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Jul 28, 2021
7 min read

The 5 stages of grief: everything you need to know

Grief is a natural process that everyone experiences at some point. Elisabeth Kübler-Ross formulated the five stages of grief to help terminally ill people talk about the feelings that they might be having. This framework has since been used to look at all types of grief. Most likely, the grieving process won’t require a visit with a healthcare provider, but there are some serious physical and mental health symptoms that you should seek help for.

steve silvestro

Reviewed by Steve Silvestro, MD

Written by Ellyn Vohnoutka, BSN, RN

Disclaimer

If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.

All human beings will feel grief at some point in their lifetime. Experiencing a strong emotional reaction is a natural response to feeling a loss. 

Over the years, researchers have categorized some of these feelings into different stages of grief. The hope is that these stages would make grief easier to talk about and study. Here’s everything you need to know about grief, the science behind it, how to cope with these feelings, and when to seek additional support.

What is grief?

Grief is a collective term for the internal emotions experienced when we lose something or someone we valued.  The feelings that people experience will vary from person to person. While we most commonly associate grief with the death of a loved one, any significant life change can trigger feelings of loss and sorrow, such as (Oates, 2021):

  • The loss of a pet
  • Divorce or the end of a romantic relationship
  • Loss of a job
  • Losing a body part or function due to illness or injury
  • Loss of a close friendship
  • A diagnosis of infertility

Losses can be actual or perceived. An actual loss can be seen and verified by others, such as with the death of a loved one. Perceived losses aren’t visible (such as a significant change in a relationship) but are just as real (Oates, 2021).

Elisabeth Kübler-Ross and On Death and Dying

The origin of the five stages of grief began as the five stages of dying, a theory first proposed by Swiss-born psychiatrist Elisabeth Kübler-Ross in her 1969 best-selling book, On Death and Dying (Newman, 2004).

Kübler-Ross’s book came from her interviews with terminally ill patients at the University of Chicago’s Billings Hospital. She noted the contrast between how death was treated in her native country versus in the United States. In Switzerland, death was treated as a natural part of life, and people died comfortably at home whenever possible. In contrast, in the U.S., death was considered a taboo subject, making it difficult for the person who was close to death as well as for their loved ones (Newman, 2004).

In On Death and Dying, Kübler-Ross pressed for a more humane approach to the dying. She wanted patients and their healthcare providers to speak openly about their terminal illnesses and their emotions. She developed the five stages of dying to be used as a framework for communication at the end of life (Newman, 2004). Many healthcare professionals began to use this same framework to describe stages of grief that people may experience as they grieve the loss of a loved one. In her final book, On Grief and Grieving, Kübler-Ross wrote about applying these same five stages to the grieving process.

What are the 5 stages of grief?

These are the five stages initially put forward by Elisabeth Kübler-Ross. Over the years, mental health professionals and even Kübler-Ross herself have proposed changes to this model, as the grieving process is not the same for everyone. However, describing the process in terms of these stages remains popular. When someone discusses five stages of grief, these are the stages they typically mean:

1. Denial

A person in the denial stage may partially or totally refuse to admit that the loss exists. They may also deny the existence of any feelings surrounding the loss. They may feel numb or that the world is meaningless or makes no sense (Oates, 2021). 

This first stage of grief is a defense mechanism. It protects the grieving person from being overwhelmed and allows them to feel the loss at their own pace. As the individual processes that the loss is real, denial will begin to fade, and they will move on in the healing process (Oates, 2021). 

2. Anger

You might be surprised to learn that anger is a necessary stage of the grieving process. While many people feel anger is an unhelpful emotion that should be avoided, it actually serves as an essential part of healing (Oates, 2021). 

Kübler-Ross felt that anger allowed for a connection to the pain of grief that was missing in the denial stage. Feeling anger and pain is a step toward coming to terms with the loss (Oates, 2021). 

3. Bargaining

Bargaining may take the form of “If this, then that” or “what if…” statements. The grieving person may direct them to God, a higher power, or healthcare providers. These statements are a way for the grieving person to acknowledge that life as they know it has changed, and they want it to go back to the way it was. This type of thinking is often accompanied by guilt, such as thoughts of, “if I’d known he was suffering, I could have helped him” (Oates, 2021).

Helping someone in the bargaining stage means listening and providing empathy. Caregivers can reassure the person that this is a normal part of the grieving process (Oates, 2021).

4. Depression

Once the grieving person has realized that they cannot alter the past through bargaining, their thoughts often turn to the present situation. In this depression stage of grief, the person may feel intense sadness or emptiness (Oates, 2021). 

This type of depression is a normal part of grieving and not a sign of clinical depression. It is an appropriate response to loss, and to not feel at least some depression would be unusual. If symptoms begin to feel severe or are persistent, some outside help may be needed (Oates, 2021).

5. Acceptance

It can take time, but eventually, the grieving person moves into the stage of acceptance. Acceptance does not mean that they are okay with the loss. It’s about accepting that the loss has happened and that life cannot be the same. The grieving person begins finding meaning in their new reality (Oates, 2021).

The person may begin to explore new roles, new connections, and new relationships. Some days will still be more challenging than others, and emotions from other stages may still surface. Through the acceptance stage, the person realizes that their life will go on (Oates, 2021).

Criticisms of the stages of grief

Even though Kübler-Ross’s 5-stage framework was highly influential, it was not without its critics. Some noted the lack of scientific corroboration. Others worried that healthcare providers would take the stages too literally (not everyone experiences all of the stages in order) (Stroebe, 2017). 

Examining this sort of process in a study is problematic, however. No two relationships are the same and comparing loss among different people is far from clear-cut. In one study, researchers found that acceptance, not denial, was the primary emotion reported after a loss when a person lost a loved one due to natural causes. Denial was a more dominant emotion when a person experienced loss due to something like a car accident or suicide. Timing was also an important factor for how people processed grief. More sudden death was more difficult for many to process than prolonged periods of dying (Maciejewski, 2007).

How to cope with feelings of grief

Everyone copes with grief differently. There is no one right or wrong way to grieve. It is a process that may never be truly completed. 

Some people have reported finding it helpful to maintain a connection to their loved one. Healthy ways to help keep a connection include (Zisook, 2009):

  • Keeping a loved one’s objects such as clothing, jewelry, or other favorite possessions
  • Creating “living legacies” by carrying on a mission or making memorial donations
  • Visiting the grave or other memorial site
  • Lighting candles or other religious observances

One review of the literature studying bereaved parents attempted to clarify if there were any science-backed interventions for grief. They arranged the interventions into five categories (Kochen, 2020): 

  • Acknowledgment of parenthood and the child’s life
  • Establishing keepsakes
  • Follow-up contact with healthcare providers
  • Education and information
  • Remembrance activities

They concluded that all of the interventions were theoretically sound, but there was no data on the effectiveness of any one over the other. They recommended that parents be offered a range of options to support their different needs (Kochen, 2020). 

When to see a healthcare provider for grief

While many people process grief on their own or together with loved ones, some people find solace in seeking help. And while depression and sadness are natural parts of the grieving process, they shouldn’t affect your ability to function in the long term. While the rule isn’t set in stone, grief following a loss typically peaks within six months and begins to subside. When the symptoms of grief continue beyond that and interfere with your ability to function, it may be a sign of a condition called “complicated grief” (Nakajima, 2018). 

While not an official diagnosis, complicated grief can include symptoms that do require immediate medical attention. These can consist of multiple signs such as (Nakajima, 2018):

  • Feeling like you may hurt yourself due to overwhelming emotion
  • Using substance abuse to cope with grief
  • Excessively avoiding any reminder of your loss
  • Constant preoccupation with the lost loved one
  • Experiencing chest pain or trouble breathing
  • Having trouble with elevated blood pressure or heart rate

The physical symptoms of complicated grief are usually related to stress and may need medical treatment until stress levels come down. The mental health symptoms of complicated grief may respond to treatment with medications such as antidepressants or a course of grief counseling or cognitive-behavioral therapy (Nakajima, 2018).

Resources for support

If you’re looking for more grief support resources or additional information, you can reach out to your healthcare provider. There are also many online support resources.

The Dougy Center offers support to children, teens, young adults, and families dealing with a loss. You can also visit Grief Speaks for an extensive list of support groups and counseling services by type of loss.

If you or someone you love is in crisis, know that immediate help is available. You can call the national suicide prevention lifeline at 800-273-8255.

References

  1. Kochen, E. M., Jenken, F., Boelen, P. A., Deben, L., Fahner, J. C., van den Hoogen, A., et al. (2020). When a child dies: a systematic review of well-defined parent-focused bereavement interventions and their alignment with grief- and loss theories. BMC palliative care, 19(1), 28. doi: 10.1186/s12904-020-0529-z. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068872/
  2. Nakajima S. (2018). Complicated grief: recent developments in diagnostic criteria and treatment. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 373(1754), 20170273. doi: 10.1098/rstb.2017.0273. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053994/
  3. Newman L. (2004). Elisabeth Kübler-Ross. BMJ: British Medical Journal, 329(7466), 627. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC516672/
  4. Maciejewski PK, Zhang B, Block SD, Prigerson HG (2007). An empirical examination of the stage theory of grief. JAMA. 297(7):716–723. doi: 10.1001/jama.297.7.716. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/205661
  5. Oates JR, Maani-Fogelman PA. Nursing grief and loss. [Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK518989/
  6. Stroebe, M., Schut, H., & Boerner, K. (2017). Cautioning health-care professionals: bereaved persons are misguided through the stages of grief. OMEGA – Journal of Death and Dying, 74(4), 455–473. doi: 10.1177/0030222817691870. Retrieved from https://journals.sagepub.com/doi/10.1177/0030222817691870
  7. Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World psychiatry: official journal of the World Psychiatric Association (WPA), 8(2), 67–74. doi: 10.1002/j.2051-5545.2009.tb00217.x. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/