The five stages of grief came from dying patients, not mourners

Key takeaways

• The five stages of grief grew out of Kübler-Ross’s 1969 work with dying patients, and grief researchers say sound evidence that mourners pass through them in order never arrived¹.
• Grief tends to come in waves: intense bursts often last 20 to 30 minutes, and for most bereaved people, symptoms ease somewhere between six months and two years after the loss³.
• In a study of 373,189 older U.S. couples, a wife’s death raised her husband’s risk of dying by 18%, and a husband’s death raised his wife’s by 16%⁵.
• Studies put prolonged grief disorder at roughly 5% to 10% of bereaved adults, with far higher rates after deaths from accidents, suicide or homicide⁶⁷⁸.
• A 16-session therapy built for grief helped 70.5% of adults 50 and older in a 2014 trial, compared with 32% who got a proven depression therapy⁹.

By 1982, the five stages of grief had been taught in about 125,000 courses, by their creator’s own estimate. Colleges, seminaries, medical schools, hospitals and social work programs all used them¹.

Denial, anger, bargaining, depression, acceptance. You’ve likely heard the list. Many people still use it to judge whether they, or someone they love, are grieving “right.”

This is the surprise. The stages came from Kübler-Ross’s 1969 book On Death and Dying, which drew on her work with people who were dying¹. Only later were they applied to the families left behind. In a 2005 book she co-wrote, she said that grief doesn’t march through the stages in a line, and that many people skip some of them¹.

In 2017, grief researcher Margaret Stroebe and two colleagues reviewed the evidence and urged health professionals to stop using the stages to guide bereaved people¹. They found little sound research behind them and warned that the model can make grieving people feel they are failing¹.

What has replaced the stages is kinder and closer to how grief feels. It also gives a clearer signal for the minority of people who get stuck, and real help when they do.

The stages spread far faster than the evidence

Stage models are tidy, which is part of their appeal. Grief is not tidy, and the research shows it.

In their 2017 review in the journal OMEGA, Stroebe’s team said stage theory lacks solid evidence, explains little and doesn’t help identify who is at risk of serious problems¹. A 2007 study claimed support for the stages, but other researchers questioned its methods, and a later attempt to repeat it gave unclear results¹.

The bigger worry is harm. Some grieving people fret that they are going through the stages out of order, the review notes. Others go looking for a counselor because a stage they were told to expect never arrived¹. Friends and clinicians may judge where someone “should” be by now¹.

The reviewers’ advice to professionals is plain: teach the stages as history, not science¹. Not feeling them does not mean grief has gone wrong. Most bereaved people adjust in their own way, and only a minority need professional help¹.

Grief moves in waves, and stepping away is part of coping

A leading alternative is the dual process model, developed by Stroebe and her colleague Schut in 1999². It describes two kinds of coping, and both are healthy²:

• Facing the loss: crying, remembering, looking at photos, feeling the absence.
• Rebuilding daily life: learning new tasks, taking on new roles, and sometimes simply taking a break from grief.

The key is moving between the two, which the model calls oscillation². Picture a widow who cries over her husband’s handwriting in the morning, then learns to pay the bills that afternoon. Neither one means she is grieving wrong. In this model, trouble looks like getting stuck on one side, such as never stepping away from the loss².

The National Cancer Institute (NCI) describes grief in similar terms. Painful feelings come and go rather than staying constant³. Intense “grief bursts” often last 20 to 30 minutes and can be set off by holidays, anniversaries and other reminders³.

Over time they come less often and hit less hard. For most people, symptoms ease somewhere between six months and two years after the loss³.

Many people also keep a bond with the person who died. They think of them, dream about them, or visit places they shared³. The VA’s National Center for PTSD notes that most bereaved people slowly return to daily life while still feeling connected to the person who died⁴. The dual process model counts continuing that bond, in a new form, as part of grief work².

That fits values many natural-health readers hold. Grief is a normal response to love, not a malfunction. Stroebe and colleagues titled a 2017 commentary in The Lancet “Grief Is Not a Disease but Bereavement Merits Medical Awareness”¹⁵.

MedlinePlus, the National Library of Medicine’s consumer site, names friends, family and faith as sources of support, and says grief counseling helps some people¹³. Prayer, time outdoors and cooking a loved one’s recipe are old ways of carrying a loss. Our article on rituals covers what research says about funerals and memorials.

Grief reaches the body, especially after losing a spouse

Grief is not only in your head. MedlinePlus lists sleep problems, appetite changes and illness among its physical effects¹³. NCI adds fatigue and notes that men tend to have more problems than women after a spouse dies³.

A large study of this “widowhood effect” followed 373,189 older married couples in Medicare records from 1993 to 2002⁵. After a wife died, her husband’s risk of death rose 18%. After a husband died, his wife’s rose 16%⁵.

One detail stands out. When a spouse died of Alzheimer’s or Parkinson’s disease, the survivor’s risk did not rise significantly⁵. The authors suggested that during a long illness, some grieving and caregiving strain may happen before the death⁵.

This was an observational study, so it shows a link, not proof of cause. Still, it’s a reason to treat the first year after a loss as a time to protect sleep, meals, medicines and checkups. Our article on the mind-body connection covers broken heart syndrome, a sudden stress reaction of the heart.

Some losses carry extra weight

Grief before a death. Grief can begin while someone is still alive, which experts call anticipatory grief. NCI estimates that about 1 in 4 patients with incurable cancer feel it, and families can too³. Talking with someone trained in grief may help a family come to terms with what’s ahead³.

Sudden and violent deaths. A sudden death is linked to more grief symptoms in the first six months, and a violent one to symptoms that last longer, according to the VA⁴. A 2020 review of 25 studies found that about half of people bereaved by accidents, disasters, suicide or homicide had prolonged grief disorder⁶. The studies varied widely, so treat that figure as rough⁶.

Losses others overlook. Some losses get little public notice: a pet, a pregnancy, an ex-spouse, a friend your family never met. If yours is one of them, your grief still counts. You may need to ask for support more directly, or find people who have lived the same kind of loss.

Children. Kids grieve too, in ways that match their age. According to NCI, children ages 3 to 6 often see death as temporary, and some believe their own thoughts caused it³. Older children understand that everyone dies and may feel guilt, anger or fear about their own death³.

NCI’s advice for adults is practical³:

• Explain the death truthfully and simply, and answer questions.
• Use the words “died” and “death.” Phrases like “passed away” can confuse young children.
• Reassure them that they will be cared for.
• Let them join memorial services if they want to, explain what will happen, and never force them.

Children often return to a loss at milestones as they grow, so their grief may resurface years later³.

When grief gets stuck: prolonged grief disorder

Psychiatry’s current diagnostic manual, the DSM-5-TR, published in 2022, and the World Health Organization’s ICD-11 both now include prolonged grief disorder⁸. We describe the criteria here rather than reproduce them.

Under the DSM-5-TR, at least 12 months must have passed since the death for an adult⁸. The core sign is intense longing for the person, or constant thoughts of them, nearly every day for at least the past month. At least three of eight other listed symptoms must also be present, the grief must disrupt daily life, and it must clearly exceed what the person’s culture or faith would expect⁸. The ICD-11 sets a shorter six-month threshold and requires fewer added symptoms⁸.

How common is it? A widely cited estimate is about 1 in 10 people bereaved by natural causes⁶⁷. A 2023 review found a similar share among adults 65 and older⁷.

A German population survey, run in late 2021 and published in 2024, found lower rates. Of 1,062 bereaved adults, 4.7% met DSM-5-TR criteria and 5.4% met ICD-11 criteria⁸. The rate depends on who is counted and how.

Grief also differs from depression. NCI says that in grief, painful feelings come and go, self-esteem stays intact, and people don’t usually feel worthless³. Grieving people may wish to join the person who died, but thoughts focused on ending their own life are a warning sign³.

NCI lists factors that raise the risk of complicated grief³:

• depending heavily on the person who died, such as a spouse;
• limited social support;
• constantly dwelling on distress;
• a past mental health condition;
• younger age.

A therapy built for grief outperformed a proven depression treatment

Researchers led by Dr. Katherine Shear have tested a treatment aimed at grief itself, called complicated grief treatment¹⁰¹¹. In a 2014 trial in JAMA Psychiatry, they studied 151 bereaved adults ages 50 and older, average age 66, recruited in the New York area⁹.

Everyone was offered 16 sessions, about once a week. About half got complicated grief treatment, and the rest got interpersonal psychotherapy, a talk therapy with a strong record for depression⁹.

By week 20, 70.5% of the grief-treatment group had responded, compared with 32% of the comparison group⁹. For about every two to three people treated, one more improved⁹.

A larger 2016 trial, funded by the National Institute of Mental Health, enrolled 395 adults¹⁰. Among people who got complicated grief treatment plus a dummy pill, 82.5% improved, versus 54.8% of those who got the dummy pill without the grief therapy¹⁰. Adding the antidepressant citalopram didn’t boost the grief therapy’s results, though it did ease depression symptoms more¹⁰. Citalopram on its own did no better than placebo¹¹.

Why does it help? An analysis listed by Columbia University’s Center for Prolonged Grief points mainly to easing guilt and reducing avoidance of painful reminders¹¹. The main trials all come from one research group, so tests by independent teams would strengthen the case⁹¹⁰¹¹. NCI also reports that cognitive behavioral therapy beat general counseling for complicated grief in one trial³.

A grief companion for the weeks, months and anniversaries ahead

This guide is ours, built from the sources above. It isn’t a schedule. Use the rows that fit and skip the rest.

When	What often helps you	What helps from others
First weeks	Keep the basics: sleep, simple meals, water, short walks. Let feelings come and go3.	Practical help, offered specifically: “I’ll bring dinner Tuesday”4.
First months	Mix grief time with rebuilding time, such as one memory and one small task a day2. Keep medical checkups, since losing a spouse is linked to higher health risk5.	Keep checking in after the crowd thins. Say the person’s name4.
Holidays and anniversaries	Plan ahead. Expect waves of pain, and choose a way to mark the day3.	Remember the date. A short note can mean a lot.
A year or more later	If longing still fills most days and life feels stuck, ask for an assessment8.	Gently mention that grief-focused therapy exists9.

What to say, and what to skip. The VA lists helpful responses: expressing sympathy, saying the name of the person who died, and asking about the death and how they feel⁴. It lists unhelpful ones: passive offers such as “call me if you want to talk,” saying the death was for the best, assuming the person is strong, and avoiding the subject⁴. We’d add one more phrase to skip: “everything happens for a reason.”

Try instead, in your own words: “I’m so sorry. Would you tell me about her?” Then listen, without fixing.

Where to find support, including help families often miss

Hospice bereavement services. If the person who died was in hospice care, Medicare rules require the hospice to have an organized bereavement program¹². Those services must be available to the family for up to one year after the death, under a plan matched to the family’s needs¹². Ask the hospice what it offers, even months later.

Support groups. Groups for widows, parents, suicide-loss survivors and others can ease isolation. Our article on peer support explains what peers can offer that clinicians can’t.

Grief-focused therapy. If you’re struggling, ask a therapist directly whether they are trained in a grief-specific treatment, such as complicated grief treatment⁹¹¹. Our guide to mental health professions explains who does what.

Medical care. If depression is part of the picture, it can be treated. The VA notes that bereaved people with major depression respond to medicine or therapy much as others do, and early treatment may prevent later problems⁴.

What the evidence says, rated

Claim	Evidence rating	What it rests on
Grief follows five stages in a set order	Evidence says no, or unsafe	Little sound evidence; Kübler-Ross herself later said the stages aren’t linear1
Most people adapt to loss without professional treatment	Strong evidence	Grief researchers’ reviews and NCI summaries13
Moving between grieving and rebuilding is a healthy pattern	Promising but early	A leading model built from research, not a treatment tested in trials12
Losing a spouse is linked to higher risk of death	Strong evidence	373,189 couples, though observational5
Complicated grief treatment helps prolonged grief disorder	Strong evidence	Two large randomized trials with consistent results, both from one research group91011
An antidepressant alone treats prolonged grief	Evidence says no, or unsafe	In a large trial, citalopram alone did no better than placebo, and adding it to grief therapy didn’t improve grief outcomes1011

Questions readers ask

The bottom line

The five stages were a well-meant idea that outran its evidence. Grief tends to come in waves, mixing pain with ordinary life, and most people find their way through it with time, people and practices that hold meaning for them.

For some, grief stays stuck at full strength, and that is not a personal failing. A therapy built for grief has strong trial results. If longing still fills your days long after a loss, or if you think about ending your life, reach out for help.

Related reading

• Rituals can steady nerves and honor a loss, but the science is young
• Most people stay steady after trauma, and resilience courses add less than promised
• What a peer who’s been there can do that a clinician can’t
• Stress can reach your immune cells, but positive thinking still can’t cure cancer
• Mandatory debriefing after trauma can backfire, while three PTSD therapies have strong evidence

Sources

1. Stroebe M, Schut H, Boerner K. “Cautioning Health-Care Professionals: Bereaved Persons Are Misguided Through the Stages of Grief.” OMEGA: Journal of Death and Dying, 2017;74(4):455-473. journals.sagepub.com
2. Stroebe M. “Ways of Coping with Bereavement: From Stages to the Dual Process Model” (conference slides summarizing Stroebe & Schut, Death Studies, 1999, and later updates). St. Francis Hospice Kaleidoscope Conference, Dublin.
3. National Cancer Institute. “Grief, Bereavement, and Loss (PDQ): Patient Information.” Last revised February 12, 2025 (republished by ColumbiaDoctors). columbiadoctors.org
4. U.S. Department of Veterans Affairs, National Center for PTSD. “Managing Grief After Disaster Events” (provider page). Last updated March 26, 2025. ptsd.va.gov
5. Elwert F, Christakis NA. “The Effect of Widowhood on Mortality by the Causes of Death of Both Spouses.” American Journal of Public Health, 2008;98(11):2092-2098. humannaturelab.net
6. Djelantik AAAMJ, Smid GE, Mroz A, Kleber RJ, Boelen PA. “The Prevalence of Prolonged Grief Disorder in Bereaved Individuals Following Unnatural Losses: Systematic Review and Meta Regression Analysis.” Journal of Affective Disorders, 2020;265:146-156. researchinformation.umcutrecht.nl
7. Thiemann P, Street AN, Heath SE, Quince T, Kuhn I, Barclay S. “Prolonged Grief Disorder Prevalence in Adults 65 Years and Over: A Systematic Review.” BMJ Supportive & Palliative Care, 2023;13(e1):e30-e42. pubmed.ncbi.nlm.nih.gov
8. Treml J, Linde K, Brähler E, Kersting A. “Prolonged Grief Disorder in ICD-11 and DSM-5-TR: Differences in Prevalence and Diagnostic Criteria.” Frontiers in Psychiatry, 2024;15:1266132. frontiersin.org
9. Shear MK, Wang Y, Skritskaya N, Duan N, Mauro C, Ghesquiere A. “Treatment of Complicated Grief in Elderly Persons: A Randomized Clinical Trial.” JAMA Psychiatry, 2014;71(11):1287-1295. pubmed.ncbi.nlm.nih.gov
10. Psychiatric News (American Psychiatric Association). “Citalopram May Offer Limited Benefit For Patients With Complicated Grief” (on Shear MK, et al., JAMA Psychiatry, 2016). 2016. psychnews.psychiatryonline.org
11. Columbia University Center for Prolonged Grief. “Publications.” Accessed October 2026. prolongedgrief.columbia.edu
12. Electronic Code of Federal Regulations. 42 CFR 418.64, “Condition of participation: Core services” (hospice bereavement counseling). Current as of October 15, 2026. ecfr.gov
13. MedlinePlus, National Library of Medicine. “Bereavement.” Updated October 9, 2026. medlineplus.gov
14. 988 Suicide & Crisis Lifeline. “Get Help.” Accessed October 2026. 988lifeline.org
15. Stroebe MS, Stroebe W, Schut H, Boerner K. “Grief Is Not a Disease but Bereavement Merits Medical Awareness.” The Lancet, 2017;389(10067):347-349 (Utrecht University record). research-portal.uu.nl