Dr. Kubler Ross Five Stages of Grief

Dr. Elisabeth Kubler-Ross revolutionized the field of therapy. The most famous result of her pioneering work is the concept of the five-stage grief cycle, which she introduced with her book, On Death and Dying, Her theories have had a profound influence on medical care of terminally ill patients. Dr. Kubler-Ross helped to bring attention to the need for supporting dying patients in a distinctly positive manner, emphasizing sensitivity, care, and focusing on the emotional impact of various forms of therapy. By trying to organize a medical system for dealing with grief and mourning, she brought increased awareness to the processes at work in these emotional states. As her work continues to inspire—as well as cause debate—today, it is important to understand just how she reached some of her conclusions, and what precisely those conclusions entail for physicians.

Dr. Kubler-Ross was one of triplet sisters born in Zurich, Switzerland on July 8, 1926. She decided to become a medical doctor early on in her childhood against the wishes of her father.  Her interest in death and dying emerged shortly into her career. She joined the International Voluntary Service for Peace, an organization that helped communities after World War II, and in a Nazi concentration camp called Maidanek, saw that children had carved butterflies into the walls by thousands before heading to the gas chamber. These butterflies signified to Dr. Kubler-Ross the moment of transformation that occurred just before a person’s death.

After writing, On Death and Dying, she became an internationally-renowned author. Shortly after publishing her book, Life Magazine published an article that exposed her and helped her to gain further credibility and awareness to a new way of dealing with patients that were dying.  Dr. Kubler-Ross suggested an entirely new way of dealing with dying patients, and outlined her ideas in a list of five discrete stages: denial, anger, bargaining, depression, and acceptance. Through her research, Kubler-Ross has come to understand that the human psyche imposes certain stages on the journey toward death, and her detailing of each of these stages represented a major breakthrough.

The Five Stages of Grief

The first of Kulber-Ross’s stages, denial, is common to any circumstances humans find to difficult handle. Denial is essentially a psychological defense mechanism people use when the truth is too uncomfortable to accept at the time. A person diagnosed with a terminal disease may insist the diagnosis is wrong, despite overwhelming evidence to the contrary. Some patients might automatically go into a state of shock, or numbness. A patient might say things along the lines of: “It can not be,” “No, not me,” “There must be a mistake.” Dr. Kubler-Ross argued that this reaction actually helps patients control the impact of death on their psychological well-being, and can thus be a necessary step.

The second of Kubler-Ross’s stages is rage and anger. Very often, patients begin to take their anger out on God. They will argue that God is unjust, that God has imposed a death sentence on them. These patients resent the fact that they will soon die. While not all patients exhibit anger, Dr. Kubler-Ross believed that a patient should be able to express his or her innermost feelings, even if they are full of rage. Sometimes a patient will even express his or her anger toward the doctor and hospital staff. He or she might even believe that the medical staff is incompetent, inhumane, and does not care about the people there in the hospital. Dr. Kubler-Ross emphasizes, “A patient who is respected and understood, who is given attention and a little time, will soon lower his voice and reduce his angry demands” (65).  During this stage, the hospital staff conveys to the patient that he or she is worthy of respect, time, and understanding. The medical staff is not to engage with anger and reassure the patient that all of his or her needs are going to be met. The patient being allowed show anger and express these feelings in an understanding, caring environment is essential for the patient and helps him or her move into the next stage of this process.

The third stage is bargaining. Very often, a patient will begin to bargain with God for more time with God.  He or she might promise to be a good person or to do something particularly worthwhile in order to get another month or year of life to postpone the inevitable. Bargaining is of course not relegated solely to the dying: we see children do this with their parents when they want something, or localized economic exchanges predicated on similar bargaining. In the example of children, a child will get mad at his or her parent and storm up to his or her room if the parent does not give into the child’s demands. Patients may experience similar frustration; they feel at the mercy of a higher authority. Dr. Kubler Ross, eloquently wrote, “In our individual interviews without an audience we have been impressed by the number of patients who promise ‘a life dedicated to God’ or ‘a life in the service of the church’ in exchange for additional time” (95). Bargaining helps patients to come to terms with the guilt of not living the perfect life. The medical staff helps the patient to overcome these fears when the self-imposed deadline has passed. A religious patient may feel guilty for not attending church as much as he or she should have, or there may be other unresolved issues. All of these should be addressed, with care and sensitivity.

The fourth stage is depression and breaks down into two sub-stages. In the first, the patient begins to regret things that have not been accomplished, past losses, and the wrongs committed. Depression is usually accompanied by guilt or shame. A counselor can help the patient to resolve any feelings of guilt and shame. In some cases, this may involve family members making realistic plans for their future and reassuring the patient that any unfinished situations are taken care of. The second sub-stage of depression is preparatory grief. Here, the patient begins to ready him or herself by taking into account the impending losses that death is going to entail. The patient may grow quiet and not any visitors. In Dr. Kubler Ross’s words, “The patient is losing everything and everyone that he or she loves. If he is allowed to express sorrow he will find a final acceptance much easier, and will be grateful to those who can sit with him during this stage of depression without constantly telling him or her not to be sad” (99).

The final stage is acceptance. Dr. Kulber-Ross notes, “Acceptance should not be mistaken for a happy stage” (124). The patient does not desire visitors because he or she is not longer in a talkative mood. By this stage, the communication between counselor and the patient has become more nonverbal than verbal. Some patients just want to hold the counselor’s hand and to sit in silence with someone that is comfortable in the presence of a dying person.

Kubler-Ross found that not all patients’ progress through the five stages presented in her study. Patients may also move back and forth among the different stages. For example, a patient may go from denial to depression, to rage and anger, then to bargaining, and back to depression. Dr. Kubler-Ross gave presentations to doctors and medical school students in which she told explained that her stages should only be used as a tool to help patients, not an exact blueprint. According to Daniel Dugan, Dr. Ross stated, “Dying patients do not have to go through stages, much less in ‘sequential’ order. Use the stages as an ‘algorithm’ to remind you to listen and to respect the depths of the person’s experience” (W-27). Every person is an individual that is going through a rough time in his or her life. The stages are only meant to be a tool for physician’s, nurse’s and counselors to be able to help there clients.

Despite Kubler-Ross’s disclaimers, numerous theorists have criticized Dr. Kubler-Ross work and the way in which she conducted her studies.  Russell Friedman and John W. James, for example, argue that, in fact, Kubler-Ross did not know what she was doing. It seems that many of Kubler-Ross’s ideas stemmed from the help she offered to four of her students at the Chicago Theological Seminary on a paper they were writing at the time.  Kubler-Ross agreed to take the students to the bedside of a dying patient to conduct an interview, and she writes:

Since the students had no clinical experience and no past encounter with terminally ill patients in a hospital, we expected some emotional reaction on their part. I was to do the interview while they stood around the bed watching and observing. We would then retire to my office and discuss our own reactions and the patient’s response. We believed that by doing many interviews like this we would get a feeling for the terminally ill and their needs which in turn we were ready to gratify if possible (38).

Friedman and James object to this kind of approach, and also argue that Kubler-Ross’s hardships in her own life may have colored her judgment. Referring to a personal collection in her book, On Grief and Grieving, Russell Friedman and John W. James writes, “She tells a gruesome story about an episode involving her father and a cherished childhood pet that caused her to make an oath to never cry again. That event, along with a host of other personal grief incidents, resulted in her bottling up a lifetime of anger that she admitted she did not deal with until very late in life” (W-38). The claim is that such anger and such unresolved issues adversely affected Kubler-Ross’s research.

Nevertheless, little concrete evidence has been presented to prove Kubler-Ross’s theories wrong. Recent researchers have been able to push the field in new directions, and Kubler-Ross’s pervading influence can be felt in contemporary therapy and treatment. For example, researchers have continued her inquest into the nature of grief and have discovered ever more complex variations of the process. What is sometimes referred to as “complicated grief” has been identified in people suffering from sudden, unexpected tragedy, such as suicide, murders, accidents, and a similarly unexpected loss.   Individuals dealing with complicated grief can suffer from depression, anger, sadness, nightmares, an increase or decrease in appetite, dry mouth, and shortness of breath, sleep disorders, and try to avoid pain. According to Alison Haustein Swan and Carleen Scott, the  symptoms of complicated grief and those of Post Traumatic Stress Disorder are similar, “When people who have experienced trauma try to avoid looking back towards the trauma, they inhibit the process whereby memories are stored as an event that happened in the past rather than as a current threat” (18).  Thus the loss become pervasive and infects all aspects of everyday life, resulting in more losses—loss of a sense safety, loss of trust, loss of jobs and relationships. Sidney Zisook and Katherine Shear offer their own, succinct definition, “Complicated grief, sometimes referred to as unresolved or traumatic grief, is the current designation for a syndrome of prolonged and intense grief that is associated with substantial impairment in work, health, and social functioning”.  Such grief can last over six months, and whoever suffers from it might view their grief itself as frightening, shameful, and weird. It is crucial for, an individual experiencing this type of grief to see a counselor, as complicated grief has been found to respond well to psychotherapy and to antidepressants.

Another example of Kubler-Ross’s influence can be seen in the use of art therapy. Recently, a couple of therapists, Bella F. Shimmel and Thelma Z. Korneich decided to use art in a bereavement therapy group, a group that was already structured after the Kubler-Ross model as a way of helping patients express their feelings in a more open manner. Bella F. Shimmel and Thelma Z. Korneich, write about how artwork helps patients to gain insight:

When appropriate, the therapists helped the members’ gain insight about the emotional content of their artwork. Even when the meaning of the art was not dealt with directly, the process of recognizing thoughts and feelings seemed to aid in the alleviation of the artist’s sorrow. Art therapy does not contain a rigid structure or set of directives; rather, the emphasis is on discovering and investigating relevant personal concerns. Many of the group members’ artworks reflected Kubler-Ross’s stages of grief, due to bereaved individual’s natural inclination and in response to the therapists’ directives.

The therapists responded to the various drawings by reflecting emotion and at times interpreting the meaning of the structure, texture, color, intensity, and the placement of art on paper. The therapists also encouraged the members to talk to each other by using art therapy as a vehicle to get group members involved in a discussion. Bella F. Shimmel and Thelma Z. Korneich’s experiment wound up suggesting that the patients were indeed following standard Kubler-Ross stages. It was another confirmation of a forty year old theory, a theory that continues to guide therapy all over the world. Whatever the disagreements may arise regarding the particulars of Elisabeth Kubler-Ross’s work, her five stages of grief have helped push the field of therapy forward, shedding new light on the stages of grieving and dying and suggesting ever-better ways for us to cope with loss.

Student Commentary

Dr. Elisabeth Kubler-Ross was a pioneer of her time. Through her research, she adopted the five-stage theory of grief. This student of psychology believes that Dr. Kubler-Ross did get the stages correct. Dr. Kubler-Ross understood that patients do not just stay in one phase, and she emphasized this fact to doctor’s, nurses and medical school students. This student believes this because she has experienced many of the same stages of grief. A person can be in denial, dissociate, and then become angry at the situation. Dr. Kubler-Ross understood that individuals start in one phase and then go to another. Her research was only meant to be a guide and she emphasized that her theory should only be used as a guide to help people.

This student also watched her grandpa go from denial, to anger, and to depression before he died. Her family would go to see him and sometimes he did not want to talk anyone, but he wanted someone to sit beside him. Other times the nurses could not do anything right, and he was angry with them. He accepted that he was going to die and helped the family with the things that needed to be taken care of. With him helping to take care of the final arrangements, he was able to accept the fact that he was going to die and had some relief. Dr. Kubler-Ross’s theories have been able to help thousands of people. Every day, universities are training medical professionals with her theories. Her theories are pushing the field of psychology even further.






Works Cited

Dougan, Daniel O. “Appreciating The Legacy Of Kubler-Ross: One Clinical Ethnical’s Perspective.” American Journal of Bioethnics 4.4 (Fall 2004): W-24-W28. AcademicSearchPremier. Web. 20 Feb 2010. <www.ebscohost.com>.

Friedman, Russell and John W. James. “The Myth Of The Stages Of Dying, Death, And Grief.” Skeptic 14.2 (2008):37-41. AcademicSearchPremier. Web. 6 March 2010. <www.ebschohost.com>.

Kubler-Ross, Elisabeth. “On Death and Dying.” First Scribner Classics Edition 1997. Macmillan Inc, New York: Macmillan, 1997. 51-125. Print.

Maciejewski, Paul K., Baohui Zhang, Susan D. Block, and Holly G. Prigerson. “An Empirical Examination Of The Stage Theory Of Grief.” JAMA 297.7 (21 Feb2007): N. pag. JAMA. Web. 5 March 2010. www.jama.ama-assn.org.

Schimmel, Bella F. and Thelma Z. Korneich “The Use Of Art And Verbal Process With Recently Widowed Individuals.” American Journal of Art Therapy 31.3 (Feb 1993): N. pag. AcademicSearchPremier. Web. 15 Feb 2010. <www.ebschohost.com>.

Swan, Alison Hauenstein and Carleen Scott. “Complicated Grief: Implications For The Treatment Of Post-Traumatic-Stress Disorder In Couples.” Sexual & Relationship Therapy 24.1 (Feb 2009):16-29. AcademicSearchPremier. Web. 17 Feb 2010. <www.esbcohost.com>.

Zisook, Sidney, and Katherine Shear. “Grief And Bereavement: What Psychiatrists’ Need To Know.” World Psychiarity 8.2. (June 2009): 67-74. Web. 18 Feb 2010.

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