The Five Stages of Grief Is Missing a Stage: Anxiety

Health and medicine explained.
Feb. 11 2013 12:32 PM

The Five Stages of Grief Should Be Changed

My bereaved clients aren’t bargaining; they’re anxious. 

Woman biting her lip because she is anxious.
When you’ve already lost the person you love, there isn’t much left to bargain for

Photo by Marili Forastieri/Photodisc/Thinkstock

When Elisabeth Kübler-Ross debuted the five stages of grief in her book On Death and Dying, published in 1969, they were intended for people facing their own deaths. Kübler-Ross later went on to apply these same five stages to the bereaved, to people who had lost a loved one, but upon closer inspection, I’m not sure they work as well. Losing a loved one is not the same as losing your life. Grief thrusts us into an uncertain world where anxiety often reigns supreme. Yet anxiety is the very element missing from Kübler-Ross’ stages.

I had my first panic attack when I was 18. It happened on a road-trip the summer after my senior year of high school. My boyfriend was behind the wheel, driving toward Washington, D.C., and suddenly my heart did a funny flip-flop thing.

I unbuckled my seat belt, flailing about for something to hold onto, and in between gasps, instructed my boyfriend to find an emergency room. For several months I’d been experiencing moments of breathlessness and lengthy episodes of heart pounding, but this time it felt different. As we hurtled toward the nearest exit, my heart took dramatic pauses, did jack-knives inside my chest and then cascaded into what felt like triple-beats. I was certain I was about to die.

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Twenty minutes later I was hooked up to an EKG in a curtained-off portion of a hospital emergency room in Virginia. Beside me, my worried boyfriend murmured into the phone to my father as we watched, with rapt attention, my now-normal heartbeat creating perfect dips and arrows on the long, thin printout unspooling from the machine. Afterward, I sat on the exam table and answered the doctor’s questions.

Do you smoke? Yes.
Do you drink?
Not really.
Do you do any drugs?
No.
Take any medications?
No.
Any history of heart problems?
No.
Do you exercise?
Fairly regular jogger.

The list went on and on. So far everything was pointing toward me being perfectly healthy, but I was determined to leave with an explanation. Instead, the doctor simply told me that I was among the one out of 10 people who experience heart palpitations. (And that I should quit smoking.)

As we drove away from the hospital, I stared out the window at the warm summer landscape, thinking about all the questions he didn’t ask.

Are you thinking of breaking up with your boyfriend? Yes.
Are you about to leave everything you’ve ever known behind and go off to college two thousand miles away?
Yes.
Is your mother dying of cancer?
Yes.

I was only 18, but that was old enough to feel painfully aware of the mind-body connection. Although I couldn’t define my problem in clinical terms, I knew that what was wrong with me might not be physical. I’m now certain that if the doctor had asked me just a few questions about my personal life, he could have easily identified my symptoms as a classic example of a panic attack.

My anxiety worsened six months later when my mother died. The panic attacks came with startling frequency, seemingly brought on by nothing at all. I could be pumping gas or lying in bed and suddenly the world would begin to swirl around me, my breath would thin out, and the only thing I felt sure of was that I was dying. But instead of dying, for the next three years I walked through my life paralyzed by debilitating anxiety. Sometimes I wished I would actually die rather than live in such a nervous state.

It’s now been close to 15 years since that ER visit, and I’ve become a therapist specializing in grief. When I look back on that time in my life, it’s easy for me to recognize how my anxiety was linked to the loss of my mother. In fact, anxiety is the most common symptom of grief that I see in my practice. But I also know that it’s often one of the most overlooked aspects of bereavement, so much so that I find myself constantly wishing that Elisabeth Kübler-Ross had included anxiety as a stage and saved us all a lot of, well, grief.

In my experience, grieving individuals almost always gravitate to the five stages at one point or another. Many of my clients immediately begin to asses their current state in terms of where they are with denial, anger, bargaining, depression, and acceptance. But while the stages were meant to be helpful, this is often where people begin to get confused. I don’t think I’m following the stages correctly, they’ll admit in a worried tone.

I don’t understand the bargaining part. I’ve been depressed for too long. I skipped the anger stage—is that okay? I don’t know where my anxiety fits in. These are the kinds of things I hear over and over again. In fact, I’ve heard them so often that I’ve now come to believe that when the five stages are applied to grief, bargaining should be replaced with anxiety.

When applied to a dying person, bargaining makes sense; following a terminal diagnosis there is often a sense of desperation, of pleading for more time. However, when you’ve already lost the person you love, there isn’t much left to bargain for. In my 2012 memoir The Rules of Inheritance, I used the five stages as a framework to illustrate my own grief process. When it came to the bargaining stage, the only way I could make sense of it was to liken it to the idea of magical thinking, a condition Joan Didion has described beautifully. I wrote about how, for years, I found myself thinking that if I worked hard enough or teetered precariously on enough sharp edges, my mother might reappear from the other side to save me.

Including anxiety in the five stages of grief would better serve the bereaved. Even more than depression, anxiety is the response my grieving clients express a desire to overcome since experiencing loss. They describe feelings of panic and obsessive thinking about their own deaths and potential illness. They tell me about bouts of helplessness and of feeling overwhelmed by life itself, about panic attacks and moments of such paralyzing fear that they pull their cars over on the way to work. I have even heard my own story about the ER told back to me countless times.

When we lose someone we love, we are thrust into a world where we feel more vulnerable than ever before. Suddenly we must face the fact that there are absolutely no guarantees in life. Everything that once seemed sturdy is now fragile, particularly the people we love. These feelings can be incredibly overwhelming and oftentimes terrifying. It takes time and work to overcome them, to feel secure again in such a now-delicate world. And for people who suffer multiple losses in a short period of time, it can take even longer.

The anxiety that comes with grief can be debilitating, but because it is not included in Kübler-Ross’ five stages, it tends to be ignored or dismissed as a different problem altogether. However, anxiety is a very real and very normal reaction to grief and it must be recognized. It is also highly treatable once it is distinguished for what it is.

There is a wonderful and unexpected gift that comes with seeing how fragile our lives are. It enables us to be more present, to feel grateful for what is right in front us, to cherish what we are able to hold onto right here, right now. But in order to reach that level of acceptance we must wade through the tremulous waters of fear and anxiety, recognizing them as a part of a larger process that will see us through to a shore where so many of us have emerged changed, if not healed.

When I look back on my frightened 18-year-old self, I’m saddened that no one was able to see what was really going on. If just one person had recognized how fragile my life had become, perhaps they could have reassured me that no matter how scared I was, I wasn’t alone.

Claire Bidwell Smith lives in Los Angeles. She is therapist specializing in grief and the author of the memoir The Rules of Inheritance. She can be found at clairebidwellsmith.com.

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