The Five Stages of Change
Bringing Grief Therapy out of the Darkness 

Ken Lucas is a licensed substance abuse therapist and is the Arizona community relations director for Valley Hope Association. He is the author of Outwitting Your Alcoholic (Idyll Arbor Press); his newest book is The Reality Between: A Buddhist Approach to Addiction, Grief, and Psychotherapy. He can be reached at kenlucasbooks.com or kenl@valleyhope.com 

by Ken Lucas, LISAC, CADAC 

What’s the first thing you think of when I mention the name Elisabeth Kubler-Ross? If you say death and bereavement you would be among the vast majority. And why not? The Swiss physician/researcher did seminal work on the grief process since her first book was published in 1969; when she died in Scottsdale in August 2004, not only was she regarded as the leading thanatologist of her time but she was the mother of the modern hospice movement. 

But as one who has used her work as an addiction therapist, I now equate her wonderful body of work with life, indeed the very essence of life. 

It’s my belief that Kubler-Ross, by limiting her work solely to death of the body, boxed herself in. I now see that her wonderful grief stages (denial/isolation, anger, bargaining, depression and acceptance) are perfectly compatible with the other small, medium and large non-death issues we all face (empty-nest syndrome, aging, graduation, marriage, divorce, menopause, retirement, job changes, change in social identity, ill health and even addiction.) In other words, it’s time for her grief process to be liberated from the dark mausoleum where it’s been since bell bottoms and tie-dye were fashionable and be reframed as Five Stages of Change. In other words, Kubler-Ross got it right the first time—she just didn’t go far enough. 

My new book, entitled The Reality Between: A Buddhist Approach to Addiction, Grief, and Psychotherapy (iUniverse.com), takes up with Kubler-Ross left off. It describes how seven years ago, I began to volunteer my time to work alongside therapist Serine Graham and others at the Franciscan Renewal Center. Serine and I co-facilitate a 90-minute drop-in group called the Many Faces of Chemical Dependency on Thursday nights from 7 to 8:30 pm. 

After doing this group for two years, one night I idly summed up what had been said by group members and was stunned to hear myself saying, "We’ve spoken a lot about grief tonight." And indeed we had. One couple was there because they had a bomb dropped on them earlier that day when their daughter self-disclosed an addiction to pot (denial/isolation). Another couple was there because the husband had just graduated from his third residential treatment program and they had severe trust issues (anger) that were audible to those in the next room. One woman member of the group solved her problem by vowing to drink only every other Saturday (bargaining.) That left one guy who seemed to know that his addictive self had just died and, head in hands, he wondered what or who was going emerge (depression). Others who had benefited from AA, NA and Al-Anon spoke of the great impact of a recovery program on their lives and thus were living in acceptance. 

So much group time and energy was devoted to grief of the body, mind, and spirit that someone who entered the group late, say, at 7:30, could easily have been forgiven for mistaking the assembly for the Grief Support Group that meets at the Casa on Tuesdays. 

As the months wore on, I began another experiment: Rather than ask for core feelings (mad, sad, glad, hurt, ashamed, afraid) as an agenda round, I produced a list of Kubler-Ross’s Five Stages of Grief and asked each person what stage best described them. It didn’t take long for them to get the point and each became adept at saying "Tonight, I’m finally into acceptance" or "I seem to be going back and forth from denial to anger." 

Many 12-Step members are familiar with Dr. Paul O’s famous phrase ("And acceptance is the answer to all my problems today.") on page 417 of the 4th edition of the AA Big Book. That was written decades ago and no doubt leads many newcomers to believe they simply need to pray and acceptance will be theirs. Perhaps. But 35 years ago, Elisabeth Kubler-Ross came along and told us that acceptance didn’t just come to us—we had to work for it by following (more or less) a well-prescribed series of steps. She said acceptance was the goal of her five-step process and we had lots of work to do before we got there. One begins with denial in her process and ends with acceptance. One begins by admitting a problem in the AA process and ends up being happy, joyous, and free at Step 12. 

It’s now disheartening to watch psychotherapists encounter anger and depression among their patients and scratch their heads as to why. What they seem to forget is anger and depression are two major players in the Kubler-Ross grief stages. I have come to believe if you have an angry or depressive patient, what I term the "grief context" of the patient should be carefully explored. Why is patient A angry? Because 40 years ago his dad walked out on the family and the patient has been stuck in the anger stage of a grief process since childhood. Why is patient B depressed? Is it because the counselor never asked about the loss she suffered months ago when a major relationship went south? 

Kubler-Ross never implied that anger and depression are stand-alone issues and neither do I. They’re merely symptoms of loss, a pool of oil (if you will) that leads us to the wealth of riches that a thorough examination of the patient’s grief context will provide. 

Then I began to see that by failing to think about and plan for physical death, we postpone the Kubler-Ross grief process until we are told of a terminal illness. Having little time to go through her grief stages, we barely get into her anger or bargaining stages when we expire. Most people do this and it leads the rest of us to believe that being angry and depressed (being in medias res of the Kubler-Ross grief stages) is what dying is all about. That is, until we observe someone who dies in acceptance and we begin to see how they planned for their death many months or years ago. 

So why is it we fail to see all changes, big and small, paramount and picayune, as part of a grief process? Perhaps it’s because in the West (western hemisphere, that is) we don’t have much of a philosophy or religion that consistently reminds us that life is a short history of hellos and good-byes. Like atomic particles, planets, solar systems, galaxies and universes, human beings come into existence and quickly depart. It’s my contention that change is the common denominator of life—that every event, from the largest to the smallest, involves change; change means loss and loss means grief. 

What if Western therapists began to see life, as Eastern practitioners do, as always impermanent, always in flux, always changing and abounding in small, large, and devastating changes, most of which are not known or seen because modern psychotherapist don’t look for them? The Buddhists know this. At the heart of the Buddhist teaching is the Truth of Impermanence. All life is constantly changing, yet we have mental and behavioral health problems because we’re very brittle people who live in an ever-changing world. It is our duty as therapists to dig for the grief context of every patient and empower him or her to become just as fluid and dynamic as the ever-changing world around us.

 Reprinted by permission of Arizona Together Newspaper, February 2005.

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