Good Grief

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Elisabeth Kübler-Ross’s “stage theory” of grief captured the popular imagination, but the reality can be far messier and tenacious.

One autumn day in 1964, Elisabeth Kübler-Ross, a Swiss-born psychiatrist, was working in her garden and fretting about a lecture she had to give. Earlier that week, a mentor of hers, who taught psychiatry at the University of Colorado School of Medicine, had asked her to speak to a large group of medical students on a topic of her choice. Kübler-Ross was nervous about public speaking, and couldn’t think of a subject that would hold the students’ attention. But, as she raked fallen leaves, her thoughts turned to death: Many of her plants, she reflected, would probably die in the coming frost. Her own father had died in the fall, three years earlier, at home in Switzerland, peaceful and aware of what was taking place. Kübler-Ross had found her topic. She would talk about how American doctors—who, in her experience, were skittish around seriously ill patients—should approach death and dying.

Kübler-Ross prepared a two-part lecture. The first part looked at how various cultures approach death. For the second, she brought a dying patient to class to talk with the students. Asking around at the hospital, she found Linda, a sixteen-year-old girl with incurable leukemia. Linda’s mother had just taken out an ad in a local newspaper asking readers to send Linda get-well and sweet-sixteen cards. Linda was disgusted by the pretense that her health would improve. She agreed to visit the class, where she spoke openly about how she felt. The students, Kübler-Ross observed, were rapt but nervous. They avoided dealing with the source of their discomfort—the shock of seeing an articulate, lovely young woman on the verge of death—by asking an abundance of clinical questions about her symptoms.

Soon afterward, as her biographer, Derek Gill, relates, Kübler-Ross took a job as an assistant professor of psychiatry at the University of Chicago. Four students from the Chicago Theological Seminary learned that she was interested in terminal illness and asked if she might help them study dying people’s needs. Kübler-Ross agreed to try. At Chicago’s Billings Hospital, she began a series of seminars, interviewing patients about what it felt like to die. The interviews took place in front of a one-way mirror, with students observing on the other side. This way, Kübler-Ross gave the patients some privacy while accommodating the growing number of students who wanted to watch.

Many of Kübler-Ross’s peers at the hospital felt that the seminars were exploitative and cruel, ghoulishly forcing patients to contemplate their own deaths. At the time, doctors believed that people didn’t want or need to know how ill they were. They couched the truth in euphemisms, or told the bad news only to the family. Kübler-Ross saw this indirection as a form of cowardice that ran counter to the basic humanity a doctor owed his patients. Too many doctors bridled at even admitting that a patient was “terminal.” Death, she felt, had been exiled from medicine.

Kübler-Ross began to work on a book outlining what she learned in her work with the dying. It came out in 1969, and, shortly afterward, Life published an article about one of her seminars. (“A gasp of shock jumped through the watchers,” the Life reporter wrote. “Eva’s bearing and beauty flew against the truth that the young woman was terribly ill.”) Kübler-Ross received stacks of mail from readers thanking her for starting a conversation about death. Angered by the article and its focus on death, the hospital administrators did not renew her contract. But it didn’t matter. Her book, “On Death and Dying,” became a best-seller. Soon, Kübler-Ross was lecturing at hospitals and universities across the country.

Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance.

The “stage theory,” as it came to be known, quickly created a paradigm for how Americans die. It eventually created a paradigm, too, for how Americans grieve: Kübler-Ross suggested that families went through the same stages as the patients. Decades later, she produced a follow-up to “On Death and Dying” called “On Grief and Grieving” (2005), explaining in detail how the stages apply to mourning. Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve. It pervades pop culture—the opening episodes of this season’s “Grey’s Anatomy” were structured around the five stages—and it shapes our interactions with the bereaved. After my mother died, on Christmas of 2008, near-strangers urged me to learn about “the stages” I would be moving through.

Perhaps the stage theory of grief caught on so quickly because it made loss sound controllable. The trouble is that it turns out largely to be a fiction, based more on anecdotal observation than empirical evidence. Though Kübler-Ross captured the range of emotions that mourners experience, new research suggests that grief and mourning don’t follow a checklist; they’re complicated and untidy processes, less like a progression of stages and more like an ongoing process—sometimes one that never fully ends. Perhaps the most enduring psychiatric idea about grief, for instance, is the idea that people need to “let go” in order to move on; yet studies have shown that some mourners hold on to a relationship with the deceased with no notable ill effects. (In China, mourners regularly speak to dead ancestors, and one study has shown that the bereaved there suffer less long-term distress than bereaved Americans do.) At the end of her life, Kübler-Ross herself recognized how far astray our understanding of grief had gone. In “On Grief and Grieving,” she insisted that the stages were “never meant to help tuck messy emotions into neat packages.” If her injunction went unheeded, perhaps it is because the messiness of grief is what makes us uncomfortable.

Anyone who has experienced grief can testify that it is more complex than mere despondency. “No one ever told me that grief felt so like fear,” C. S. Lewis wrote in “A Grief Observed,” his slim account of the months after the death of his wife, from cancer. Scientists have found that grief, like fear, is a stress reaction, attended by deep physiological changes. Levels of stress hormones like cortisol increase. Sleep patterns are disrupted. The immune system is weakened. Mourners may experience loss of appetite, palpitations, even hallucinations. They sometimes imagine that the deceased has appeared to them, in the form of a bird, say, or a cat. It is not unusual for a mourner to talk out loud—to cry out—to a lost one, in an elevator, or while walking the dog.

The first systematic survey of grief was conducted by Erich Lindemann, a psychiatrist at Harvard, who studied a hundred and one bereaved patients at the Harvard Medical School, including relatives of soldiers and survivors of the infamous Cocoanut Grove fire of 1942. (Nearly five hundred people died in that incident, trapped in a Boston night club by a revolving front door and side exits welded shut to prevent customers from ducking out without settling their bills.) Lindemann’s sample contained a high percentage of people who had lost someone in a traumatic way, but his main conclusions have been borne out by other researchers. So-called “normal” grief is marked by recurring floods of “somatic distress” lasting twenty minutes to an hour, comprising symptoms of breathlessness, weakness, and “tension or mental pain,” in Lindemann’s words. “There is restlessness, inability to sit still, moving about in an aimless fashion, continually searching for something to do.” Often, bereaved people feel hostile toward friends or doctors and isolate themselves. Typically, they are preoccupied by images of the dead.

Lindemann’s work was exceptional in its detailed analysis of the experience of the grieving. Yet his conception of grief was, if anything, more rigid than Kübler-Ross’s: he believed that most people needed only four to six weeks, and eight to ten sessions with a psychiatrist, to get over a loss. Psychiatrists today, following Lindemann’s lead, distinguish between “normal” grief and “complicated” or “prolonged” grief. But Holly Prigerson, an associate professor of psychiatry at Harvard, and Paul Maciejewski, a lecturer in psychiatry at Brigham and Women’s Hospital, in Boston, have found that even “normal” grief often endures for at least two years rather than weeks, peaking within six months and then dissipating. Additional studies suggest that grief comes in waves, welling up and dominating your emotional life, then subsiding, only to recur. As George A. Bonanno, a clinical psychologist at Columbia University, writes in “The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss” (Basic; $25.95), “When we look more closely at the emotional experiences of bereaved people over time, the level of fluctuation is nothing short of spectacular.” This oscillation, he theorizes, offers relief from the stress grief creates. “Sorrow . . . turns out to be not a state but a process,” C. S. Lewis wrote in 1961. “It needs not a map but a history.”

To say that grief recurs is not to say that it necessarily cripples. Bonanno argues that we imagine grief to be more debilitating than it usually is. Despite the slew of self-help books that speak of the “overwhelming” nature of loss, we are designed to grieve, and a good number of us are what he calls “resilient” mourners. For such people, he thinks, our touchy-feely therapeutic culture has overestimated the need for “grief work.” Bonanno tells the story of Julia Martinez, a college student whose father died in a bicycling accident. In the days after his death, she withdrew from her mother and had trouble sleeping. But soon she emerged. She went back to school, where, even if sometimes she felt “sad and confused,” she didn’t really want to talk to her friends about the death. Within a few months, she was thriving. Her mother, though, insisted that she was repressing her grief and needed to see a counsellor, which Julia did, hating every minute of it.

Bonanno wants to make sure that we don’t punish this resilient group inadvertently. Sometimes the bereaved feel as much relief as sorrow, he points out, especially when a long illness was involved, and a death opens up new possibilities for the survivor. Perhaps, he suggests, some mourners do not need to grieve as keenly as others, even for those they most love.

Yet Bonanno’s claims about resilience can have an overly insistent tone, and he himself turns out to be a rather imperfect model of it. He thrived after his own father died, but, as he relates in his book’s autobiographical passages, he became preoccupied, many years later, with performing an Eastern mourning ritual for him. The apostle of resilience is still in the grip of loss: it’s hard to avoid a sense of discordance. All of which forces the question that’s at the heart of all thinking about grief: Why do people need to grieve in the first place?

To the humanist, the answer to that question is likely to be something like: Because we miss the one we love, and because a death brings up metaphysical questions about existence for which we have few self-evident answers. But hardheaded clinicians want to know exactly what grieving accomplishes. In “Mourning and Melancholia” (1917), Freud suggested that mourners had to reclaim energy that they had invested in the deceased loved one. Relationships take up energy; letting go of them, psychiatrists theorize, entails mental work. When you lose someone you were close to, you have to reassess your picture of the world and your place in it. The more your identity was wrapped up with the deceased, the more difficult the loss. If you are close to your father but have only a glancing relationship with your mother, your mother’s death may not be terribly disruptive; by the same token, a fraught relationship can lead to an acute grief reaction.

In the nineteen-seventies, Colin Murray Parkes, a British psychiatrist and a pioneer in bereavement research, argued that the dominant element of grief was a restless “searching.” The heightened physical arousal, anger, and sadness of grief resemble the anxiety that children suffer when they’re separated from their mothers. Parkes, drawing on work by John Bowlby, an early theorist of how human beings form attachments, noted that in both cases—acute grief and children’s separation anxiety—we feel alarm because we no longer have a support system we relied on. Parkes speculated that we continue to “search” illogically (and in great distress) for a loved one after a death. After failing again and again to find the lost person, we slowly create a new “assumptive world,” in the therapist’s jargon, the old one having been invalidated by death. Searching, or yearning, crops up in nearly all the contemporary investigations of grief. A 2007 study by Paul Maciejewski found that the feeling that predominated in the bereaved subjects was not depression or disbelief or anger but yearning. Nor does belief in heavenly reunion protect you from grief. As Bonanno says, “We want to know what has become of our loved ones.”

When my mother died, Christmas a year ago, I wondered what I was supposed to do in the days afterward—and many friends, especially those who had not yet suffered an analogous loss, seemed equally confused. Some sent flowers but did not call for weeks. Others sent well-meaning e-mails a week or so later, saying they hoped I was well or asking me to let them know “if there is anything I can do to help.” One friend launched into fifteen minutes of small talk before asking how I was, as if we had to warm up before diving into the churning waters of grief. Without rituals to follow (or to invite my friends to follow), I felt abandoned, adrift. One night I watched an episode of “24” which established the strong character of the female President with the following exchange about the death of her son:

AIDE: You haven’t let your loss interfere with your job. Your husband’s a strong man, but he doesn’t have your resilience.
PRESIDENT (sternly): It’s not a matter of resilience. There’s not a day that goes by . . . when I don’t think about my son. But I’m about to take this nation to war. Grief is a luxury I can’t afford right now.

This model represents an American fantasy of muscling through pain by throwing ourselves into work; it is akin to the dream that if only we show ourselves to be creatures of will (staying in shape, eating organic) we will stave off illness forever. The avoidance of death, Kübler-Ross was right to note, is at the heart of this ethic. We have a knack for gliding over grief even in literary works where it might seem to be central, such as “Hamlet” and “The Catcher in the Rye.” Their protagonists may be in mourning, but we tend to focus instead on their existential ennui, as if the two things were unrelated. Bonanno says that when he was mourning his father he had to remind himself that “just about any topic pertaining to a dead person . . . still made people in the West uncomfortable.”

Uncomfortable and sometimes—the Johns Hopkins psychologist Kay Redfield Jamison, an expert on bipolar disorder, suggests—impatient. In her new memoir, “Nothing Was the Same” (Knopf; $25), about the death of her husband, Jamison describes an exchange, three months after his death, with a colleague who asked her to peer-review an article. Finding it difficult to switch from contemplative sadness to hardheaded rationalism, Jamison snapped, “My husband just died.” To which her colleague responded, “It’s been three months.” There’s a temporal divide between the mourner and everyone else. If you’re in mourning—especially after a relationship that spanned decades—three months may seem like nothing. Three months, to go by Prigerson’s and Maciejewski’s research, might well find you approaching the height of sorrow. If you’re not the bereaved, though, grief that lasts longer than a few weeks may look like self-indulgence.

Even Bonanno, trying to offer a neutral clinical description of grief, betrays how deeply he has bought into the muscle-through-it idea when he describes a patient who let sad feelings “bubble up” only when she could “afford to.” Many mourners experience grief as a kind of isolation—one that is exacerbated by the fact that one’s peers, neighbors, and co-workers may not really want to know how you are. We’ve adopted a sort of “ask, don’t tell” policy. The question “How are you?” is an expression of concern, but mourners quickly figure out that it shouldn’t be mistaken for an actual inquiry. Meanwhile, the American Psychiatric Association is considering adding “complicated grief” to the fifth edition of its DSM (the Diagnostic and Statistical Manual of Mental Disorders). Certainly, some mourners need more than the loving support of friends and family. But making a disease of grief may be another sign of a huge, and potentially pernicious, shift that took place in the West over the past century—what we might call the privatization of grief.

Until the twentieth century, private grief and public mourning were allied in most cultures. In many places, it used to be that if your husband died the village came to your door, bearing fresh-baked rolls or soup. As Darian Leader, a British psychoanalyst, argues in “The New Black: Mourning, Melancholia, and Depression” (Graywolf; $16), mourning “requires other people.” To lose someone was once to be swept into a flurry of rituals. In many nations—among them China and Greece—death was met with wailing and lamentation among family and neighbors. Some kind of viewing followed the cleaning of the body—what was known as a wake in Ireland, an “encoffining” in China. Many cultures have special mourning clothes: in ancient Rome, mourners wore dark togas, and the practice of wearing dark (or sometimes white) clothes was common in Continental Europe in the Middle Ages and the Renaissance. During the Victorian era in England and the United States, family members followed an elaborate mourning ritual, restricting their social lives and adhering to a dress code. They started in “full mourning” (for women, this was stiff black crêpe) and gradually moved to “half mourning” (when gray and lavender were permitted). Among Hindus, friends visit the house of the bereaved for twelve days and chant hymns to urge the soul on to the next world. In the Jewish shivah, a mourner sat on a low chair and chose whether to acknowledge visitors; those mourning their parents may recite the Kaddish for eleven months, supported by a minyan of fellow-worshippers. Even at the turn of the twentieth century, “the death of a man still solemnly altered the space and time of a social group that could be extended to include the entire community,” notes Philippe Ariès, the author of the magisterial “The Hour of Our Death” (1977), a history of Western attitudes toward dying.

Then mourning rituals in the West began to disappear, for reasons that are not entirely evident. The British anthropologist Geoffrey Gorer, the author of “Death, Grief, and Mourning” (1965), conjectures that the First World War was one cause in Britain: communities were so overwhelmed by the sheer numbers of dead that they dropped the practice of mourning for the individual. Certainly, there does seem to be an intuitive economy of grief: during war, plague, and disaster, elaborate mourning is often simplified or dispensed with, as we now see in Haiti. But many more Americans died during the Civil War than during the First World War; it seems, then, that broader changes in the culture hastened the shift.

Even before the war, according to Emily Post, mourning clothes were already becoming optional for any but the closest of kin. More people, including women, began working outside the home; in the absence of caretakers, death increasingly took place in the protective, and isolating, swaddling of the hospital. With the rise of psychoanalysis came a shift in attention from the communal to the individual experience. Only two years after Émile Durkheim wrote about mourning as an essential social process, Freud’s “Mourning and Melancholia” defined it as something fundamentally private and individual. In a stroke, the work of mourning had become internalized. As Ariès says, within a few generations grief had undergone a fundamental change: death and mourning had been largely removed from the public realm. In 1973, Ernest Becker argued, in “The Denial of Death,” that avoidance of death is built into the human mind; instead of confronting our own mortality, we create symbolic “hero-systems,” conceptualizing an immortal self that, through imagination, allows us to transcend our physical transience. (“In the early morning on the lake sitting in the stern of the boat with his father rowing, he felt quite sure that he would never die,” the young Nick Adams thinks in the last line of Ernest Hemingway’s “Indian Camp.”) Gorer himself had diagnosed an over-all silencing of the mourner: “Today it would seem to be believed, quite sincerely, that sensible, rational men and women can keep their mourning under complete control by strength of will and character, so that it need be given no public expression, and indulged, if at all, in private, as furtively as . . . masturbation.” Ariès added that this silence was “not due to the frivolity of survivors, but to a merciless coercion applied by society.”

In the wake of the AIDS crisis and then 9/11, the conversation about death in the United States has grown more open. Yet we still think of mourning as something to be done privately. There might not be a “right” way to grieve, but some of the work Bonanno describes raises the question of whether certain norms are healthier than others. In Western countries with fewer mourning rituals, the bereaved report a higher level of somatic ailments in the year following a death.

Today, Leader points out, our only public mourning takes the form of grief at the death of celebrities and statesmen. Some commentators in Britain sneered at the “crocodile tears” of the masses over the death of Diana. On the contrary, Leader says, this grief is the same as the old public grief in which groups got together to experience in unity their individual losses. As a saying from China’s lower Yangtze Valley (where professional mourning was once common) put it, “We use the occasions of other people’s funerals to release personal sorrows.” When we watch the televised funerals of Michael Jackson or Ted Kennedy, Leader suggests, we are engaging in a practice that goes back to soldiers in the Iliad mourning with Achilles for the fallen Patroclus. Our version is more mediated. Still, in the Internet age, some mourners have returned grief to a social space, creating online grieving communities, establishing virtual cemeteries, commemorative pages, and chat rooms where loss can be described and shared.

In “On Death and Dying,” Elisabeth Kübler-Ross, too, emphasized community by insisting on the importance of talking to the dying. Against the shibboleth that we die alone, Kübler-Ross thought that we should die with company. “On Death and Dying” shaped our grieving styles by helping establish the hospice movement and by an updated notion of the “good death,” in which the dying person is not only medically treated but emotionally supported.

Yet the end of Kübler-Ross’s own life was a lonely one. Like many pioneers, she was driven by messianic convictions that sometimes distanced her from her friends and family. Named “Woman of the Decade” by Ladies’ Home Journal in the nineteen-seventies, she separated from her husband and left him with the children, bought a house in Escondido, California, called it Shanti Nilaya (Final Home of Peace), and, in 1977, established it as a “growth and healing center” for the dying. She became a devoted exponent of reincarnation, arguing that death was a transition to a better stage, akin to breaking out of a cocoon. (As a volunteer in Europe after the war, she had been moved by the sight of butterflies carved into the walls of the children’s barracks at Majdanek, a concentration camp.)

Then, in 1995, Kübler-Ross suffered a stroke that left her paralyzed on one side. By 1997, living a severely circumscribed life in Arizona, she had grown depressed. “For 15 hours a day, I sit in this same chair, totally dependent on someone else coming in here to make me a cup of tea,” she told a reporter from the San Francisco Chronicle. She became known as “the death-and-dying lady who can’t seem to manage her own death.” Her isolation was chronicled in the documentary “Facing Death” (2003). It showed a solitary Kübler-Ross in her cluttered home. “I always leave the television on,” she says. “That way something is always moving.” An English muffin hardens next to her on a plate. She says that she got in the habit of saving food in case she is hungry later in the day. Her son Kenneth lives nearby and stops in “from time to time.” Yet she seems as hauntingly alone as the patients she interviewed some thirty years earlier.

It has become a truism of the hospice movement that people resist death if they have something left they need to say. After the documentary, Kübler-Ross emerged from her anomie to revisit what she had written about grief. Realizing that the stage theory had grown into a restrictive prescription for grief, she collaborated with David Kessler, a hospice expert, to write “On Grief and Grieving.” Near the end of a chapter about her own grief—which arrived late in life, following the death of her ex-husband—she noted, “I now know that the purpose of my life is more than these stages. I have been married, had kids, then grandkids, written books, and traveled. I have loved and lost, and I am so much more than five stages. And so are you.”

“On Grief and Grieving” was a personal triumph of sorts for the ailing Kübler-Ross. Yet her crusade to open up a conversation about death and grief was ultimately distorted by her own evasions: the woman who wanted us to confront death unflinchingly came to insist that it was really an opportunity for personal growth among the survivors, as if it were a Learning Annex class. As she put it in an essay for an anthology, “Death: The Final Stage of Growth” (1997), “Confrontation with death and dying can enrich one’s life and help one to become a more human and humane person.” This approach—suffused with an American “we can do it better” spirit—made grief the province of self-help rather than of the community. In the end, Kübler-Ross could perhaps have done more to help her own family grieve after her death. Like many Americans, she planned her funeral, and insisted it be a “celebration” rather than an occasion for mourning. Dozens of “E.T.” balloons were released into the air, symbolizing “unconditional love.” Perhaps we were to picture her bicycling through the sky toward home.

Behind the balloons the painful fact of mourning remains: even a good death is seldom good for the survivors. The matter-of-fact mordancy of Emily Dickinson, the supreme poet of grief, may provide more balm to the mourner than the glad tidings of those who talk about how death can enrich us. In her poem “I Measure Every Grief I Meet,” the speaker’s curiosity about other people’s grief is a way of conveying how heavy her own is:

I wonder if It weighs like Mine—
Or has an Easier size.



I wonder if They bore it long—
Or did it just begin—
I could not tell the Date of Mine—
It feels so old a pain—



I wonder if it hurts to live—
And if They have to try—
And whether—could They choose between—
It would not be—to die. ♦