The stage theory of grief.

To the Editor: The cohort study investigating the stage theory of grief by Dr Maciejewski and colleagues presents a review of the literature that we feel is selective. We believe that the variability in the nature and course of grief makes it untenable to maintain that “the stage theory of grief remains a widely accepted model of bereavement adjustment. . . .” Not everyone goes through an orderly sequence of reactions with defined stages. A 2001 report by the Center for the Advancement of Health concluded that “grief theory has moved away from the original multistage theory most closely associated with Dr Elisabeth Kubler-Ross; as currently understood, grief is not divisible into distinct stages.” A subsequent report concluded that “ . . . responses to loss are widely variable and there is no one clearly defined course or process of bereavement or grieving.” In the article by Maciejewski et al, almost one fifth of the participants did not fit the stage model in advance, and the authors excluded these 58 participants (18%) with complicated grief disorder before they conducted their statistical analyses. An additional 168 individuals ( 65% of those who refused to participate) declined to be interviewed because they were either “doing fine” (n=23) or were not interested or had no reason (n=145). These may have been persons who experienced no distress in response to their loss. Thus, almost 40% of the eligible bereaved participants (226/575) were excluded (by choice or design) from the reported analyses. A selective exclusion of these tails of the distribution could have maximized the possibility that “stages” would be found in the remainder of the sample. Additionally, although the data were collected longitudinally, they were not analyzed longitudinally to examine within-participant patterns of response. Instead, 1 data point was randomly selected per respondent for analysis. This strategy would mask within-participant fluctuation in response over time that has been found in bereavement research and thereby inflate apparent across-time differences. A mistaken belief in the stage model of response to loss can have devastating consequences. Not only can it lead bereaved persons to feel that they are not coping appropriately, but it also can result in ineffective support provision by members of their social network as well as unhelpful and potentially harmful responses by health care professionals.