Kübler-Ross model

The Kübler-Ross model, commonly referred to as the "five stages of grief", is a hypothesis introduced by Elisabeth Kübler-Ross asserting that when a person (or a survivor) is faced with the reality of impending death or other extreme, awful fate, he/she will experience a series of emotional "stages": denial; anger; bargaining; depression; and, acceptance (in no specific sequence). This hypothesis was introduced in Kübler-Ross' 1969 book On Death and Dying, which was inspired by her work with terminally ill patients. Motivated by the lack of curriculum in medical schools, at the time, addressing the subject of death and dying, Kübler-Ross started a project about death when she became an instructor at the University of Chicago's medical school. This evolved into a series of seminars; those interviews, along with her previous research, led to her book. Her work revolutionized how the U.S. medical field took care of the terminally ill. In the decades since her book's publication, Kübler-Ross' concept has become largely accepted by the general public; however, its validity has yet to be consistently supported by the majority of research studies that have examined it.

Kübler-Ross noted that these stages are not meant to be a complete list of all possible emotions that could be felt, and, they can occur in any order. Her hypothesis holds that not everyone who experiences a life-threatening/-altering event feels all five of the responses, as reactions to personal losses of any kind are as unique as the person experiencing them.

Stages

The stages, popularly known by the acronym DABDA, include:

1. Denial — "I feel fine."; "This can't be happening, not to me."
   Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of possessions and individuals that will be left behind after death. Denial can be conscious or unconscious refusal to accept facts, information, or the reality of the situation. Denial is a defense mechanism and some people can become locked in this stage.
2. Anger — "Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?"
   Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Anger can manifest itself in different ways. People can be angry with themselves, or with others, and especially those who are close to them. It is important to remain detached and nonjudgmental when dealing with a person experiencing anger from grief.
3. Bargaining — "I'll do anything for a few more years."; "I will give my life savings if..."
   The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if I could just do something to buy more time..." People facing less serious trauma can bargain or seek to negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it's a matter of life or death.
4. Depression — "I'm so sad, why bother with anything?"; "I'm going to die soon so what's the point?"; "I miss my loved one, why go on?"
   During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed. Depression could be referred to as the dress rehearsal for the 'aftermath'. It is a kind of acceptance with emotional attachment. It's natural to feel sadness, regret, fear, and uncertainty when going through this stage. Feeling those emotions shows that the person has begun to accept the situation.
5. Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."
   In this last stage, individuals begin to come to terms with their mortality, or that of a loved one, or other tragic event. This stage varies according to the person's situation. People dying can enter this stage a long time before the people they leave behind, who must pass through their own individual stages of dealing with the grief.

Kübler-Ross originally applied these stages to people suffering from terminal illness. She later expanded this theoretical model to apply to any form of catastrophic personal loss (job, income, freedom). Such losses may also include significant life events such as the death of a loved one, major rejection, end of a relationship or divorce, drug addiction, incarceration, the onset of a disease or chronic illness, an infertility diagnosis, as well many tragedies and disasters.

As stated before, the Kübler-Ross Model can be used for multiple situations where people are experiencing a significant loss. The subsections below explain how the model is applied differently in a few specific situations. These are just some of the many examples that Kübler-Ross wanted her model to be used for.

Children grieving in divorce

Denial – Children feel the need to believe that their parents will get back together or they will change their mind about the divorce. Example: “Mom or Dad will change their mind”

Anger – Children feel the need to blame someone for their sadness and loss. Example: “I hate Mom for leaving us”

Bargaining - In this stage, children feel as if they have some say in the situation if they bring a bargain to the table. This helps them keep focused on the positive that the situation might change and less focused on the negative, the sadness they’ll experience after the divorce. Example: “If I do all of my chores maybe Mom won’t leave Dad”

Depression - This involves the child experiencing sadness when they know there is nothing else to be done and they realize they cannot stop the divorce. The parents need to let the child experience this process of grieving because if they do not it will only show their inability to cope with the situation. Example: “I’m sorry that I cannot fix this situation for you.”

Acceptance – This does not necessarily mean that the child will be completely happy again. The acceptance is just moving past the depression and starting to accept the divorce. The sooner the parents start to move on from the situation the sooner the kids can begin to accept the reality of it.

Grieving a break-up

Denial – The person getting broken up with is unable to admit that the relationship is really over. They may try to continue to call the person when that person wants to be left alone.

Anger – When the reality sets in that the relationship is over, it is common to demand to know why they are being broken up with. This phase can make them feel like they are being treated unfairly and it may cause them to become angry at people close to them who want to help aid the situation.

Bargaining – After the anger stage, one will try to plead with their former partner by promising that whatever caused the breakup will never happen again. Example: “I can change. Please give me a chance”.

Depression – Next the person might feel discouraged that their bargaining plea did not convince their former partner to change their mind. This will send the person into the depression stage and can cause a lack of sleep, eating and even disrupt daily life tasks such as bowel movements.

Acceptance – Moving on from the situation and person is the last stage. The person accepts that the relationship is over and begins to move forward with their life. The person might not be completely over the situation but they are done going back and forth to the point where they can accept the reality of the situation.

Grieving in substance abuse

Denial – People feel that they do not have a problem concerning alcohol or substances. Even if they do feel as if they might have a small problem they believe that they have complete control over the situation and can stop drinking or doing drugs whenever they want. Example: “I don’t have to drink all of the time. I can stop whenever I want.”

Anger – The anger stage of abusers relates to how they get upset because they have an addiction or are angry that they can no longer use drugs. Some of these examples include “I don’t want to have this addiction anymore.” “This isn’t fair, I’m too young to have this problem.”

Bargaining – This is the stage that drug and alcohol abusers go through when they are trying to convince themselves or someone else that they are going to stop abusing in order to get something out of it or get themselves out of trouble. Example: “God, I promise I’ll never use again if you just get me out of trouble.”

Depression – Sadness and hopelessness are important parts of the depression stage when dealing with a drug abuser. Most abusers experience this when they are going through the withdrawal stage quitting their addiction. It is important to communicate these feelings as a process of the healing.

Acceptance – With substance abusers admitting you have a problem is different than accepting you have a problem. When you admit you have a problem this is more likely to occur in the bargaining stage. Accepting that you have a problem is when you realise that you have a problem and start the process to resolve the issue.

As stated above, according to her hypothesis, Kübler-Ross claimed these stages do not necessarily come in order, nor are all stages experienced by all patients. She stated, however, that a person will always experience at least two of the stages. Often, people will experience several stages in a "roller coaster" effect—switching between two or more stages, returning to one or more several times before working through it. Women are more likely than men to experience all five stages.

However, the Kübler-Ross hypothesis holds that there are individuals who struggle with death until the end. Some psychologists believe that the harder a person fights death, the more likely they will be to stay in the denial stage. If this is the case, it is possible the ill person will have more difficulty dying in a dignified way. Other psychologists state that not confronting death until the end is adaptive for some people.

Cultural relevance

A dying individual's approach to death has been linked to the amount of meaning and purpose a person has found throughout his lifetime. A study of 160 people with less than three months to live showed that those who felt they understood their purpose in life or found special meaning, faced less fear and despair in the final weeks of their lives than those who had not. In this and similar studies, spirituality helped dying individuals deal with the depression stage more aggressively than those who were not spiritual.

Pedagogical relevance

Studies of pedagogy, the process of teaching, suggest that the patterns of grief are one way of describing the basic patterns of integrating new information that conflicts with previous beliefs. Also, see Learning theory (education)

"All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." said Arthur Schopenhauer of the learning process, which corresponds to the five stages of grief with ridicule being denial, opposition being anger and bargaining, and acceptance being depression and acceptance.

There is also a hypothesis which suggests that this learning process is the same pattern seen in the back-and-forth looping movement of a particle being disturbed by a wave. Emotional intensity moves up and down and up again, while knowledge moves backward, forward, back, and then forward again, until the individual is happy with the way they have integrated the new information with the old.

Criticism

The extensive scientific studies of George Bonanno argue that the Kübler-Ross stages of grief do not exist. Bonanno's research shows that most people who experience a loss do not grieve, but are resilient. If there is no grief, there can be no stages of grief. In Bonanno's book, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss, he summarizes his rigorously peer-reviewed research based on thousands of subjects and conducted over more than two decades. His findings conclude that a natural resilience is the main component of grief and trauma reactions. The logic is that if there is no grief, there are no stages to pass through. Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome, rather than something to be feared as has been the thought and practice until his research.

A 2000–2003 study of bereaved individuals conducted by Yale University obtained some findings that were consistent with the five-stage hypothesis and others that were inconsistent with it. Several letters were also published in the same journal criticizing this research and arguing against the stage idea. Skeptic Magazine published the findings of the Grief Recovery Institute, which contested the concept of stages of grief as they relate to people who are dealing with the deaths of people important to them. The research methods have been questioned. There are limitations because she only used personal interviews. The interviews should have been followed by different forms of data gathering. A suggestion for other methods would be behavioral studies or personal diaries kept by terminal patients.

The hypothesis tends to prescribe instead of describe grief. Because the hypothesis is so well known, people tend to rush, or get pressured, through the stages, instead of letting them happen naturally. There is some kind of “imaginary” schedule connected to the stages.

A person might be overlooked if family members are going through the stages on a "schedule". The person might be forgotten if the people around him/her are focused on how they themselves are supposed to be feeling and ignoring indications from others.

Kübler-Ross did not take the personal environment into consideration. If patients are surrounded by positive experiences, they will experience things differently than if they were surrounded by negatives.

Grief communication

Grief communication occurs in grief-stricken people, through their emotions, actions, and words. Kubler-Ross placed much emphasis on communication. When a person is approaching death and is going through the five stages of her model she believed that person wanted to review his or her life, the illness he or she has, and his or her imminent death. When a patient and physician could discuss this courageously and candidly a good death would be possible. This model and her thoughts are influential to health care providers; it provides guidance to approaching and interacting with people experiencing grief.

Additional theoretical models

Charles A Corr: a social psychologist and recent researcher who wants to help caregivers, researchers, and educators move beyond limitations of the stage theory. He stresses:

• Individual coping strategies: His model, "must encompass the fact that people may try out certain coping strategies only to reject them." In addition, a person may pursue several strategies at the same time even if they are not compatible. People differ in tasks and needs that are important to them as well as in their method of coping. Most importantly, Corr stresses that the model must respect individuality.
• Patient empowerment: Corr discusses the importance of greater empowerment for those who are dying and for those who are involved with caregiving of the terminally ill. In order to do this, people need to recognize that a dying person continues to be a living person to cope with the stresses of the illness.
• Practical guidelines for caregivers: For the caregiver to improve how they deal with the problems, stresses, and issues of the dying person.^{[citation needed]}

Debbie Messer Zlatin:

• She took focus away from how the observer deals with dying process and tried to learn how the dying person interprets his/her own reality.
• Exploratory study: she interviewed terminally ill people by asking them to relate the story of their illness. In this study she found that people had a variety of different "life themes".
• Life themes: An example would be one woman who characterized herself as a "crusader" who told the truth and stood up against pressures. She was able to keep her life integrated despite her terminal illness because of her sense of who she was and what her life meant.
• Importance of integration of themes: As a result of the studies conducted by Zlatin it was found that there is an important difference between people who do and do not have integrated life themes. It was also found that certain types of life themes are more important than others. If the caregiver can be informed of the dying person's life themes, then they could be more useful in understanding and helping the terminally ill person.^{[citation needed]}

William McDougall: researcher, founder of field of social psychology. He kept a journal of his own terminal illness, and provided an intellectual approach.

• He dealt with his need to avoid increasing pain and his need to remain alert and mentally fit. As a result, the last few weeks of his life dealt with this confrontation.
• He found when his intellect was the most inspired was when his pain was most intense. Therefore, he did not feel like he was defeated.
• McDougall did not concentrate on emotions, nor did he attempt to create a list of developmental tasks. Rather, he attempted to utilize his skills and knowledge to integrate his death and dying into his view of himself and his world.
• This approach stresses personal uniqueness because it is individual-centered.

Further reading

• Kübler-Ross, E. (1969) On Death and Dying, Routledge, ISBN 0-415-04015-9
• Kübler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss, Simon & Schuster Ltd, ISBN 0-7432-6344-8
• Scire, P. (2007). "Applying Grief Stages to Organizational Change"
• An Attributional Analysis of Kübler-Ross' Model of Dying, Mark R Brent. Harvard University, 1981.
• An Evaluation of the Relevance of the Kübler-Ross Model to the Post-injury Responses of Competitive Athletes, Johannes Hendrikus Van der Poel, University of the Free State. Published by s.n., 2000.

External links

• Elisabeth Kübler-Ross Homepage
• Elisabeth Kübler-Ross - Five Stages of Grief
• On Death and Dying - Interview with Elizabeth Kübler-Ross M.D.
• Beware the Five Stages of Grief - TLC Group Editorial
• "Good News About Grief" - A different take on whether or not there are 5 stages. 1/24/11 by Ruth Davis Koningsberg