The five stages in coping with dying & bereavement does not measure up to the standards of a sound theory in contemporary thinking, can actually do damage when misapplied or applied too rigidly, & should be set aside

The ‘five stages’ in coping with dying and bereavement: strengths, weaknesses and some alternatives. Charles A. Corr. Mortality, https://www.tandfonline.com/doi/abs/10.1080/13576275.2018.1527826

ABSTRACT: This article offers a reflective analysis of one well-known psychological theory, the so-called ‘five stages’ in coping with dying and coping with bereavement. Despite widespread acceptance among the general public and continued presence in some forms of professional education, it is argued that the ‘five stages’ model is less attractive than it initially appears. Significant criticisms of the theory are set forth here, as well as notable strengths of its underlying foundations. Lessons to learn about this theory are offered in terms of both coping with dying and coping with bereavement. In addition, examples of alternative theories from the literature are presented in both spheres. The conclusion is that although the five stages model is important as a classical theory with constructive historical implications, it does not measure up to the standards of a sound theory in contemporary thinking, can actually do damage when misapplied to individuals or applied too rigidly, and should be set aside as an unreliable guide to both education and practice.

KEYWORDS: Five stages, Kübler-Ross, coping, dying, bereavement

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Carl Jung (1954, p. 7) once offered the following comment:

Theories in psychology are the very devil. It is true that we need certain points of view for their orienting and heuristic value; but they should always be regarded as mere auxiliary concepts that can be laid aside at any time.

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In her book, On Death and Dying (1969), Elisabeth Kübler-Ross reported that a series of interviews with adults who had a terminal illness had led her to formulate a theoretical model of five psychosocial stages (see Table 1). She interpreted these stages as ‘defense mechanisms’ that ‘will last for different periods of time and will replace each other or exist at times side by side’ (p. 138). The possibility of stages existing simultaneously or ‘side by side’ was not well developed, perhaps because the very word ‘stage’ suggests linearity and perhaps also because there was some ambiguity in the way individuals were portrayed in this model. Were the stages descriptive or prescriptive? Was it that individuals might, may, will or must move through the five stages?

There can be no doubt that Kübler-Ross’s five stages appealed to many who read about or heard of this model. Her work helped to bring the situation of dying persons and issues involved in coping with dying to public and professional attention. She drew attention to the human aspects of living with dying and her model identified common patterns of familiar psychosocial reactions to difficult situations.

There are, however, major difficulties in accepting the five stage model as it was originally presented. Early research by others (e.g. Metzger, 1980; Schulz & Aderman, 1974) did not support this model. In addition, since its initial appearance in 1969, there has been no independent confirmation of its validity or reliability, and Kübler-Ross advanced no further evidence on its behalf before her death in August 2004. On the contrary, many clinicians who work with the dying found this model to be inadequate, superficial, and misleading (e.g. Pattison, 1977; Shneidman, 1980/1995; Weisman, 1977).

[Table 1.]

Responding to past and present losses

Anticipating and responding to losses yet to come Described as a stage ‘almost void of feelings’ Source: Based on Kübler-Ross (1969). Widespread acclaim in the popular arena contrasts with sharp criticism from scholars (e.g. Klass, 1982; Klass & Hutch, 1986), and there is no evidence that this model is employed in contemporary hospice programmes that have caring for the dying as their primary focus. One detailed and authoritative evaluation of this stage-based model by a well-known psychologist raised the following points: (1) the existence of these stages as such as not been demonstrated; (2) no evidence has been presented that people actually do move from stage 1 through stage 3; (3) the limitations of the method have not been acknowledge; (4) the line is blurred between description and prescription; (5) the totality of the person’slifeis neglected in favour of the supposed stages of dying; and (6) the resources, pressures and characteristics of the immediate environment, which can make a tremendous difference, are not taken into account (Kastenbaum, 2012). In addition, Weisman (1972) pointed out that ‘denial’ and ‘acceptance’ arethemselves complex and not as simple as they first appea r(and, one might add that ‘depression’ must mean something more akin to ‘sadness’ than to ‘clinical depression’ unless we think that this stage in coping with dying reflects a major psychiatric disorder).

Apart from the implication that there are only five ways to cope with dying, a primary criticism of this model is that there is no reason to think that these particular five ways are linked together as stages in a larger process (Corr, 1993, 2011). In fact, Kübler-Ross herself argued for fluidity, give-and-take, the possibility of experiencing two of these responses simultaneously, and an ability to jump around from one stage to another. This is more realistic and closer to what Shneidman (1973,p.7)calleda‘hive of affect’,i.e.abusy, buzzing, active set of feelings, attitudes and other reactions to which a person can return from time to time, or again and again, now expressing one posture, now another, sometimes simultaneously, sometimes repeatedly, sometimes with long intervals in between. If so, the language of ‘stages’, with its associated implications of linear progression/regression, is not really appropriate for a cluster of disconnected coping strategies. Numerous vignettes in On Death and Dying that describe different individuals experiencing different reactions and responses to life-threatening illness do not support claims that any one of these individuals has or will move through all five of the ‘stages’. This stage theory is attractive because it seems to describe a relatively simple, straight-lined, predictable course of behaviour, one culminating in a clear end –but that does not mean the fivestage model is a sound theory.

Unfortunately, some enthusiasts have misused this model by objectifying dying persons as a ‘case of anger’ or a ‘case of depression’; others have told ill persons that they have already been angry and should now ‘move on’ to bargaining or depression; and still others have become frustrated by those whom they view as ‘stuck’ in the dying process. Kübler-Ross could have modified her theory after its initial presentation. She might not have contented herself with simply repeating its main elements in her many presentations and other publications. And she might have addressed criticisms or misuses of the fivestage model. But she did none of these things. As she left it, the five-stage model stands on nothing more than one author’s clinical impressions from 50-year-old interviews. Unfortunately, the result (contrary to Jung’s advice) is that employing this model all too often tends to force those who are coping with dying into a pre-established framework that suppresses their individuality. Thus, Rosenthal (1973, p. 39), as he was coping with his own dying, wrote, ‘Being invisible I invite only generalizations’.