Q: I understand the theory of Elisabeth Kübler-Ross’s grief-stage model, which she made famous in On Death and Dying, but how can it be used to guide practical interventions in therapy?
A: People’s experience of grief is as unique as their lives and their losses. But although many people experience common responses to loss, as Elisabeth Kübler-Ross would always say, the stages—Denial, Anger, Bargaining, Depression, Acceptance—were never meant to tuck messy emotions into neat packages. Still, her model not only offers deep clinical insight, but can help therapists set reasonable treatment goals for clients dealing with grief, especially when they seem stuck in a certain stage of it. And rather than addressing grief as a problem to be fixed, the model can help clients embrace it as a natural part of life’s experience.
While Kübler-Ross’s stages are often conceived in a certain order, most clinicians know that they’re not stops on some linear timeline, and not everyone goes through all of them or in a prescribed order. What clinicians don’t often realize, however, is that the stages can provide a practical framework to help us identify what clients may need in their journey toward healing.
Editor’s note: In this excerpted version of the article, we focus on how to help clients navigate two of these stages—Denial and Acceptance. To read about helping clients through the other three stages, check out the full version in our July/August 2016 issue.
Denial: Increase Reality of the Loss
When we’re in the denial stage of grief, we may be paralyzed with shock or blanketed with numbness, but even though some people may say things like “I can’t believe he’s dead,” denial doesn’t mean denial of the actual death. Instead, it means the death is just too much for a person’s psyche to take in. In this stage, the world can seem meaningless and overwhelming. Life makes no sense. We may wonder how we can go on, if we can go on, why we should go on. These feelings are important: they’re the psyche’s protective mechanisms. Letting in all the feelings associated with loss at once would be overwhelming emotionally. Still, it’s important not to get stuck in this stage, which is what happened to Mary.
Mary mentioned to her therapist on multiple occasions that she couldn’t visit her husband’s grave even though it had been 14 months since he’d died. She also shared that her friends and family were worried that she wouldn’t give away any of his clothes and that his bathroom items were still in place, as if he could walk in at any moment. Her response was that she just couldn’t believe he was gone, but her denial was turning into guilt for not visiting his grave.
Already Mary’s therapist had had multiple discussions about what keeping her husband’s possessions intact meant to her and why her daughter might be pushing her to get rid of them. In the course of the discussions, however, Mary always got defensive, refusing to discuss the issue. So realizing that she was stuck in the denial stage and unable to move forward, her therapist decided gently to increase the reality of the loss. First, he asked if she’d be willing to walk around the perimeter of the cemetery.
“Are you hoping I’ll go in?” Mary asked skeptically.
“No, I’m just hoping you’ll walk around the parameter,” her therapist responded.
Mary agreed. In her next session, after walking around the cemetery, she reported that she felt relieved there wasn’t pressure to go in. Her therapist simply commended her for taking the walk and asked if she’d be willing to do it again. After the second time, she was much more relaxed and even reported a feeling of calmness.
“Would you be open to walking a third time?” her therapist asked.
“Now you want me to try to walk in,” Mary guessed.
“No,” he replied, “I’m just asking you to walk around it again.”
Mary agreed and returned for her next session holding back tears. She said, “As I walked, I began to think about why you’re having me do this. Then it hit me. I’m walking around a cemetery every Sunday because he’s dead. He’s gone.”
The therapist sat and witnessed her grief.
Mary asked, “Now what?”
The therapist said, “That’s it, nothing more. You did well.”
The next week, she threw away her husband’s razor and toothbrush. A few weeks later, without any prompting, she went to his grave. The simple act of having her walk around the cemetery opened her connection to her loss and helped her face her feelings about it.
Acceptance: Find a “Good” Bye
A client may say, “You don’t know what my husband was like in his last year with cancer. I keep thinking about his body deteriorating and all those horrible memories are frozen in my mind. I’ll never accept his death: it was too horrible.”
This is an indication of a “bad” bye—when the client is fixated on the last year, hour, or moments that were so hard. But therapists can help clients find a “good” bye by helping them zoom out of that painful timeframe and inquiring about the whole course of the relationship with the loved one. So a therapist might say to a client, “You told me about your dad’s last hour. Tell me about your earliest memory of your dad.” Or “Tell me your favorite memory of your dad.” Or “You’ve told me about your husband’s last year. Tell me about your first year together.” This helps the person say a “good” bye to the whole relationship, instead of focusing too narrowly on those last challenging days or hours.
Of course, people usually go through all the stages of grief without any therapeutic guidance or direction, but it’s helpful for clinicians to know the stages of loss in order to understand the fluid feelings of grief and offer structure to clients who need more support. After a loss, some clients may look as if they’re running from grief, but they’re really running from the pain that comes with it. In fact, the journey through grief, with all the stages that Kübler-Ross captured so indelibly in her model, are the stops along the way that help us heal.
This blog is excerpted from "Moving through Grief" by David Kessler. The full version is available in the July/August 2016 issue, OCD: Is There Any Way to Turn It Off?
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