Loss, Yearning and Acceptance

Like most doctors over the last forty years, I was raised on the works of Elisabeth Kübler-Ross.

She was a Swiss-born psychiatrist and the author of the influential book On Death and Dying, where she first discussed what is now known as the Kübler-Ross model.

She was born in Zürich, Switzerland, and interestingly was one of a set of identical triplets. She graduated from the University of Zürich medical school in 1957 and a year later moved to the United States to continue her studies.

As she began her practice, she later wrote that was appalled by the hospital
treatment of patients who were dying. She began giving a series of
lectures featuring terminally ill patients, forcing medical students to
confront people who were dying. Her extensive work with the dying led
to the publication of On Death and Dying in 1969. She wrote over 20 additional books on the subject of dying.

She also proposed the now famous Five Stages of Grief
as a pattern of phases, most or all of which people tend to go through,
in sequence, after being faced with the tragedy of their own impending
death.

The five stages of grief are, in order:

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

The five stages have
since also been adopted by many as applying to the survivors of a loved
one’s death. Some of us have also applied these stages to the understandng of people’s psychological responses to chronic illness.

As influential as the theory has become, it has not, until now, been subjected to much research.

A study on the stages of grief was published in Journal of the American Medical Association at the end of February by researchers from Yale School of Medicine. The entire article is available for free download.

What they found was that in contrast to the Kübler-Ross model, yearning and acceptance are the two most salient emotions individuals experience after a significant loss.

The study was based on interviews with 233 bereaved individuals living in Connecticut between January 2000 and January 2003. The vast majority were spouses of the deceased and the remaining were adult children, parents, or siblings of the deceased.

The lead author Paul Maciejewski, assistant professor of psychiatry and director of the Statistical Modeling Core of Women’s Health Research at Yale, had this to say:

"We found that disbelief was not the initial, dominant grief indicator. Acceptance is the norm in the case of natural deaths, even soon after the loss. And yearning, not depression, was the most common potentially adverse psychological response."

Yearning is one of the defining features of grief and is an emotion that most clearly reflects the absence of the deceased.

"Yearning is a longing for reunion with the deceased loved one, heartache about an inability to reconnect with this person. Individuals may cognitively accept the death of a loved one, but they may still pine for them and experience pangs of grief  (i.e. yearning)."

According to the study, disbelief, anger, and depression were not as prominent as yearning and acceptance. However, each grief indicator varied as a function of time  after the loss. In partial support of the stage theory, disbelief reached its peak immediately following the loss. Yearning, anger and depression reached their respective peaks at four, five and six months after the loss and acceptance reached its peak beyond six months after the loss.

These feelings peak and begin to decline by six months in the case of a natural death. Those who experienced the loss were more likely to be accepting of the death if it occurred within six months or longer after a diagnosis. The research confirmed what we see in clinical practice: deaths due to trauma or that occur within six months or less of diagnosis cause the most distress.

As Maciejewski said:

"The persistence of negative emotions beyond six months following the death reflect a more difficult than average adjustment and suggests a need for evaluation by a mental health professional and potential referral for treatment."

This is important research that gives all of us some practical guidance on how to understand, help and support people at a time of loss. It is also important to note that the study did not examine the mitigating effects of religious or spiritual beliefs, which we know can help people deal with loss.

After all, funerals are not held for the dead, but for the people left behind.

“Bereavement is a darkness, impenetrable to the imagination of the unbereaved."
–Iris Murdoch (Irish-born Writer and Philosopher, 1919-1999)