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Rethinking Kübler-Ross

Question: Do people grieve in stages, as Kübler-Ross suggested?

Dr. Katherine Shear: Yeah. I mean, I think Kübler-Ross did an enormous service to medicine and to the world at large by drawing attention to the importance of basically reactions to dying and then to death itself. However, her insights or whatever – her ideas, I think, about what exactly happens have not turned out to be very helpful because they don't turn out to be very accurate. And so what I think about the trajectory of grief really is informed very much so by many colleagues who have now done work looking closely at that process in different kinds of situations. And I think that I put it together in a slightly different way than maybe some other people do, but I think that what actually happens when someone dies –again, that you're very close to – that's really what we're talking about here, because you don't go through such a dramatic process when it's someone that you know. So this is someone very, very close. So what happens – how I understand what happens is that we have to start with what is that love relationship to start with. And love is something that we all feel and that we're biologically probably programmed to feel.

In psychology or psychiatry, we talk about a love relationship as an attachment relationship. And so the attachment system is a biological system that actually occurs in other animals, not only in humans. And it begins even before we're born. So a baby can recognize its mother on the very first day of its life. And then, of course, you've got that very strong attachment relationship between an infant and its caregiver – usually its mother and other people in its environment. And as the child grows older, there may be a couple of other people to which it's very, very attached. And actually what starts to happen also as a child gets older is that he child starts to learn how to be a caregiver. Because, of course, the mother is the caregiver early on, so as we get older and by the time we're adults, we are caregivers for the people that take care of us. So what happens when someone dies is that we lose not only the person who's taking care of us, but also a person who we put a lot of energy and a lot of ourselves into, taking care of them. And actually, it turns out that for adults, if you make them decide is it more important –you know, if you make them choose – is it more important to take care of someone else or to be taking care of yourself, do you have any idea what they'd say? So basically they will always say – most of the time say – that it's much more important to feel good about taking care of someone else.

So now let's go back to the bereavement situation. Because what's happened is someone has died who's very important to you to being sort of – it's the person who you turn to when you're under stress or the person who's kind of behind you, cheering for you when you're trying something new or having confidence in you when you're doing something, and that's very important. But this is also the person that you do those things for and that you try to protect and help in their life. So when they die, by definition, you failed as a caregiver.

So basically the two things that happen when someone dies is that attachment system gets very activated and so does the caregiver system. And what does that mean in everyday life? Well, that means that you start to think, well, how am I going to manage without this person? And then you also think, why didn't I prevent this death? I should have done something to make it better. Take the World Trade Center; a lot of people had the thought, why didn't I stop this person from going to work that day, even though these are not rational thoughts, of course, you're going to manage without this person. Of course you didn't do something to lead to this person's death. But they're automatic, instinctive thoughts. So that's the first thing that happens.

And so you start to have these different kinds of problems to solve, and that's really acute grief. That's what you start to think about and you start to think a lot about you try to find the person for both reasons, in your mind. Because we think of a very special place in our minds for the person who we're so attached to. And so what we have to do is we have to gradually come to terms with the fact that that person is gone forever. And that information is very difficult to accept. And so we don't accept it right away.

In the beginning, we feel a sense of disbelief and we also people will feel like they're going to see the person walk into the room. Sometime they have that feeling. And so they oscillate between facing it and then setting it aside. You get this kind of oscillation during acute grief and gradually you find some way – and people do this differently – but to think about the fact, okay, they're gone and that it's natural for people to die. And you come to terms with that emotionally as well as kind of cognitively or in your thoughts. So you have two basic forms of grief. And you have this oscillating trajectory that eventually leads to a place where it's in the background and where you just kind of revisit it from time to time in your life.

Recorded on November 3, 2009
Interviewed by Austin Allen

The grieving process, says the Columbia psychiatrist, doesn't happen in defined stages; it's about breaking an "attachment system."

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