June 28, 2022

5 Stages of Grief (And When It’s Not Depression)

If you’re grieving, it affects you in all aspects of life – at work and social situations, day-to-day life, and more. Though grief can feel overwhelming, understanding the five stages of grief (denial, anger, bargaining, depression, acceptance) and how to spot which stage you’re in, makes it manageable. Dr. Judy breaks down those stages in this MedCircle session.

Kyle Kittleson: What is the difference between grief and breavement?

Dr. Judy Ho: So grief is the process of the grieving a loss. And bereavement is actually the state of loss. So people use it interchangeably all the time. I mean, that’s such a fine-tuned distinction.

Kyle Kittleson: So there are the popular stages of grief.

Dr. Judy Ho: Yes.

Kyle Kittleson: And what are they?

Stage 1 & 2: Denial and Anger

Dr. Judy Ho: So the Kubler-Ross Model, the five stages of grief talks about five different stages that people go through. And the first one is denial. It’s everybody’s favorite stage. Like it’s not happening. And it’s a very rudimentary coping response. It’s a very visceral reaction of, there’s no way, this doesn’t make any sense. That’s the first stage.

And the second stage is anger. And when you asked me in the last episode, why? Why did this happen? That’s exactly what anger is. That’s that stage of …

Kyle Kittleson: So that would be telling on what stage you’re in.

Dr. Judy Ho: Yeah.

Kyle Kittleson: Now, do you have to go through all five stages or can I just bypass and go right to stage five?

Dr. Judy Ho: No, I think that when Kubler-Ross first proposed it, she was thinking that it was going to be a linear process. But as we’ve learned, it’s circular, it skips stages and comes back. So I think the idea still is that most people will have gone through most of the stages, but in terms of the order, in terms of how much you come back, and double back on it, it’s all varied.

Kyle Kittleson: So it kind of sounds like they are less stages and just five different feelings or symptoms that you may or may not go through after you suffer a loss.

Dr. Judy Ho: Yeah. I mean, I think that that would be much more accurate because everybody’s experience with grief is different. There’s no one way to grieve. Its really interesting.

Kyle Kittleson: Right. This is how you have to do it.

Dr. Judy Ho: Yeah. It’s really interesting when people say things like, “Oh, well, as a grieving wife, I thought that she would be different at the funeral.” How would you know what she’s thinking? And why is there one way? Why do you think that your experience might apply to hers? And so it’s interesting when people have that judgment. And I think the judgment comes because people are very uncomfortable with grief. It’s a terrible thing. You don’t know what to say. Are you saying the right thing? And I think they’re just trying to make sense of the process, but what makes sense for you does not have to make sense for someone else and vice versa.

Kyle Kittleson: That’s really big. When my grandmother died, my brother was playing poker and I remember being really angry at him going, “What are you doing playing cards when our grandmother just died?” And then I realized, yes, but this is how he has to deal with it. If that’s a distraction for him, that’s a mechanism for him that works. So I can’t judge or take my grief out on him.

Dr. Judy Ho: Exactly. And I think that that is again, is important to know that just because they don’t look like outwardly grieving, doesn’t mean that internally they’re not struggling a lot.

Kyle Kittleson: Yeah. I get that.

Dr. Judy Ho: Yeah.

Kyle Kittleson: Okay. So we have denial, then we go to anger.

Stage 3: Bargaining

Dr. Judy Ho: Anger, and the third one is bargaining. So this is okay, well, how many more days do they have? Can they make it to the wedding? Even though we’ve lost them, this is like really final. I mean, this is really interesting, sort of like magical thinking that can happen during this phase, especially with children. Well, but what if grandpa could come back? What if he could send us a message, then we could really have that last conversation with him? And so that bargaining stage is important because again, it’s sort of like you’ve gone through the denial, and you’ve gone through maybe the anger, and now it’s like, okay, well let me just pray to God and see if there’s any way we can still have any kind of communication with him. And I think this is when, and not to knock it, because I know that a lot of people really enjoy this and it helps them to get closure. They might go and seek out a medium. They might go and try to have some kind of semblance of what’s the afterlife look like for this person?

And so I think that actually bargaining is a very interesting stage because for a lot of people, they do very many different things in the bargaining stage. And it’s really just about kind of trying to wrestle with this idea that it’s final. Is it really final? And if the person’s still alive, but they’ve been diagnosed with a terminal illness, you’re already starting to grieve them, even though they’re there. And that bargaining stage is especially prominent then. Let’s go to a different doctor. Let’s go to five doctors. Maybe one of them will say that it’s not terminal. And then we’ll have a chance.

Kyle Kittleson: Can we stay on that for just a moment, this idea that we can grieve something that we know is inevitable or we assume that is going to happen. But we’re grieving it before it’s even happened. What’s going on there?

Dr. Judy Ho: Well, I think when we are faced with inevitability and we know that it’s coming, then people have a hard time staying mindful of the present moment. They kind of already fast-forward to the fact that they’ve already lost this person. And that’s why the grief starts early.

Kyle Kittleson: Yeah. It’s kind of like how, when people are in bad relationships and then they break up and you go, “How are you doing?” They’re like, “I’m actually doing pretty good.” It’s because they’ve been grieving the death of that relationship while they were in it.

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Dr. Judy Ho: Because they already see the inevitability of that breakup.

Kyle Kittleson: Yeah. So by the time it happens, it’s like, oh, I’ve already gone through this emotionally.

Dr. Judy Ho: Yes. Exactly.

Kyle Kittleson: I get that.

Dr. Judy Ho: Yeah. Yeah. So it makes a lot of sense. And I think unfortunately, I mean, you lose out on that time that you can still have with that person in some ways.

Kyle Kittleson: Right. Interesting.

Dr. Judy Ho: Yeah.

Kyle Kittleson: Interesting. Instead of being in that moment?

Dr. Judy Ho: Yeah.

Kyle Kittleson: Yeah. I get that.

Dr. Judy Ho: Really sad. I mean, I think again, it’s hard, you can’t control that really. You try your best and it’s hard. And again, because grief is so universal, we’ve all been through it. And I certainly wish sometimes that I was more mindful in the final days of my grandmother dying, who was like a second mom to me. But it was just so hard. I would look at her and she was so sick at that time already, I was just thinking about when she was going to die. Right. And it’s so hard, so hard.

Kyle Kittleson: And do you think that is a way the body copes?

Dr. Judy Ho: Yeah. Because when you have an attachment to someone it’s really hard to imagine your life without them. And once you know that that’s coming, and there’s like a very finite sort of timeframe that that might happen, it’s almost like a protective mechanism. Well, I’m just going to basically act as if it’s already happened so that my body, so that my mind can really get used to this idea. And so you kind of start that grieving process early, but you kind of miss out on some of the more beautiful moments of trying to stay there.

Kyle Kittleson: The times, the last moments. Or people say this isn’t going to happen.

Dr. Judy Ho: Oh yeah.

Kyle Kittleson: And they live in that denial space, which is the first stage.

Dr. Judy Ho: Definitely. Absolutely.

Kyle Kittleson: I see that. Okay. This is making sense. All right. So we have denial, we have anger, we have bargaining. What’s the fourth one?

Stage 4: Depression

Dr. Judy Ho: Fourth stage is depression. So we’ve been talking about this concept of depression. Is it going to be something that morphs into major depressive disorder or is it a type of depression that kind of stays in the realm of normal grieving process? But either way, the fourth stage is depression, where you actually … Starts to sink in that this is happening, that it’s real, you’ve gone through denial, anger and bargaining supposedly at this point, if we’re thinking about it linearly. And you are now despondent. Okay, now I have to actually deal with this. And so a lot of different kinds of symptoms can come up that mirror or mimic major depressive disorder. But as I mentioned before, there are some key differences. Like usually the person still feels okay about themselves. The self-esteem is still intact and it’s not every single day, every moment of the day, like depression can be for some people. Clinical depression, that is.

Stage 5: Acceptance

Dr. Judy Ho: And the final stage is acceptance. Like, yes, this has happened. And I’ve gone through the waves of emotion and I have to live my life. I have to move on. Perhaps people do develop a new understanding about life. I know a lot of people who’ve gone through a loss and it has changed their priorities in life. They decide that they want to spend more time with their families. They decide that they want to spend more time recreationally, having more fun, like soaking up what life has to offer outside of work. People sometimes throw themselves into volunteer work, helping other people who are grieving.

And so I think sometimes a worldview will shift, but a lot of the acceptance phase is kind of well, this is how it is. And I still have to move on and live my life to the best of my ability. But of course, you don’t always stay there. And I think that’s why the model is maybe too simplistic in its first formation, because you can be in acceptance for two months and all of a sudden, go right back to denial or all of a sudden, go right back to depression. And that’s what confuses people about grief. Like, whoa, I thought that I went through everything.

Kyle Kittleson: I thought I did this.

Dr. Judy Ho: I’m done. You’re never done with grief. I don’t think you’re ever done with grief honestly.

Kyle Kittleson: Is it bad if I just find myself right in the fifth stage of acceptance? I go, did I even do the other ones?

Dr. Judy Ho: No, because I think a lot of people, sometimes again, we’ve skipped stages, sometimes the stages are very fleeting. And I think perhaps when you’ve had acceptance, it’s likely that you’ve gone through some of the other stages earlier on, so that when the finality of the loss actually happens, you’re already accepting of it. And that’s what we’re talking about in terms of the earlier grief happening when the person perhaps was alive but you know that that’s coming, that sometimes people feel like they’ve already gone through all those emotions beforehand.

Kyle Kittleson: Is there a wrong way to grieve?

Dr. Judy Ho: No.

Kyle Kittleson: There’s not?

Dr. Judy Ho: No. And what really drives me crazy is when people feel like there’s just such judgment of how somebody else grieves. Like you just don’t know how that works for someone. And sometimes the grief can be delayed. So oftentimes there’s a lot to do, especially if you’re an immediate family member of the person that has died. You’ve got to rally the rest of the family and friends, put together a memorial, deal with funeral arrangements. You don’t even have time to deal with grief. And it’s not until months later that all of a sudden, you have a breakdown, you start crying and you really realize, at that point, that you’ve lost somebody important to you. And there’s no timeline for that either. Some people will have delayed grief two or three years later, five years later, ten years later. I’ve had patients come being like super depressed after 10 years of losing their son. They’ve kind of lived what seemed like a pretty normal existence until then. And all of a sudden, 10 years later, it hit them. Wow, like I have not dealt with the loss of my son.

Kyle Kittleson: So from a personal standpoint, my mother died when I was 16. I’m 33 years old. I don’t have a picture of her up in my house. I don’t have a picture of her on my phone. If right now you wanted to see a picture of her, I couldn’t do that because the idea of seeing a picture of her puts me in that state of depression. I think that stage of depression, of man, this really sucks for me. Does that mean I haven’t dealt with it?

Dr. Judy Ho: I don’t think it necessarily means that you haven’t dealt with it. Although I think if the emotions are still so raw in a way that having a photo of her would be inciting to you, it probably means that there’s still some emotions there that you haven’t fully confronted. It doesn’t mean that you haven’t dealt with it at all, but it just means that maybe there are some emotions that you have been afraid of, that you’ve been putting off. And it makes sense, because you’re like this is what I need to do to like live my life and carry on every day.

And so again, that’s not even a wrong way to grieve either. Everybody has to sort of have their sort of boundaries around grief also. And you still have to get up, you still have to go to work, you have to do stuff. And if you know that having the photo around is going to impede with that, that’s why you do it. It’s not even a negative coping strategy so to speak. But it may mean though that there might be some emotions in there that you just haven’t allowed yourself to feel because it’s still very, very crucial and very important to you, this phase of your life. And losing your mom at 16, I mean that’s really tough. Again, because you weren’t even an adult yet.

Kyle Kittleson: Right. Can you ever be in one of the timelines too long?

Dr. Judy Ho: I don’t think that you can be in a specific timeline for too long, per se, as long as it doesn’t start impacting your life in a super negative way. If that denial is so bad that your friends and family are angry with you, that you’re still in denial, that you isolate, that you don’t talk to people, then I think it can be a problem. And certainly if you’re in that depression stage for too long, and the symptoms morph into a major depressive disorder, and you’re not addressing it and treating it, then that could be a problem too.

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Disclaimer: This information is not specific medical advice and does not replace information you receive from your healthcare provider. This is only a brief summary of general information. It does NOT include all information about conditions, illnesses, injuries, tests, procedures, treatments, therapies, discharge instructions or lifestyle choices that may apply to you. You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

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