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Saturday, 16 June 2012

Is there a way we all grieve? Claudia Hammond interviews Ruth Davies Konigsberg All in the Mind, Radio 4, 14.06.11


Is there a way we all grieve? The five stages of grief - denial, anger, bargaining, depression and acceptance were proposed more than forty years ago by the psychiatrist Elizabeth Kubler-Ross and are now taught across the world. But with little evidence that these stages are what people really experience when they are bereaved - how did they become so popular and what research has been done into the process of grief?

Text of interview

Claudia Hammond (CH): When a person’s bereaved we’re told they will go through a grief process that consists of five stages: Denial, Anger, Bargaining, Depression and then finally Acceptance. These stages were proposed more than 40 years ago by psychiatrist Elizabeth Kubler-Ross. The stages have become so well-known that they’re now taught across the world and have even made it into popular culture with appearances in the Simpsons and The Office. Damien Hurst even did a series of paintings called DABDA named after the acronym for the stages. But despite 40 years of fame, there’s surprisingly little evidence that these are the experiences people really have when they’re grieving. Ruth Davies Konigsberg has looked in depth at this subject and is the author of The Truth About Grief. I asked her what the concept behind the stages is.  

Ruth Davies Konigsberg (RDK):  The sort of overarching idea behind the stages, of course, is that you need to go through them in order to come out the other side: as painful as it might be it’s beneficial in the end to have that whole experience. And you need to take your time to go through them. They were always conceived of as being sequential, so that one always has to follow the other – you can’t just skip them and go straight to depression for example or acceptance; they are all necessary steps along the, quote/ unquote, ‘journey’ of grief.

CH: And how did the idea of these stages of grief come about? 

RDK: Well, Elizabeth Kubler-Ross popularised the notion of the five stages, although they’d been brewing in the social sciences a little bit. What Kubler-Ross did, she applied them to one’s own death and that was how they were originally conceived in her own book, On Death and Dying, that was published in 1969. She was very interested in ‘end of life issues’ and to her credit she brought a lot of attention to these issues and she was doing revolutionary interviews with dying patients at the University of Chicago which she then turned into her theory about how one goes through these stages when one is facing one’s own death.
CH: What evidence is there to support the idea that you do go from denial to anger to bargaining to depression and finally get to this acceptance stage?

RDK: Very little. In fact what the evidence shows, and there’s some very interesting studies being done where people who were bereaved were actually interviewed on a daily basis, and the fluctuations are very vast on a day to day basis. And they are probably vast even hour to hour. So the experiences are very up and down. You may experience some of the emotions that are described in some of those stages but they certainly don’t go in any kind of progression, and moreover you don’t have to experience them in order to grieve successfully.

CH: So I suppose with something like anger, you might feel angry if you blame someone else for the death, but if an older relative dies at the end of their life, anger might not be something you feel.

RDK: Absolutely. You might feel angry, you might feel depression, you might feel a whole bunch of different things – the checklist of grief symptoms is very long. And moreover you might feel angry one minute and have happy memories the next. So it’s very up and down and it’s much less predictable than the Stages might have you believe.

CH: So why do you think this idea has taken hold and has persisted for so many decades if it doesn’t actually fit in with what people’s real experiences are?

RDK: It’s very sort of appealing in a way – it’s very neat and tidy and again it helps practitioners because it gives them a sense of something they can tell their clients or tell people who are bereaved. And the other thing is that there’s always confirmation bias: once those stages were out there, people would remember, of course, or take into account when they are experiencing one of the so-called stages, but disregard when they’re not. So it shows the power of theories and how once a theory gets popularised they become self-perpetuating.

CH: Does it matter if it’s not quite what happens if it still gives people some idea of the huge, overwhelming range of emotions that people can feel?

RDK: Well, it matters only for those who don’t experience it. It’s very reassuring for people who do maybe experience some of the emotions, but it’s also very stigmatising for people who don’t. So that’s where it becomes harmful, I think: if it doesn’t line up with what you’re actually experiencing you might feel you are grieving incorrectly or there’s something wrong with you or you’re in denial and you need help. So that’s where it becomes problematic.

CH: So what research has been done into how people do actually grieve? What can we tell people for how they do it – is there an average length for grieving and then moving on?

RDK: One thing you always hear is that everyone’s grief is unique and there is no timeline for grief. But there actually have been quantitative studies where some patterns have emerged. George Bonanno up at Columbia University has been doing some work looking at widows and widowers and what he found was that for people whose spouses died of natural causes that for the most part, the majority of people, their most intense symptoms seemed to abate by about six months. And that it’s really a small minority, probably about 10 to 15 percent of people, who have really prolonged difficulties. And that’s probably past a year where, if you’re still having a hard time and really unable to function, where you still haven’t got back on your feet. Those people are now what physicians consider to be suffering from ‘complicated grief’.

CH: That sounds like quite a low percentage who actually have real, long-lasting difficulty with it. You talk in your book about the extent of grief counselling that’s on offer in the United States. Would you say that we are pathologising grief, when for many people it’s just a very normal process?

RDK: Yes, I think there is that tendency. The idea that everyone should see a counsellor certainly I think is an overreach. What the research has shown is that the small percentage who are having the hardest time are obviously the ones who really can be helped by bereavement interventions. So for everybody else, grief more or less gets better with time on its own. When you compare people who had interventions, whether it’s support groups or individual counselling, with the group of people who didn’t have interventions, both get better in the same amount of time. So what that means is that counselling for the majority of people doesn’t measurably benefit the recipients.

And I think another thing that the Stages did was that they actually lengthened our expectations of grief, of how long it’s supposed to last. And so now certainly I think, although there are double standards in this in terms of gender, one thing that the Stages have done is lengthened our expectations. Grief can be very hard on some people and on others it isn’t so hard. It’s definitely something that we seem to have a natural resilience to be able to handle.

The other thing is that when I say that symptoms of grief alleviate by a certain time or what have you, I certainly don’t mean that those bereaved people still don’t miss their lost loved one – it doesn’t mean you’re a cold person if you’re back on your feet and able to smile or laugh. People still think and feel about their lost loved one for years and years and years. But that’s not grief. Loss is for ever, but thankfully, grief is not.

CH: Ruth Davies Konigsberg.      

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