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Stages of Grief Theory Put to the Test

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TUESDAY, Feb. 20 (HealthDay News) -- New research challenges and confirms some of the commonly held beliefs about the process of grieving.

The study found that for older people mourning a death by natural causes, a yearning or pining for the lost loved one, and an acceptance of their loss, come first in the grieving process.

That's at odds with the standard "five stages of grief " theory held by psychologists that lists disbelief, yearning, anger, depression and acceptance as the phases of emotions bereaved individuals typically pass through.

Instead, "this study basically shows that yearning is the dominant negative grief symptom following the loss, not disbelief, sadness or depression," said Holly Prigerson, director of the Center for Psycho-Oncology and Palliative Care Research at the Dana-Farber Cancer Institute in Boston. "And, overall, the main reaction was a high degree of acceptance," she added.

The researchers found that soon after a death, acceptance becomes the most commonly felt emotion for the bereaved, rather than the expected disbelief or depression. Acceptance is also the last emotion to reach its peak, they noted.

The study is published in the Feb. 21 issue of the Journal of the American Medical Association.

The researchers also found that negative emotions such as anger had largely peaked by six months after the loss. This suggests that if someone seems stuck in their grief after this time period, they may be having a more difficult time coping with their loss and may need counseling or additional support.

The five stages of grief theory has evolved over time but originally was developed as a four-stage theory of grief: shock-numbness, yearning-searching, disorganization-despair and reorganization. Then, world-renowned psychiatrist, Dr. Elisabeth Kubler-Ross wrote a book called On Death and Dying, which adapted the four-stages of grief into a five-stage response of the terminally ill to their impending death. This work evolved into the five stages of grief commonly recognized today, according to background information in the study.

"The five stages have been accepted as gospel and truth without study. There's been no previous empirical research," said Prigerson.

And, that's where this study comes in. To test the five stages of grief, renamed in this study as the five indicators of grief, Prigerson and colleagues from Yale University School of Medicine recruited 233 adults living in Connecticut who had recently lost a loved one to participate in the study.

The study participants were predominantly white (97 percent), mostly spouses of the deceased (84 percent) and were an average of almost 63 years old. All of their loved ones had died of natural causes and had non-traumatic deaths. According to the study authors, this population represents the typical bereaved person in America.

The study volunteers were interviewed at about six, 11 and 20 months after the loss of the loved one.

The researchers devised a grief indicator scale of one through five to indicate how strongly a grief emotion was being felt. A score of five meant that emotion was felt very strongly.

In the first six months after the loss, the average score for acceptance was 4.11, and yearning was 3.77. Depression was the next most common emotion with a score of 2.29, followed by disbelief with 2.27 and anger at 1.87.

During the next six months, all of the negative grief indicators, with the exception of depression, went down, and the level of acceptance went up. Depression scores stayed the same in the six- to 12-month period following the loss. During the next 12 months, all of the negative grief indicators declined, while acceptance continued to rise.

"Negative grief indicators peak at six months post-loss," said Prigerson.

"The expression of grief is a very complex phenomenon with a great deal of individual variability," said Shirley Otis-Green, a senior research specialist at City of Hope National Medical Center in Duarte, Calif.

And, that expression doesn't necessarily follow an orderly timeline, said Kristin James, coordinator of the Heartlight Program, a family bereavement program at Children's Memorial Hospital in Chicago.

"It's important to attempt to quantify grief if you can, but while this study may describe what happens on average, there are so many events that can spark these emotions again. It's not easy to say that at one month or at six months you should be done with this emotion," said James.

James said that especially with non-typical deaths -- the type that weren't studied here -- it's difficult to pin down what's "normal" grief and what's not. For example, she said, if a child loses a parent, they may just be starting to grieve at around six months, because grieving is often delayed in children.

More information

To read more about grief and loss, visit the National Cancer Institute.

SOURCES: Holly Prigerson, Ph.D., director, Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, and associate professor, psychiatry, Harvard Medical School, Boston; Shirley Otis-Green, MSW, senior research specialist, City of Hope National Medical Center, Duarte, Calif.; Kristin James, L.C.P.C., coordinator, Heartlight program, Children's Memorial Hospital, Chicago; Feb. 21, 2007, Journal of the American Medical Association
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