Q: I understand the theory of Elisabeth Kübler-Ross’s grief-stage model, which she made famous in On Death and Dying, but how can it be used to guide practical interventions in therapy?
A: People’s experience of grief is as unique as their lives and their losses. But although many people experience common responses to loss, as Elisabeth Kübler-Ross would always say, the stages—Denial, Anger, Bargaining, Depression, Acceptance—were never meant to tuck messy emotions into neat packages. Still, her model not only offers deep clinical insight, but can help therapists set reasonable treatment goals for clients dealing with grief, especially when they seem stuck in a certain stage of it. And rather than addressing grief as a problem to be fixed, the model can help clients embrace it as a natural part of life’s experience.
While Kübler-Ross’s stages are often conceived in a certain order, most clinicians know that they’re not stops on some linear timeline, and not everyone goes through all of them or in a prescribed order. What clinicians don’t often realize, however, is that the stages can provide a practical framework to help us identify what clients may need in their journey toward healing.
Denial: Increase Reality of the Loss
When we’re in the denial stage of grief, we may be paralyzed with shock or blanketed with numbness, but even though some people may say things like “I can’t believe he’s dead,” denial doesn’t mean denial of the actual death. Instead, it means the death is just too much for a person’s psyche to take in. In this stage, the world can seem meaningless and overwhelming. Life makes no sense. We may wonder how we can go on, if we can go on, why we should go on. These feelings are important: they’re the psyche’s protective mechanisms. Letting in all the feelings associated with loss at once would be overwhelming emotionally. Still, it’s important not to get stuck in this stage, which is what happened to Mary.
Mary mentioned to her therapist on multiple occasions that she couldn’t visit her husband’s grave even though it had been 14 months since he’d died. She also shared that her friends and family were worried that she wouldn’t give away any of his clothes and that his bathroom items were still in place, as if he could walk in at any moment. Her response was that she just couldn’t believe he was gone, but her denial was turning into guilt for not visiting his grave.
Already Mary’s therapist had had multiple discussions about what keeping her husband’s possessions intact meant to her and why her daughter might be pushing her to get rid of them. In the course of the discussions, however, Mary always got defensive, refusing to discuss the issue. So realizing that she was stuck in the denial stage and unable to move forward, her therapist decided gently to increase the reality of the loss. First, he asked if she’d be willing to walk around the perimeter of the cemetery.
“Are you hoping I’ll go in?” Mary asked skeptically.
“No, I’m just hoping you’ll walk around the parameter,” her therapist responded.
Mary agreed. In her next session, after walking around the cemetery, she reported that she felt relieved there wasn’t pressure to go in. Her therapist simply commended her for taking the walk and asked if she’d be willing to do it again. After the second time, she was much more relaxed and even reported a feeling of calmness.
“Would you be open to walking a third time?” her therapist asked.
“Now you want me to try to walk in,” Mary guessed.
“No,” he replied, “I’m just asking you to walk around it again.”
Mary agreed and returned for her next session holding back tears. She said, “As I walked, I began to think about why you’re having me do this. Then it hit me. I’m walking around a cemetery every Sunday because he’s dead. He’s gone.”
The therapist sat and witnessed her grief.
Mary asked, “Now what?”
The therapist said, “That’s it, nothing more. You did well.”
The next week, she threw away her husband’s razor and toothbrush. A few weeks later, without any prompting, she went to his grave. The simple act of having her walk around the cemetery opened her connection to her loss and helped her face her feelings about it.
Anger: Express Anger, Pain, and Fears
In the process of grieving, it’s important to help clients find ways to express their anger without hurting other people or themselves. If they can’t express their anger or if they misdirect it, they might become stuck in this stage, and often it’s because they can’t get angry with the person who died or, for some, with God.
But anger serves a purpose in grieving, giving temporary structure to the feeling of nothingness that often comes with loss. For instance, grief may at first feel like being lost at sea, with nowhere to drop an anchor, no connection to anything. But getting angry at someone—maybe a person who didn’t attend the funeral—becomes something solid to hold onto, and experiencing this kind of strength through anger often feels better than feeling unmoored.
Therapy during this time can help give structure to the expression of anger. As clients feel and explore the feelings that come up in the wake of their loss, they usually find that the basic source of their anger is the fact their loved one has died.
It’s important to help grieving clients explore their anger without judgment and then to find ways of safely expressing it. Sometimes it helps to have them share what they’re feeling with friends and family, or maybe just to scream into a pillow. In any case, you’ll want to help people find ways to get the anger out without hurting themselves or someone else. Once they’ve done so, they often come to see the anger as another indication of the intensity of their love for the one they lost.
Bargaining: Work Through the What-Ifs
Before the death of a loved one, bargaining is often an internal plea, such as, “Please, God, let my wife live five more years and I’ll be a better husband.” After death, bargaining involves what-ifs and regrets. We want to go back in time: find the tumor sooner, recognize the illness more quickly, stop the accident from happening. Guilt is often the bargainer’s companion—the if-onlys cause us to find fault in ourselves and what we think we could’ve done differently. But as we move through the bargaining process, the mind eventually comes to recognize the sad reality that our loved one is truly gone.
When John’s wife died, for instance, he began to see billboards for all the other hospitals in his area at which his wife hadn’t been treated. One billboard read, “We have the answer for cancer,” and John became obsessed with the thought, What if I’d just taken her to another hospital?
Understanding that John was stuck in the what-if stage of bargaining, his therapist had him write down all the what-ifs that plagued him around his wife’s death. The first one was “What if we’d gone to the hospital on the billboard? Then she might’ve been cured of cancer.” After they discussed the reality of whether a change of hospital would really have prevented his wife from dying, the therapist had John make a line through each of his what-if statements and write “even if” instead. So his statement became “Even if we’d gone to that hospital, she wouldn’t be cured of cancer.” They then spent time discussing how the even-ifs were just as true as the what-ifs. For example, did the other hospitals really have a cancer cure that they didn’t share with his wife’s hospital? Or was that just a marketing stance? Once John began to let go of the idea of a magical missed cure, he found a certain kind of peace.
Depression: Allow and Validate Situational Depression
For many people, grief can lead to intense feelings of depression. They withdraw from life, lost in a fog of sadness, wondering, perhaps, if there’s any point in going on. Though depression is a common issue in the mental health world, when it comes to grief, depression is situational. Someone has died, and we’re depressed: that’s the situation. In our modern world, we try to stamp out depression at all costs, but sometimes we need to recognize it as a natural response to loss in order to move past it.
Jeanette told her therapist that she wanted to get over the depression she was feeling after her friend had died, three months before. She said she was doing everything she could to move past it: keeping busy, distracting herself, not thinking of her friend.
The therapist asked her, “What would happen if you just felt your feelings, even if they’re sad and depressing? Can you allow yourself to just feel sad?”
“My family and friends would disapprove,” Jeanette responded. “They all want me to snap out of it.”
Since the therapist didn’t hear any harmful thoughts or signs of clinical depression in Jeanette, she said, “What would happen if you just allowed yourself to feel your feelings without judging them?”
For the next few weeks, Jeanette explored each and every one of her feelings of sadness in her sessions, giving her depression its due, even though she sometimes felt that discussing the sadness was pointless. But as she allowed herself to feel whatever came up, she said the sadness lessened. The therapist supported her willingness to give herself permission to grieve, pointing out that resisting sadness and depression in grief can take more energy than feeling it and moving through it.
Acceptance: Find a “Good” Bye
A client may say, “You don’t know what my husband was like in his last year with cancer. I keep thinking about his body deteriorating and all those horrible memories are frozen in my mind. I’ll never accept his death: it was too horrible.”
This is an indication of a “bad” bye—when the client is fixated on the last year, hour, or moments that were so hard. But therapists can help clients find a “good” bye by helping them zoom out of that painful timeframe and inquiring about the whole course of the relationship with the loved one. So a therapist might say to a client, “You told me about your dad’s last hour. Tell me about your earliest memory of your dad.” Or “Tell me your favorite memory of your dad.” Or “You’ve told me about your husband’s last year. Tell me about your first year together.” This helps the person say a “good” bye to the whole relationship, instead of focusing too narrowly on those last challenging days or hours.
Of course, people usually go through all the stages of grief without any therapeutic guidance or direction, but it’s helpful for clinicians to know the stages of loss in order to understand the fluid feelings of grief and offer structure to clients who need more support. After a loss, some clients may look as if they’re running from grief, but they’re really running from the pain that comes with it. In fact, the journey through grief, with all the stages that Kübler-Ross captured so indelibly in her model, are the stops along the way that help us heal.
Photo by Lukas Rychvalsky/Pexels
David Kessler, MA, RN, FACHE, is one of the world’s foremost experts on healing and loss. He’s the author of six bestselling books. His newest is Finding Meaning: The Sixth Stage of Grief. He coauthored two bestsellers with Elisabeth Kübler-Ross.