The stage theory of dying was first proposed by the Swiss-American psychiatrist, Elisabeth Kübler-Ross in her book, On Death and Dying (1969), is perhaps the single theoretical model that is best known to the general public in the entire field of studies about death and dying (thanatology). In its simplest form, this theory claims that dying people will proceed through five stages: denial, anger, bargaining, depression, and acceptance. More broadly, the theory maintains that other individuals who are drawn into a dying person's experiences, such as family members, friends, professional care providers, and volunteer helpers, may also experience similar "stages of adjustment."
Origins of the Theory
Kübler-Ross explained in her book that she was a new faculty member in psychiatry at a Chicago-area teaching hospital in the fall of 1965 when four theological students seeking assistance with a student project approached her. They had been assigned to write about a "crisis in human life" and had chosen to examine death as "the biggest crisis people had to face" (p. 21). In order to tackle this topic, she agreed to help them gain access to and interview some dying patients. According to Kübler-Ross, she encountered unexpected resistance from the physicians and others who were responsible for the patients whom she and her students wanted to interview: "These doctors were both very defensive when it came to talking about death and dying and also protective of their patients in order to avoid a traumatic experience with a yet unknown faculty member who had just joined their ranks. It suddenly seemed that there were no dying patients in this huge hospital" (p. 23).
Eventually, however, some suitable patients were found, and Kübler-Ross developed a procedure whereby she would approach likely candidates, secure their permission, and then interview them about their experiences, while the students and others who came to observe would do so from behind a one-way glass mirror. Following the interviews and the return of the patients to their rooms, the group would discuss the patients' responses and their own reactions.
On Death and Dying is based on interviews with approximately 200 adult patients during a period of less than three years. Examples from the interviews, along with the clinical impressions and the theoretical model that Kübler-Ross formed from these experiences, were subsequently reported in her book.
Stage Theory of Dying Examined
The theoretical model that Kübler-Ross developed from her interviews postulated that with adequate time and support, dying persons experience or work through five stages, including denial, often expressed as "No, not me, it cannot be true," is described as an individual's unwillingness to acknowledge or broad rejection of the fact that he or she is actually dying; anger, typically expressed as "Why me?," is a protest acknowledging at least in some degree that the individual is dying but simultaneously objecting or complaining that it is not fair or right that it should be happening; bargaining, often expressed as "Yes me, but ...,"is less outraged and more resigned to death while focusing (whether realistically or unrealistically) on what might be done to postpone death or to have it occur at a time or in ways that are more acceptable to the individual; depression, which involves a great sense of loss and which can take the form of "reactive depression" (responding to losses the individual has already experienced) or "preparatory depression" (emphasizing impending losses, including the anticipated loss of all love objects); and acceptance, described as "almost void of feelings" (p. 113), a "final stage when the end is more promising or there is not enough strength left to live" (p. 176).
A valuable addition to this five-stage theory, which is often overlooked, is the observation that "the one thing that usually persists through all these stages is hope" (p. 138) and the comment that "it is this hope that should always be maintained whether we can agree with the form or not" (p. 265).
Understanding Stage Theory of Dying
Kübler-Ross sought to address a dehumanization and depersonalization that dominated the experiences of the dying persons with whom she came into contact. She believed that dying was often a lonely, impersonal experience for such persons, and thus an unnecessarily difficult burden for them to bear. In fact, Kübler-Ross found that most of her patients feared dying even more than death itself. For those who were isolated in their dying and who felt unable to help themselves or to find reasons to be hopeful, Kübler-Ross offered them a constructive opportunity by asking them to help teach others about their experiences. She was especially concerned that dying persons should share their experiences with and become teachers to their professional caregivers and their family members. At the same time, she asked others not to be judgmental about the reactions dying persons have to their experiences, but to try to enter into their perspectives and understand the origins of those reactions.
The theory that resulted was essentially an effort "to categorize crudely the many experiences that patients have when they are faced with the sudden awareness of their own finality" (p. 29). The "stages" within that theory were themselves understood by Kübler-Ross as "reactions," "defenses" or "defense mechanisms," "coping mechanisms," and "adaptations and defenses." At one point, Kübler-Ross wrote that these stages "will last for different periods of time and will replace each other or exist at times side by side" (p. 138), while in another place she stated, "these stages do not replace each other but can exist next to each other and overlap at times" (p. 263). The stages are, in other words, a fairly loose collection of psychosocial reactions to experiences associated with dying. As such, they remind us that dying is a human process, not merely a series of biological events. Also as such, they are not confined solely to dying persons, but may be experienced by others who enter into the worlds of those who are dying.
As initially proposed, the five stages in this theory were described in very broad terms. Denial and acceptance, for example, were presented as essentially mirror opposites, with the other three stages functioning mainly as transitional reactions experienced while moving from denial to acceptance. Both denial and acceptance were formulated in ways that permitted them to apply to a spectrum of reactions: from a complete rejection of one's status as an ill or seriously ill person to an unwillingness to admit that one is dying or that one's death is more or less imminent; and from acknowledgement, resignation, and acquiescence to welcoming.
Of denial, Kübler-Ross wrote, "Denial, at least partial denial, is used by almost all patients, not only during the first stages of illness or following confrontation, but also later on from time to time" (p. 39). More importantly, she added this further comment about denial: "I regard it [as] a healthy way of dealing with the uncomfortable and painful situation with which some of these patients have to live for a long time. Denial functions as a buffer after unexpected shocking news, allows the patient to collect himself and, with time, mobilize other, less radical defenses" (p. 39). Not everyone who took up this theory viewed denial in this constructive way.
Like denial and acceptance, anger, bargaining, and depression as the other stages in this theory were said to vary in their intensity, character, and focus. Individuals will differ, for example, in whether or not they experience anger, what arouses their anger, the object(s) on which it fixes, its degree, whether it is rational or irrational, and how it is expressed. One troubling feature of anger is that it is said to be "displaced in all directions and projected onto the environment at times almost at random" (p. 50).
As for bargaining, this reaction seems to reflect a view that one can postpone death or manipulate one's experiences of dying usually through more or less explicit promises involving a prize and some deadline: "I will faithfully follow the prescribed regimen you prescribe, if it will only ward off my death"; "I will pray each day, if you will preserve me from this awful fate"; "I need to stay alive until my son is married." Promises are usually addressed to presumed authorities, such as God or a physician, but Kübler-Ross noted, "none of our patients have 'kept their promise'" (p. 84).
Criticisms of the Stage Theory of Dying
There are essentially three distinct types of criticisms that have been raised against the stage theory of dying. First, some commentators have noted that empirical research has provided no support for this model. Kübler-Ross herself offered nothing beyond the authority of her clinical impressions and illustrations from selected examples to sustain this theory in its initial appearance. Since the publication of her book in 1969, she has advanced no further evidence on its behalf, although she has continued to speak of it enthusiastically and unhesitatingly as if its reliability were obvious. More significantly, there has been no independent confirmation of the validity or reliability of the theory, and the limited empirical research that is available does not confirm her model.
Second, the five sets of psychosocial reactions that are at the heart of this theory can be criticized as overly broad in their formulation, potentially misleading in at least one instance, insufficient to reflect the full range of human reactions to death and dying, and inadequately grounded for the broad ways in which they have been used. The expansive way in which these five reactions are formulated has already been noted. Kübler-Ross did not, of course, invent these five reaction patterns; her inspiration was to apply them individually to the human experiences of dying and facing death, and to link them together as part of a larger theoretical schema. Among its peers, the trait of depression seems most curious as an element in a healthy, normative process of reacting to dying— unless it really means "sadness"—since clinical depression is a psychiatric diagnosis of illness. Moreover, just as Kübler-Ross seems sometimes to acknowledge that a particular individual need not experience all five of these reactions, so one need not believe there are only five ways in which to react to dying and death. Finally, Kübler-Ross has applied this theory to children and to bereavement in ways that are not warranted by its original foundations in interviews with dying adults.
Third, the theory can be criticized for linking its five reaction patterns together as stages in a larger process. To a certain extent Kübler-Ross seems to have agreed with this point since she argued for fluidity, give and take, the possibility of experiencing more than one of these reactions simultaneously, and an ability to jump around from one "stage" to another. If that is true, then this is not really a theory of stages, which would require a linear progression and regression akin to the steps on a ladder or the calibrations on a thermometer or a hydraulic depth gauge. In short, the language of "stages" may simply be too restrictive and overly specific for what essentially appear to be a cluster of different psychodynamic reactions to a particular type of life experience.
This last point is particularly important because if this theory has been misused in some ways, its most unfortunate mishandling has come from those who tell dying persons that they have already experienced one of the five stages and should now "move on" to another, or from those who have become frustrated and complain about individuals whom they view as "stuck" in the dying process. When coupled with the limits of five categories of reaction to dying, this schematic approach tends to suppress the individuality of dying persons (and others) by coercing them into a rigid, preestablished framework in which they are expected to live out an agenda imposed on them at the end of their lives. That is particularly ironic and unfortunate since Kübler-Ross set out to argue that dying persons are mistreated when they are objectified and dealt with in stereotypical ways. As she insisted, "a patient has a right to die in peace and dignity. He should not be used to fulfill our own needs when his own wishes are in opposition to ours" (p. 177).
One serious evaluation of this stage theory of dying by Robert Kastenbaum raised the following points:
- • The existence of these stages as such has not been demonstrated.
- • No evidence has been presented that people actually do move from stage one through stage five.
- • The limitations of the method have not been acknowledged.
- • The line is blurred between description and prescription.
- • The totality of the person's life is neglected in favor of the supposed stages of dying.
- • The resources, pressures, and characteristics of the immediate environment, which can make a tremendous difference, are not taken into account.
As a result, what has appeared to be widespread acclaim for this theory in the popular arena and in certain professional quarters contrasts with sharp criticism from scholars and those who work with dying persons.
What Can Be Learned from Stage Theory of Dying?
Charles Corr has suggested that there are at least three important lessons to be learned from the stage theory of dying. The first lesson is that those who are coping with dying are living human beings who will react in their own individual ways to the unique challenges that confront them and who may have unfinished needs that they want to address. The second lesson is that others cannot be or become effective providers of care unless they listen actively to those who are coping with dying and work with them to determine the psychosocial processes and needs of such persons. And the third lesson, a point that Kübler-Ross always stressed, is that all individuals need to learn from those who are dying and coping with dying in order to come to know themselves better as limited, vulnerable, finite, and mortal, but also as resilient, adaptable, interdependent, and worthy of love.
Reflecting at least in part on the stage theory of dying, some writers have called for broader task-based or contextual theories of dying that would strive to offer more respect for the individuality and complexities of the many different ways in which persons live out their experiences of dying and of coping with dying. Various contributions have been made toward developing such broader theoretical frameworks, some emerging from lessons learned in reflecting on the stage theory of dying, but no final theory has yet been developed.
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CHARLES A. CORR DONNA M. CORR