Grief and Loss: Beyond the Five Stages

Photo by Connor Scott McManus: https://www.pexels.com/photo/brown-wooden-chair-beside-window-13745224/

You have probably heard of the five stages. Denial, anger, bargaining, depression, acceptance. You may have arrived at grief expecting to move through them in sequence, emerge somewhere near acceptance, and find yourself more or less restored.

That is not what grief is. And it is not what Kübler-Ross intended when she described those stages in 1969 — a point she clarified repeatedly, and that has been largely ignored in the fifty years since.

Grief does not follow a sequence. It does not resolve on a timeline. It does not, for most people, end in acceptance as a fixed destination. And it is not only about death.

Up to now, you may have been carrying grief with a map that does not match the territory — telling yourself you are doing it wrong, that you should be further along, that what you are feeling is disproportionate or self-indulgent. But what if there is a better way to understand what is actually happening?

This article is about what grief actually is, what the evidence says about how it moves through people, what gets in the way of processing it, and when it becomes something that warrants clinical attention.

What grief actually is

Grief is the internal experience of loss. Bereavement — the state of having lost someone — is one context for grief, but far from the only one. People grieve the end of relationships, the loss of health, the loss of a version of themselves they thought they would become, the loss of a future they had planned around someone who is now gone, the loss of safety, the loss of a home, a role, an identity.

Grief is not a disorder. It is a normal, adaptive response to losing something that mattered. The pain of grief is, in some sense, proportional to the love or attachment that preceded it — which is why grief that seems excessive to an outside observer is rarely excessive to the person experiencing it.

What makes grief complicated — clinically and personally — is not its presence but its variability. No two people grieve the same loss the same way. The factors that shape a grief response include the nature of the loss, the quality of the attachment, the circumstances of the death or ending, the person's prior loss history, their available support, their cultural context, and their neurobiological baseline. To compare your grief to someone else's, or to a timeline, is to misunderstand what grief is.

The problem with the five stages

Elisabeth Kübler-Ross developed her stage model not from research on bereavement but from her work with terminally ill patients — people facing their own deaths, not the deaths of others (Kübler-Ross, 1969). The stages she described — denial, anger, bargaining, depression, acceptance — were observations about the psychological experience of dying, not a prescriptive sequence for grieving.

The model was adopted into popular culture as a grief framework with extraordinary speed and equally extraordinary inaccuracy. It became a measuring stick: where are you in the stages? Have you reached acceptance yet? This framing has caused significant harm to grieving people, who frequently conclude that they are failing at grief when their experience does not map onto the sequence.

The empirical literature does not support a stage model of grief. Bonanno (2004), whose research on resilience in bereavement is among the most cited in the field, found that the most common trajectory following loss is resilience — not a staged recovery, but a relative maintenance of functioning with periods of acute distress. Prolonged, debilitating grief affects a minority of bereaved people, not the majority.

Worden's tasks model (2009) offers a more clinically useful framework: grief as involving four tasks rather than stages — accepting the reality of the loss, processing the pain, adjusting to a world in which the person or thing is absent, and finding a way to maintain connection with what was lost while moving forward. Tasks, unlike stages, are not sequential and can be returned to repeatedly.

What grief actually feels like

Grief is not primarily sadness, though sadness is part of it. The phenomenology of grief is considerably more varied — and more physical — than most people are prepared for.

Cognitive disruption. Difficulty concentrating, memory problems, confusion, and a sense of unreality are among the most consistent cognitive features of acute grief. The brain is, quite literally, reorganising around an absence — updating a world model that was built around the presence of whoever or whatever is gone (O'Connor, 2019).

Physical symptoms. Chest tightness, fatigue, disrupted appetite, sleep disturbance, and somatic pain without clear medical cause are well-documented features of bereavement (Stroebe et al., 2007). The phrase "died of a broken heart" has a physiological basis: bereaved individuals, particularly older adults, show elevated cardiovascular risk in the period following loss.

Anger. Grief and anger are closely connected — at the person who died, at the circumstances, at people who are not grieving the way you think they should, at yourself. Anger in grief is not a stage to pass through. It is a recurring feature that tends to surface and resurface.

Relief. Following losses that involved suffering, caregiving, or a long deterioration, relief is common — and frequently accompanied by guilt about feeling it. Relief is not a sign of insufficient love. It is a human response to the ending of a painful situation.

Searching behaviour. Many bereaved people experience an impulse to look for the person who is gone — catching themselves reaching for the phone to call them, thinking they have seen them in a crowd, hearing their voice. This is not pathological. It is the attachment system doing what it was built to do (Bowlby, 1980).

Grief in waves. Most people describe grief not as a continuous state but as something that comes in waves — periods of relative functioning punctuated by acute surges of pain, often triggered by something small and apparently unrelated. A song. A smell. A particular quality of afternoon light. These surges do not indicate that the person is not coping or not progressing. They indicate that the loss mattered.

Types of grief that often go unrecognised

Disenfranchised grief is grief that occurs in the context of a loss that is not openly acknowledged, publicly mourned, or socially supported (Doka, 2002). It includes grief for: a relationship that was not publicly recognised (a secret relationship, an estranged family member), a pregnancy loss, the loss of a pet, the loss of someone to addiction or suicide, the loss of a person who is still alive but no longer present in the same way — through dementia, estrangement, or serious illness.

People experiencing disenfranchised grief frequently receive less social support than those in more conventionally recognised bereavements, because the loss itself is not visible or validated. The grief is no less real. The isolation compounds it.

Ambiguous loss is a concept developed by Boss (1999) to describe losses that lack clarity or closure. There are two forms: physical absence with psychological presence (a missing person, a soldier listed as missing, a child given up for adoption) and psychological absence with physical presence (a family member with advanced dementia, an estranged parent who is still alive). Ambiguous loss is among the most difficult to process because the normal grief tasks cannot be completed — there is no confirmed ending to accept, no body to mourn, no clear before and after.

Cumulative grief occurs when losses accumulate faster than they can be processed — a pattern seen in people with chronic illness, in healthcare workers, in older adults who have outlived their peers, and in communities that have experienced systemic trauma. The grief from earlier losses remains unprocessed when the next one arrives.

Anticipatory grief is grief that begins before the loss itself — during a terminal illness, a relationship that is visibly ending, or a transition that involves the loss of a previous life. It is not the same as the grief that follows the loss, and does not replace it.

When grief becomes complicated

Most grief, while painful, does not require clinical intervention. It resolves — not in the sense of disappearing, but in the sense of becoming integrated into the person's ongoing life rather than dominating it.

Prolonged Grief Disorder (PGD), introduced as a diagnosis in the DSM-5-TR (American Psychiatric Association, 2022), describes a grief response that remains intense and impairing beyond twelve months (six months for children), characterised by persistent yearning for the deceased, difficulty accepting the loss, bitterness or anger, difficulty engaging with life, and emotional numbness. PGD affects an estimated 10% of bereaved individuals (Shear, 2015) and is associated with elevated risk of suicidality, substance use, and physical health deterioration.

Risk factors for PGD include a sudden or traumatic death, a loss by suicide, a highly dependent or ambivalent attachment to the deceased, a prior history of depression or anxiety, limited social support, and concurrent stressors.

PGD responds to specific psychological treatment. Complicated Grief Treatment (CGT), developed by Shear et al. (2005), is the most evidence-based intervention — it draws on elements of CBT, interpersonal therapy, and exposure-based work, and has demonstrated superiority to standard depression treatment for this presentation.

If you are also neurodivergent

Grief in neurodivergent adults has features that are not well represented in the mainstream grief literature. Alexithymia — difficulty identifying and describing emotional states — is common in autistic adults and can make the internal experience of grief difficult to access or name. The grief may be present physiologically and behaviourally while remaining inaccessible emotionally.

Autistic adults may also experience intensified responses to changes in routine and environment that accompany loss — a grief within grief, related not only to the person but to the entire structure of life that was built around them. The loss of a long-term partner, for instance, involves the loss of shared routines, predictable environments, and a reliable source of co-regulation — all of which carry particular weight for a neurodivergent nervous system.

Grief support that relies heavily on verbal emotional processing may not be the most effective approach for all neurodivergent individuals. Body-based approaches, creative expression, and structured frameworks for making sense of loss may be more accessible. Resources specifically for neurodivergent adults navigating grief are available at Mindpath Academy.

When to seek professional support

Grief does not always require professional intervention. But the following warrant clinical attention:

• Grief that remains intensely impairing beyond twelve months

• Thoughts of suicide or of wanting to join the person who died

• Significant functional impairment — inability to work, care for dependants, or meet basic needs

• Substance use as a primary coping strategy

• Complete absence of grief following a significant loss, particularly if accompanied by numbness or disconnection

A general practitioner is a reasonable starting point. A clinical psychologist with experience in bereavement and trauma can provide assessment and evidence-based treatment.

→ Download the free Grief and Loss Self-Guide A clinical resource covering what grief actually is, the types of grief that often go unrecognised, and how to know when professional support is warranted.

→ Book a single coaching session with Dr Melanie du Preez One session. No package required. A space to talk honestly about what you are carrying and what support is available.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20–28. https://doi.org/10.1037/0003-066X.59.1.20

Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Harvard University Press.

Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. Basic Books.

Doka, K. J. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice. Research Press.

Kübler-Ross, E. (1969). On death and dying. Macmillan.

O'Connor, M. F. (2019). Grief: A brief history of research on how body, mind, and brain adapt. Psychosomatic Medicine, 81(8), 731–738. https://doi.org/10.1097/PSY.0000000000000717

Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372(2), 153–160. https://doi.org/10.1056/NEJMcp1315618

Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. JAMA, 293(21), 2601–2608. https://doi.org/10.1001/jama.293.21.2601

Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370(9603), 1960–1973. https://doi.org/10.1016/S0140-6736(07)61816-9

Worden, J. W. (2009). Grief counselling and grief therapy: A handbook for the mental health practitioner (4th ed.). Springer.