Yearning, not sadness, at grief's core, study says

Professional help is recommended if acceptance doesn't occur by 6 months after loss

February 21, 2007|By Ronald Kotulak | Ronald Kotulak,Chicago Tribune

CHICAGO -- When a loved one dies, people go through five stages of grieving, according to accepted wisdom: disbelief, yearning, anger, depression and acceptance.

Now the first large-scale study to examine the five stages shows that not only are they accurate but also if a person has not reached the acceptance stage after six months, he or she might need professional help dealing with bereavement.

The study, published in today's issue of the Journal of the American Medical Association, also found that, contrary to common belief, yearning or missing a loved one is far more prevalent than depression - meaning mental health experts might need to refocus their attention on the feeling of loss when someone experiences prolonged grief.

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

"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, but most do, she said.

The three-year study of 233 individuals participating in the Yale Bereavement Study found that disbelief reached a peak one month after loss and then declined. Yearning steadily increased and reached its high point at four months before declining. Anger then rises to a peak at five months before diminishing, and depression increases and peaks at six months post-loss before falling. Acceptance increased throughout the duration of the study.

"We found that disbelief was not the initial, dominant grief indicator," said lead author Paul Maciejewski, assistant professor of psychiatry and director of Yale's Statistical Modeling Core of Women's Health Research. "Acceptance is the norm in the case of natural deaths, even soon after the loss. And yearning, not depression, was the most common potentially adverse psychological response."

The study also found that when people are diagnosed with a terminal illness more than six months before death, the survivors have an easier time dealing with their grief, Prigerson said. Loved ones had a more difficult time dealing with bereavement if a terminal diagnosis is made less than six months before death, she said.

"If it's an anticipated death, acceptance becomes a part of it earlier than if the death is faster," said Ramona Behrendt, senior oncology social worker at the University of Chicago, who has been working with dying patients and their families for 25 years. "People have not had time to absorb that this truly is happening. They're still in a shock and despair kind of mode and they didn't really have a chance to do the unfinished business of grief."

People also have a harder time dealing with grief when a loved one dies abruptly, such as in an accident, Prigerson said. Ninety-six percent of people, however, die of chronic disorders, such as heart disease or cancer, she said.

Although the five stages of grief have been in general use for several decades, Prigereson said they had never been thoroughly studied. J. Bowlby and C. Parkes first proposed that there is a natural and progressive psychological response to loss in the early 1960s and 1970s. Elizabeth Kubler-Ross, then at the University of Chicago, popularized in the late 1960s a five-stage response of terminally ill patients to the awareness of their impending death: denial, anger, bargaining, depression and acceptance.

Although survivors do not generally go through a bargaining stage, Prigerson said she and her colleagues were surprised to find how closely their bereavement followed the same pattern of grief as they adjusted emotionally and cognitively to the loss of someone close.

"The surprising finding was that in normal grief, each of the five stages peaked in exactly the same sequence, and all before six months," Prigerson said. "This would suggest that people who have extreme levels of depression, anger or yearning beyond six months would be those who might benefit from a better mental health evaluation and possible referral for treatment."

Ten to 15 percent of the bereaved survivors in the study experienced prolonged grief, she said.

Ronald Kotulak writes for the Chicago Tribune.

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