Coping with Grief: The Nine Stages of Grief

Article Highlights: Our Nine Stages of Grief

1. Hope —tormented hope
2. Anxiety —anguished apprehension
3. Depression —angst-ridden sadness
4. Denial —confused rejection
5. Pain and guilt ­—agonizing self-blame
6. Anger and bargaining —bitter resentment
7. Acceptance —practical relief
8. Depression —second round of sadness
9. Reverie and revival —renaissance

Overview

At the end of death’s long trail, when all the grieving has been done, and the elusive closure has passed, what is often left for those who’d been spiritually inseparable from the departed is the dawning of an intuitive contemplation that can be as enriching as first-found love. Among all the stages of grief, this article endeavors to heighten that particular aspect of the hugely emotional grieving stages.

For many, this genesis begins as an inspiring infatuation with the past, only to then develop into a pervasive recovery mechanism, a unique type of silver lining for the frequently debilitating grieving process. Depression and anxiety, both persistent travelers across all the stages of grief, gradually give way to a sweeping revival.

In this article, we refer to it as the reverie —the highly intuitive and inspirational reverie. It is the ray of sunshine that elevates the memory of the lost soul and cherishes it while the rest of life goes on.

At the home care agency where I’ve worked for more years that I care to recall, we’ve come up with the following nine stages of grief, each one a set milestone in the overall process. We hope you will join us in this story of the daughter of an honored general, all the way to her hugely uplifting renaissance in the last stage. In the meantime, here is a word about Kubbler-Ross.

Kubbler-Ross

Kubler-Ross, the now famous psychiatrist, set the signposts of grief, the stages, at five, namely denial and isolation, anger, bargaining, depression, and acceptance. Many who followed espoused those five stages, some expanding them to seven. In our assessment of the story that follows, a story of a daughter’s immense love for her father, we recognized nine distinct stages of grief.

In all the available material on the grieving process, what stands out the most is the fact that people grieve individually, each in their own way. Even Kubler-Ross, who first came out with the much-discussed “five stages of grief”, emphasized this point, that there is no set sequence to those stages, and the second stage can be experienced first, the third last, and so on.

Stage 1: Hope —frustrating, tormented hope

Daughter-father love and hope

One day last summer, a social worker who often referred business to us at the home care agency called me to say she wanted me to go visit a nearby family with the view to helping them out with a caregiver. She explained that this involved a daughter-father relationship, the daughter a retired judge, and the father a 3-star general in his late-seventies, a highly-decorated Vietnam hero, and a lifetime diabetic who had developed the beginnings of gangrene in one leg. She said that their relationship oozes with love, and that the caregiver would have to accompany the general to a nearby hospital where his surgeon would carve out bits of creeping gangrene in his leg and put fresh bandaging around the cut.

When I arrived there, Ms. Mendelsohn —who promptly asked me to call her Emma— met me at the door, and as soon as she started talking, I could see that she was about highly emotional and to burst into tears. She must have been in her early sixties, and the social worker had mentioned that she’d been a district judge, now retired to care full-time for her father.

“My dad is wheelchair-bound. I’m going to wheel him in, but first…” overcome with emotions, the sentence remained unfinished. The thought came to me that this judge who probably heard nothing but people’s life stories of misfortune every day, was now choking at the very mention of her dad. I felt a rush of sympathy as well. “I’m sorry,” she then managed to say, “it’s just that I can’t bear the thought that I may be losing him. . . but let me go get him.” Her emotional state was contagious, to say the least.

She came back pushing a large wheelchair. In the chair, his legs draped by a shiny U.S. flag with a 3-star insignia stitched on one side, was this imposing figure of a man, his erect posture in dire contrast to his kind and inviting face. I also promptly saw a five-foot pole stemming from one of the corners of the chair and holding at the top another insignia in the form of a postcard-sized flag. The three stars on the flag were made of a bronze metal while the flag itself was of a navy-blue velvety material with golden embroidery around the edges. The vibrant quality of the shiny flag, the insignias and the sight of the figure of the general were, at first, more than just a little intimidating, despite him looking quite sickly, and with hollowed cheeks. But what was even more touching was the emotional relationship between those two, a relationship built on love.

I spent the better part of an hour at their home. I felt that Emma was latching on to me. She kept saying that: “what I want to do when Dad gets better. . .” while, all the time, her face was anguished with the futility of her hopeful words. She held back the tears in her distressed eyes with sheer determination. She at one point then collected herself and declared that the general’s doctor had mentioned that once they licked the gangrene problem, “Dad would be alright. . .” Again, her relationship to her dad was supercharged with, at this stage, naked emotions.

She let me go after promising her that I’d come back in the next couple of days with a male caregiver.

The visit left me utterly dejected. Although over the years I’d helped literally hundreds of families, I’d rarely seen a daughter’s love that stark and all-embracing, and the hope so mangled with a labyrinth of emotions.

Emma’s visible symptoms in that first stage of grief included:

• Confused emotions
• Hope mixed with fear
• Withdrawal, isolation, and apathy
• Dejectedness

Stage 2: Anxiety —anguished apprehension

Daughter-father highly stressful stage of grief

I stayed in touch with Emma, and visited the general and Jeremy, the caregiver we assigned to the general, every two or three weeks. Jeremy had done an outstanding job, getting the general, a person in endlessly chronic pain, to relax to him and let him do his job.

The diabetes was not letting up. It was rampant, not helping much with the gangrenous leg. The surgeon at the hospital where Jeremy took the general every ten days or so kept having to hack away at the blackened tissues closest to the cut. What was worse though was that the general was understandably not coping all that well. He was constantly in pain, despite his pain medication, feverish, and in perceptible overall decline.

Every time I went there I spent a few minutes with Emma. She was wasting away as well, not with illness, but with a kind of relentless anxiety that was eating away at her. “I can’t sleep more than an hour at a time,” she confided in me one day when I asked how she was faring. “I realize that he won’t be with me much longer and, frankly, it drives me nuts.” I convinced her that day to take a walk with me around the cluster of houses where they lived, hoping to give her stress some respite. When stress lingers in the body and is not allowed to stand down, not even for short breaks, it turns toxic. Her anguish was turning that way.

Her symptoms in this second stage of grief included:

• Stress turning to distress
• General and chronic anxiety
• Loss of appetite
• Loss of weight
• Sleeplessness and disturbed dreams
• Apathy

Stage 3: Depression — angst-ridden sadness

Daughter-father stage of depression and despair

When I saw Emma a few weeks later, she was in a pretty dark frame of mind and looking sick, her cheeks hollowed and her front above the eyebrows scarred by parallel lines that I hadn’t noticed before. I believed that in her mind, she had already lost her dad. “I am not able to do anything for him any longer,” she told me. “He is dying right in front of my eyes.”

Jeremy told me then that she wasn’t eating any of the food he prepared, and she stayed in bed most of the time, just ruminating and secluded from the outside world.

I tried desperately to talk her out of that mindframe, but she wouldn’t even go out for a walk with me. “I just want to be left alone,” she said to me, obviously going through a major depression, so I had no choice but to bid her farewell and leave.

In retrospect, Emma’s symptoms in stage three included:

• Fatigue and lethargy
• Sense of worthlessness
• Guilt, helplessness
• Irritability, restlessness
• No appetite and loss of weight
• Sleeplessness

Stage 4: Denial —confused rejection

Daughter-father stage of denial and alienated

Then one day Jeremy called me to say that the general had passed. “He had taken his pain and sleeping meds,” Jeremy said, “and he passed away as peacefully as could be, given his constant pain in the leg.”

“What about Emma?” I asked. “She kept saying no, no . . . and withdrew once more to her bedroom.” Her father’s death was obviously entirely overwhelming.

I rushed there, worried about Emma, and anxious to give Jeremy a hand with what needed to be done following the general’s death. She was in the living room and, at first glance, she appeared distracted, spaced out, and seemingly out of what was at hand. I tried to talk to her, but as far as I could tell, she seemed alone and simply wasn’t there for me or anyone else. Her grief had taken the path of denial.

At his funeral, and towards the end of the ceremony, when the U.S. Army Honor Guard had presented Emma with the folded flag, and when veterans had been requested to give the deceased his final salute, we were both in a torrent of tears, our emotions supercharged, and with me trying wishfully to allay Emma’s grief. At that point, she reached out to me and said: “I don’t want anything to do with all that,” to which she then added, “I will never let him go.”

In the car going back to her home, Emma was again numb and distracted, unable to concentrate on anything I said. She seemed utterly out of touch and, I could only surmise, extremely lonely.

Her signs and symptoms in that stage 4 can be summed up as follows:

• Numbed disbelief (“It’s not true”, and “This can’t be happening to me”)
• Emotionally distraught and alienated from people
• Bereaved, orphaned, lacking in purpose

Stage 5: Pain and guilt —agonizing self-blame

Daughter-father stage of grief with wild mood swings

Although Jeremy had left and my agency’s role with the family had ended, I kept visiting Emma every time I was in the neighborhood. In one of her less angry moods, I surmised that she really appreciated my visits.

The first time I found myself with her after the general’s death and burial, she was drinking wine although it was still mid-morning (I later also learned that she was taking 3 or 4 pills a day of some opioid). She seemed to repeatedly vacillate between one moment exhibiting anger and guilt feelings, and the next moment appearing to be totally exhausted. She kept saying things like, “I wish I’d been kinder when he was in dire pain,” and, “There is nothing left for me to do now”. She also berated herself, lashing out with things like, “It’s all my fault, not just recently, but going back when Mom was still alive.”

I could have told her many things to mitigate her nasty mood swings, but she was again in a world of her own, not disposed to be kind to herself.

Emma’s signs and symptoms in this stage 5 can be summarized as follows:

• The shock and denial had worn off
• Excruciating pain and suffering
• Taken to alcohol and opioids
• Filled with remorse and guilt

Stage 6: Anger and bargaining —bitter resentment

Daughter-father stage of grief with rage and frustration

The next time I visited Emma, the social worker who had referred Emma to my home care agency was there as well. Emma was clearly in a lashing out mood, particularly angry at the doctors who’d looked after her father. At one point, when Emma had gone to the kitchen, the social worker looked at me and explained, “Bottled-up emotions translating to anger at the world out there.” She then went on to say, “She’s now railing at the doctors, but don’t be surprised if she lashes out at you or me as well.”

In the next instance, when Emma was back, she went on a tantrum of, “Why me, why couldn’t I have been spared?” She had barely taken a breath when she went at it again, “All I want now is to be left in peace.”

The social worker and I kept looking at each other, particularly when Emma held her face in both hands, railing again. It was hard to watch, for this was the same kind and generous person that I’d earlier met.

Emma’s signs and symptoms in this stage 6 included:

• Bitterness and resentment (lashing out at others and fate)
• Extreme irritability and nervousness
• Mistrust
• Sarcasm and cynicism

Stage 7: Acceptance —practical relief

Daughter-father stage of grief was “back to down to earth awareness”

This was the stage of grief in which Emma regained her worldly consciousness and accepted her father’s ultimate demise. His death became real and the equivocating and fudging had gone, and so had the anger and railing. These were replaced by a nascent sense of closure, or at least the beginning of that process in which there is acceptance of the irreversible fact that life must and will go on.

I met Emma by chance at a community gathering when she had slipped into this stage of acceptance. She greeted me with a smile and, at one point, applauded one of the speakers with enthusiasm —A sign, I felt, of her attempt at coming out again and keeping her loneliness at bay.

Stage 8: Depression —second round of sadness

Daughter-father stage of grief “feeling alone and sad”

The next time I met Emma was at the request of the social worker who had referred her to me and who’d become a dear friend. She said simply that Emma was down on her luck again and would benefit greatly from a visit.

Sure enough, I found Emma in an utter state of dejection, not unlike what I’d seen of her earlier on when she was frantic at not being able to do anything for her failing father. When all had been said and done, she was, once again, on her own, terribly lonely, dejected, and seeped in reflection with a downward tilt. We talked, but she really wanted to be left alone, perhaps to commiserate her aloneness and lack of fortitude.

In that stage 8, the signs and symptoms I gathered included:

• Commiseration and self-pity
• Loneliness
• Fatigue
• The loss again seeming overwhelming

Stage 9: Reverie and revival —renaissance

Daughter-father final stage of grieving

One day, and completely out of the blue, Emma called me. She sounded almost manic in her exuberance. “How are you stranger?” She started off by saying, “Given up on me, have you?” Frankly, after being a little surprising, her tone brought endless cheer to my morning. I liked Emma and had suffered with her, not naturally to the extent that she’d suffered, but I had nevertheless often felt deeply saddened by her grieving travail.

And here she was, pepped up and sounding jubilant. After talking with her for a few moments, I felt that her renaissance was for real, and that this wasn’t some medication or opioid pill talking to me. She turned down to earth and simply happy-sounding. I really relished that and told her that I’d pass by one day soon and take her out on a walk.

Signs and symptoms of Emma’s renewal in this final stage:

• An upward turn and renewed sense of hope
• Uplifting acceptance
• Promising realism
• A desire to departmentalize and solve problems

Things you can do to help your friend

There are naturally things that you can say and do in each of the eight stages leading to the final revival. But instead of listing them individually, here is our short list of things we can all do across all stages to better serve the grieving person.

• Don’t be hampered by time expectations (give the grieving person all the time they need)
• Be conscious of the stages of grief (that will enable you to react intelligently and with compassion)
• Let the person go through what they need to feel (including tears, denial and anger)
• Don’t tell them how strong they are and how this will soon pass (in so doing, you risk to shed your credibility)
• Just be available, at times in the background (your discreet presence may be of comfort, even when the grieving person is railing)
• Help your friend memorialize the departed (ask them what they need towards honoring the dead)

But above all, allow yourself to display the full extent of your compassion; when your sympathy is real, it will seep through all stages of the storm.