Although discredited, the five stages of grief is mentioned in 60pct of sites included a description (from brief mention to detailed elaboration) of the those stages

Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal. Kate Anne Avis, Margaret Stroebe and Henk Schut. Front. Psychol., December 2 2021. https://doi.org/10.3389/fpsyg.2021.772696

Abstract: Kübler-Ross’s stage model of grief, while still extremely popular and frequently accepted, has also elicited significant criticisms against its adoption as a guideline for grieving. Inaccurate portrayal of the model may lead to bereaved individuals feeling that they are grieving incorrectly. This may also result in ineffectual support from loved ones and healthcare professionals. These harmful consequences make the presentation of the five stages model an important area of concern. The Internet provides ample resources for accessing information about grief, raising questions about portrayal of the stages model on digital resources. We therefore conducted a systematic narrative review using Google to examine how Kübler-Ross’s five stages model is presented on the internet. We specifically examined the prominence of the model, whether warnings, limitations and criticisms are provided, and how positively the model is endorsed. A total of 72 websites were eligible for inclusion in the sample. Our analyses showed that 44 of these (61.1%) addressed the model, indicating its continued popularity. Evaluation scores were calculated to provide quantitative assessments of the extent to which the websites criticized and/or endorsed the model. Results indicated low criticalness of the model, with sites often neglecting evaluative commentary and including definitive statements of endorsement. We conclude that such presentation is misleading; a definitive and uncritical portrayal of the model may give the impression that experiencing the stages is the only way to grieve. This may have harmful consequences for bereaved persons. It may alienate those who do not relate to the model. Presentation of the model should be limited to acknowledging its historical significance, should include critical appraisal, and present contemporary alternative models which better-represent processes of grief and grieving.

Discussion

Principal Findings

The purpose of this study was to gain better understanding of the presentation of Kübler-Ross’s five stages model on the internet. The concern to examine inclusion of the model on websites arose in large part from its critical assessment in scientific reviews and in the accounts of clinicians. Notably, scientific sources have drawn attention to the absence of a body of empirical research and lack of validity regarding the model. Clinicians have pointed to potential negative consequences for bereaved people who do not “conform” by going through the stages but who think that they should be experiencing them. In the face of these criticisms, it is important to explore how the model is presented to professionals and lay people in general, and to bereaved persons in particular. Technological advances have meant that the internet system is widely used for the giving to and seeking of support among bereaved persons, providing ample resources for accessing information about grief. This raises questions about the portrayal of the stages model through websites. We therefore conducted a systematic narrative review to examine the presentation of the five stages model of grief on the internet, investigating three research questions.

Our first research question addressed the prominence of the model; how frequently is it mentioned on websites providing information about grief? The results indicated the continued popularity of the model; 61.1% of websites included a description of the five stages, with accounts varying from brief mention to detailed elaboration of the model. This is a conservative estimate, given a further nine sites mentioned “stages” in general, indicating the possibility that nearly three quarters of all the sites referred to the model, at least non-specifically. This frequent inclusion is in line with Corr (2018, 2019a) research results; the five stages were described in the majority of his sampled textbooks. Similarly, it seems to echo Sawyer et al. (2021) findings mentioned earlier, that roughly 68% of the general public and 44% of mental health professionals endorsed the stages. Furthermore, an exploration of the word count providing information about the five stages also highlighted the prominence of the model, with over a third of the sites devoting 50% or more of their word count to the stages. Taken together, these results raise the question why there is such continued attention to the model, especially given that there have also been notable criticisms. The popularity of the model may stem from its ability to create order during a time of complexity, resulting in a positive narrative where one prevails over the despair of grief, culminating in the final stage of acceptance. The following quote cited on one of the reviewed websites encapsulates this: ‘Stage theories “impose order on chaos, offer predictability over uncertainty, and optimism over despair”’ (Shermer, 2008, p. 6). However, as the same website goes on to conclude, the appeal of the stages model in creating a narrative of hope is not equivalent to scientific importance: “Stages are stories that may be true for the storyteller, but that does not make them valid for the narrative known as science” (p. 9).

While our results showed that the five stages were mentioned frequently, closer examination of the data suggests differences in the portrayal of the stages between the included domain extensions. In particular, Dutch domain extensions appeared to refer to the model less frequently than the other domain extensions. This finding suggests that different countries may regard the model differently. The reasons behind these apparent differences are unclear, but one could speculate that a multitude of cultural and structural factors could play a role such as: underlying societal beliefs about death and dying, quality and quantity of educational programs providing information about issues surrounding grief, and ease of information accessibility, for example, to alternative models of grief.

Our second research question pertained to how the model was evaluated; what warnings, limitations and criticisms concerning the model were provided on the sites? Our exploration indicated that the most frequent types of warnings were those cautioning against the rigidity of the model, particularly nearly 60 percent of sites included warnings that the stages are non-linear and a half of the sites cautioned that not all five stages have to be experienced. This type of evaluation is also consistent with Corr (2018, 2019a) analyses, which established that non-linearity and not having to experience all stages were the most commonly mentioned critiques in his sample of textbooks. However, close examination of these types of warnings showed that they often lack a critical stance, endorsing the existence of the model by giving the message that one will/should experience the stages, just not in a rigid manner with the five stages following on in a strict order. Moreover, as critics have pointed out, the word “stages” itself implies rigidity, such that warning against rigidity actually presents a confusing message. This is one of the model’s most contentious features, with proponents using non-linearity to underline the model’s broad interpretation possibilities and therefore wider application, while opponents have argued that it disqualifies the model. Friedman (2009) made the latter point on one of the websites in our sample:

We [have] compared the stages of a butterfly to the alleged stages of grief, to show the problem with any stage theories of grief. To wit: Stages in order to be called stages must go through an orderly progression, each and every time. Starting as an egg, a potential butterfly must go through the four stages Egg, Caterpillar (Larva), Pupa (Chrysalis) Adult (Imago). It cannot elect to skip the larval stage and jump right over to the pupal stage.

Elisabeth Kübler-Ross herself constantly stated that the stages didn’t all happen and not necessarily in order, if at all. We just can’t find a way to use the idea of stages which really are absolute—see Butterfly reference—for something as variegated as human grief (p. 11).

In addition to warnings of rigidity, our analysis established that a number of warnings of existence, limitations and criticisms of the five stages model were sometimes included on some of the websites, albeit very infrequently (the mean score for criticalness was 1.9 out of a possible total score of twelve points). The fact that a large portion of websites lacked any critical appraisal highlights concerns about the representation of the model, particularly with regard to the lack of evidence and the potential for harm. These concerns should give one pause for reflection about the use of the five stages model as a contemporary guideline for bereaved.

Our final research question explored how the model was endorsed; how positively was it presented on the websites? Our analysis uncovered a number of different types of endorsements, which was defined in our study as statements showing support or approval of the five stages model. The most frequent endorsements were definitive statements (statements of unconditional approval) regarding the existence of the stages. As our results showed, the concerns we mentioned above were again confirmed. The high frequency of definitive statements about the stages’ existence is of considerable significance, since it suggests that the stages are an actuality; wrong conclusions about the validity of the five stages can easily be drawn by those accessing certain websites. The concern that this can have potentially harmful consequences for bereaved persons remains. The definitive endorsement of many sites on the internet can easily be interpreted as conveying the message that those who do not experience the stages are grieving incorrectly. As indicated earlier, advertising these stages as a certainty for bereaved people is unfounded. The implications of uncritical acceptance of the five stages model should not be underestimated; as one of the authors of our sampled websites cautions:

As we have pointed out in past articles, Kübler-Ross defined these “phases” as those experienced by a person dealing with the diagnosis of a terminal illness, and not as stages faced by someone who has faced a significant emotional loss. This misconception of their intended purpose has frustrated many grievers who felt that failure to progress through them could leave them forever in misery (Moeller, 2017, p. 6).

Furthermore, a definitive portrayal of the model can result in ineffectual support from loved ones or healthcare professionals. Insights from research on social and group norms have shown that violation of norms can lead to negative emotional reactions like anger or blame (Ohbuchi et al., 2004; Stamkou et al., 2019) as well as forms of social sanctions and punishment (Fehr and Fischbacher, 2004; Falk et al., 2005; Peters et al., 2017). A loved one or healthcare professional may, therefore, react in a negative way if they feel that the bereaved individual is violating the norm by not going through the stages. These reactions could result in bereaved people feeling alienated, an implication that is particularly worrying given that various studies have demonstrated the protective effect of social support in preventing negative effects in bereaved individuals (e.g., Hibberd et al., 2010; Çakar, 2020; Chen, 2020). Bereaved people themselves may also feel that there is something wrong with them for not grieving in line with the norm and may seek therapy to help move through the stages and grieve in the “correct” way. These endeavors may be unnecessary, especially considering that psychological interventions appear to be hardly or not effective for the bereaved population for whom there is no other indication (yet) than that they have lost a significant person (Schut et al., 2001; Wittouck et al., 2011). To put it concisely, presenting the five stages model in an uncritical and definitive light could lead to the belief that those who do not experience the stages are abnormal, a misconception which has important implications and potential harmful consequences for bereaved individuals.

In general, results showed low criticality with sites which often included definitive statements of endorsement neglecting such warnings. Our conclusion is that the model is not being accurately portrayed to bereaved people, with the dangers of using it as a contemporary guideline largely being ignored.

Limitations of This Analysis

Limitations of this analysis need to be addressed. First, we noted the gap in time between the selection and analyses of the websites. While the majority of the sites were still operational when the data were analyzed (and, therefore, still relevant and accessible to the public as currently as 2020), an updated analysis could give insight into recent trends concerning the portrayal of the five stages model. This would be especially interesting in light of the recent corona pandemic. Many noteworthy questions have arisen regarding how the portrayal of grief has changed as a result of COVID-19, including ones about the application of theoretical approaches (cf., Stroebe and Schut, 2020). An analysis of information on grief-related websites subsequent to the current pandemic would add further insights into how understandings of grief have changed following COVID-19. For example, one relevant question in the context of our study is whether the sites have continued to advocate the five stages model under these changed circumstances.

Another limitation relates to the restriction to English and Dutch language websites. While this analysis ensured that both developing countries and non-English sites were represented, one avenue for future research could be to include more country-specific domain extensions, in order to achieve further representation of different cultures and languages and establish the influence of the five stages model in other parts of the world.

Additionally, an important limitation of this study has to do with the review process itself. Analysis of written text can lend itself to subjective interpretation (Given, 2008, p. 120–122). Certain warnings, limitations, critiques and endorsements were, for example, worded more implicitly than others, making them open to interpretation. An example of this is seen in the following text taken from one of our websites: “You may go back and forth between them or skip one or more stages altogether” (What is normal grieving WebMD, n.d., p. 4). While the text is not explicitly stating that the stages are non-linear, the phrase “back and forth” could be interpreted as implicitly implying non-linearity. An analysis of the researchers’ thought processes behind the determination of the different criticisms and endorsements revealed that while there was often agreement concerning the presence of a criticism or endorsement on a website (interrater agreement was nearly 96 percent), there was occasional disagreement about the exact statement representing these criticisms and endorsements. One possible explanation for this is that websites may possess multiple phrasing of the same premise, resulting in certain statements resonating with a particular individual more than others, but culminating in overall agreement of the message of the website. However, such differences occurred with too little frequency for the patterns of results to be affected.

Finally, two additional avenues for future research should be considered. Firstly, while the use of quantitative data was deemed appropriate for this study, future studies incorporating qualitative data may add additional insights (e.g., qualitative research may be better-able to establish whether the overall thrust of the five stages presentation in the website is endorsing, while only “lip service” is paid to criticisms). Furthermore, future research could play an important role in further validating the scoring system used in this study in the context of both digital and non-digital informational resources.