Kubler-Ross Redux

Francis Dominic Degnin M.P.M., Ph.D.Department of Philosophy & World ReligionsUniversity of Northern IowaClinical EthicistWheaton Franciscan Health Care of Iowa

ObjectivesTo be able to explain the “positive”

role of each of Kubler-Ross’ first four stages of Grief.

To identify when a stage is serving a positive role for a patient and when it is not.

To explain the role and limits of Kubler-Ross’ model.

Kubler-Ross’ Stages of Grief1 Denial

2 Anger

3 Bargaining

4 Depression

5 Acceptance

Which are usually thought of as “bad”?

Which is usually thought of as “good”?

What if we reverse this?

DenialNot just a river in Africa

When one would otherwise be overwhelmed, it allows on to continue to function.

Accepts the shock in “bits” instead of all at once.

ExamplesBilly Bud

Maria and Ishmael

(Nuland, How We Die)

When Is it a Problem?

When our denial, instead of helping us to function and cope, puts us or others at greater risk of harm.

AngerWhat is “Catharsis”?

◦Not just an emotional outpouring

◦An emotional release which brings insight (psychology)

◦A fundamental source of truth (Ancient Greek)

What does Anger Have to Teach Us?

Something has to stop

or

Something has to change

It may also help give us the strength to make the change.

Common Mistake

We usually assume that what has to stop or change is in someone else.

More often, it is something in ourselves.

Examples:

Blaming one’s spouse for problems in one’s marriage.

Staying in a bad marriage.

◦The woman on her 3rd divorce

When is it a Problem?When we misplace responsibility

When we hang onto anger beyond the point where it is helpful.

The Necessity of ForgivenessForgiveness is not “being a doormat”.

Forgiveness is “letting go” when one is ready to move on.

Forgiveness often involves the other person, but doesn’t have too.

Forgiveness does not mean taking away responsibility.

Example: Abused sister in TN.Example: “Never again!”

BargainingA bit like denial, it helps one to cope

with the situation in “bits” so as not to be as overwhelmed.

Can help to think through and clarify one’s values.

Like Denial, is a problem when it starts to have negative impacts on one’s ability to cope or places oneself or others at greater risk for harm.

DEPRESSION Has a very bad name in our society

People who aren’t “happy” are often stigmatized (weak, defective, etc.)

Anti-depressants are the second most prescribed drugs, at over $10 Billion/year. One person in 10 over the age of 12. 70% are women.

http://www.nimh.nih.gov/about/director/2011/antidepressants-a-complicated-picture.shtmlhttp://www.npr.org/blogs/health/2011/10/20/141544135/look-around-1-in-10-americans-take-antidepressants

The AMA and the APA both state that at least a couple of periods of “situational” depression are normal over the course one’s life.

Of course, clinical and situational depression need to be treated somewhat differently.

What possible positive benefit might depression have for a person?

Depression: A “little” death?A subtheme running through every

major religion is the claim that:

“only when knows how to die does one know how to live”

What does this mean?

On the First Day of Death & Dying:• I ask my students to set aside their beliefs in an

afterlife.

• There is a great deal that facing that discomfort, that dis-ease, has to teach us.

• And that there tends to be a fundamental difference, even in those how believe an afterlife, between:

Those who have faced their fears and learned from them

And those who use their belief in an afterlife to escape from those fears.

The Fundamental Question

If one accepts the possibility that this life may be ALL there is….

What question does it raise?

“What makes this life worth living?”

When one answers this question, not intellectually, but in one’s body and one’s heart, one lives very differently.

In Depression, one experiences a deadening of affect and value in life.

This raises that fundamental question:

Is anything in this life worthwhile?

Suicide becomes a possibility.

But for those who work through their depression, the answers they find often result in a rich, deep, and fulfilling life.

Examples:Melissa, Psych Nurse Practitioner

David, quadriplegic

Epic of Gilgamesh

Tuesdays with Morrie

The Death of Ivan Illych

Common Threads? One cannot be truly happy until one has come to care

for someone or something else more than just oneself.

We also need to feel that we have something to contribute to others.

It is the sense of felt connection to others, or to something larger than oneself, which transforms.

This is not primarily an intellectual answer, it cannot be forced.

Plays on the inverse relationship between pain and world.

Depression

If accepted and worked through, can lead one to a rich understanding of the meaning for life.

If suppressed, it usually just becomes more powerful.

When is the Stage Going too far?When one is ready to commit

suicide or it otherwise puts oneself or others at risk.

But the real problem is that we so often drug people without providing other resources for working through depression.

AcceptanceIf one has truly “worked through”

the other stages, acceptance is a rich and wonderful outcome.

Too often, however, it’s really what Neeld calls “the booby prize”, or resignation.

Elizabeth Neeld, Seven Choices: Finding Daylight after Loss Shatters your World