Kübler-Ross model

The Kübler-Ross model postulates 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. 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 later in life that the stages are not a linear and predictable progression and that she regretted writing them in a way that was misunderstood. Rather, these are a collation of five common experiences for the bereaved that can occur in any order, if at all.

Stages

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

1. Denial — The first reaction is denial. In this stage individuals believe the diagnosis is somehow mistaken, and cling to a false, preferable reality.
2. 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 this happen?".
3. 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 in exchange for a reformed lifestyle. People facing less serious trauma can bargain or seek compromise.
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 individual becomes saddened by the mathematical probability of death. In this state, the individual may become silent, refuse visitors and spend much of the time mournful and sullen.
5. Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."; "Nothing is impossible."
   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.

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.

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 (or to justify continuing their use of drugs and/or alcohol). Example: “God, I promise I’ll never use again if you just get me out of trouble.” “...If you let me stay here, I will never do drugs/alcohol again.”

Depression

Sadness and hopelessness are important parts of the depression stage when drug abusers are faced with the reality of living a life without their substance of choice. Most abusers experience this when they are going through the withdrawal stage quitting their addiction.

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.

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. 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.

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, he summarizes his peer-reviewed research based on thousands of subjects over two decades and concludes that a natural resilience is the principal component of grief. The logic is that if there is no grief, there are no stages of grief to pass. Bonanno's work has also demonstrated that absence of grief or trauma symptoms is a healthy outcome.

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. 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.

According to Baxter Jennings et al., 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.

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.

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 Foundation
• DABDA: The Five Stages of Coping With Death – about.com
• "On Death and Dying" – interview with Elizabeth Kübler-Ross M.D.
• "Beware the Five Stages of 'Grief'" – TLC Group editorialde:Elisabeth Kübler-Ross#Die fünf Phasen des Sterbens