Stages of Grief - Elisabeth Kubler Ross

I first started working with Kubler-Ross's "stages of grief" back when I began my life as a minister in Port Simpson in 1992.  I've returned to it often and still find it to be a helpful way of understanding grief and loss.  Kubler-Ross dedicated her life to working with the dying, the ill, the lost, and the bereaved.  She has left a great legacy of wisdom.  Wisdom which is helpful when "Living on The Edge".

The following interpretation is with thanks to Alan Chapman. 

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Five Stages of Grief

(Based on the Grief Cycle model first published in On Death & Dying, Elisabeth Kübler-Ross, 1969. Interpretation by Alan Chapman 2006-2009.)

            Also known as the 'grief cycle', it is important to bear in mind that Kübler-Ross did not intend this to be a rigid series of sequential or uniformly timed steps. It's not a process as such, it's a model or a framework. There is a subtle difference: a process implies something quite fixed and consistent; a model is less specific - more of a shape or guide. By way of example, people do not always experience all of the five 'grief cycle' stages. Some stages might be revisited. Some stages might not be experienced at all. Transition between stages can be more of an ebb and flow, rather than a progression. The five stages are not linear; neither are they equal in their experience. People's grief, and other reactions to emotional trauma, are as individual as a fingerprint.

            The model recognizes that people have to pass through their own individual journey of coming to terms with death and bereavement, etc., after which there is generally an acceptance of reality, which then enables the person to cope.

            Again, while Kübler-Ross's focus was on death and bereavement, the grief cycle model is a useful perspective for understanding our own and other people's emotional reaction to personal trauma and change, irrespective of cause. 

1 - Denial         

Denial is a conscious or unconscious refusal to accept facts, information, reality, etc., relating to the situation concerned. It's a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change that can be ignored. Death of course is not particularly easy to avoid or evade indefinitely.

2 - Anger          

Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Knowing this helps keep us detached and non-judgmental when experiencing the anger of someone who is very upset.

3 - Bargaining              

Traditionally the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. People facing less serious trauma can bargain or seek to negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it's a matter of life or death.

4 - Depression             

Also referred to as preparatory grieving. In a way it's the dress rehearsal or the practice run for the 'aftermath' although this stage means different things depending on whom it involves. It's a sort of acceptance with emotional attachment. It's natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality.

5 - Acceptance             

Again this stage definitely varies according to the person's situation, although broadly it is an indication that there is some emotional detachment and objectivity. People dying can enter this stage a long time before the people they leave behind, who must necessarily pass through their own individual stages of dealing with the grief.

(Based on the Grief Cycle model first published in On Death & Dying, Elisabeth Kübler-Ross, 1969.  Interpretation by Alan Chapman 2006-2009.)

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Personally, I live in and out of all of these places, and more, on a regular basis.  My cancer journey began in August 2004 with a diagnosis of stage 4 colon cancer, I've had a couple of serious recurrences, and now live with a persistent and painful presence of cancer in my very bone.  Alas!  There seems to be no escaping it!  

Not to stay focused on the negative.  My journey has been, and continues to be, filled with many experiences of great joy, deep peace, and real hope.  These things go hand in hand with the otherwise "afflictive" emotions that together form the complex emotional climate of my heart and soul. I find that I can be more authentic in my experiences of the many good things in life when I am also honest and authentic with my very real grief. 

Peace and blessings... Rob; in Vancouver

"For those who seek to understand it, death is a highly creative force. 

The highest spiritual values of life can originate from the thought and study of death."
Elisabeth Kubler-Ross

Twenty Faces of Grief: Mitch Carmody

Video Link

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Mitch Carmody

http://www.heartlightstudios.net/home

Death Awareness

David Kuhl is a Vancouver doctor, researcher, and the author of "What Dying People Want: Practical Wisdom for the End of Life".   David's book is based on research that he did with people who were living with a terminal illness.  "David Kuhl has peeled back the cover on the inner experience of living with dying. What Dying People Want synthesizes the wisdom of ancient mythology and insights from depth psychology with real-life perspectives of people living in the long shadow of death.  Kuhl's message is brimming with hope.  This book has relevance for us all."  Ira Byock. M.D. author of "Dying Well"

In his book David speaks of "time and anxiety" and suggests the following exercise as a way coming to grips with the proximity of death in our lives.

Instructions:  Adapted from “What Dying People Want” by David Kuhl pp 29-30

1. Think of the line above as representing your lifetime. Place an X on the line to show where you believe you are at present. Once you have done this take note of your feelings. Do you have a sense of relief? Of anxiety? Of fear? What else comes up for you?
2. Think of six significant events in your life. Number these events 1 through 6 and place the numbers on the line. Again, take note of your emotions as you recall these events.
3. Consider the line between X and DEATH. How would you like to live this period? Is there anything special you would like to do? Choose six significant events that you would like to “fit in” before the end of your life. Number these events 1 through 6, and place the numbers on the line.

I have worked with this exercise twice now since I was diagnosed. Once in the Fall of 2004 and again this Summer.  On each occasion I have found myself placing the X fairly near to the end of the line.  I have found it helpful each time, both in assessing what has been important in my life and in determining how to live with what time I have left.  It is interesting for me to note that I have now lived much longer than what I had anticipated shortly after my diagnosis in 2004.

There have been times during the past 6 years where I have enjoyed the sense of a much longer "future horizon".   These were times when I was able to make plans and commitments that went years into the future.  Whilst in the midst of lengthy periods of remission I have even believed, at times, that I might live out a normal life-span.  Regrettably this is much less so now.  With each recurrence I am jolted back to reality and made to realize again that "life is short"!

David asks his readers to imagine a scenario where you have just learned that you have a terminal illness and only 6 to 12 months left to live.  You now place an X very near to the end of the life-line above.  He then asks... 

1. Would you live differently?   
2. Starting when?   
3. Would you care as much what other people think about you or about what you do, how you live?   
4. How would you fill your time?

Good questions!

Peace and blessings... Rob; in Vancouver

"Life is short.  And we do not have long to gladden the hearts of those who walk the way with us.  So let us be swift to love.  And let us make haste to show kindness." Henri Amiel

"Living on the Edge"

For the past 6 years I've felt as though I have been living on the edge of death.  Or perhaps the edge of life, depending on how you look at it.  Either way, living with metastatic cancer is "living on the edge".  I tend not to share many of my thoughts about this dimension of the journey.  It is not the kind of thinking that people normally want to engage in.  But it is the kind of thinking that late-stage cancer survivors are drawn to.  At least occasionally.

I can't imagine any cancer survivor who hasn't delved a little into the "existential questions" of life and death.  For those of us with metastatic or recurrent cancers, these questions become more pressing.  To avoid them is to live in denial of our mortality.

Henri Nouwen offers up the following as food for thought...

"Is death something so terrible and absurd that we are better off not thinking or talking about it? Or... 
Is it possible to befriend our dying gradually and live open to it?  Trusting that we have nothing to fear.  
Is it possible to prepare for death with the same attentiveness that our parents had in preparing for our birth?"   
Henri Nouwen "Our Greatest Gift"

Beginning in July, I will have the opportunity to explore these and other questions in a new program I am facilitating at InspireHealth, Vancouver's integrated cancer care center. "Living on the Edge" will be a small support group for "late-stage" cancer survivors.  Themes explored will include: facing death; accepting our mortality; getting the most out of THIS life; doing what is life-giving; finding friends for the journey; engaging family and friends; and life after death, to name but a few.

So, over the next few months, I will be using this space to share some of my own personal reflections on this aspect of the cancer journey.  Please do not be alarmed or think that I am feeling any closer to the end of MY journey.  I am not! The truth is I have been living with this awareness of the "proximity of death" for most of the past 6 years. Much of what I'll be sharing here will come from what has been on my mind from time to time over the past several years, the "unpublished" pages of my journal.

If you're interested you can start by reading some of my previous posts on death and dying...  here.

Be well... Rob; in Vancouver

“There is no cure for birth and death,
save to enjoy the interval.”

George Santayana

Choices in Healing

Michael Lerner is the author of “Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer” (availble to read online). He's one of our leading thinkers when it comes to integrated cancer treatment. Here's what he would do if he faced a cancer diagnosis, in his own words…

• “I would give careful thought to choosing a mainstream oncologist. I wouldn’t need someone with wonderful empathic skills--I’m fortunate to have other people in my life who provide that. But I would want a doctor who was basically kind, and on top of the medical literature regarding my disease. I would look for a doctor who was willing to take the time to answer my questions, and who supported my commitment to be deeply involved in my treatment decisions, and my commitment to complementary therapies. Finally, I would want a doctor who would stick with me medically and emotionally if recovery were not possible and I faced death.
• I would use mainstream therapies that offered a real chance for recovery, but I would probably not use experimental therapies or therapies with a low probability of success that were highly toxic or compromised my capacity to live and, if it came to that, die as I chose.
• I would use complementary therapies. I would look for a good support group and a psychotherapist experienced in working with people with cancer. I’ve been a vegetarian for many years, but I would look for ways to enhance my nutrition. I would meditate and practice yoga more often, and spend more time in Nature, taking walks in the woods, by the ocean, and in the mountains.
• I would definitely use traditional Chinese medicine, both herbs and acupuncture.
• I would strive for life, for recovery, with every possible tool and resource I could find. But if recovery were not possible, I would also work to face death in a way that deepened my growth and led to some resolution of my life and relationships.
• I would pay a great deal of attention to the inner healing process that I hope a cancer diagnosis would trigger in me. I would give careful thought to the meaning of my life, what I had to let go of, and what I wanted to keep.
• I would spend time with the people I value, and with books, writing, music, and my own vision of God. I would do everything I could do that I didn’t want to leave undone. I would not waste time with old obligations, though I would try to extricate myself from them decently.
• I would try to live my own life my own way. I would try to accept the pain and sorrow inherent in my situation, but I would also look searchingly for the beauty, wisdom, and joy."

Well said Michael!!

TTFN... Rob; in Vancouver

"Everyone has a doctor in him or her; we just have to help it in its work. The natural healing force within each one of us is the greatest force in getting well. Our food should be our medicine. Our medicine should be our food."

Hippocrates

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Michael Lerner on Healing

To Everything There is a Season

"To everything there is a season and a time for every matter under heaven…A time to be born and a time to die…” Ecclesiastes

 

In the course of my life as a minister I have spent much time in the presence of the dying and the bereaved. The names of those I have accompanied through these stages are written in my journals and their stories inspire my life and ministry. I believe that to walk with someone through the final stages of life is one of the most sacred experiences we can have.

From a spiritual perspective, "palliative", or "end-of-life", care is very much a service of “accompaniment”. The word accompaniment really names it well when you look at the Latin roots com-panis, "with bread". To accompany is to “break bread with”. It is to walk the journey with another as a companion for a particular and significant stage of life. When I remember those who have accompanied me in the difficult stages of my journey, I think of the following qualities that I value in them:

• availability and commitment;
• an ability to be a “non-anxious" presence;
• honesty, humility, and compassion;
• a capacity to both listen and reflect;
• a comfort level with silence;
• a sense of humor; and
• a certain wisdom that comes from experience.

It is also important to me to have a person who shares somewhat of my spiritual orientation. In that way we can use a common language of symbol, story and prayer.

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A particular challenge for the person living in the advanced stages of cancer is, “knowing when to let go”.  It seems to me that in the cancer journey there is a time to fight the "dragon" with all of the weapons we can muster. I've also seen that there can come a time when it's helpful to "let go", so that the final stage can be one of peace and dignity and not one of prolonged pain and suffering.

"Letting go" is not giving up. Death is not defeat or failure. It’s not about winning or losing, but rather about accepting the very imminent reality of our mortality. My experience has been that when the terminally ill reach the place of "letting go" a deep peace follows for the individual, their family, and their friends. Discerning the time of this transition is deeply personal and needs to be respected by caregivers and family alike.

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End-of-life care belongs to the family. It is another area of medicine which is being reclaimed through patient and family empowerment and education. Many hospitals and communities now have progressive Palliative Care programs that help our loved ones through the final stages of life with dignity and respect.

In Canada, Dr. David Kuhl has written an insightful book on palliative care. “What Dying People Want: Practical Wisdom for the End of Life” is an excellent account of David’s 15 year experience of palliative care in Vancouver. In it he addresses such issues as: Time and Anxiety; Bad News; Physical Pain; Life Review; Speaking the Truth; Self-Realization; and Transcendence.

In the US, Dr. Ira Byock has written and advocated extensively on end-of-life care. His website, http://www.dyingwell.org/, has numerous helpful resources and an excellent synopsis of the “Developmental Landmarks and Taskwork for the End of Life”. It is helpful reading if you, or a loved one, are facing end-of-life issues.

In peace... Rob; in Vancouver

"I wanted a perfect ending. Now I've learned, the hard way, that some poems don't rhyme, and some stories don't have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what's going to happen next. Delicious Ambiguity". Gilda Radner

originally posted in July 2007

Facing Death

One of the central characters in the novel “Snow Falling on Cedars” by David Guterson, is a young Japanese American girl by the name of Hatsue. Hatsue lives in two worlds, the modern world of 20th Century America and the ancient world of her traditional Japanese roots. She learns of her Japanese roots through an elder in her community, Mrs. Shigemura. I was struck by this particular exchange…

“Mrs. Shigemura taught her to seek union with the greater life and to imagine herself as a leaf on a great tree. The prospect of death in the autumn, she said, was irrelevant next to its happy recognition of its participation in the life of the tree itself. In America, she said, there was a fear of death; here life was separate from being. A Japanese, on the other hand, must see that life embraces death, and when she sees the truth of this, she will gain tranquility.”
David Guterson “Snow Falling on Cedars”

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Death is a difficult thing to face and talk about.  We often want to avoid thinking or talking about it in order to stay focused on the positive. But my experience has been that thoughts and questions about death inevitably emerge in the wake of a life-threatening diagnosis. Thus, it can be healthy, helpful, and indeed "positive" to reflect on death from time to time rather than leave it as an unnamed fear in the back of the mind.

In my experience as a pastor I have had the humble blessing of being with dying people and their loved ones on well over 200 occasions as I accompanied them through the final days and "celebrated life" in various memorial formats.  I remember each person well.  Their names are written in my journals and the witness of their "living and dying" informs my understandings of "life and death". 

In many instances I have found that the level of anguish and grief surrounding death is very much lessened as folks make their peace with it along the way.  One of the strange blessings of cancer is that it does allow for time for people to move through stages, to adjust to,  and to prepare for death.  This often means that important things can be said and done which can make this stage of life a rich blessing for both the person dying and their special friends and family.

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In many respects living with cancer ultimately means facing the reality of our mortality.  For me, this process began very shortly after my diagnosis in August 2004. My surgeon was fairly certain of the advanced staging of my cancer and he shared all of the information with me in an honest and caring way. I have a vivid memory of a long and tearful night in the hospital listening to Simon and Garfunkel on the headphones and adjusting to the news of my cancer. It was fairly clear to me that death was a possibility. Not a possibility I wanted to pursue, but one that I needed to face.

Facing death remains an ongoing theme in my cancer journey and it weaves like a golden thread in and out of my journal as it does my consciousness. My challenge has been to face death in a life-giving way that helps me to overcome my fear and that truly brings "tranquility".

Death… I wouldn’t want to dwell on it… but I wouldn’t want to ignore it either!

Deep peace of the Autumn Forest to you…  Rob

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“There is no cure for birth and death,
save to enjoy the interval.”

George Santayana (1863 - 1952)

originally posted June 2007