sagher, a. d. (2016) models of transformation: an evaluation of kubler ross

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Amira D. Sagher (2016). Models of Transformation: the nature of self-actualisation 1 Amira D. Sagher Published online by OMpassion CIC, Bracknell, United Kingdom. January 2016 This paper forms a contribution to the Institute of Noetic Sciences, California as part of their research in transformational therapies. Introduction to the Model Elizabeth Kübler-Ross is a Swiss-American psychiatrist, who developed the model; Five Stages of Grief to help people deal with death and dying. She, alongside a group of Theology students, interviewed hundreds of dying patients across four years of research. From her work Kübler-Ross discovered how death was often seen as a catastrophic happening and that many people lived in denial of what is an inevitible event (Kübler-Ross, 1972). She also found that many of the complications of dying patients who, decades later in life, experience various somatic moans and groans that cannot be understood medically, is related to a “peculiar sense of guilt” (Kübler - Ross, 1972, p. 174). She explained this using the example of a small child who wishes that their parent would ‘drop dead’, as a normal, insincere expression of emotion. However if the parent were to really die the child would experience feelings of self-blame, as if somehow they had caused the event to happen. In a similar way, Kübler-Ross explains how many people harbour unncessary feelings of guilt that are related to our insecurities about death. In later life, these people may feel almost as if they have committed a crime and have to be punished before they die. They suffer far beyond current medical understanding. In this denial of death, societies have evolved to develop destructive technologies to defend against the new and varied threats we face to modern survival. In short, Kübler-Ross says that “we live in the illusion that, since we have mastered so many things, we shall be able to master death too.” ( Kübler-Ross, 1972, p.175). It is arguably this fear of death that also drives mankind in to attach so much to an ‘egoic’ sense of self (Welwood, 2000). Models of transformation, necessarily imply a a transcendent dimension that exists within the person’s psychological potential. The development of a model that deals with death and dying evolved in order to help patients, loved ones and those involved in their care understand and move through identifiable stages of the grieving process. There are five key stages which form the framework of learning how to live with death, dying and loss. The model also functions as a set of tools to help a person contextualise and identify what they may be feeling, whether they are care staff, family members or the patient. These stages are; Denial; Anger; Bargaining; Depression; and Acceptance. The Five Stages of Grief Denial According to Kübler-Ross, denial is nature’s way of letting in only as much as a person can handle. New pieces of reality gradually become accepted and the person becomes stronger, while at the same time becoming more aware of all the feelings they have previously denied (Kübler-Ross, Kessler & Shriver, 2014). This process of self- awareness is a common theme woven throughout various approaches to psychotherapy (Neff et al., 2007; Kabat-Zinn, 1982; Rogers, 1986) with the core aim of integrating the person. When major change happens for us, the process of adaptation may seep forward in little chunks or waves of reflection as a result of functional denial. Models of Transformation An evaluation of Kübler-Ross

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Explores the nature of self-transcendence in relation to the grieving process.

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Page 1: Sagher, A. D. (2016) Models of Transformation: an evaluation of Kubler Ross

Amira D. Sagher (2016). Models of Transformation: the nature of self-actualisation

1

Amira D. Sagher

Published online by OMpassion CIC, Bracknell, United Kingdom.

January 2016

This paper forms a contribution to the Institute of Noetic Sciences, California as part of their research in transformational therapies.

Introduction to the Model Elizabeth Kübler-Ross is a Swiss-American psychiatrist, who developed the model; Five Stages of Grief to help people deal with death and dying. She, alongside a group of Theology students, interviewed hundreds of dying patients across four years of research. From her work Kübler-Ross discovered how death was often seen as a catastrophic happening and that many people lived in denial of what is an inevitible event (Kübler-Ross, 1972). She also found that many of the complications of dying patients who, decades later in life, experience various somatic moans and groans that cannot be understood medically, is related to a “peculiar sense of guilt” (Kübler-Ross, 1972, p. 174). She explained this using the example of a small child who wishes that their parent would ‘drop dead’, as a normal, insincere expression of emotion. However if the parent were to really die the child would experience feelings of self-blame, as if somehow they had caused the event to happen. In a similar way, Kübler-Ross explains how many people harbour unncessary feelings of guilt that are related to our insecurities about death. In later life, these people may feel almost as if they have committed a crime and have to be punished before they die. They suffer far beyond current medical understanding. In this denial of death, societies have evolved to develop destructive technologies to defend against the new and varied threats we face to modern survival. In short, Kübler-Ross says that “we live in the illusion that, since we have mastered so many things, we shall be able to master death too.” (Kübler-Ross, 1972, p.175). It is arguably this fear of death that also drives mankind in to attach so much to an ‘egoic’ sense of self (Welwood, 2000). Models of transformation, necessarily imply a a transcendent dimension that exists within the person’s psychological potential. The development of a model that deals with death and dying evolved in order to help patients, loved ones and those involved in their care understand and move through identifiable stages of the grieving process. There are five key stages which form the framework of learning how to live with death, dying and loss. The model also functions as a set of tools to help a person contextualise and identify what they may be feeling, whether they are care staff, family members or the patient. These stages are; Denial; Anger; Bargaining; Depression; and Acceptance.

The Five Stages of Grief Denial According to Kübler-Ross, denial is nature’s way of letting in only as much as a person can handle. New pieces of reality gradually become accepted and the person becomes stronger, while at the same time becoming more aware of all the feelings they have previously denied (Kübler-Ross, Kessler & Shriver, 2014). This process of self-awareness is a common theme woven throughout various approaches to psychotherapy (Neff et al., 2007; Kabat-Zinn, 1982; Rogers, 1986) with the core aim of integrating the person. When major change happens for us, the process of adaptation may seep forward in little chunks or waves of reflection as a result of functional denial.

Models of Transformation

An evaluation of Kübler-Ross

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Anger Anger is considered to be a necessary stage of the healing process. The more anger that is felt, the more it will begin to dissolve, and the more a person can recognise that underneath their anger is pain. Anger is considered as strength, and as an anchor. Anger provides structure to temporary to the nothingness of loss as it is often projected out onto other people, facilitating a sense of connection to the world. The disorientation that major changes can elicit, can render a person feeling ungrounded and so anger may be one way in which emotional pain and social connection can both be experienced.

Bargaining Loved ones may feel like they would ‘do anything’ to let a person live. Patients who are dying may also express similar wishes. They may enter into requests with God such as promising not to be angry ever again if He ‘just let them live’. This type of bargaining implies a context of punishment and reward, associated with feelings of guilt that Kübler-Ross observed frequently in the mood behaviours of older people. During the anger stage, a person may become lost in a maze of emotional negotiations and ‘what if’s’. The ‘what if’s’ however, also function to find a sense of ‘cause’ and effect that is associated with guilt.

Depression After bargaining, the person’s attention focusses on the present. Empty feelings present themselves, and grief enters their lives on a deeper level. Depression after a loss is often seen as unnatural or something to be fixed or to snap out of. The loss of a loved one is in actuality, a very depressing situation though, and depression is a normal and appropriate response. Depression may be one of the necessary steps in accepting loss and may arise as a reactive or withdrawn state. For the patient, this may be experienced as crying and talking and then later becoming quiet and withdrawn.

Acceptance Living with the reality that the loved one is physically gone or will be physically gone is the defining feature of the acceptance stage. For the person left behind they may find new inspiration to enjoy and live life but they may also feel that they are betraying their loved one. For the person who is dying, acceptance of their death may emerge as a profound, transcendent experience whereby the person takes solace in themselves or God, with the love of their families around them. In the final days of life, some dying people may wish to say goodbye to their loved ones before the time comes. As Kübler-Ross explains, until the final decathexis or distancing from this world is experienced by the dying person, the entire transformational process is suffused with hope and faith. The ultimate stage of acceptance is often characterized by a sense of peace beyond words (Kübler-Ross, 1969). The patient just wants the companionship of a person who is comfortable to sit and hold their hand. (Kübler-Ross, 1972). This stage can also be termed as preparatory grief. (Kübler-Ross, 1972). For loved ones and family members, the acceptance stage is managed differently, who in their actively supportive role, necessarily do not separate from their loved one. Although each stage embodies a consistent theme between those affected by death or dying, the behaviours that emerge within these themes vary between the patient, the loved ones and the care givers. It is possible, that loved ones may often not reach the stage of acceptance until the person dies, because of the difference between ‘hope’ that family members might have and the inner ‘knowing’ of death arriving that is often reported by the dying person (Kübler-Ross, 1972).

Moving through the stages Care staff can help patients move through one or all of these stages through their enduring, compassionate presence, given the security the patient feels from knowing that they will be with them until the end. However, given the cultural stigma around death, not all care staff may find this process easy. In California researchers measured the response time between patients ringing for the nurse and the nurse actually coming into the room. They found that terminally ill patients had to wait twice as long as other patients for the nurse to respond, and that this may be due to the personal emotional difficulty in managing a dying patient (Kübler-Ross, 1972). The denial and fear that many people face with the subject of death, may explain why models of grief appear as discrete stages. It takes time for the person to integrate radically new, previously denied realities. The experiences associated with these new realities are likely unconceivable until they happen. While these stages do not necessarily adhere to a chronological timeline, and while some people may not experience each stage

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distinctively (Kübler-Ross, 1972) others may become ‘fixated’ on a particular stage (Germain, 1980) and so support may be necessary in order to move through it. Kübler-Ross also emphasises that some stages can be moved through in minutes or hours while other stages may naturally take longer. A qualitative analysis of a single case study of ‘Anne’ (Todres et al., 2000) who, as an intensive care nurse herself, was admitted to an intensive care unit on three occasions. The study found that her experiences in a life threatening condition centred around themes of denial and conflict, personal struggle with feelings of loss of control and the need to trust. Alleviating factors included feeling reassured by the presence of a doctor who knew her personally, being able to be part of decisions being made and her assertive husband who was an advocate for her as someone who knew her as a person, beyond the technical environment. During this life-threatening crisis, there was a strong need for a sense of familiarity and continuity, which her husband and family provided. In this example, Anne did not experience acceptance of death, and perhaps this is a natural function of the person when death is not guaranteed, perhaps as a means of facilitating the body to stay alive.

Discussion of the Model Patients like Anne experience feelings of isolation, anxiety, fear, paranoia and depersonalisation during what is a very uncertain time. Not knowing what is happening to them can exacerbate a sense of insecurity and add to the levels of worry and disorientation (Hupcey & Zimmerman, 2000; Todres et al., 2000). In Anne’s case, she experienced what she describes as the ‘twilight zone’, which included distortions in sense of time, bodily perception and visual perception. Similar experiences are also found in states of consciousness in terminally ill patients who are facing imminent death (Papathanassoglou & Patiraki, 2003) as well as those experiencing ‘peak states’ during meditation (Hagerty et al., 2013). The research suggests that across the processes involved in dealing with death and dying, therapeutic presence, therapeutic touch and the support and sense of intimacy this brings to a person’s isolation within a ‘technical’ environment, may be all that is needed to move through the natural grieving and loss stages (Todres et al., 2000). For staff, the process of empathic acceptance is a primary feature of managing end of life care (Bailey et al., 2011). In 1981, Lancaster Osteopathic Hospital in Lancaster, Pennsylvania, explored ways of supporting grieving families who had experienced a perinatal death. The protocol they developed functioned in a way that returned control to parents and laid the groundwork for realistic, guilt-free grieving. (Carr et al., 1985). The stages outlined by Carr et al. support Kübler-Ross’s model, and include; denial, acceptance, withdrawal, numbness, attempt to accept through partially talking about the death, expressing anger, envy, resentment, guilt, self-blame, and depersonalisation. In a qualitative study using unstructured observations of practice and semistructured interviews in a large Emergency Department over a 12 month period (Bailey et al., 2011), behaviours of emergency staff were defined by developmental stages that included; interpersonal relations; management of emotional labour; and the development of emotional intelligence (defined as self-awareness, self-management, social awareness and relationship management). These components allowed nurses to recognise others needs, to regulate their own emotions and use their intuition to guide their decisions. Barriers that prevent the transition to emotional intelligence are thought to contribute to occupational stress, burnout and withdrawal from practice. Nurses who invested their therapeutic self into the nurse–patient relationship were able to manage the emotional labour of caring for the dying and their relatives through the development of emotional intelligence. These staff members found reward in end-of-life care that ultimately created a more positive experience for the patients and their relatives, and they found a transcendent dimension to what they at first may have been fearful of (Bailey et al., 2011). Although therapeutic intimacy is required to develop intuition in the care of the dying associated with caring excellence, the emergency environment and nature of emergency presentations constrain the development of such a relationship (Bailey et al., 2011). The individual level of emotional development of staff members must also be considered. Kübler-Ross’s model has been successfully applied to other contexts. Zell (2003) studied Professors in the physics department at a large university whose response to a crisis threatening the department’s survival, equated with Kübler-Ross’s stages in her study with terminally ill patients. The department and its members emotionally

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invested in their role and the department as an extension of their sense of self. Applying Kübler-Ross’s model to organizational change within a hospital setting was also successful in helping physicians and staff cope with the imposition of electronic health records (McAlearney, Hefner, Sieck & Huerta, 2015). Other contexts for this model include the child-birthing process, a physically ‘critical’ time for the mother and child, the potential mourning of the biological state of being pregnant while also experiencing profound transformation with the birth of new life and with a new identity as a mother. Survivors of critical illnesses, who have been through the stages of learning to accept their death and yet survived, report positive transformations in outlook and purpose that remain across time (Papathanassoglou & Patiraki, 2003). This suggests that working through these stages is a transformative mechanism in itself, at least in situations in which a major change is imposed onto the person from external circumstances. Throughout the research on psychological transformation, themes of trust, control and risk are at the root of emotional coping stages, regardless of the context. Polarities such as conflict vs. acceptance; and control vs. trust, are relevant functional states which a person dealing with profound change moves between, and which may underpin the stages of any model depicting the process of adaptation to major change. From the research reviewed on this model, it is important to consider the potentially functional role of guilt in the grieving process. In a similar way that anger provides an anchor, structure and connection to the world during very unfamiliar times, guilt may in fact be a form of compassion, but which arrives in the presence of self-judgment. The insecurity of how am ‘I’ to blame. Experientially, guilt and compassion can be felt in similar parts of the body. The body is a sensory-emotional map represented in the brain (Damasio, 1999; Tsakiris & Haggard, 2005) and so the location of an emotional experience may be an indication of what is happening for the person at a primary level. Guilt is something everyone can feel for different reasons, from childhood to old age, yet there is little understanding of how it functions for the person at a sensory or transpersonal level. Although there are few studies that have distinguished self vs. other-compassion, other-compassion/sympathy and guilt have been positively correlated (Harth et al., 2008). While guilt could be considered functional, it is functional for the non-transcended person. Self transcended people score highly in morals, values and ethics (Maslow, 1964) and so by definition are unlikely to behave in unethical ways. For others, it is their ‘mistakes’ and ‘misperceptions’ that can lead the psyche to attach to situations and build a negative construct of self. Since altruism is observed in various animal behaviour (Panksepp, 1991). it is considered an innate force. In human beings, compassion may be a more evolved form of this, its drive also being innately altruistic. In this way, altruism and compassion are fundamental needs. While many psychological approaches talk about its components (nonjudgmental presence, kindness, love) few mention compassion specifically. To understand the true nature of guilt could further develop this enriching model. From the premise of innate, primal altruistic drives, much more could be learned about the basis and function of emotions and their pattern of prevalence during the grieving process. This insight would develop the process of transcending judgmental entanglements of the psyche as a pathway for transformation.

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