Book Report: On Death and Dying – Part I

Note: Extracted from part of book report I submitted for the course Grief Counselling in 2017 Spring

Introduction

On Death and Dying was first published in 1969, authored by Elisabeth Kübler-Ross based on her experience working with terminally ill patients and their families. That was the time when medical practitioners were highly authoritarian leaving almost no room for patients to participate in decisions and society also avoided talking about death openly and privately.

Abstract

Death is a universal fear. When the time comes, patients will be increasingly fearful and lonely as they were taken out from their familiar environment and medical personnel in hospital are busily preoccupied with his heart rate, pulse, electrocardiogram or pulmonary functions, his secretions or excretions but no one try to understanding their needs, worries and feelings making the process impersonal to repressing medical personnels anxieties inside. (Chapter 1)

In Chapter 2, Kübler-Ross expressed that we are less able to defend physically as technology advanced, new weapons of increasing power of destruction continue to be invented, and this intensified our fear of destruction and anxieties towards death. Medical development to prolong life and depersonalized medical care was used to master death. Kübler-Ross invited us to face our own death for inner peace so we have the courage to encounter patients death and re-think how science and technology can bring us a more humanistic world.

Chapter 3 – 7 explained the five stage of grief, also known as Kübler-Ross model.

Stage 1: Denial and Isolation (Chapter 3)

It is a temporary defense of not accepting the shocking news. They tends to believe that the diagnosis is not right or they are recovering and need not to go through further diagnosis and treatment in a short while.

Stage 2: Anger (Chapter 4)

Patients anger will be displaced and projected randomly to family members and hospital staff through complaints and guilt or shame induction resulting in less visit and avoidance. This, then, intensifies the anger in patients a vicious cycle of alienation is thus formed. Inside their anger and attention seeking acts are the fear of being forgotten, and sometimes envy of healthy people. Thus, anger shouldnt be taken personally.

Stage 3: Bargaining (Chapter 5)

Patients attempt to ask, towards God usually, for the last reward (i.e. postponing death according to the self-imposed deadline) in exchange with good behavior. Behind this could be quiet guilt towards God (e.g. not attending church, not devoted enough into the religion) or deeper, unconscious hostile wishes that needs to be taken care of.

Stage 4: Depression (Chapter 6)

As patients illness progress, they became weaker, more hospitalization and operations were imposed, sooner or later sense of great loss” will become dominate. This is the stage which patients are preparing themselves to separate from this world and losing everything they love through grief (aka. preparatory grief), communications will shift to non-verbal one and their circle of interest decreases. Thus, there arent need to cheer them up as this normally serves our own inability to face death.

Some complications may result if patients had unresolved griefs as a result of past losses or regrets of havent taking certain opportunities when they are well.

Stage 5: Acceptance (Chapter 7)

It is a stage which patients are void of feelings and death could be a relief. Patients family will need more support than patients themselves. Their circle of interest further shrank. Nonverbal communication reminds them that they wont be left alone until the very end.

If patients family failed to distinguish or accept that patients are under this stage, blaming them for giving up too early or try real hard to prolong their life, they will feel dismay and angry to their family.

Kübler-Ross talked about Hope in patients that exist in all stages in Chapter 8. Hope maintains that their sufferings will pay off eventually by recovering, by a new drug or treatment plan that helps, if they endure it a bit longer. Hope also gives them a sense of meaning in their sufferings. Kübler-Ross reminded family members and caring professionals to maintain hope but not reinforce hope at the stage of final acceptance.

Chapter 9 focuses on how patients family can help and the adjustment and preparation needed by family members when patients become weaker and eventually pass away. Family members should maintain a balance between taking care of patients and their own needs for their well beings during patients hospitalization. 

Direct communications, discussions and expression of feelings between patients and their family members about the impending death not only can avoid anger, alienation and isolation but bring closeness and deeper sense of meaning to all. After all, patients can see through the make-believe mask of their family members. This not only prepares patients to go through anger and preparatory grief and eventually accept their impeding death, but their family members to go through similar stages. 

Kübler-Ross suggests that family members will feel void and emptiness after the funeral when relatives depart, thus right timing for human beings to talk and care them, and allow them to express their angry, despair or loneliness. Children and adolescence should be taken care of as well. For members who are pre-occupied with fantasies with the deceased, we should understand and allow them to express their feeling and not to ridicule or confront them too frequently. 

Additional interviews, their transcripts and analysis can be found in Chapter 10. For Chapter 11 & 12, Kübler-Ross shared the adversaries and oppositions from medical personnel throughout her works of interviewing terminally ill patients, and how this helps bringing a whole new perspective to medical personnel to provide humanistic and less impersonal medical care, and the courage to face death for both medical personal, patients themselves and their families.

 

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Bowen Family Therapy

ISS Family Institute (HK): Bowen Theory – Introduction [English] [Chinese]

  • More organized notes on Bowen Theory – 4 Foundation Concepts (Anxiety, Two Basic Life Forces, Emotional System and The Family as an Emotional Unit) and 8 Emotional Processes

Psychology In Seattle: Bowenian Therapy (10 mins)

  • 10-minute video going through concepts like Anxiety, Togetherness vs Separateness, Feelings vs Intellect, Differentiation and Triangulation, and Critiques

Erica E. Hartwell: Bowen’s Eight Concepts (30 mins)

  • 30-minute video going through concepts like Anxiety, Differentiation, Two basic life force: togetherness and separateness, emotional system and family as an emotional unit) and Triangles, and Process like Nuclear Family Emotional Process, Family Projection Process, Multi-generational Transmission Process, Sibling Position and Emotional Cut-off

Diane Gehart: Bowen YouTube (30 mins) 

  • Therapy Textbook Author going through Bowen Family Therapy which is informative, clear and easy to understand

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Book Report & Reflection: The Gift of Therapy – Irvin D. Yalom (1)

Gift-of-Therapy

Extracted from part of the first assignment I submitted when I was studying  Counselling Skills.

Highlights

I have read the first twelve chapters (excluding the Introduction) of “The Gift of Therapy” from Irvin D. Yalom up to this moment.

In the introduction chapter, Irvin objected the way Psychiatry was being driven to be – focus more on psychopharmacology and abandoning psychotherapy to make the theory more economical. Irvin pointed out the counter productiveness and the danger of self-fulling prophecy being brought to the less severely impaired patients if emphasis were put on a quick and precise vision-limiting diagnosis with a brief and focused therapy (Ch2).

He believed that human has an in-built force towards self-actualization and the patient will grow when obstacles were removed (Ch1) and gradual unfolding of the patient allows therapist to know the patient as fully as possible (Ch2).

Irvin seeks for a more humanly, interactive and equal way to treat his patients by admitting his errors (Ch9), letting the patient’s comment of towards his words matter to him (Ch7), being supportive (Ch5), care about the relationship between himself and his patients (Ch4) and avoid tin-can therapy and prefabricated technique (Ch10) to all clients. He is taking a more humanistic approach which takes time and is opposite to what he described the managed-care industry heading to.

Reflections

One of the good reminders I found is the diverse view of therapy hour between the client and the therapist in Chapter 6. Irvin, the therapist, thought that his client should found his interpretations of an event or thoughts described by his client most valuable. However, it turns out that his client didn’t notice his interpretation as if he hadn’t speak at all but words he doesn’t notice e.g. his apologies for being late, his compliments and his fun-making tease. It may be that these little acts make the relationship more like friendship and the support coming from this relationship is more authentic and genuine.

“I am human and let nothing human be alien to me” (Ch6) from Terence is being quoted by Erich Fromm when teaching Empathy. To expose ourselves to any kind fantasy of the patients allowed us to exercise accurate empathy. However, as every of us have our own pain and dark side that we aren’t fully aware of, this is why Irvin suggested student therapist should experience the therapeutic process (Ch12) to make those pain and dark side up in the conscious level so as to avoid displacement. Experiencing therapeutic process also allows therapists to experience as a client the things that will happen – project on to, idealize, depend on and granting power to the therapists.

To be a good counselor in the eye of one’s clients isn’t an easy task. It requires therapeutic technique to discover the issue and guide the patient through questions and sometimes challenges at the same time allows the client to experience empathy, respect and unconditional positive regards, not to say knowledge to psychology and variety of therapies – so many things to balance and think of.

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Factors of successful therapies

Further little research on the analysis of outcome studies of therapies on the relationship factor of four area of therapeutic factors contributed to the positive change in people – this is from Michael J. Lambert in 1992.

  1. client factor / extratherapeutic change (40%), those factors that are qualities of the client or qualities of his or her environment and that aid in recovery regardless of his or her participation in therapy (i.e. factors that are not related to/ outside of the treatment);
  2.  relationship factors // common factors (30%) that are found in a variety of therapy approaches, such as empathy and the therapeutic relationship
  3. expectation / expectancy (15%), the portion of improvement that results from the client’s expectation of help or belief in the rationale or effectiveness of therapy]
  4. techniques (10%) (some says 15% [2] ), those factors unique to specific therapies and tailored to treatment of specific problems.

Remarks – Given that the session last for 50-minute once or occasionally twice a week but contributing 40%-45% of a successful therapy  …  this is far from insignificant :O

Reference

[1] Wikipedia, “Common factors theory”, https://en.wikipedia.org/wiki/Common_factors_theory (Accessed 4th Oct, 2015)
[2] Cynthia Franklin, Rowena Fong eds., The Church Leader’s Counseling Resource Book: A Guide to Mental Health and Social Problems, Oxford University Press (2011) p.173

(Extracted from part of my assignment)

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