I never had the honor to meet the famed Elisabeth Kübler-Ross, MD (1926-2004), yet I have spent much of my career as a thanatologist getting to know her through her work on the five stages: denial, anger, bargaining, depression, and acceptance (On Death and Dying, 1969).
From all accounts I have heard, she was a challenging woman, and an amazing thanatologist. A woman who bravely expanded into qualitative research to explore the experiences of the dying, and later, her work grew to be used to describe the experiences of the grieving. Subsequently, others have built upon her work to include additional stages. Grief specialist David Kessler, MS, added the sixth stage of finding meaning. Others have added sub-stages, as in the case of the EKR Foundation and the for understanding grief.
There is much to learn from this early work and from those who built upon Kübler-Ross' original theory. Yet, I would posit there remain two predominant concerns with stage theory in the context of grief: one is that it fails the standards for scientific inquiry, and the other is that it is being applied prescriptively, instead of descriptively.
The Issue With a Stage Model Theory of Grief
When we teach students about methods of scientific inquiry, we often break it down into four goals or objectives: we seek to describe (or define), explain, predict, and control. We must first be able to understand what we are studying -- that is where the description is so important. How is something measured? What are we seeing? What is the person's experience?
Then we need to be able to explain how it fits into the larger context: are there interrelationships between variables, events, and experiences? We need that information to then look for predictive relationships: what influences or has a direct or indirect effect on the other, and by how much? It is only then that we can attempt to control various factors to improve outcomes, such as increasing adaptation and good health, or decreasing barriers to good healthcare, and so on.
Circling back to the five stages: Kübler-Ross's work never fully graduated from the descriptive to the explanatory. The stages have been studied to describe what patients were experiencing, yet they have repeatedly failed to matriculate from the explanatory level of scientific inquiry because they are neither universal nor uniform. Many have attempted to study grief, but there is so much variability across individuals (granted, that is true for just about every psychological phenomenon), that it is improbable we will ever be able to fully quantify it. And if we cannot quantify the amounts or conditions, then how can we use it predictively? Thus, Stage Theories of Grief will continue to fail the general line of scientific inquiry.
This is vastly different than the extensive work that has been done with complicated or prolonged grief, where we can evaluate and measure the severity or duration of a person's experience of grief (see the DSM-V-TR [2022] and ICD-11 [2018]). However, if you were to ask a patient or client what they know about grief, chances are the only remotely "scientific" thing they know are the five stages.
So, despite this lack of scientific support, why are we still "stuck" on the stages? Because they are easy. They make sense, they fit our personal observations, and to be honest, they just feel right.
A Love Affair With Stage Theories
Developmental psychologists adore stage theories. From Jean Piaget's cognitive development to Erik Erikson's psychosocial stages, developmentalists have attempted to understand how humans grow and change over time. Often, we break down a person's development into "chunks" or stages, based on major milestones (bio-physical, neurocognitive, psychosocial) achieved. The beauty of theories is that it gives us a framework to test against reality -- does the data support the premise?
There are two other prevailing arguments for why we have such an affinity for staging human experience. First, it is often parsimonious and allows us to feel we understand more complex phenomenon. And second, it offers us a gestalt that has high face validity: I see a person before me and I see behavior A, and I know that they have experienced situation B, and Eureka! I get it! Because of the first argument, it allows us to use a mental heuristic (or shortcut) in how I respond to them. Like many heuristics, we are now afforded a cognitive script that takes less mental energy or psychosocial effort to navigate difficult situations. Yet, like many other interactions between individuals, when we rely on heuristics, we are employing stereotypes, in which we engage in reductionistic practices where we may minimize or diminish the experiences of the human person before us.
A Problem in Practice
Grief does not follow a uniform or consistent trajectory -- there is nothing magical about 1 year in this context. Similarly, there is nothing universal about how we express our grief in socially patterned expressions of mourning. Yet, due to the mental heuristic and perceived face validity (which is to say, it is not valid!) of the stages, I have observed countless clinicians, clergy, and well-intended friends and family try to force a person's grief process into the mold of the stages -- even individuals may judge their own experience as poor or that they are "grieving wrong" if they don't grieve along this trajectory. This is incredibly dangerous, as it can further alienate those who are suffering from receiving the support and healthcare they need. It invalidates, suffocates, and disenfranchises those who are grieving -- and this is particularly problematic when you have an individual who has been historically marginalized. It becomes a barrier to cultural humility and negates other attempts to help the person to heal. And when we focus too much on this one very limited approach to understanding the human experience of grief and loss, we collectively fail to pursue better or more nuanced grief theories that allow for the full range of affective and cultural experiences.
So, why am I arguing that the "stages" be retired? Because they do those of us in the healthcare industry a disservice, as it has turned Kübler-Ross' original work that was wonderfully descriptive into something that has become stereotyped to the point of being dangerously prescriptive.
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Rebecca S. Morse, PhD, MA, is a behavioral and developmental psychologist and thanatologist. She is a past president of the Association for Death Education and Counseling and is the director of research training at the Institute for the Psychological Sciences at Divine Mercy University.