act as a support group before and after the death/loss
3) stuart, you are right on target. Everyone experiences grief differently, and this study was aiming to find any commonalities that may exist in grieving people. They purposefully excluded anybody who was considered to have 'complicated grief' and were trying to define grief as experienced by a group. The authors make plain to say they understand this population study does not always guarantee an individual will follow this exact pattern. And the big point of this study was to find evidence for stages of grief. And on another note, my condolences to you for your mother and wife.
5) sharonbkatz, Yes there are very many different models for grief out there, but I think the reason they went with this one (which was not solely Kubler-Ross BTW, just based on her and some others) is because it is well recognized. And to your first, second and third points, the study was aiming to show clinical support, orderly grief, and the commonality of the grief experience. They did that pretty well, but again this applies to a population not to an individual. And for point 4, the authors suggested using this to help identify complicated grief, which some would call an abnormal response to a overwhelming stress that requires more intense help and support.

I would be interested in the Six R's if you can point me to a good resource that you trust.

Great comments everyone, and come over to Pallimed if you get a chance.

-Christian

Read more...

stuart

Thanks for your comments. I would also be inetersted in a source for the the six R's

sharonbkatz

The information on the 6 R's is contained in Treatment of Complicated Mourning by Therese A. Rando. This is an excellent comprehensive textbook. She is also the author of several other books including Grief, Dying & Death: Clinical Interventions for Caregivers and Parental Loss of a Child in addition to numerous articles.

pkimelma

You did not indicate if the JAMA article was looking at the dying, the survivor, and/or if it included divorce as well. Kubler-Ross was focused on the person dying (how they come to deal with being told they are dying) and how Hospices could assist in that. Yearning implies a focus on the survivor after the death.

valpodoc

As someone who takes care of terminally ill patients and their families, I am of the opinion that this subject is much more difficult than it initially appears. Observations include: 1.Grief may be subjective, i.e. the surviving spouse may function quite well at work, but be completely socially withdrawn otherwise. This might indicate that people could potentially be in various stages of grief depending on the activity they are pursuing. 2.Grief/resolution may be confounded by social/ethnic mismatches. 3.Grief is dependant on social support. One of the reasons I believe Hospice works is it becomes a surrogut support group (one with experience).

stuart

The five stages idea seems way too cookie cutter for me. I have been through two grieving situations in the relatively recent past (mother and wife) and have not identified any real similarities between my processing of the two events or between the process and the five stages. Is there any real evidence for the five stages idea?

meomaxy

I wish I could remember where I saw it, but I remember seeing an article about a study not exactly about grief, but I think about trauma and PTSD. The question was who does better, those who suppress their emotions or those who went through some sort of grief counseling where they were encouraged to talk about the traumatic event over and over. The finding was that the suppressers did better, which was counter to what the whole grief counseling industry was supposed to be about.

I have no opinion about the stages of grief, but I have to think that one's response would have to vary from person to person, not just because of psychological variations but also due to one's attitude about life's expectations.

Just a few generations ago, it was typical for children to die, wives to die in childbirth, infections to strike down young men and women. If people then grieved the way you would expect people to grieve today, it would be hard to imagine how society could have functioned.

Read more...

sharonbkatz

I am a psychologist and nurse who has specialized in the areas of grief and loss for the past 27 years. I am the author of the American Counseling Association's on-line countinuing education course on Grief Counseling. While the medical profession still may use Kubler-Ross' stage model, grief professionals have moved beyond the use of that model because (1) there is little clinical support for stage models; (2) stage models give the false impression of an orderly grief process; (3) stage models give a false impression of the commonality of the grief experience; and (4) stage models propagate the view of a 'normal' vs 'abnormal' grieving process. An excellent example of a more useful and current model is Therese Rando's Six "R"s, a process model which is very comprehensive and useful in understanding grief. Another example of more current thinking beyond stage models is William Worden's Task Model.

Read more...

Pallimed1

Stephen, I agree that it is nice to see such difficult to grasp topics such as grief looked at in a more scientific way. While grief and other subjects like it can be very complex and may never be boiled down to a simple explanation, I think we all learn a bit more by asking these tough questions.

As a hospice physician, I found this study insightful and helpful. I write about the JAMA grief article from a MD perspective more on my blog Pallimed. To answer/reply to a few of the comments:
1) pkimelma: this study looked at a group of people who had a death of a loved one in the past year. Mostly white elderly females who lost a spouse.
2) valpodoc, I agree that hospice workers often act as a support group before and after the death/loss
3) stuart, you are right on target. Everyone experiences grief differently, and this study was aiming to find any commonalities that may exist in grieving people. They purposefully excluded anybody who was considered to have 'complicated grief' and were trying to define grief as experienced by a group. The authors make plain to say they understand this population study does not always guarantee an individual will follow this exact pattern. And the big point of this study was to find evidence for stages of grief. And on another note, my condolences to you for your mother and wife.
5) sharonbkatz, Yes there are very many different models for grief out there, but I think the reason they went with this one (which was not solely Kubler-Ross BTW, just based on her and some others) is because it is well recognized. And to your first, second and third points, the study was aiming to show clinical support, orderly grief, and the commonality of the grief experience. They did that pretty well, but again this applies to a population not to an individual. And for point 4, the authors suggested using this to help identify complicated grief, which some would call an abnormal response to a overwhelming stress that requires more intense help and support.

I would be interested in the Six R's if you can point me to a good resource that you trust.

Great comments everyone, and come over to Pallimed if you get a chance.

-Christian

Read more...

stuart

Thanks for your comments. I would also be inetersted in a source for the the six R's

sharonbkatz

The information on the 6 R's is contained in Treatment of Complicated Mourning by Therese A. Rando. This is an excellent comprehensive textbook. She is also the author of several other books including Grief, Dying & Death: Clinical Interventions for Caregivers and Parental Loss of a Child in addition to numerous articles.