As we pass the milestone of living for a full twelve months in a pandemic it’s inevitable that people will reflect on what the year has brought. We’ve seen people struggle with mental health, loneliness, zoom fatigue, lockdown fatigue. Yet there’s been little focus on one of the most profound of emotions that many are feeling as a consequence of the pandemic: grief. Grief is still an incredibly private emotion for many of us in the UK. There are cultures that have very different, and arguably much healthier, approaches but here, for many, it is something to be dealt with alone. Stiff upper lip and all that.
As we find it difficult to talk to people about our emotions, it’s somewhat inevitable that we will turn to pop culture and the media to guide us. And when it comes to grief there is one model that has permeated – the five stages of grief. These stages have been a mainstay of films, TV and books since they were first described by Elisabeth Kübler-Ross in her hugely influential 1969 book On Death and Dying.
Also known as the Kübler-Ross model, it was originally (and only) intended to describe the emotional journey that terminally ill patients often find themselves on. It was never supposed to be an instruction manual, and was never intended for use outside of palliative care. Kübler-Ross never even called them stages or showed that any individual patient experienced all five[1]. But the model has taken on a life of its own that even its originator lamented[2]. These stages – denial, anger, bargaining, depression and acceptance – have become the commonly accepted way that grief does and should progress. But does this model reflect reality?
As I’m writing this piece for The Skeptic, I’m pretty sure you’ve guessed already that the answer is ‘no’. The Kübler-Ross model is well-known, pervasive, and wrong. That’s not to say that it’s completely unhelpful – the emotions described in it are all commonly experienced during the grieving process, but they don’t happen in a particular order and they aren’t experienced in isolation. For example, you don’t go through your ‘anger’ phase where all you feel is anger and then never feel angry about your loss again.
Now, you might say “who cares?” If the model is helpful does it matter if it’s not right? My response is that it we’d have to show that it was helpful first, and the research suggests that it’s really not. As far back as 1993, Dr Charles Corr wrote in the journal Death Studies:
“some of the most knowledgeable and sophisticated clinicians who work with those who are coping with dying have made clear their view that the stage-based model put forth by Kübler-Ross is inadequate, superficial, and misleading.” [3]
Alternative Models
The five stages of grief were never meant to describe the process of grieving that follows the death of a loved one. So when it comes to bereavement, what are people to do? Is there a model that people can turn to in order to help process and navigate their grief, and to identify when their grieving has become unhealthy? There is. It’s called the Dual Process Model. It was described by Margaret Stroebe and Henk Schut in their 1999 paper[4], which they have subsequently revised in 2010[5] and 2016[6]. So what is this Dual Process Model? I will let the originators explain:
“The DPM specifies two types of stressors: loss orientation and restoration orientation. This specification is necessary because research has shown that bereaved people not only have to cope with the loss of the loved person himself or herself, but also have to make major adjustments in their lives that come about as secondary consequences of the death. Both of these aspects are potential sources of stress and anxiety. Loss-oriented coping thus refers to dealing with, concentrating on, and working through some aspect of the loss experience itself (e.g., crying about the death, yearning for the person, looking at his or her photograph). Restoration-oriented coping, on the other hand, includes mastering of the tasks that the bereaved person had undertaken, dealing with arrangements for reorganizing life, and developing new identities.” 5
One of the key aspects to the Dual Process Model is that those experiencing grief oscillate between their loss-oriented coping and their restoration-oriented coping. In other words, it recognises that people will have days where all they want to do is cry and look at old photos and lament their loss, and they’ll also have days where they want to be completely distracted and do things that have no association with the person they’ve lost. It recognises that switching between these two mindsets is normal and healthy and necessary to process grief and accept life without their loved one.
The model also allows for unhealthy behaviour to be identified – if someone is perpetually stuck in one coping strategy, for example – and offers bereavement councillors and other professionals guidance on how to help people with their bereavement. A 2019[7] systematic review found that the model “accurately represents the bereavement experience and can be used to understand how bereaved individuals cope”. In other words, the model works!
Loss and Covid
I began this piece talking about the pandemic so I feel I should end on that topic too. The pandemic has had a huge impact on our ability to grieve. Hospital patients have had to die alone, restrictions have been placed on how many people can attend funerals, and it has not even been possible to share a cup of tea with someone from outside your household for most of the past year, let alone a comforting hug. The potential for people to engage with restoration-oriented coping methods has been severely restricted[8] and the long-term consequences of this are, as yet, unknown.
Grieving is a process. It is unique to each and every person, and to each and every bereavement. Feeling conflicting emotions, feeling emotionally numb, and feeling overwhelmed with emotion all are part of grieving, of adjusting to the new world – a world where there’s a massive hole that feels like it will always gape wide. But over time that hole will slowly close. Signs of it will always exist, there will be a scar that will never fully fade, but the gaping maw of loss and heartbreak will fill and memories will once again bring joy rather than pain.
The five stages of grief are a simplistic representation of this process, and one that was never intended by their creator. They fail to reflect the diversity and complexity of the emotional journey that bereaved people undertake. The death toll of the pandemic has been staggering, and for each person lost there are many more who grieve for them. Understanding the complexities of that grief and not reducing it to a cliché is the least we can do.
References
[1] Corr, Charles A. 2020. “Elisabeth Kübler-Ross and the ‘Five Stages’ Model in a Sampling of Recent American Textbooks.” OMEGA – Journal of Death and Dying 82 (2): 294–322. https://doi.org/10.1177/0030222818809766.
[2] Kübler-Ross, Elisabeth. 2009. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy and Their Own Families. 40th Anniversary Edition. Routledge.
[3] Corr, Charles A. 1993. “Coping with Dying: Lessons That We Should and Should Not Learn from the Work of Elisabeth Kübler-Ross.” Death Studies 17 (1): 69–83. https://doi.org/10.1080/07481189308252605
[4] Stroebe, Margaret S, and Henk Schut. 1999. “Meaning Making in the Dual Process Model of Coping with Bereavement.” Death Studies 23 (3): 197–224. https://doi.org/10.1037/10397-003.
[5] Stroebe, Margaret, and Henk Schut. 2010. “The Dual Process Model of Coping with Bereavement: A Decade On.” Omega: Journal of Death and Dying 61 (4): 273–89. https://doi.org/10.2190/OM.61.4.b.
[6] Stroebe, Margaret, and Henk Schut. 2016. “Overload: A Missing Link in the Dual Process Model?” Omega (United States) 74 (1): 96–109. https://doi.org/10.1177/0030222816666540.
[7] Fiore, Jennifer. 2019. “A Systematic Review of the Dual Process Model of Coping With Bereavement (1999–2016).” OMEGA – Journal of Death and Dying. https://doi.org/10.1177/0030222819893139.
[8] Albuquerque, Sara, Ana Margarida Teixeira, and José Carlos Rocha. 2021. “COVID-19 and Disenfranchised Grief.” Frontiers in Psychiatry 12 (February): 10–13. https://doi.org/10.3389/fpsyt.2021.638874.
