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The Work of Kubler-Ross

Before the 1970s, psychologists treated death as taboo. One of the most important influences on changing attitudes was the work of a thanatologist (expert in studying death) named Elizabeth Kubler-Ross. Her book On Death and Dying (1969) was a landmark publication, signaling a new era of open discussion on the topic.

Kubler-Ross got the idea for her book after working with terminally ill patients for two and a half years. In the preface she said she wrote the book not as a textbook on how to manage dying patients, but to "encourage others not to shy away from the 'hopelessly' sick but to get closer to them."

The few who can do this will also discover that it can be a mutually gratifying experience; they will learn much about the functioning of the human mind, the unique human aspects of our existence, and will emerge from the experience enriched and perhaps with fewer anxieties about their own finality. (Kubler-Ross, 1969)

Kubler-Ross identified five stages in the attitudes of a terminally ill patient. These were conceived as interchangeable phases, not necessarily stages in the sense of a fixed sequential ordering of development. In other words, she did not emphasize the exact ordering of these reactions, just the fact that different, identifiable reactions occurred.

What stages did Kubler-Ross identify?

1. Denial and isolation. The reaction of many people, told they have a terminal illness, is "No, not me! It can't be true! This is a natural defense against the shock of impending death, but usually it is only temporary. "Among our two hundred terminally ill patients, I have encountered only three who attempted to deny [death] to the very last," wrote Kubler-Ross. The rest moved on to other attitudes.

2. Anger. A distinct stage for many terminally-ill patients was a sense of anger and injustice: "Why me?" This anger emerged at irregular times and was sometimes directed against people who had nothing to do with the basic situation. Often this was a difficult stage for relatives and doctors as well as the patient.

3. Bargaining. Many patients felt they could strike some kind of bargain to postpone death. One type of bargain involved good behavior. Patients stopped smoking, they volunteered to undergo painful therapies, and they devoted themselves to church activities. Kubler-Ross suggested these patients were operating on the premise that good behavior would be rewarded. If there were justice in the world, death would be postponed or eliminated by sufficient good behavior.

A second sort of bargain involved deadlines, such as a relative's wedding. The patient seemed to be saying, "God, if you let me live to see this wedding, then you can take me." Kubler-Ross noted that the patients never kept these promises, however; once the deadline was past, they would set up another deadline or special event to live for, and they would try to prolong the process.

4. Depression. Kubler-Ross writes, "When the terminally ill patient can no longer deny his illness, when he is forced to undergo more surgery or hospitalization, when he begins to have more symptoms or becomes weaker and thinner, he cannot smile it off anymore." Sometimes patients sink into depression after they get beyond denial, anger, and bargaining. Accepting the inevitability of death, they feel hopeless. The sense of impending loss of life becomes overwhelming. Medical expenses mount and patients may lose their life savings, be forced to sell a house which they built for their old age, or in other ways give up the hopes and dreams which gave life meaning.

5. Acceptance. The final stage of dying is acceptance. It is not a time of joy or happiness-more like "quiet expectation" in Kubler-Ross's words.

What are some criticisms of Kubler-Ross's work?

Critics of Kubler-Ross say her scheme could lead to unreasonable pressures on a dying patient. After reading Kubler-Ross, a physician may expect a certain sequence of events. A patient who does not conform to the Kubler-Ross sequence may be seen as difficult or uncooperative. Lofland (1979) criticized the "happy death movement," which (she said) might prevent dying people from expressing their true feelings.

Kubler-Ross also drew criticism when she seemed to cross the border from science into the occult. In the 1960s, in the book On Death and Dying, Kubler-Ross suggested that working with terminally ill patients would help caretakers come to grips with their own "finality." A decade later, she was denying that finality. As Lindsey (1979) reported in The New York Times :

In the past three years...Dr. Ross has begun to encounter growing skepticism from her medical peers over two elements that she added to her theories.

How did Kubler-Ross appear to reverse her opinion about death's finality?

First, she began to offer in her workshops for the dying a strong rope of hope: "There is no death," she said, but "life after life," a happy existence in which all the physical ailments and mental problems of the body disappear. It was, some critics noted, the same kind of hope that many organized religions had offered man for centuries. This message added considerably to the popularity of her workshops for the dying, according to her aides.

Second, she raised scientific skepticism with her statements that she had encountered "materialized" supernatural spirits and had given names to four of them—"Mario," "Anka," "Salem," and "Willie." She said she believed that she had lived in the time of Jesus under the name of Isabel. Dr. Ross has scoffed at the criticism from her peers, saying they will eventually see her as prophetic in the future. (Lindsey, September 17, 1979, p.B10)

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