In 1969, Dr Elisabeth Kubler-Ross published a book entitled 'On Death and Dying' which outlined what are now familiarly known as the 5 stages of grief. These are:
Denial
Anger
Bargaining
Depression
Acceptance
Most commonly, these are seen as reactions to death and can guide you through the journey of grief. It's non-linear, meaning you don't have to go through these stages in the specific order, it's cyclical, meaning you can move around the stages and move back and forth, and it's asymetrical, meaning that you won't necessarily spend the same amount of time in each stage. You also might not experience any of these- it's suggested, not compulsary. As an example- you could spend years in denial, which leads onto depression, but then also generates a short burst of anger, before you go back to being in denial. Each individual will likely move through a semblance of these stages before coming to the big boss- acceptance. This could take days, weeks, months or years.
What you do in each of these stages will also be entrirely personalised- for some denial may be shutting down and dissociating from the situation- for others, it may be creating constant movement and busy-ness (University of Washington, 2020). Either way, you're trying to tell yourself that you're fine when you're really not.
Kubler-Ross argued, and I fully agree, that this model can be applied to any situation- not just the 'classical' bereavement grief. From a bereavement, to leaving a job, to graduating university, from dropping a piece of toast jam side down... the possibilities are endless. Obviously, the depth and breadth of the situation will determine what kind of responses you have. If dropping a piece of toast triggers months of depression, you maybe should seek some help with that. But having said that- nobody can dictate to you how you cope in a certain situation, and your reaction to any situation is most likely valid. Nobody, except you, can fully acknolwdge how your past experiences and traumas and coping styles feed into your stages of grief.
DENIAL (more than just a river in Egypt - sorry...)
A feeling of emotional numbness, or blunting, is the most common response in this stage. Shutting off emotions can help to dissociate from the situation and 'pretend' like nothing has happened. Although this can appear like an incredibly unhelpful stage and a massive barrier to 'moving on', it can act as a vital coping mechanism after the initial shock and can give you some time and space after the event. I personally see this as one of the most important stages- being faced with unprocessed trauma if you are not in a place (mentally, physically, spiritually, emotionally, financially, socially) where you can process that trauma will just end up traumatising you more. Denial is your brain's way of not biting off more than you can chew until you're ready to start feeling things.
ANGER
Anger in itself, in any setting, tends to be more of a taboo emotion- particularly for women. And lots of people feel inceredibly uncomfortable with anger, both in terms of sitting with it and internalising, or expressing it and externalising. The expression of the anger is an incredibly healthy thing, and potentially cathartic- as long as the anger is expressed in a healthy way (think- going for a run, screaming into a pillow, writing it down and then burning it). And in contrast to denial when you might be feeling not much, anger can leave you feeling a lot.
This anger may be directed in many different directions- at the situation, the world, yourself, other people, the person who's died. If you find yourself as the recipient of this anger, remind yourself that the fuel for this fire isn't actually anger; it's usually pain.
BARGAINING
Again, this can be directed in many different directions- making deals with yourself, a higher power, other people- with the ultimate goal of self-soothing the feelings of grief. Unfortunately, no matter how much you try, the devil doesn't bargain and this ultimately won't make you feel any better or undo the situation (even if you ask really nicely). This stage might also include a lot of 'what if...' questions and remeniscing about the past to identify things yourself or others could have done differently that might have prevented or changed the situation.
DEPRESSION
This is seen as a persistent sadness, often associated with feelings of emptiness and is probably the most 'expected' and 'socially acceptable' response to a difficult life situation (which makes it no less easier to deal with, but you may take some comfort in knowing that you won't be the only one feeling this way, and that this is 'normal').
n.b 'normal' goes in inverted commas, because normal literally doesn't exist as a universal concept.
Feeling down, sad, blue etc etc is 'normal', however, if experiencing (or someone else expresses to you) thoughts that life is not worth living or you'd be better off dead- this is suicidal ideation and is the first step in a suicidal crisis. Establish the extent of the crisis (eg are there any suidical plans or behaviours), follow the principles of Mental Health First Aid and escalate to emergency services/healthcare professionals as appropriate- I have provided some resources at the end of this post.
ACCEPTANCE
Acceptance does not translate to the absence of grief. It often means that the grief has become manageable in a day-to-day situation, but may still become triggered at times when you suddenly remember something (like being triggered by a sound, smell or sight) or in times of hightened stress. Some people use the 'ball in the box' analogy to show how grief can change over time (Herschel, 2017), or consider people to 'grow around their grief' to represent not the grief getting smaller, but you getting bigger (Cruse, n.d). In acceptance, you don't have to feel okay or to have moved on- just come to terms with the trauma enough that you have space in your life for other things.
You can click the link above to see someone explain the ball in the box more eloquently that I ever could- or you can keep reading and watch me try.
In this example, the box is your life, the ball is your trauma, and the button within the box is a reaction to that trauma (which could really look like anything- crying, withdrawal, frustration, confusion etc.). Because the box is your life, the size of the box is fixed and doesn't change. What does change, is the size of the ball. When the ball is big, you're going to be hitting the button nearly constantly- and that is painful, hard, exhausting. Over time and with processing and support, you can get the ball to shrink. The ball hits the button less frequently, and there's more space in the box to be filled up with things that bring you joy. It doesn't necessarily mean that the button will be any less painful when it does get hit, but it's not such a constant onslaught of emotion. And in a counter-intuitive way, it can make it feel worse when the ball does hit the button because you're just not expecting it- you don't get a second to prepare and the grief smacks you round the face and knocks the wind out of you. Some people might get the ball to disappear at some point. Others will just live with a really little ball that bounces round a big box and occassionally hits the button. You'll still have bad and painful days- but hopefully more good days than bad.
(Adapted from Herschel, 2017)
In my personal life, I try and track where I am in these stages of grief with various situations that I know impact on my life- often in a negative way.
After I lost a friend to suicide, I felt myself tangibly shift between each stage and relatively quickly (within 6 months) reached a stage of acceptance. As soon as other triggers came into play and life got tough in other ways, I slipped right back down that ladder. I now see myself move between stages on an almost daily basis, and in a therapy session if we're discussing it, can swing through all 5 in 90 minutes- it's whiplash inducing. The presence of trauma responses and symptoms in this situation have made it that much harder to get back to acceptance of the situation- but I'm working on it- and I can now recognise that I can have acceptance over the situation and be sad about it. They are not mutually exclusive.
After leaving nursing, I had to adapt to a life without something that I had envisaged being a part of my life forever. I think my predominant feelings about this now are are anger and bargaining, but often I find myself in denial about the situation and that for me can look like toxic positivoty and toxic hope - "I'm 100% going to return to nursing someday, this is just a blip, I just need to give it a year or so". These statements could be true, but I have to work really hard at not pinning my entire future on these and try to recognise the flexibility of the future matched up with what I do with my time whilst I'm not in nursing.
One of the hardest concepts in grief is that nobody can tell you how to do it. They can tell you what worked for them, they can stick you on antidepressants and in therapy and in send you self-help books, and you still might just have to figure it out for yourself. At times I feel like screaming at my therapist to just tell me the answer because the ball is hitting my button and it hurts- but I do also recognise that she doesn't necessarily know the answer, and she can't fix the problem. The ideal fix would be to undo the trauma and take it back to a time where there was no ball and no button- but that's not possible.
What has helped for me is talking. Whether that be in therapy, or on social media, with friends, or in groups (my uni have set up a bereavement support group which I've been attending and it's lovely having a safe space to talk about grief).
As promised- general resources:
Bereavement-
Cruse - 0808 808 1677
Survivors of Bereavement by Suicide (UKSOBS) - 0300 111 5065
Blue Cross (pet bereavement) - 0800 096 6606
Mental health-
Samaritans - 116 123
MIND - 0300 123 3393 (link is to bereavement info)
Shout (text) - 85258
Emergency care-
GP
NHS 111 (UK)
999 (UK)
I was recently contacted by a staff member working at The Recovery Village, a US based mental health organisation that works primarily with addiction. They have directed me to a number of their incredibly helpful resources about addiction, substance use and grief and these pages really help to explain the intersections between these factors that can complicate dealing with any of these issues. The link to their resource is here: https://www.therecoveryvillage.com/mental-health/grief/substance-abuse/ and they can be contacted with any more specific questions relating to substance use and grief, which is not an area I am any sort of expert in.
If there's any questions about any of this, please drop me a message either on this post, on Instagram or Twitter (@christienursing). Please note I am not a medical professional, nor do I proclaim to be an expert in grief, but if I can help in any way, I'm more than happy to.
Christie x
References and resources:
Cruse (n.d) 'Understanding the five stages of grief'. Available at: https://www.cruse.org.uk/understanding-grief/effects-of-grief/five-stages-of-grief/ (Accessed 10.10.2022)
Herschel, L. (2017) 'Ball in the box' [Twitter] 29 December 2017. Available at: https://twitter.com/laurenherschel/status/946888282444460033?lang=en
Kubler-Ross, E. (1969) 'On Death and Dying' . New York: Scribner
University of Washington (2020) 'The stages of grief: accepting the unacceptable'. Available at: https://www.washington.edu/counseling/2020/06/08/the-stages-of-grief-accepting-the-unacceptable/#:~:text=Persistent%2C%20traumatic%20grief%20can%20cause,adapt%20to%20a%20new%20reality. (accessed 05.10.2022)
The Recovery Village (2022) 'Grief and substance abuse'. Available at: https://www.therecoveryvillage.com/mental-health/grief/substance-abuse/ (accessed 11.11.2022)