Dr. Elisabeth Kübler-Ross published her
seminal work
On Death and Dying in
1969. Prior to this
mental health professionals had done some work in the area of
death and
dying but generally left the area to the expertise of
clergy who could offer comfort that other professionals could not. The book became popular in both mental health circles and in the general public. What made the book interesting to a lay audience were the five stages of facing death, which Kübler-Ross culled together from her discussions with
terminally ill patients.
Kübler-Ross received her medical degree from the University of Zurich in 1957, before she immigrated to the United States. She was teaching at the University of Chicago in the sixties when a colleague – Dr. Sydney Margolin - suggested death and dying as a research topic. In order to study and teach at the same time, she offered a seminar course on death and dying at the university in which she invited terminally ill patients at the University of Chicago hospitals to attend and discuss their thoughts and feelings in front of the mixture of medical, psychology, sociology and theology students. The results of the class she then published in On Death and Dying (Rosen).
The timing of Dr. Kübler-Ross’ study was an ideal one. In the mid-part of the twentieth century in the United States, there was a growing geriatric population. This was as a result of advances in both medical care and job automation, which greatly reduced the number of young and sudden deaths. This growing population was dying slowly and suffered from reduced physical ability, which left them time to think about what was coming eventually. The elderly had to be taught to deal with slow death, and the slow loss of ability, because, “If "[man’s"] ability to defend himself physically is getting smaller and smaller, his psychological defenses have to increase manifoldly. (Kübler-Ross 11)”
However, Dr. Kübler-Ross’ stages of death have universal applicability because she and her students did not limit themselves to the elderly. In fact some of the most (for lack of a better word) interesting cases in the book are middle age and younger patients who find they are facing a terminal illness.
The first thing to understand before trying to offer therapy to a dying patient it is important to remember that death is not a natural thing for a human being. While, death itself is a natural process, man coming to grips with death is not. Unconsciously man cannot imagine himself dead. If he thinks of himself as dead it is not a result of anything natural, normal or to be expected, it is always though some sort of outside attrition that strikes him down.
As a result of this inability to conceptualize death, the dying go through a process of coming to grips with what is before them. It is seen in five steps:
- denial and isolation
- anger
- bargaining
- depression
- acceptance
The First Stage: Denial
The first stage of coming to terms with death is denial. Almost every patient has some form of denial at any given stage of this progression to self-actualization. Typically, the patients who show the most marked signs of denial are those people who are told about the terminal nature of their disease by a physician or medical worker with whom they are not acquainted with. This is logical, because it is much easier to question the veracity of information from an unknown source. In addition, denial is more common in patients who are told of the nature of their disease without consideration for their ability to handle the information.
Typically, the best time to give news of this sort is when a patient has family members or other members support network present. In addition, some hospitals with religious affiliation will also have clergy available to help counsel those patients with strong religious beliefs.
It is also noteworthy that those with strong religious beliefs or background use denial as much as those without any formal training in religion. This Kübler-Ross points out is because religion cannot be the panacea for dealing with death. Fundamentally, each individual much shoulder at least some grief on their own, and once that happens the burden can be too much. As a result denial appears, because it “functions as a buffer after shocking news” and helps with the burden, because, “Who was it who said, ‘We cannot look at the sun all the time, we cannot face death all the time (Kübler-Ross 35).’”
For those patients who have a particular attachment for denial, there is a common response which Kübler-Ross calls “physician shopping”. This entails a patient who keeps going to different doctors seeking someone who reads the x-ray the right way. Patients who do this often keep in contact with one physician even as they shop around, because unconsciously it seems, the bad news has taken effect.
Most patients who are in denial will eventually want to talk about death. In fact once they are ready, they find great comfort in going into detail about how they think it will happen or what they would like their funeral to be like. However, usually before that point the other four stages need to be dealt with.
Finally, before moving onto the next stage, it should be noted that there is the rare case that stays in denial until the end. She found this in a patient who found out in her mid-forties that she had inoperable cancer. The woman was a single mother who had two young boys. As her answer to the question below indicates she is staying in denial because she feels that she needs to remain strong for her children.
DOCTOR: I’d be curious how you took this, when it was told to you that you had a malignancy. How did you take it after postponing, postponing to hear the truth?
PATIENT: When I first heard I went all to pieces.
DOCTOR: How?
PATIENT: Emotionally.
DOCTOR: Depressed, crying?
PATIENT: Ah ha. I always thought that I couldn’t have anything like that. Then when I realized how serious it was I thought it’s something I have to accept, going all to pieces will solve nothing (Kübler-Ross 164).
While,
Dr. Kübler-Ross feels that progression through the various stages is better than not going through them, it is all right if the patient chooses not to move forward at all. In the end, it is up to the patient to decide how to
cope, not their
psychologist or
clergyman.
The Second Stage: Anger
The second stage, anger, is often the most difficult on the family, and if the patient is in the hospital, on the nursing staff. The anger, which manifests itself, is the byproduct of the understanding that death is in fact near that comes with the end of denial and often the patient’s inability to do things for themselves.
This newfound anger is generally spread around randomly to anyone who which the patient comes into contact. This means those who are trying to help out. Nurses complain of patients in this stage because no matter what they do, it is always wrong. If the patient wants to be left alone and they are, they will complain of abandonment when the nurse comes around the next time. If the patient is too warm and the air conditioning is turned on, then he will complain shortly thereafter that he too cold.
To those looking at this from the other side, this behavior can seem petty and mean. However, if the family and the nursing staff put themselves in the position of that patient, these kinds of behaviors can be understood.
If a person is an active their entire life, and then is immobilized while they wait death, it is logical that they try to direct those who take care of him. He lives vicariously through them, trying to hold some control when he is the position to physically have none. Dr. Kübler-Ross writes of a nun whom she encountered in the hospital who could get around but still projected her anger by directing others:
Sister I. was an angry, demanding patient who was resented by many within and outside the hospital because of her behavior…She made it a habit while hospitalized to go from room to room, visiting especially sick patients and eliciting their needs. She would then stand in front of the nurses’ desk and demand attention for these patients, which the nurses resented as interference and inappropriate behavior (Kübler-Ross 50).
In the case of Sister I, she was very sick herself and was angry by the way her illness (
cancer) slowed her down, but would not act out in a way that typically would fit a person in the second stage (complain about her own predicament). Rather she chose to channel her anger on behalf of the
slights she thought the other patients were receiving at the hands of the nurses. In response, Dr. Kübler-Ross and the hospital
chaplain sat down with Sister I. and discussed her own predicament. At first she did not want to speak of herself, and was full of
rage, however, over time they were able to get her to talk about how she was feeling. After the three of them had spent some time together and she was able to talk about herself she no longer harassed the nurses.
Dr. Kübler-Ross suggests giving patients who are in the anger stage exactly what she and the chaplain gave Sister I.: as much time as needed. If a patient is permitted his anger for the moment, it will often defuse itself.
The Third Stage: Bargaining
The third stage is a variation on anger. As Kübler-Ross herself puts it, “If God has decided to take us from this Earth and he did not respond to my angry pleas, he may be more favorable if I ask nicely (Kübler-Ross 72).” She goes on to say that this is behavior familiar to any parent. When a child asks to do something and parents refuses, the child might for a while act out angrily and walk off. However, before too long the child will be back to see if they can change the ruling with a different approach.
Typically a patient in this stage simply wants a reprieve from death or simply to feel normal again for a while. During this stage those activities that a patient enjoyed are prized. For example, if a patient was a golfer, he might wish for one more round, or if a mother wanted to see her son’s wedding, she bargains for just a little more time.
In those cases where one of these activities can be accomplished there is often a hollowness that follows as the end of life is still always there. The example of the mother who wanted to see the wedding, Dr. Kübler-Ross provided from her own experience. The mother was a patient whose disease required she be hospitalized because of her reliance of pain medication.
With combined efforts, we were able to teach her self-hypnosis which enabled her to be quite comfortable for several hours. She had made all sorts of promises if she could only live long enough to attend this marriage. The day preceding the wedding she left the hospital as an elegant lady… I will never forget the moment when she returned to the hospital. She looked tired and somewhat exhausted and – before I could say hello – said, “Now don’t forget I have another son (Kübler-Ross 73)!”
The Fourth Stage: Depression
After the denial, and the hopefulness found in anger or bargaining the patient finally cannot continue on for one or more of several reasons. Typically, the patient will become depressed after the illness gets worse and he cannot go on as he rejecting his illness as he did before. At this point depression sets in because the patient begins to mourn the losses he already sees in himself.
The other main cause for depression at this point if a patient’s health is still holding out, tends to be financial. With the high cost of hospitalization and long-term treatment, eventually, everyone no matter how rich is impacted. Finances hit home with dying people not in numeric terms but in unexpected changes in dreams. A patient may have to sell the home he had cherished for years, or force his wife to work full time. In addition, the loss of a job and it’s related identity as the illness gets worse can cause a crisis.
Dr. Kübler-Ross separates these two different depressions into two different types: “reactive depression” and “preparatory depression” (Kübler-Ross 76). The depression associated with the loss of self she labels reactive. It is the depression a woman faces is she loses a breast to cancer and reacts by feeling less feminine. Meanwhile, the loss of the future, or the preparatory depression, is seen because of lost opportunities.
She suggests therapists take two markedly different tracks while addressing each depression. Addressing what they are reacting to and possibly putting a better spin on things can counteract the “reactive depression”. The example she uses in On Death and Dying is of the woman losing a breast to cancer. The depression she faces is reactionary, and Dr. Kübler-Ross suggests complimenting some other feminine feature she has (Kübler-Ross 77).
Meanwhile, she cautions against using the same technique with preparatory depression, as putting a better spin on things actually prevents a patient from coming to terms with his death. It is only by allowing this depression to be experienced, Dr. Kübler-Ross feels, that a patient can finally come into the last stage of acceptance. In fact she feels that this type of depression often can be counseled with out words.
The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier, and he will be grateful to those who can sit with him during this stage of depression without constantly telling him not to be sad… In preparatory grief there is no or little need for words. It is much more a feeling that can mutually expressed (Kübler-Ross 77).
The Fifth Stage: Acceptance
“Acceptance should not be mistaken for a happy stage. It is almost void of feelings (Kübler-Ross 100).” Dr. Kübler-Ross describes the stage of acceptance as one that is more peaceful. Once the patient has made it through the depression, he is able to have moments of acceptance. However, the patient is not in a fixed position and can revert to a previous stage again.
Dr. Kübler-Ross describes acceptance as a time of sleep for the dying, as well as one of quiet. Often when family members visit, the loved one simply wants to be with them, not necessarily to interact with them. It is with this slowness that death finally catches up to the patient it has been stalking during this process.
In the best of scenarios, the family has been present for all of these stages and can take some kind of hope from it. Dr. Kübler-Ross writes that hope is often ever-present though out these stages, and even if not all the stages can be completed that hope can often be found.
Conclusions
As mentioned in the beginning of the paper, Dr. Kübler-Ross’ influence on the way western society deals with death has been profound. In response to On Death and Dying and other works, a network of hospice centers has sprung up to meet the needs of those at the end of their lives.
The problem however is that all of Kübler-Ross’ work has been though interviewing those who are dying and interpreting their reactions. Many psychiatrists – while appreciating the focus she put on end of life issues – do not agree with her five stages epistemological lens.
Most shockingly, however, is that after experiencing two strokes herself she seems to have changed her mind. In 1997 she told a reporter from the San Francisco Chronicle:
For 15 hours a day, I sit in this same chair, totally dependent on someone else coming in here to make me a cup of tea. It's neither living nor dying. It's stuck in the middle. My only regret is that for 40 years I spoke of a good God who helps people, who knows what you need and how all you have to do is ask for it. Well, that's baloney. I want to tell the world that it's a bunch of bull. Don't believe a word of it (Skeptic).
However after saying this to the reporter she published in 2001 with David Kessler,
Life Lessons: Two Experts on Death and Dying Teach Us About the Mysteries of Life and Living, which was in following with all of her previous work. Needless to say this calls into question the weight that should be given to anything she has published. Perhaps in the end, whether she believes in her own writing is beside the point. Her work has opened the field of grief studies and counseling, where there is ample room to add to what we know of how humans deal with death.
Works Cited
Kübler-Ross, Elisabeth. On Death and Dying. New York: Macmillan Publishing Co., 1969.
Rosa, Emily. "A Deathbed Confession of the Guru of Death and Dying." Skeptic 1997, Vol. 5 Iss. 2.
Rosen, Jonathan. “Elisabeth Kubler-Ross.” The New York Times Magazine 1/22/95