A Look at the Stages of Dying and Grief
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A Look at Elisabeth Kubler-Ross’s Stages of Dying and Grief
Vickie Ray
EPY 525
Spring 2011
A Look at the Stages of Dying and Grief
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Abstract
Elisabeth Kubler-Ross originally identified five stages of death and dying. She later
incorporated these stages into the process we face when we grieve the loss of a loved one. She
was quick to point out that the five stages are on a continuum on which we may move forward or
backward at any time. The stages she identified have often been criticized. However, no one
can deny the positive impact her study had on the emotional and mental care terminally ill and
dying patients.
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Elisabeth Kubler-Ross originally addressed the five stages of death and dying in 1969
in her book “On Death and Dying”. At this time significant gains were being made in the
medical care that was available. She realized that people were living longer after being
diagnosed with a terminal illness. According to Kubler-Ross (1969), this led to lower morbidity
rates and an increased number of elderly people in society.
The resulting change in society led
to an increased number of people living with emotional and behavioral issues. Those issues
included an increased fear of death and a need for coping skills to deal with the issues related to
death and dying (Kubler-Ross, 1969). To better understand what the dying had to tell us and
how we could help them, she began working with terminally ill patients (Nevid & Rathus,
2010,). She noted some common threads in what she saw and came up with what she perceived
to be five stages in dealing with death. Kubler-Ross (1969) realized that to help these patients
face death, we must help them to live fully with the time they have left.
Kubler-Ross began by taking a look at the fear of death and dying. It is usually not death
itself that is feared, but the dying process and the uncertainties that come with that process
(Kubler-Ross, 1969). She stated that “fear is a natural emotion, but people are born with only
two inherent fears: the one, of falling from high places; and the other, the fear of sudden loud
noises” (1983, p. 60). Knowing this, we must accept that we acquire our fear of death from other
people as we grow-up. Fear is an emotional response that a caring counselor can help their client
work through. However, we must remember that sometimes there are physical needs that must
be met first (Kubler-Ross, 1983). This is especially true when working with terminally ill
patients. Counselors who have successfully dealt with and worked through their own death
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issues can help dying patients with their fears. As with any client, it is important to help the
client identify their own strengths and weaknesses.
In 2005, Elisabeth Kubler-Ross and David Kessler’s book “On Grief and Grieving” took
the same five stages of death and dying that Kubler-Ross identified earlier and applied them to
grief. According to Kubler-Ross and Kessler (2005), we go through these stages not only after
the death of a loved one, but in the case of a long, drawn-out illness, we go through these same
stages in anticipation of death. This is referred to as anticipatory grief. Even though we may
experience anticipatory grief, we will still experience grief and the same five stages after our
loss.
Even looking back to old cultures, customs, and people, we can see that death has been
associated with things that are bad or frightening (Kubler-Ross, 1969). Family and friends are
left to cope with feelings like anger and resentment over the death of their loved ones. This may
be where Kubler-Ross saw the link between the stages of dying and grief. Since the five stages
of death and dying appear to be the same for grief and grieving, I will examine the stages and
how they are experienced in both situations.
When faced with death and dying, there is a need for us to think about our own
immortality. People react and face the possibility of their own death the same way they have
handled things in their past (Kubler-Ross, 1969). If denial has been their typical coping
mechanism, then that is how they will face the possibility of death. If past stressful situations
have been met with open confrontation, the same can be said about how death will be faced. In
either situation, some hope about the possibility of living must be present.
According to Kubler-Ross (1969), the first stage, in what has become known as the five
stages of dying and grief, is denial and isolation. The belief that it cannot be me was a common
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theme among the patients she interviewed. Although denial may not be present at all times, it is
a healthy way of dealing with a stressful situation. For most people, denial is only temporary
(Kubler-Ross, 1969). Denial is also used by dying patients to help family members that are not
ready to accept that their loved one is dying (Kubler-Ross, 1969).
Kubler-Ross also includes isolation in the first stage. After the initial shock and denial,
patients appear to be able to isolate the reality of death into a compartment that is separate from
the rest of their life (Kubler-Ross 1969). This allows the patient to maintain some hope while
beginning to face the reality of their own mortality. Other terms for this stage include shock,
numbness, and disbelief (Friedman, 2008).
Kubler-Ross and Kessler (2005) later acknowledge that over the years the term denial
had been misinterpreted. They noted that for those who are dying it is more a disbelief. For
those who are grieving, “denial is more symbolic than literal” (Kubler-Ross and Kessler, 2005, p.
8). It is not the denial of the death, but more a matter of coming to terms with the fact that you
will never see the person again.
In the context of grief, numbness, which is experienced during denial, is defined by
Friedman (2008) as “the result of an overload of emotional energy in reaction to a death” (p. 39).
Friedman acknowledged that numbness is experienced by many people, but he maintained that it
is not a stage. He also notes that a counselor can cause harm by insisting that the client is in
denial when they are not. As a counselor, the important thing, whether you believe denial is a
stage or not, is to listen and understand what your client is telling you.
Kubler-Ross identified the second stage as anger. Individuals that have moved to this
stage have recognized that they are going to be able to get through their situation (Kubler-Ross,
2005). Anger can range from mild to strong and be aimed at a variety of targets from the
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situation to a myriad of people (Kubler-Ross, 1969). At times the anger appears almost random.
During grief, anger may even be directed at the loved one we have lost or even God (KublerRoss & Kessler, 2005). Friedman (2008) acknowledges that there are often things that happen,
relative to the death of a loved one, that cause us to feel anger. However, it is not a universal
feeling and therefore is not a stage (Friedman, 2008).
Anger often surfaces ahead of other feelings and emotions that are harder to accept and
manage (Kubler-Ross & Kessler, 2005). Anger can be very difficult for friends and family to
accept, especially when it is directed at God. They do not know what to say or do and are
uncomfortable being around someone experiencing anger. However, “anger is a necessary stage
of the healing process” (Kubler-Ross & Kessler, 2005, p. 12). An empathetic counselor can
recognize a person’s need to experience and express their anger during death or the grieving
process. This allows the person to feel unconditional positive regard.
Only by allowing our self to feel all the anger we are experiencing can we get to the
feelings underneath. Anger gives us the strength we need to get by until we are able to accept
the pain of the loss that is tucked away under the anger (Kubler-Ross & Kessler, 2005).
The next stage is bargaining. This stage can take on several forms. Before death,
bargaining is a time to make realistic and unrealistic promises, usually to God, if He will heal or
grant more time (Kubler-Ross, 1969). According to Kubler-Ross (1969), these promises may be
the result of some perceived guilt. For the person grieving the loss of a loved one, it becomes a
series of “what if...” statements. Bargaining also moves from the past to the future after the loss
of a loved one (Kubler-Ross & Kessler, 2005). For example, we may ask God to spare our
family from any other tragedies.
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Just as with the first two stages, the bargaining stage is an important step in the healing
process. It can provide a brief respite from the pain of loss (Kubler-Ross & Kessler, 2005).
During the bargaining process our mind works through all the other possible scenarios we have
created and settles into the conclusion that our loved one is truly gone (Kubler-Ross & Kessler,
2005).
While examining this stage, Friedman (2008) recognizes that it is natural for someone
who is dying to try and bargain. However, it does not make sense for someone who is grieving
the loss of a loved one. When the label yearning is used for this stage instead of bargaining, it is
a more realistic description for someone who is grieving (Friedman, 2008).
Once bargaining has allowed us to accept the reality of our circumstances, we must now
face the situation head-on. This moves us into the fourth stage which is depression. Although
depression can be a mental illness, it is a natural response to the realization that there has been a
great loss (Kubler-Ross & Kessler, 2005). This could be the loss of a loved one or, for the dying
patient, the loss of a healthy, productive life. “Depression is a way for nature to keep us
protected by shutting down the nervous system so that we can adapt to something we feel we
cannot handle” (Kubler-Ross & Kessler, 2005, p. 21).
For the dying patient there are two types of depression, reactive and preparatory (KublerRoss, 1969). Reactive depression is the result of worrying about issues surrounding those that
will be left behind. This could include worry over finances, the care of household
responsibilities, or the care of children. Preparatory depression occurs when the dying patient
begins to realize all the love losses that will occur (Kubler-Ross, 1969).
Caregivers, family and friends may be able to help the patient through their reactive
depression by assisting the patient with things like childcare and reorganization of household
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responsibilities (Kubler-Ross, 1969). It is much more difficult to help with preparatory
depression. This is something the patient must work through alone (Kubler-Ross, 1969).
Sometimes the only thing we can do is sit quietly with the patient or pray with them. Only by
letting the patient completely and fully work through preparatory depression, can acceptance be
achieved (Kubler-Ross, 1969).
Depression is a time to allow the sadness and full extent of the loss to wash through your
mind (Kubler-Ross & Kessler, 2005). Not doing so is like trying to hold back floodwaters with a
dam that has leaks. The floodwater is still there but continuously seeps through. By opening the
dam fully, the floodwaters can wash through to the other side and rebuilding and healing can
begin. Well meaning friends and family may want to try and lift the spirits of the person
experiencing depression. This is usually because they are uncomfortable being around all that
sadness (Kubler-Ross and Kessler, 2005). As long as depression is the normal reaction to the
loss being experienced and does not turn into clinical depression, it is beneficial and necessary to
the healing process.
Friedman (2008) identifies the following symptoms that are common to both people who
are grieving and those who are clinically depressed:

lack of concentration,

disruptions in sleeping patterns,

changes in eating patterns,

roller-coaster of emotions,

decline in energy level.
He believes this is a normal reaction to loss and should not be defined as a stage.
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Working through the previous four stages allows us to move on to the fifth stage which
Kubler-Ross (1969) identifies as acceptance. Acceptance does not equal happiness (KublerRoss, 1969). For patients who can look back and see the purpose, meaning, and fulfillment that
their life has brought, acceptance appears to come without much assistance (Kubler-Ross, 2005).
Others may struggle and require more help to achieve the peace that comes with acceptance.
Acceptance does not occur all at once, but is a process that occurs as we slowly integrate the new
reality into our life (Kubler-Ross, 2005). It is the realization that we have begun to live again
without the all consuming feelings and emotions associated with loss, whether the loss is one of
health or a loved one. Friedman (2008) argues that “the concept of acceptance is confusing, if
not moot” (p.71) since there is no denial in the beginning.
Through every stage, Kubler-Ross (1969) found hope to be the common constant.
Webster (1991) defines hope as a “desire accompanied by expectation of or belief in fulfillment”
(p. 186). It is hope that provides the mind with the strength and spirit to endure (Kubler-Ross,
1969). Once hope is gone, death seems to be imminent.
Developmentally, children do not have the same understanding of death as adults
(Kubler-Ross, 1969). As they age and move through different developmental stages, they may
experience the grief again with the new understanding they gain (Himebauch et al., 2008).
Children under the age of three may express grief in the form of separation anxiety (Himebauch
et al., 2008; Kubler-Ross, 1969). From age two to six, children may perceive death as temporary
(Himebauch et al., 2008). They may also believe that the death is the result of something they
did or said. Usually around age nine, children realize that death is permanent (Kubler-Ross,
1969). However, they may not believe that it can happen to them (Himebauch et al., 2008).
Adolescents have an adult understanding of death but may have difficulty identifying and
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expressing feelings (Himebauch et al., 2008; Kubler-Ross, 1969). Children need to be listened to
as they struggle to deal with death and grief. They need a significant adult to talk with and a safe
environment to express their emotions (Himebauch et al., 2008).
Kubler-Ross and Kessler (2005) acknowledge that movement through the five stages is
fluid and non-linear. Every person may not even experience every stage. There is also no set
length of time that each individual stage will last. At any time we may experience any of the
stages. Even the achievement of acceptance does not mean that we will no longer feel anger or
depression over our loss. However, the more fully we allow our self to feel each emotion, the
more we are able to heal (Kubler-Ross, 1969).
Every person’s loss is unique. No two people will react or feel the same way (KublerRoss & Kesler, 2005). Each person must travel their own personal journey. When we arrive on
the other side, our life will be different. Therefore, the way we live our life will also be changed.
By having some idea of what to expect, hopefully we will be better equipped to make the
journey, wherever it may carry us.
Elisabeth Kubler-Ross used the information she discovered in her study of death and
dying to give voice to those who seemed to have no voice. What she learned helped friends,
family, and caregivers understand the needs of the dying. The information she learned help spur
the initiation of the hospice movement. Although there have been many opponents to her five
stages of death and dying, the information she shared improved the care and treatment for the
terminally ill and dying.
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References
Friedman, R., & James, J. W. (2008). The myth of the stages of dying, death and grief. Skeptic,
14(2), 37-41.
Himebauch, A., Arnold, R. M., & May, C. (2008). Grief in children and developmental concepts
of death #138. Journal of Palliative Medicine, 11(2), 242-243.
Kubler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Kubler-Ross, E. (1983). On children and death. New York, NY: Simon & Schuster.
Kubler-Ross, E., & Kessler, D. (2005). On grief and grieving. New York, NY: Simon &
Schuster.
(1991). New Webster’s dictionary and Roget’s thesaurus. New York, NY: Ottenheimer
Publishing.
Nevid, J.S., & Rathus, S. A. (2010). Adolescent and adult development: going through changes.
In C. Johnson (Ed.), Psychology and the challenges of life (pp. 454-491). Hoboken, NJ:
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