Most people’s anguish eases after six months; others might need treatment, study finds
By Ronald Kotulak
Tribune science reporter
Published February 20, 2007, 10:31 PM CST (http://www.chicagotribune.com/news/nationworld/chi-0702210198feb21,1,938128.story)
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 suggests that they are accurate, and that if a person has not moved through the negative stages in six months, he or she may need professional help dealing with the bereavement.
The study, published in Wednesday’s issue of the Journal of the American Medical Association, also found that, contrary to common belief, yearning or missing a loved one is a far more dominant emotion than depression—meaning mental health experts who treat the grief-stricken may need to refocus attention 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 Prigerson, associate professor of psychiatry at Harvard Medical School and director of the Dana-Farber Cancer Institute’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 individuals interviewed as part of the Yale Bereavement Study found that disbelief reached a peak one month after the loss, 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 at six months. Acceptance is strongly present even from the first but becomes ever more dominant as time passes.
Christine Reilly, 39, of Whitman, Mass., said 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,” she said. “I can close my eyes and feel Michael’s presence with me every single day.”
After Michael’s death, Reilly said, she and her husband experienced 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 tend to be better able to deal with their grief when the loved one had been diagnosed with a terminal illness more than six months before death. 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 she would suffer.
“If it’s an anticipated death, acceptance becomes a part of it earlier than if the death is faster,” said Ramona Behrendt, a senior oncology social worker at the University of Chicago. “People have not had time to absorb that this truly is happening.”
People also have a harder time dealing with grief when a loved one dies unexpectedly, 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 Maciejewski, an assistant professor of psychiatry at Yale.
Although the five stages of grief have been in general use for several decades, Prigerson said they had never been thoroughly studied. John Bowlby and Colin Parkes first proposed in the early 1960s and 1970s that there is a natural and progressive psychological response to loss. Elisabeth 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 bereavement followed the same pattern as people adjusted emotionally and cognitively to the loss of someone close.
Prigerson and Maciejewski said that although they believe the five stages of grief are a universal human response to loss, studies would have to be carried out in other cultures to find out if the results reported Wednesday held true outside the U.S.
But the researchers said they were struck by the finding that in normal grief, each of the five stages peaked in exactly the same sequence, and the four negative stages by six months. Acceptance, the fifth stage, kept increasing.
“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,” Prigerson said.
Ten to 15 percent of the bereaved survivors in the study experienced prolonged grief, she said. They still felt a great loss and yearning for a loved one more than six months later and were far from accepting the reality of the death. “They are people who have a very close dependent relationship to the person who died,” Prigerson said. “That person really made them feel safe and secure and defined who they are.”
People suffering from prolonged grief may have trouble working and may be at risk for other problems, such as high blood pressure, suicidal thoughts and excessive drinking and smoking. Intervention should focus on encouraging a person with prolonged grief to dwell less on the loss, to reconnect with relatives and friends, and not to feel guilty about moving on with life, Prigerson said.
Because most deaths result from chronic diseases, it’s important that a spouse and other relatives discuss the seriousness of a diagnosis and the possibility of death, Behrendt said.
“If you have a chance to say goodbye, and you and your loved one have had a chance to really do a life review, you’re going to be able to move on a lot better than people who’ve never communicated with the dying patient,” she said.
rkotulak@tribune.com
Copyright © 2007, Chicago Tribune
Original article location http://www.chicagotribune.com/news/nationworld/chi-0702210198feb21,1,938128.story
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