DABDA

We have all heard of Elisabeth Kübler-Ross and the 5 stages of grieving, denial, anger, bargaining, depression, and finally acceptance (also called DABDA).  In the context of working with those who are grieving. Education says “We don’t use the five stages anymore”, but really, they never should have been used for grieving.  That’s not who she wrote them for.  Those five stages were meant for something called anticipatory grief, which is the experience of grief before a loss actually occurs.  It’s basically bracing for a death. Kübler-Ross observed people in a unit where patients had terminal diagnoses and her observations were written specifically about how those patients were responding and coping with their own end of life.  In that context, perhaps, it’s a cancer diagnosis or congenital heart failure or some other life limiting diagnosis that has been given to a person who thought they were going to live a much longer life.
While these ‘stages’ were never meant to be applied to all experiences of grief and certainly not prescriptive in nature, they resonated with people. The public read these 5 stages and said “Yes, I have had that when grieving and it applies” or “I can imagine going through those stages of grief when I lose a loved one”.  In the scientific community we may not use this model any longer as there are many grief theories out there, we however, cannot ignore it or Kübler-Ross’s work just as we cannot ignore Freud when learning about early psychology. Some of the criticism comes from the word stages when what she was describing was ‘experiences’. By the use of the word stages it makes it sound like a linear path through grief instead of the messy rollercoaster of emotions that are experienced.  A stage sounds like once experienced and worked through you move on to the next one and so on until you are no longer grieving.  That is ridiculous, we can experience deep sadness at the same time we are experiencing acceptance of the loss while bargaining with a higher power for a different reality and anger that we can’t change that the loss happened. Beyond that, there will never be a day when you are no longer grieving. You will never wake up one day and think, “I just don’t miss that person anymore, I’m done grieving”. 
This should have never been ascribed to what a person goes through after they have experienced a loss of a loved one.  These stages don’t fit that experience, and we shouldn’t try and force them to, all grief is not the same and the act of grieving your own life that is coming to an end prematurely is not the same as grieving a life lost of someone you loved.  Why then did Kübler-Ross’s book On Death and Dying (1969) become so popular? Because these stages resonate with people, a non-grieving person can imagine doing these things if they lost someone they loved, however, when it really happens there is no bargaining, there is no denial, accepting that they have died happens whether you want to or not upon seeing their body (a subject I will explore further in another post). A person who is not grieving can imagine refusing to accept that their person has died and shaking their fist at the sky and screaming at the universe, they can imagine begging whatever higher power they ascribe to, to please bring them back before slipping into a depression until finally acceptance of the loss comes and they find healing.  Those of us who work with the grieving and have experienced significant losses ourselves know, that’s just not how it goes.  
Limitations of this model are that the word stages makes it seem like it is a linear progression through these emotions, perhaps like a bell curve starting with a low level of denial, building into anger and peaking at bargaining with your maker to finally slipping down the other side of the bell into depression and finally bottoming out into acceptance.  Here’s the thing though, grief isn’t linear.  It’s chaotic and messy, it doesn’t fit into neat stages, but is instead like trying to traverse a mine field that you have no idea how far until relative safety and then, sometimes when you think you are in a safe zone you take a confident step only to find a bomb.  
To begin, let’s call the 5 stages of grief, ‘some of the experiences of anticipatory grief’.  There are many experiences that happen to those who have been given a terminal diagnosis and not all of them are negative.  I would also like to separate these experiences into two categories, the fight experiences and the peace experiences.  Denial, anger and bargaining would be within the fight experiences while depression and acceptance are part of the peace experiences.  There is a model of grief that was designed for those who were grieving after a loss called the dual process model (Stroebe & Schute), in this model it acknowledges that there is deep sadness at times, where a person is unable to to do much but think about their personal loss and how it impacts their life, and then there is the process of continuing with the act of living, finding meaning in life again.  This fight/peace experience is much like that, where people are oscillating between fighting for their own life and finding peace with their upcoming death.  At times you are raging against the unfairness of dying with so much left to be done and at times you acknowledge that there is nothing to change it and instead enjoy what is left with the people you love.  As people progress in their illness, they are less in the fight experience and more in the peace experience as is expected.  I believe this was the reason that Kübler-Ross put her stages in the order she did, because most people are not accepting of the diagnosis in the beginning as well as most people are not denying that they are dying as they approach death.  While the order is intentional, she did not intend for them to be fully linear, after denial comes anger once you are done being angry you start bargaining.  If given much thought at all, it is clear that a person who is denying they are dying is both angry and bargaining, its all at once not stages, just as a person can be both depressed and accepting.  
People are complex, and grief more so.  There is no subscription of emotions that a person will experience in any semblance of predictable order as they are dying or as they are grieving.  Stop using the 5 stages as a guideline of if you are grieving ‘right’ or expecting your grieving patient to experience those stages, it was not written for those who are grieving a loss.