Life Review and Coping With Mortality: Kübler-Ross and Beyond

Introduction: Mortality and the Need for Closure

For most of us, a sense of impending mortality prompts a need to find closure, conduct a full life review, and seek reconciliation (Clarke, 2007). The reality that death is a natural process — leading toward an inescapable final destination — seems implausible at first glance. For a variety of reasons, death has become a taboo subject that no longer represents an accepted progression of life, but rather something unnatural to be wrestled against. Coming to terms with impending mortality is challenging and calls forth a range of deep emotions that need to be expressed. Expressing these intense feelings and reviewing one's life is essential to finding peace and allowing true healing on an emotional and spiritual level (Sand et al., 2009).

The Life Review Process

The life review process is described as a "naturally occurring, universal mental process" (Butler, 1963). In other words, it is a normal developmental task of old age. The later years of life are conducive to the life review process, as individuals are typically becoming more disengaged from society and thus have more time for self-reflection (Clarke, 2007). The process is hypothesized to be experienced by all older adults, either consciously or unconsciously (Butler, 1963). However, it is important to note that the life review process occurs not only in the elderly, but also in the terminally ill or condemned (Breitbart et al., 2004). A sense of mortality and vulnerability motivates the individual to look back and reassess their life in view of imminent death.

The extent to which the life review is experienced varies. For some it manifests as only brief, insignificant thoughts. For others, the process may take the form of mild nostalgia or regret. In its more severe form, it can be experienced as anxiety, guilt, and/or depression. The severity of the life review is in part due to the outcome of that review. According to Butler, as individuals realize that there is limited time remaining to them, they will examine the kind of life they have lived (1963). They may deem it a success or a failure, and from there make a determination as to who they ultimately became and how they feel about it.

The DABDA Model: Kübler-Ross's Five Stages

If the review results in a negative evaluation, the person may fall into despair and be filled with regrets. He or she may want to change their life but may not feel they have enough time, thus making the prospect of death difficult to endure (McPherson et al., 2007). Psychological manifestations may take the form of guilt, depression, and anxiety. If, however, the individual assesses their life to be a success, the review can be therapeutic and aid in preparation for death, eliminating fear. This may account for the wisdom and serenity one often observes in older adults (Clarke, 2007). For some, it also prompts the desire to leave a legacy. Butler states, "There is perhaps no other group that can tell us something about the nature of human life with all of its successes and problems better than old people" (1963). Thus, the oral history can provide a means by which older adults make their mark on succeeding generations (Clarke, 2007).

Denial and Anger: The First Two Stages

The DABDA theory of coping with death, created by Dr. Elisabeth Kübler-Ross, identifies five common stages — denial, anger, bargaining, depression, and acceptance. Dr. Kübler-Ross was a Swiss-American psychiatrist renowned for her pioneering work in near-death studies and her acclaimed book On Death and Dying, published in 1969. The five stages were based on her research and interviews with more than 500 dying patients. These stages describe the psychological and emotional responses that many people experience. It has been noted that not everyone goes through all five stages, nor would they necessarily go through them in sequence (Friedman & James, 2008). Although other models have been developed to explain how people cope with grief and loss, the five stages of the Kübler-Ross model remain the most widely recognized by the general public.

In facing one's own mortality, it would be logical that denial is the first psychological reaction. As much as we rationally know that we all die, we do not truly believe it will happen to us. Somehow the idea of death seems glaringly absurd — it is something that happens to others. Denial is an exaggeration of the normal process of selective attention, used in order to function normally, particularly in the face of challenges. The psyche allows traditional ego defense mechanisms to take over as a means to alleviate distress (Knight & Emanuel, 2007). Denial is often reflected in a disconnected attitude toward negative news and a continuation of making plans for the future — scheduling holidays, designing home renovations, investing — all while being aware that time is running out.

When utilized appropriately, denial can be helpful. During this stage it is important to discover the things most important in life and take a brief rest from intense emotion. However, denial can be deemed excessive if it results in a persistent refusal to discuss an illness or situation due to fear (Sand et al., 2009). Disbelief, shock, or numbness can be experienced to such an extent that it culminates in an attitude of non-acceptance. Cancer might be referred to as a mere "rash," or there may be denial of the need for medication or changes in diet or lifestyle (Schroepfer, 2007). Often, people who fall into this category do not possess the confidence in their own abilities to face and adjust to problems. Denial must be respected as a coping mechanism. Some people refuse to discuss or think about their illness all the way up until the time of death. However, most people eventually reach a stage when it becomes a relief to discuss some of their fears. Extreme denial prevents the sharing of unrealistic fears, causing anxiety to escalate and blocking meaningful communication with loved ones.

Anger is the second stage of the DABDA theory. Once denial has passed and impending mortality becomes real, a dying person may feel the need to gain the permission of loved ones to express their anger, fearing they might alienate those they love most (McPherson et al., 2007). However, by expressing feelings of anger — at the illness, at the unfairness of the world, or even at a higher power — a dying person is actually preparing for peace and acceptance. As the life review begins, one may start to recognize their own role in all that has happened to them. Most people describe this as a freeing experience (Carlander et al., 2011). It is characterized by an acknowledgment that the individual is not to blame for the illness and that dying does not indicate a failure in life. This realization of personal responsibility is critical in overcoming feelings of anger.