Stage 3: Bargaining

The five stages of grief model (or the Kübler-Ross model) is popularly known as a model that describes a series of emotions experienced by people who are grieving: denial, anger, bargaining, depression and acceptance. In actuality, the Kübler-Ross model was based on people who are dying rather than grieving. Although commonly referenced in popular culture, studies have not empirically demonstrated the existence of these stages, and the model has been considered by some to be outdated[1] and unhelpful in explaining the grieving process.[2][3]

The model was introduced by Swiss-American psychiatrist Elisabeth Kübler-Ross in her 1969 book On Death and Dying,[4] and was inspired by her work with terminally ill patients.[5] Motivated by the lack of instruction in medical schools on the subject of death and dying, Kübler-Ross examined death and those faced with it at the University of Chicago's medical school. Kübler-Ross's project evolved into a series of seminars which, along with patient interviews and previous research, became the foundation for her book.[6] Although Kübler-Ross is commonly credited with creating stage models, earlier bereavement theorists and clinicians such as Erich Lindemann, Collin Murray Parkes, and John Bowlby used similar models of stages of phases as early as the 1940s.[7]

Stage 3: Bargaining

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Kübler-Ross later noted that the stages are not a linear and predictable progression and that she regretted writing them in a way that was misunderstood.[8] "Kübler-Ross originally saw these stages as reflecting how people cope with illness and dying," observed grief researcher Kenneth J. Doka, "not as reflections of how people grieve."[9]

Kübler-Ross originally developed stages to describe the process patients with terminal illness go through as they come to terms with their own deaths; it was later applied to grieving friends and family as well, who seemed to undergo a similar process.[10] The stages, popularly known by the acronym DABDA, include:[11]

In a book co-authored with David Kessler and published posthumously, Kübler-Ross expanded her model to include any form of personal loss, such as the death of a loved one, the loss of a job or income, major rejection, the end of a relationship or divorce, drug addiction, incarceration, the onset of a disease or an infertility diagnosis, and even minor losses, such as a loss of insurance coverage.[8] Kessler has also proposed "Meaning" as a sixth stage of grief.[13]

In Questions and Answers on Death and Dying, Kübler-Ross answered questions after the publication of her first book, On Death and Dying. She emphasized that no patient should be directly told that they are dying and that practitioners should try to wait until the patient asks about death to discuss it. [12] A few other tenets that she believes in include those practitioners should listen to the patient first and foremost, patient's right to self-determination should still be practiced, and practitioners should avoid trying to force anything family members and the dying are not in the same stage.[12]

"There's denial, which we saw a lot of early on: This virus won't affect us. There's anger: You're making me stay home and taking away my activities. There's bargaining: Okay, if I social distance for two weeks everything will be better, right? There's sadness: I don't know when this will end. And finally there's acceptance. This is happening; I have to figure out how to proceed.Acceptance, as you might imagine, is where the power lies. We find control in acceptance. I can wash my hands. I can keep a safe distance. I can learn how to work virtually."[14]

A widely cited 2003 study of bereaved individuals conducted by Maciejewski and colleagues at Yale University obtained some findings consistent with a five-stage hypothesis but others inconsistent with it. Several letters were also published in the same journal criticizing this research and arguing against the stage idea.[17] It was pointed out, for example, that instead of "acceptance" being the final stage of grieving, the data actually showed it was the most frequently endorsed item at the first and every other time point measured;[18] that cultural and geographical bias within the sample population was not controlled for;[19] and that out of the total number of participants originally recruited for the study, nearly 40% were excluded from the analysis who did not fit the stage model.[20] In subsequent work, Prigerson & Maciejewski focused on acceptance (emotional and cognitive) and backed away from stages, writing that their earlier results "might more accurately be described as 'states' of grief."[21]

George Bonanno, Professor of Clinical Psychology at Columbia University, in his book The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss,[2] summarizes peer-reviewed research based on thousands of subjects over two decades and concludes that a natural psychological resilience is a principal component of grief[22] and that there are no stages of grief to pass. Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome.[23][24]

Among social scientists, another criticism is a lack of theoretical underpinning.[3][25] Because the stages arose from anecdotes and not underlying theoretical principles it contains conceptual confusion. For example, some stages represent emotions while others represent cognitive processes. Also, there is no rationale for arbitrary dividing lines between states. On the other hand, there are other theoretically based, scientific perspectives that better represent the course of grief and bereavement such as: trajectories approach, cognitive stress theory, meaning-making approach, psychosocial transition model, two-track model, dual process model, and the task model.[26]

Misapplication can be harmful if it leads bereaved persons to feel that they are not coping appropriately or it can result in ineffective support by members of their social network and/or health care professionals.[3][20] The stages were originally meant to be descriptive but over time became prescriptive. Some caregivers dealt with clients who were distressed that they did not experience the stages in "the right order" or failed to experience one or more of the stages of grief.

Criticism and lack of support in peer-reviewed research or objective clinical observation by some practitioners in the field has led to the labels of myth and fallacy in the notion that there are stages of grief.[24][25][27][28] Nevertheless, the model's use has persisted in popular news and entertainment media.

Elisabeth Kubler-Ross developed the five stages of grief in her 1969 book, On Death and Dying. Grief is typically conceptualized as a reaction to death, though it can occur anytime reality is not what we wanted, hoped for, or expected.

Persistent, traumatic grief can cause us to cycle (sometimes quickly) through the stages of grief: denial, anger, bargaining, depression, acceptance. These stages are our attempts to process change and protect ourselves while we adapt to a new reality. While there are consistent elements within each stage, the process of grieving looks different for everyone.

It is rare to move through the stages in a linear way. It is normal to experience ups and downs in mood, thoughts, attitudes, and behaviors. It can be difficult maintaining acceptance while things feel so unacceptable.

The five stages of grief model was developed by Elisabeth Kübler-Ross, and became famous after she published her book On Death and Dying in 1969. Kübler-Ross developed her model to describe people with terminal illness facing their own death. But it was soon adapted as a way of thinking about grief in general.

Since the five stages were first developed, there have been lots of new ways of thinking about grief. At Cruse, our understanding has grown over the years, based on research into the best ways to help and understand bereaved people.

Objectives:Describe the five stages of death, as outlined by Elisabeth Kubler-Ross.Describe alternative paradigms for experiencing death and grief, in addition to those introduced by Kubler-Ross.Explain the potential underlying process generating these outwardly demonstrated stages to provide a context for supporting patients, families, caregivers, and healthcare providers experiencing death.Outline interprofessional team strategies for improving care coordination and communication in a dying patient.Access free multiple choice questions on this topic.

Dr. Elizabeth Kubler-Ross introduced the most commonly taught model for understanding the psychological reaction to imminent death in her 1969 book, On Death and Dying. The book explored the experience of dying through interviews with terminally ill patients and outlined the five stages of dying: denial, anger, bargaining, depression, and acceptance (DABDA). This work is historically significant as it marked a cultural shift in the approach to conversations regarding death and dying. Prior to her work, the subject of death was somewhat taboo, often talked around or avoided altogether. Dying patients were not always given a voice or choices in their care plan. Some were not even explicitly told about their terminal diagnosis. Her work was popular in both the medical and lay cultures and shifted the nature of conversations around death and dying by emphasizing the experience of the dying patient.[4][5] This led to new approaches to working with patients through the final phase of life. She highlighted the importance of listening to and supporting their unique experiences and needs and spurred new perspectives on ways practitioners can support terminally ill patients and their family members in adjusting to the reality of impending death.[6]

Kubler-Ross and others subsequently applied her model to the experience of loss in many contexts, including grief and other significant life changes. Though the stages are frequently interpreted strictly, with an expectation that patients pass through each in sequence, Kubler-Ross noted that this was not her contention and that individual patients could manifest each stage differently, if at all. The model, which resulted from a qualitative and experiential study, was purposely personal and subjective and should not be interpreted as natural law. Rather, the stages provide a heuristic for patterns of thought, emotions, and behavior, common in the setting of terminal illness, which may otherwise seem atypical.[7] Facility with these patterns can help health care providers provide empathy and understanding to patients, families, and team members for whom these patterns may cause confusion and frustration.[6] 2ff7e9595c