Five phases of grief

Elizabeth Kübler-Ross was a doctor in Switzerland who studied the effects of grief on people who learned they had a terminal illness. Her studies showed a trend for people to experience five distinct phases of emotion and reactions. Not all people experience all five phases, nor do people necessarily take them in order.

I will cover these stages and some of their meanings and implications soon. First I would like to discuss what this model can help with and what it isn’t designed to assist.

The Kübler-Ross model is probably the most famous model of grief. It is well used in television and pop psychology as a script that people will go through (youtube example from The Simpsons). To take it out of the pop psychology script and bring it back to real life, consider the following.
Being a model, it describes common experience. Outliers and other oddities are taken out of the data such that an “average” can be created. This means that this model may, or may not, apply to you or the situation you are aiding in. This doesn’t mean that someone who doesn’t follow this model is wrong, weird or faulty. It just means this model doesn’t apply.

The model was based on observing people who knew they were going to die. It can be extended to any up coming expectation of loss, such as a job, a partnership, house, country and so on. While this model may be applicable to sudden and unexpected loss, it often does not apply to it, nor was it based on observing people who experienced sudden and unexpected loss. In practical terms, that means if you know you are going to lose something (life, job, partner etc), this model is likely to be useful, whereas if you find yourself unexpected affected by the loss of something (life, job, partner), this model is probably not useful to you.

I see a large proportion of people who are going through the end stages of their relationship go through phases of this model while they are coming to terms with the cessation of their partnership. Often their partners, who had very little idea it had come to this, go through another grief process as their relationship unexpectedly ends.

On with the phases/stages/levels or whatever you choose to call it.

Anger is a response to your perception of personal power being decreased. Often this is due to someone or something crossing a boundary, but in this case, it is the knowledge of the upcoming loss. You are going to lose something and you are not only unhappy about it, you are angry.

People who experience this stage will often be very down on themselves, lash out seemingly irrationally at those around them, push people away and may act quite aggressively. A great deal of this aggression is transferred anger at the situation being passed to others and self. It is an attempt to compensate for the perceived loss of power.

Anger can drive efforts to change the situation and avoid the loss. It is a great fuel if balanced, but it often clouds the issue and you can miss opportunities that can change the situation. That is the risk if the anger goes too far.

Summary: Anger is an emotional response to the impact of loss and how that changes the self. Aggression can be transferred away from the loss to bystanders. Anger can be channeled towards positive outcomes. Anger is not wrong or bad.

Some say that Denial is a river in Egypt, but it is more than that. It is an attempt to hide from the severity of the loss, a dulling down of the pain associated and the impact it is going to have on ones life. Denial is a safety mechanism to avoid being overwhelmed by loss.

It can be easy to mis-diagnose someone as being in denial because they do not appear to be doing anything about the upcoming loss. We may feel that something should be done about the situation and we see no action, the individual doesn’t want to discuss the expected loss, and seems to be determined to get on with their life. What we may not see is the internal battle to understand the enormity of the loss and internal processing of how that loss is going to affect the world, both subjectively and objectively. For example, if you learn you are going to die, who will feed the dog, look after the children and will you go to a better place? Some people prefer to do a great deal of this processing internally rather than talking about it. You don’t have to talk.

In balanced doses, denial is useful for continuing the life process while the mundanity of life continues. At some stage, someone has to cook dinner, wash the clothes and so on. Becoming lost in the process of life can be a respite from grappling with the expectation of loss and how that is going to affect the world.

Out of balance, denying the probability of loss can deny the person of pre-processing the loss and preparing for change. Being lost in denial can interfere with setting up changes in life for the upcoming loss and leave the person in a different form of grief, that which occurs with sudden and unexpected loss. More on that in another post.

Denial can also concatenate with Bargaining to create a search for the miracle solution. I’ll discuss that in more depth in the Bargaining phase.

Summary: Denial in balanced doses allows for the continuation of life before the loss, can be a safety valve when things are too intense and can allow a person to internally process the implications of change. In excess denial can delay change and leave someone dealing with unexpected loss instead. Denial is not a bad thing, or wrong.

In general, bargaining is trying to get what you want for the cheapest price. The harder, more complex, or impossible something is, the more we will offer.

In expected grief, the bargain has a central theme of trying to stop the loss or offset the negative aspects of the loss. It can take the form of offering to do something, pay something or sacrifice something.

In balanced amounts, bargaining can help you to find ways to minimise and offset the negative aspects of the loss and how it will affect you.

When balance is lost with bargaining, one can attempt to find a miracle solution to an impossible problem and offer incredible amounts to effect it. If this combines with denial, one can end up joining cult groups, losing all your assets to a con artist or embarking on an endless search for a way out of the change required by loss. This can be quite damaging to the self and may domino effect harm to others who care about you.

Summary: Bargaining is a natural part of searching for solutions. It is just an extension of problem solving. In moderation it can help find solutions to loss or minimise difficulties created by change. When out of balance, bargaining can lead to significant drama that can distract from the upcoming loss. If bargaining is combined with denial, this drama can become damaging to the self and others.

The emotions involved with expected loss and change can sometimes feel overwhelming. 

Diagnosis vs Formulation

I went to an autoelectrician the other day to get the headlights for my car fixed. He suggested that it was probably the headlight switch in the colum, but wasn’t going to commit to that without checking it out. He also said it could be a fuse, the relay, wiring, a problem with the Earth and a few other possibilities. After looking at it, he gave a positive diagnosis of a damaged switch. He said I might be able to get a second hand one, or I might be able to purchase it first hand from the manufacturer (I have an old car, kind of like me).

I asked him how he knew and he said he tested the inputs and outputs of the switch and could definately say that the switch was not relaying the proper information. This was his test that validated his diagnosis, which was one of the probable expected diagnosies he had formulated in our initial discussion.

Similarly I went to a doctor (general practitioner) with a really sore throught a few years ago. He listened to my symptoms, took a look at my throat and told me I had tonsillitis. He proscribed some antibiotics specific to this kind of infection as my treatment. I asked him how he knew I had tonsillitis and he described the way to tell inflamed tonsils and the low likelihood of it being anything else. I asked him if there was any actual test he could perform to be certain and he offered to take a sample and have a lab test it. This would prove, conclusively, that I had tonsillitis. 

I went to see a psychiatrist many years ago. He listened to my list of symptoms and told me I had cyclothymia. I asked how he knew and he said I fitted enough of the profile of cyclothymia for him to diagnose it as such. I asked if there as any test he could perform to make sure and he said there was not and pointed out that mental health diagnoses do not work that way. He prescribed medication to fix it. I looked up the medication and it’s primary side effect is that if you don’t have cyclothymia before taking the medication, you probably will after taking it. Not a good selling point. I went back to the psychiatrist and asked for another option.

What gets me is, how can they call it a diagnosis when there is no test to actually prove conclusively that their opinion is correct? Isn’t that a formulation, not a diagnosis?

For example, schizophrenia has an interesting diagnostic criteria. The combinations that this “diagnosis” can demonstrate are huge, the causes are varied. You only have to display two of five major categories, each major category has multiple sub categories which you only need one in to make that category count. What conclusive test is there? No blood test, no scan, no reflex or pain test. Nothing.

Schizophrenia is not an isolated mental illness in this respect. Consider borderline personality disorder. It’s diagnostic criteria are also quite strange. One must demonstrate five of a possible nine symptoms for an extended period of time. Again, there is no actual test. 

This blog does not preclude the possibility that either of these, or many other labels, actually exist. The formulation of these theories for a person quite often give added insight for the practitioner to look for specific indicators, history factors and give guidance for proposed treatment and recovery plans. What I object to is the use of the word “diagnosis” without an actual test. Giving such authoritative chronic diagnoses limits people to believing that they are stuck with this illness for the remainder of their lives and thus cannot get better, lessen their symptoms and get back to leading a worthwhile life.

You can change your behaviours. You can thrive.