Data Back Some Grief Theories, Refute Others

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 death.

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 report

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 one.

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 2003.

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 the subjects.

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.

Acceptance, Yearning Most Common

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.

Knowledge Fosters Acceptance

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>.▪