Yale study confirms validity of long-held 5 stages of grieving

CHICAGO —  Accepted wisdom says that when a loved one dies, people go through five stages of grieving: disbelief, yearning, anger, depression and acceptance.

Now the first large-scale study of the five stages suggests that they are accurate, and that if a person has not moved through the negative stages after six months, he or she may need professional help to deal with the bereavement.

The study, published in Wednesday’s Journal of the American Medical Assn., also found that, contrary to common belief, yearning or missing a loved one is a more dominant emotion than depression -- meaning mental health experts who treat the grief-stricken may need to refocus on feelings of loss.

“It’s important both for clinicians and the average layperson to understand that yearning and not sadness is what bereavement is really all about,” said study author Holly G. Prigerson, associate professor of psychiatry at Harvard Medical School and director of Dana-Farber’s Center for Psycho-Oncology and Palliative Care Research.

“It’s about yearning, pining, longing and being angry and protesting that you can’t have this person back,” Prigerson said. Not everyone follows the exact same pattern of grieving, she said, but most do.

The three-year study of 233 people interviewed as part of the Yale Bereavement Study found that disbelief reached a peak one month after a death and then declined. Yearning steadily increased and reached its high point at four months before declining. Anger rises to a peak at five months, and depression peaks six months after a death. Acceptance is strongly present from the beginning, but becomes more dominant as time passes.

Christine Reilly, 39, of Whitman, Mass., says she still misses her son, Michael, who died in 1999 at age 5 after battling cancer for more than four years. “It’s his physical presence, the laughter, the jokes, the hugs, the kisses and things that you miss. I can close my eyes and feel Michael’s presence with me every single day.”

After his death, Reilly said, she and her husband experienced feelings of anger and depression. “But after a period of time, four or six months, you sort of realize that Michael’s in a much better place,” she said. “There’s nothing we can do. We can’t bring him back, and there’s no point in being angry.”

The couple gradually accepted Michael’s death and decided to move on. “The first five years that Michael was alive, cancer dictated what my life was going to be like,” Reilly said. “I had two choices after Michael died. I could let cancer continue to dictate my life, or I could dictate my life. I chose to take over at that point and not let cancer run my life.”

According to Prigerson, the Yale study found that survivors tended to deal better with their grief when the loved one had been diagnosed with a terminal illness more than six months before dying. Reilly said that in the last six months of Michael’s life, when his condition steadily worsened and doctors said he wouldn’t make it, she started coming to terms with the loss.

People have a harder time dealing with grief when a loved one dies suddenly and tragically, such as in an accident, the authors of the Yale study said. But such deaths are far less common than those due to chronic health conditions or terminal disease.

“Acceptance is the norm in the case of natural deaths, even soon after the loss,” said the study’s lead author, Paul K. Maciejewski, an assistant professor of psychiatry and director of statistical research in women’s health at Yale.