The death of a loved one is most frequently followed by feelings of both
yearning and acceptance. Most of the negative feelings associated with the
death of a loved one begin to diminish by about six months after the
These are the findings from an analysis of more than 200 people enrolled in
the Yale Bereavement Study, the vast majority of whom were widowed and whose
loved ones died of a terminal illness. The results were published in the
February 21 Journal of the American Medical Association.
"What does typical grief look like? That is what we were trying to
determine here," study co-author Holly Prigerson, Ph.D., told
Psychiatric News. Prigerson is an associate professor of psychiatry
at Harvard Medical School and director of the Center for Psychooncology and
Palliative Care Research at the Dana Farber Cancer Institute.
A variety of experts have theorized that there are different stages
inherent in the grieving process. For instance, based on the theories of other
grief experts, such as Elisabeth Kubler-Ross, M.D., John Bowlby, M.D., and
Collin Murray Parkes, M.D., Selby Jacobs, M.D., in his 1993 book
Pathological Grief: Maladaptation to Loss postulated that response to
loss progresses through the stages of numbness and disbelief, separation
distress and yearning, depression and mourning, and recovery or acceptance
within a six-month period after a loved one's death, according to the
In this study, Prigerson and her colleagues empirically measured whether
and how often bereaved individuals experienced the emotions described by
Bowlby and Parkes and others for up to two years after the death of a loved
Prigerson emphasized that people who met criteria for complicated grief
disorder and those who lost a family member or loved one due to an unnatural
cause such as suicide or murder were excluded from the study.
The sample came from t he Yale Bereavement Study, a longitudinal
examination of a sample of bereaved subjects living in Bridgeport, Fairfield,
and New Haven, Conn., and data were collected between January 2000 and January
In Bridgeport and Fairfield, the researchers obtained a list of names from
the American Association of Retired Persons Widowed Persons Service, a
community-based outreach program. In New Haven, they identified subjects via
names listed in the obituary section of the New Haven Register as
well as through newspaper ads and flyers discussing participation in their
study. In addition, the chaplain's office of a local hospital referred some of
They sent a letter to the bereaved people describing the study and inviting
them to participate. Of the 575 people contacted, the final sample included
233 people who completed the Inventory of Complicated Grief—Revised. The
35-question instrument measures how often people experienced disbelief,
yearning, anger, and acceptance in relation to their loved one's death. About
84 percent of the respondents were spouses of the deceased.
Researchers evaluated participants at least once at three points after the
deaths of their loved ones: between one and six months, six and 12 months, and
one and two years.
Prigerson and her colleagues found that from one to 24 months after a loved
one's death, acceptance was most frequently endorsed by bereaved subjects, and
yearning was the most frequently endorsed negative grief reaction.
For instance, in the first six months after the loved one's death, mean
scores for acceptance were 4.11 on a scale of 1 to 5 on the Inventory of
Complicated Grief—Revised, compared with yearning (3.77), depression
(2.29), disbelief (2.27), and anger (1.87). On the scale, which measures
frequency of grief symptoms, 1 indicates experiencing the emotion less than
once a month, and 5 indicates experiencing it several times a day.
The frequency scores for acceptance continued to increase through the six
to 24 months after the death, while the other grief indicators continued to
decline. The majority of the negative grief indicators had already begun to
decline within six months of the loved one's death. For example, from 12 to 24
months after the death, acceptance was by far the most commonly endorsed
symptom (mean score 4.70), followed by yearning (2.64), depression (1.80),
disbelief (1.61), and anger (1.55).
When the researchers rescaled the grief measures to place the scores on a
scale from 0 to 1, they found that the grief indicators peaked in the sequence
predicted by the stage theory of grief (disbelief, yearning, anger,
depression, and acceptance).
"The odds of each of these indicators peaking in this exact sequence
by chance is miniscule," Prigerson noted. "Our results both
confirm and disconfirm the stage theory of grief," she noted.
The findings that acceptance and yearning are most frequently experienced
by bereaved individuals buck traditional grief stage theory findings, which
postulate that people uniformly experience disbelief immediately following the
death of a loved one and eventually arrive at acceptance.
However, the sequence of negative grief indicators experienced by the
bereaved support stage theories of grief, the authors explained.
In addition, according to the findings, people who reported knowing of the
decedent's terminal prognosis for at least six months prior to the actual
death reported acceptance more frequently after a loved one's death than did
people who reported knowing of the patient's terminal diagnosis for less than
six months prior to the death.
As to why acceptance was so commonly endorsed by participants, Prigerson
remarked that most of the subjects were older widows "with a fair amount
of preparation for their loved one's deaths."
Prigerson noted in an interview with Psychiatric News that since
the paper had been published, she has received a great deal of e-mail from
relatives of people who had died, for instance from parents who lost children
to traumatic means such as murder, expressing dismay that acceptance was the
most frequently endorsed grief indicator found in the study.
She said that grief response is likely to differ among people who lose a
child or who lose a spouse to murder or suicide, for instance, and that the
findings from her study focus on reactions in those who lost loved ones to
natural causes later in life.
One person wrote that "science and grief don't mix," prompting
Prigerson to disagree.
"The outpouring of emotions triggered by this article, especially
from groups not studied, suggests a need for much more research on this
topic," she said, such as comparing grief reactions among those who lose
loved ones to different causes or comparing parents' grief reactions with
those of individuals who are related to the deceased in other ways.
Prigerson and her colleagues have submitted results of a field trial of
consensus criteria for a category called prolonged grief disorder that defines
the parameters of persistently severe, distressing, and disabling grief being
proposed for inclusion as a new disorder in DSM-V.
Prigerson is chair of the DSM-V work group on bereavement and has
proposed that prolonged grief disorder be included in DSM-V based on
the results of the field trial.
An abstract of "An Empirical Examination of the Stage Theory
of Grief" is posted at<jama.ama-assn.org/cgi/content/abstract/297/7/716>.▪