March 9
th marked an important anniversary for me. Twenty-nine years ago, I moved into my office in Long Beach, California, beginning a people-helping career that has now spanned nearly three decades. Along the way, I have been involved in several “nuances†of career all related to caring for people: pastoral care, professional counseling, hospice clinician, and education of human service and health care professionals already in practice. Now my career has come full circle so that I am working with men and women in the “sunrise†of their careers in health care. It has already been a great ride and should God grant me good health and the energy to continue work with collegiates, I look forward to another 20 years or so of this work.
In the midst of our celebrating anniversaries, however, we can also take opportunity to look back. That is why during this next year, my 30
th in the profession of caring for the dying and bereaved, I thought I would occasionally look back at the people whose work has most influenced my own. Six or seven times in the next twelve months, I will use
GriefPerspectives as an opportunity to talk about one of the “influential voices†whose work has, at least in part, shaped my own.
Undoubtedly, some of these figures will be obscure to many clinicians; I find we often use the ideas and theories of people without even being aware of the source of those ideas. Other names will be people whose names readers recognize but whose work is not widely known. Then there will be others—like this month’s choice, Elisabeth Kübler-Ross—who will possess names known to a wide variety of people whether trained in our field or not.
To those who have read my work or heard me speak, the choice must seem odd of Kübler-Ross to “lead the way†in this endeavor. I have been no slight critic of the ubiquitous five-stage process that she so clearly articulated in the late 1960s. Though I had learned her name along the way somewhere, my introduction to her work came as a collegiate when in a psychology course, we were assigned to read
Death: The Final Stage of Growth (Prentice-Hall, 1975), one of Kübler-Ross’ most recent books at that time. In actuality, a collection of essays for which Kübler-Ross acted as the editor, this book may have been the seminal work that launched my career.
Her straightforward five stages of the dying process provided order to the strange world of dying, not just for me but also for a generation of baby boomers and our elders trying to make sense of life in a volatile world (remember the 60’s and 70’s?) In the Introduction to the volume, the Swiss-born psychiatrist wrote:
“Death always has been and always will be with us. It is an integral part of human existence. And because it is, it has always been a subject of deep concern to all of us. Since the dawn of humankind, the human mind has pondered death, searching for the answer to its mysteries. For the key to the question of death unlocks the door of life.†Then Kübler-Ross went on to assert, “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†(Kübler-Ross, 1975, p. 1).
“The highest spiritual values of life can originate from the thought and study of death.†Though I do not remember it now, perhaps that statement first caught my eye. Perhaps, I thought, it was possible to weld my growing “call†to pastoral ministry with a healthy understanding of death. Possibly, I do remember thinking, we could marry the worlds of theology and psychology, after all. Even in my days as a youngster, death and its rituals had fascinated me. After my own father’s death in 1993, I found in his collection of photographic slides one of me at about age five inquisitively inspecting a headstone in the Hoy family plot near the Canadian capital of Ottawa!
For whatever the reasons that Kübler-Ross’ work first grabbed my attention, what I know more than three decades from those early years as an undergraduate, is that her contribution to our field is incalculable. While I stand with most of my colleagues in rejecting the scientific validity and clinical usefulness of her five-stage theory, here are three important gifts I believe Elisabeth Kübler-Ross gave to all of us.
First, she let death “out of the closet†in North America.
Revisionist history is a dangerous pastime but at the risk of such, the decade of the 1960s is not the best model for how we want to deal with death. The decade had just begun when a young, energetic John F. Kennedy was elected president of the United States, promising a new era for technology and innovation. The world joined in horror and heartbreak with his young family to grieve his assassination less than three years later, to only to be followed in less than five years more by the assassination of Martin Luther King and the president’s younger brother, Robert. Before the decade ended, soldiers were dying
en masse in a far-off place called Vietnam. Yet, the advancing technology the young president had promised was delivering breakthrough medical advances that postponed—and even prevented—death to millions.
By the time Kübler-Ross published her first book,
On Death and Dying in 1969, “natural†death was most often occurring in the back wards of hospitals, far from the observance of most people. For the first time in history, people were living into adulthood without ever having witnessed a person die. A wise mentor of mine used to say, “People are down on whatever they aren’t up on.†In the 1960s, modern people were at once frightened of nuclear annihilation and at the same time, quite complicit in not using the “D†word. In other words, our society was not “up†on death, in part because so few experienced it first-hand. Kübler-Ross made it possible for people—and especially health care professionals—to talk a bit more openly about death. In fact, it was a 1973 church discussion of Kübler-Ross’ book that inspired Ottawa urologic surgeon Balfour Mount to organize Canada’s first palliative care program (A Moral Force, 2005).
Second, Kübler-Ross acknowledged that the experience of death included some very real emotional attributes. 
One criticism leveled at Kübler-Ross’ five stages is that the theory describes only emotional states: denial, anger, bargaining, depression and acceptance even though the dying process includes the holistic experiences of emotional, physical, cognitive, social and spiritual. Nevertheless, Kübler-Ross was among the pioneers who actually acknowledged that the dying process included an emotional component, both for dying patients and those who loved them. In fact the publisher’s front cover description of her 1969 book read, “What the dying have to teach doctors, nurses, clergy and their own families.â€
In a world that had become exceedingly technology-focused, day-to-day experience with human emotion received short shrift. Rationality was held up as the supreme value; emotionality was viewed as weakness. The “order of the day†seemed to become, “Let cooler heads prevail.†Perhaps the labeling of her “stages†with emotional terms even contributed to the theory’s “stickiness†and staying power, still quoted by millions as if there were some empirical evidence to it.
Third, she provided “order†in the chaotic world of global grief.
While scholars and clinicians alike have long sense concluded that few people progress through the “neat†five-stage sequence envisioned by Kübler-Ross, one of her great gifts was providing some descriptive order to the chaotic experience of pre-death grief. While we might not often observe all five of her stages in one person, and while many other emotions (like guilt and jealousy, to name just two) often loom much larger than the five she labeled, at least the notion of stages suggests a process through which one travels. By 1975, of course, Kübler-Ross was already talking about the lack of precision in her original stages, suggesting that some people did not experience one or another while other bereaved people re-experienced one (often anger) at a second or third point in their grief journey.
While some of us have objected to the rigidity of Kübler-Ross’ “stages,†at least she pointed us in the direction of resolution (“acceptanceâ€) rather than leaving the deeply-grieving person to conclude he or she might always feel this way. In a word, she prescribed order in a process that
feels chaotic because it
is chaotic. Perhaps this future hopefulness stands as her most enduring legacy.
References:
Kübler-Ross, E. (1975).
Death: The Final Stage of Growth. Englewood Cliffs, NJ: Prentice-Hall.
A Moral Force: The Story of Dr. Balfour Mount. (2005, April 25).
Ottawa Citizen. Accessed from
http://www.canada.com/ ottawacitizen/story.html?id=896d005a-fedd-4f50-a2d9-83a95fc56464
Author:
William G. (Bill) Hoy is an educator, counselor and author who has specialized in end-of-life and bereavement care for nearly 30 years. Dr. Hoy’s passion is equipping the next generation of physicians and other healthcare professionals through his research, writing and teaching responsibilities on the clinical faculty in Medical Humanities at Baylor University. His newest book is
Do Funerals Matter? The Purposes and Practices of Death Rituals in Global Perspective (Routledge, 2013).
