Kübler-Ross model

The Kübler-Ross model, or the five stages of grief, is a series of emotional stages experienced by survivors of an intimate's death, wherein the five stages are denial, anger, bargaining, depression and acceptance.

The model was first introduced by Swiss psychiatrist Elisabeth Kübler-Ross in her 1969 book, On Death and Dying, and was inspired by her work with terminally ill patients.^[1] Motivated by the lack of curriculum in medical schools on the subject of death and dying, Kübler-Ross examined death and those faced with it at the University of Chicago medical school. Kübler-Ross' project evolved into a series of seminars which, along with patient interviews and previous research, became the foundation for her book. Since the publication of "On Death and Dying", the Kübler-Ross model has become accepted by the general public; however, its validity is not consistently supported by the majority of research.

Kübler-Ross noted that the stages are not a complete list of all possible emotions, and can occur in any order, and that not everyone who experiences a life-threatening or life-altering event feels all five of the responses.

Stages

The stages, popularly known by the acronym DABDA, include:^[2]

Denial — One of the first reactions is Denial, wherein the survivor imagines a false, preferable reality.
Anger — When the individual recognizes that denial cannot continue, it becomes frustrated, especially at proximate individuals. Certain psychological responses of a person undergoing this phase would be: "Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?"; "Why would God let this happen?".
Bargaining — The third stage involves the hope that the individual can avoid a cause of grief. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Other times, they will use anything valuable against another human agency to extend or prolong the life. People facing less serious trauma can bargain or seek compromise.
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 individual becomes saddened by the certainty of death. In this state, the individual may become silent, refuse visitors and spend much of the time mournful and sullen.
Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."
In this last stage, individuals embrace mortality or inevitable future, or that of a loved one, or other tragic event. People dying may precede the survivors in this state, which typically comes with a calm, retrospective view for the individual, and a stable condition of emotions.

Kübler-Ross later expanded her model to include any form of personal loss, such as the death of a loved one, the loss of a job or income, major rejection, the end of a relationship or divorce, drug addiction, incarceration, the onset of a disease or chronic illness, an infertility diagnosis, and even minor losses.

Both sufferers and therapists have reported the usefulness of the Kübler-Ross Model in a wide variety of situations. The subsections below give a few specific examples of how the model can be applied in different situations:

Situations

Children grieving in divorce

Denial: Children feel the need to believe that their parents will get back together, or will change their mind about the divorce. Example: “Mom and Dad will stay together.”
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 only shows 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 children can begin to accept the reality of it.^[3]

Grieving a lost amorous relationship

Denial: The person left behind is unable to admit that the relationship is over. He/she may continue to seek the former partner's attention.
Anger: The partner left behind may blame the departing partner, or him/herself.
Bargaining: The partner left behind may plead with a departing partner that the stimulus that provoked the breakup shall not be repeated. Example: "I can change. Please give me a chance." Alternatively, he/she may attempt to renegotiate the terms of the relationship.
Depression: The partner left behind might feel discouraged that his or her bargaining plea did not convince the former partner to stay.
Acceptance: Lastly, the partner abandons all efforts toward renewal of the relationship.^[4]

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 the existence of a problem is different from accepting the problem. When a substance abuser admits that he/she has a problem, this is more likely to occur in the bargaining stage. Accepting that he/she has a problem is when you realise that you have a problem and start the process to resolve the issue.^[5]

As stated above,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 always experiences at least two of the stages. Often, people 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.^[2] Women are more likely than men to experience all five stages.^[2]

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.^[2]

Pedagogical relevance

Pedagogical studies suggest that the stages of grief exemplify the basic process of integrating new information that conflicts with previous beliefs.

Criticism

In George Bonanno's book, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss,^[6] he summarizes his peer-reviewed research based on thousands of subjects over two decades, to conclusion that a natural resilience is the principal component of grief.^[7] The logic is that if there is no grief, there are no stages of grief to pass.^[8]^[9]^[10] Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome.^[8]^[9]

A 2000–2003 study of bereaved individuals conducted by Yale University obtained some findings consistent with the five-stage hypothesis and others inconsistent with it. Several letters were also published in the same journal criticizing this research and arguing against the stage idea.^[11] 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.^[12]

According to Baxter Jennings, Kübler-Ross did not adequately take the personal environment into consideration. If patients are surrounded by positive experiences, they will experience things differently from how they would if they were surrounded by negatives.^[13]

Grief communication

Grief communication occurs in grief-stricken people, through their emotions, actions, and words. Kübler-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

Corr

Charles A. Corr 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. 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.

Debbie Messer Zlatin

She took the focus away from how the observer deals with the 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.

McDougall

William McDougall 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.^[14]

Notes

↑ Broom, Sarah M. (Aug 30, 2004). "Milestones". TIME.
↑ 2.0 2.1 2.2 2.3 Santrock, J.W. (2007). A Topical Approach to Life-Span Development. New York: McGraw-Hill. ISBN 0-07-338264-7.
↑ "The Grieving Process Of Divorce". Positive Parenting. Retrieved 10 April 2012.
↑ Bugg, Lyssa. "Dr. Kubler Ross - Stages of Grief". Retrieved 9 June 2013.
↑ Crain, Tracy. "Counseling and Therapy". Tarrant County Mental Health and Substance Abuse. Retrieved 10 April 2012.
↑ http://www.perseusbooksgroup.com/basic/book_detail.jsp?isbn=0465013600 The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After a Loss
↑ Bonanno, George A. (January 2004). "Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events?". The American Psychologist 59 (1): 20–8. doi:10.1037/0003-066X.59.1.20. PMID 14736317.
↑ 8.0 8.1 The Neuroscience of True Grit. Gary Stix, 15 February 2011. Scientific American.
↑ 9.0 9.1 New Ways to Think About Grief. Ruth Davis Konigsberg, 29 January, 2011, Time Magazine.
↑ "New Ways to Think About Grief". Time. 29 January 2011.
↑ MacIejewski, Paul K.; Zhang, Baohui; Block, Susan D.; Prigerson, Holly G. (2007). "An Empirical Examination of the Stage Theory of Grief". JAMA 297 (7): 716–23. doi:10.1001/jama.297.7.716. PMID 17312291.
↑ Friedman, Russell; James, John W. "The Myth of the Stages of Dying, Death and Grief". Skeptic Magazine 14 (2): 37–41. Also available as: "Stages of Grief: The Myth". The Grief Recovery Institute. January 5, 2012.
↑ Jennings, Baxter. "Kubler-Ross and other Approaches". University of Kentucky Department of Philosophy. Retrieved 10 April 2012.
↑ Gemmill, Charlene. "Kubler-Ross and other Approaches". University of Kentucky Department of Philosophy. Retrieved 10 April 2012.