Anxiety- The Missing Stage of Grief

by Claire Bidwell Smith

  My colleague Dr. B.J. Miller, former director of the Zen Hospice Project and a hospice and palliative care specialist at the University of California–San Francisco Medical Center, has many thoughts on why we grieve the way we do, and you’ll hear them throughout this book. As a sophomore in college, Miller was in an accident that left him a triple amputee. He used his experience as the motivation for becoming a doctor and helping others to heal. He says:

  I think a lot of our culture’s stunted grief has to do with emotional fidelity. I meet a lot of folks who are angry, for example. They are angry at themselves, or they feel guilty. But once you open it up, they’re really just in grief. And this is because as a society, we are bad at grief. We don’t honor it, and we don’t give it space.

  I think this is a mark of our society being a very young one. Every older culture does this a lot better. I mean, in other places you have six or twelve months of a grieving period where the world doesn’t expect much of you, where you even wear different clothes so people know the zone you’re in. To me that seems so enlightened. This idea that you’re supposed to bounce back in two weeks seems not just impossible, but also disrespectful.

  Grief is this sweet little window where you’re really tender and where you’re setting up this relationship with the loved one who gets to live within you going forward. In our society we largely shut all that down, which is just sad, and a mark of our own immaturity.

  When we choose not to shut down the grief process, there are many paths to healing our grief. Like Kübler-Ross says, you will never get over the loss of your loved one, but you can learn to live in the world without them, and you can even find ways to thrive. But getting there means understanding how the grief process works.

  UNDERSTANDING THE TRADITIONAL FIVE STAGES

  In 1969 a Swiss doctor introduced a five-stage model of grief, and today this is still the model that most people think of when they experience a loss. While there have been many other theories about grief introduced in the decades since, the five stages that Elisabeth Kübler-Ross coined—denial, anger, bargaining, depression, acceptance—continue to pervade our culture.

  THE KÜBLER-ROSS FIVE-STAGE GRIEF MODEL

  Denial —This first stage of loss is the one that helps us survive the initial emotional impact. The feelings of numbness, shock, and denial help us cope with the day-to-day survival in the first weeks and months after a loss. It is not uncommon to feel overwhelmed and like life feels meaningless. A range of emotions will return eventually.

  Anger —Anger is a powerful emotion that gives us strength and represents real feelings and an underlying pain. It is not uncommon to find yourself irrationally angry at family members, people who did not attend the funeral, or medical personnel who attended to your lost loved one. Try to be careful how you express this anger outwardly, but do find healthy ways to release it. This is a necessary stage of grief.

  Bargaining —In this stage, grievers may find themselves bargaining with their higher power or with themselves, trying to find any way to alleviate the pain they are feeling over their loss. “What if” questions may preoccupy you throughout this stage, or you may find yourself wishing yourself back to the past. This stage is often short-lived or one that filters in and out through your grief process.

  Depression —Following the previous stages, grievers find themselves truly facing the loss in a way they had not yet. Often, doing so brings on a heavy sense of sadness and feelings of emptiness. You may find yourself feeling hopeless about the future or about how you will ever live without your person. These feelings are normal and natural. Some people need additional support and work to move through this stage and return to a place of better functioning, while others move into and out of this stage naturally.

  Acceptance —In this final stage, people reach a level of acceptance about the loss. You may not ever feel that it is “okay” that your loved one died, but in this stage you come to accept that will have to live your life without them and hopefully embrace your “new normal.” You may never feel over the loss, but you can learn to live without your person.

  ANXIETY: THE MISSING STAGE

  Since the inception of the five stages, many other theories about grief have surfaced in the clinical world. Notably, those by Thomas Attig and J. William Worden have made great strides in looking beyond the traditional five stages, and their ideas have been incorporated into this book. But I cannot overlook our culture’s insistence upon holding on to the Kübler-Ross model, and that is why I have chosen to talk about anxiety as a “missing” stage.

  What is interesting to me about the five stages is that Kübler-Ross originally intended them to be applied to patients who were dying, not patients who were grieving. When she wrote the stages, she was working as a physician in a hospital in Chicago, and her focus was to bring more awareness to the experience of dying patients. By working closely with, and interviewing, dozens of them, she observed a process that many patients went through upon learning they had a terminal diagnosis.

  First, the patients were in denial. Then they became angry. After that they began to bargain—with themselves, with their higher power, even with the medical staff. When that still didn’t change their diagnosis, they became depressed. Following that stage, most patients reached a level of acceptance.

  This makes sense, right? I’ve always thought so, especially after working in hospice and seeing so many dying patients go through this particular five-stage process. However, after the popularity of these dying stages caught on, they were then applied to the grieving process, and that’s where things went awry. And it is precisely this dilemma—the average individual who comes to me expresses distress and confusion about how they are moving through the grief process.

  The famed five stages simply don’t work as smoothly when applied to a person who is grieving. To be fair, Kübler-Ross later went on to note that she regretted writing the stages in a way that was misunderstood, and she explained that the stages were not meant to be a linear and predictable progression. But it was too late—the model had already been swept away and adopted by Western culture at large. Even today, you can find the five stages everywhere you look, from jokes on late-night television about newly elected political candidates to social media posts about housewives trying to give up wine.

  So in addressing this “missing stage,” I feel that I am amending the mold rather than breaking it. The majority of my clients come to my office using the stages as a reference point, so I want to work with a model with which all of you are already familiar.

  WHERE DOES ANXIETY FIT INTO GRIEF?

  Grief is one of the most painful experiences we will face as humans. It is not something easily quantified or defined. At its core, grief is the series of emotions we feel when we lose someone we love. Intense sadness, anger and frustration, disbelief, and, yes, anxiety are among the predominant feelings.

  It is only natural that we experience some level of anxiety following a major loss. We spend most of our lives walking around thinking that we will wake up tomorrow as planned. And while grief itself has not changed much over the years, our relationship with death has. Life expectancy over the past century has increased dramatically due to medicine and science and technology. We are living longer than ever before, with the basic assumption that most of us will make it into our eighties and nineties. It has also become much less common to lose children during childbirth or in childhood to various diseases.

  These advances are wonderful, but as a result we have grown less accustomed to facing death during our lives, and, thus, we are less adept at moving through grief. Death has also become very medicalized, the majority of people now dying in hospitals and care centers rather than at home. And while we seem to know more than ever about the psychology of grief, we nonetheless continue to live in a society that shies away from death, creating a systemic problem of feeling isolated as we experience the loss of a loved one.

  Because grief is so painful, we tend to be more priva
te about it, seeking consultation with therapists and reading books about it. In general, we are not privy to the grief processes of the people around us, so when it happens to us, we can often feel as though we have no role models for how to grieve, no framework with which to go about the process.

  In On Grief and Grieving, Elisabeth Kübler-Ross writes about depression, “See it as a visitor, perhaps an unwelcome one, but one who is visiting whether you like it or not. Make a place for your guest. Invite your depression to pull up a chair with you in front of the fire, and sit with it, without looking for a way to escape.” I’ve always thought that this quote applies to grief as a whole. I’ve never met a person who was able to lose a loved one and skip the grief process. Even those who try, who attempt to suppress it or just move quickly past it, will find that it simply isn’t going anywhere until it’s had its way with you.

  Most people push themselves to get through their grief as quickly as possible and return to their lives. Grief-related anxiety is most often a result of trying to suppress or avoid the strong emotions that come with loss. As painful as they are, we must let them course through us. They’re not going anywhere until they do. Grief has its own time line and its own plan for you. The more you try to wriggle free of its grasp, the tighter it gets.

  And this is precisely how anxiety develops. I believe the anxiety comes from three places. One of them is due to this attempt to push away or suppress the grief process, which leads to unresolved grief and inner-lying tensions that bubble up in the form of anxiety. Another is this stark reminder that loss brings of the uncertainty of life and the existential dizziness that comes as a result. And yet a third reason we may experience anxiety following a loss is due to the nature of the death itself—in certain cases, it can be quite traumatic to watch or hear about how a loved one died.

  As I stated in the beginning of this chapter, I don’t think Kübler-Ross’s five stages work as an exact formula to which to adhere. The stages can certainly be used as guideposts and as a potential framework, but they are much more fluid and dynamic than the way in which they were originally structured. However, for our purposes and to help further contextualize, here is where I see anxiety sitting within the five-stage model.

  Denial

  Anger |

  Bargaining |— ANXIETY

  Depression |

  Acceptance

  Anxiety comes after anger but before, or alongside, depression. Bargaining, which currently sits between the two, is the stage that I believe applies least to the grieving process. The only way I can make sense of it is to liken it to magical thinking. We rarely see grieving individuals bargaining with themselves or higher powers to bring back the deceased, but we do see a kind of wishful thinking, a magical thinking either that somehow life will go back to normal or that we will be able to move through the grief process unscathed.

  But magical thinking is only a thin sliver of the grief process. Following the anger stage, anxiety is much more prevalent than bargaining. Therefore, if I were to insert anxiety, it would come after denial and anger but before depression and acceptance.

  It makes sense that we experience shock and denial following the loss of a loved one. Even with the death of someone who has had a long illness, it can still be startling to experience their actual absence, and there is often a certain period of denial before the reality of the loss truly sets in.

  The following stages—anger, anxiety, and depression—are all so fluid that it is hard to put them in a linear order. Some people never experience anger, but if they do, it is often a way of masking deeper pain and sadness, so sometimes it does come before depression. Anger is a quick way to push away sadness. It’s always easier to be mad than it is to feel pain.

  Some of us experience intense bouts of anger: anger with ourselves, anger with medical professionals, even anger with the deceased. I often see more anger in my male clients, as it is culturally more acceptable for men to exhibit anger than it is for them to exhibit more vulnerable emotions of fear or sadness. Regardless, anger is almost always a mask for pain.

  Throughout this book, you will hear many stories of people who were overcome with bouts of anger throughout their grief process, much of it inextricably linked to their anxiety levels. Anger is a way of expressing frustration, and there is nothing quite so frustrating as feeling out of control.

  When anger subsides or when it is worked through to uncover what lies beneath, we are left facing the truth of what is at hand. We have lost someone very dear to us, and our world has been forever altered. This is where anxiety comes into play. We are finally facing the loss head-on, and it is agonizing. We are horrified that our person is really gone. We are scared of the pain we are experiencing. We are fearful that more bad things could happen. And as a result, we are set adrift in a sea of uncertainty and anxiety.

  But along with that anxiety can also come depression. They go hand in hand. This has been well documented for centuries. By facing the rawness of life in this way comes an ocean of depression across which we must swim. Yet even after the depression sets in, you may also continue to feel anxiety, the two of them interwoven, coming in waves.

  But all of these emotions are just that—emotions. They don’t last forever. We move in and out of them, release them, return to some, rest in one for a while, find meaning in another. Acceptance is the phase of embracing your new normal. This does not mean you are “over” the loss. As Kübler-Ross states, we will never get over the loss of someone dear to us. But we can learn to live with the loss, as we would learn to live with a missing limb. It is possible to return to our lives and remember how to make meaning and purpose without that person by our side. That is what acceptance means.

  For some people, even after they achieve a level of acceptance, they may continue to experience bouts of depression or anxiety related to the loss long into their lives, and this is normal. It’s not always about ridding ourselves of these emotions altogether but rather learning how to manage them and learning how not to let them control our lives.

  OTHER MODELS OF GRIEF

  In his book Grief Counseling and Grief Therapy, Dr. J. William Worden proposed that there are four tasks of grieving (notice tasks instead of stages). He suggests that they do not need to be followed in a linear fashion, but they do need to be addressed in order to fully move through the grief process.

  J. WILLIAM WORDEN’S FOUR TASKS OF GRIEVING

  Task 1. Accept the Reality of the Loss

  The foundation for healing begins with acceptance of the loss. This does not mean to suggest that you feel okay about your loved one’s death but that you work to face it early. Rituals like funerals and memorial services, or tending to a loved one’s grave, are important ways to work toward acceptance.

  Task 2. Process Your Grief and Pain

  Everyone has unique ways of processing grief; the emotions vary for each individual. It is important to use action to process your grief—setting up a scholarship in your loved one’s name, investing in hobbies, or joining a grief group. Using action is a way for us to move through our pain rather than avoiding it.

  Task 3. Adjust to the World Without Your Loved One

  This third task urges us to get used to our new and altered world. Everyone manages this in different ways. For some, it means cleaning out your person’s belongings from your home or making other plans on Saturdays when you used to go to the movies with your loved one. Bigger adjustments, such as financial plans or child rearing, are also part of facing this new reality. Working on task three is an important way to become accustomed to your new world.

  Task 4. Find a Way to Maintain a Connection to Your Loved One

  In his original model, Worden urged grievers to withdraw emotional energy from their loved one and reinvest it elsewhere. But later he became convinced that the opposite needed to occur—grieving individuals experienced the most healing and peace when they were able to find ways to stay connected to their loved one. This means incorporating our loved one
’s memories into our daily lives and current families by continuing traditions, telling stories, and honoring values that our loved one held dear.

  Alternatively, Dr. Thomas Attig invites us to look at grief through a slightly different process than both Kübler-Ross and Worden, but still uses many of the same suggestions. In his book How We Grieve: Relearning the World, he outlines several phases of the process that are helpful to consider.

  THOMAS ATTIG’S GRIEF PROCESS

  1. Changes in the Physical World

  In this phase, we must address the changes that have occurred in our physical world. This means looking at how the loss has impacted us in realms such as living space and work, financial, and physical health.

  2. Changes in Relationships with Others Still Living

  In phase two, we must understand how our relationships with the people around us have changed now that a loved one is gone—for instance, how your relationship with your mother might change after your father dies or how your marriage is affected in the wake of losing a child. Coming to terms with these changes and working to negotiate new roles is integral to healing.

  3. Changes in Perspective on Time

  Attig encourages us to examine our perspective on time (a sense of the past, present, and future): What does our life look like now that this loss has occurred? Losing someone significant has a profound impact on the way we view the time line of our life and our future going forward.

  4. Changes in Spiritual Grounding

  Evaluating or perhaps simply considering our spiritual grounding in the world is an important part of the grief process. It is only natural that we explore our beliefs and sense of purpose following a loved one’s death.