Death is a stage in human development which causes concern and dread for most people. Over the past thirty years, numerous psychologists have tried to define the stages which are experienced by the terminally ill. Most notably, Elisabeth Kubler-Ross, in 1969, said that the dying person goes through the stages of denial, anger, bargaining, depression, and acceptance. The role of the death counselor, therefore, is to help the terminally-ill patient get through these stages and also to assist that person in their transition from this life.
Counselors can help the terminally ill in three general ways. First, they can help them get their soul in order by sharing Christ with them. Of course, this particular task must be done with great care so as not to unnecessarily upset the ill person. Second, the counselor can help the dying person get their "personal" house in order by being willing to discuss such things as living wills, assisted suicide, and any other issues which might have suddenly become relevant. Finally, the counselor can help the client deal with their condition by helping them find a support group for their particular condition, by helping him or her through any of their death anxieties, and by possibly bringing them into contact with a care facility like Hospice.
Grace Craig (1996) calls death the "ultimate critical event" (p. 666). She points out that in death we stop experiencing, that we leave behind those who are close to us, that we leave things in our life undone, and that we prepare to enter into a state of the unknown. For these reasons, people are preoccupied with thoughts of dying, plus they also have a natural fear of having to experience their own death. Douglas Hacker (1994) writes that even adolescents have a dread of death. J. Davis Mannino (1997) writes that a career in death and dying chooses you rather than you choosing it, again suggesting that normal people, at all ages, do not look forward to their own death. In her book, Craig (1996) describes death as the final stage of human development. Therefore, because death weighs so heavily upon each of us, and especially upon those who have a serious illness, counseling those who are terminally ill is very difficult. However, it is also very important.
The Death Counselor And The Stages Of The Death Experience
Jeffrey A. Kottler and Robert W. Brown (1992) write that the death counselor "helps the dying in their final transition, the last exit from life" (p. 278). To do that effectively, the counselor must first understand the psychological stages which might be experienced by their terminally-ill patient. Craig (1996) identifies the five stages of death which were initially described by Elisabeth Kubler-Ross in 1969. These stages are denial, anger, bargaining, depression, and acceptance.
In the denial stage, the ill person is in a state of denying their condition because he or she has difficulty accepting the inevitability of their end. There is a sentiment within most of us which says that death always happens to the other guy, and of course, until we experience it for ourselves, it does. Next, during the anger stage, the individual feels resentment because of the realization that some of their plans in this life might not be fulfilled. In the bargaining stage, the individual seeks to buy more time. In II Kings 20:1-6, for example, when told to get his house in order, King Hezekiah turned himself toward the wall, prayed to the Lord, and asked for more time. In response to that gesture, the king was given an additional fifteen years. Many terminally-ill patients might go through a similar period where they desperately try to get for themselves a little more time on this earth. If, or when, that bargaining process fails, then the ill person will probably next enter into the depression stage where he or she will begin to feel both hopeless and helpless. This stage will then most likely be followed by the acceptance stage in which the person quietly accepts their fate and begins to wait for their departure.
Craig (1996) points out that these stages for the person who is dying are typical but not necessarily absolute. Not everyone goes through each of the above stages, and not everyone goes through those stages in any particular order. A person might even remain in one or more of the stages for a very long time. By persistently denying their condition, for instance, a patient might stay in the stage of denial for a lengthy time but then progress through the others more rapidly. Craig (1996) indicates that the patient's behavior toward their death can be affected by many things, one of which is religious persuasion. In the above biblical reference, King Hezekiah had exercised his faith in God and asked for more time. One terminally-ill, Christian patient might attempt to do the same thing and, by so doing, extend their time in the stage of either denial or bargaining. Another Christian patient might take an entirely different approach and simply resign themselves to their fate, thus moving to the acceptance stage more quickly. The counselor needs to know which stage their patient is in so that he or she can address the individual's psychological needs.
The stages which were identified by Kubler-Ross are not absolute. Her effort to identify such stages has also not been the only attempt by counselors to describe the psychological stages of the terminally-ill. Brandon Hunt (1996), in a study of those diagnosed with Acquired Immune Deficiency Syndrome (AIDS), indicates that numerous counselors have tried to identify the different stages experienced by the terminally-ill. The stages noted by S. E. Nichols in 1986, just to name one, are the crisis, transitional, and deficiency stages (Hunt, 1996). While being very similar to those of Kubler-Ross, Nichol's stages do not explicitly describe a bargaining phase. For Nichols, the crisis stage addresses the patient's denial and anxiety over dying while the transitional and deficiency stages consider the patient's state of depression and of his or her coming to terms with their condition. Nichols concludes that it is necessary to encourage and educate clients to be active participants in their medical care (Hunt, 1996). Thus, while numerous psychologists and counselors might have tried to identify the psychological stages of the terminally ill, it seems that none of these attempts have really produced anything new.
Counseling Approaches
Christina Rasmussen amd Christiane Brems (1996) state that the level at which death anxiety is experienced and expressed appears to vary greatly from one individual to another. For this reason, the counselor might be able to help the terminally-ill patient in a variety of ways, but he or she will have to be adaptable to the patient's immediate needs. The first and most important way to help is to show the patient how to get their soul in order. Next, the counselor can try to help the patient get their house in order, and finally, the counselor can help the client deal with their condition and some other logistical issues. As will be pointed out below, these ways for helping are not necessarily the order in which the counselor will be able to help.
Getting One's Soul In Order. For each of us, it is important to have a right relationship with the Lord, but this is especially important for the person whose life will soon be ended. We are eternal beings, bound for the judgment of our heavenly Father. Therefore, it is very important for each of us to be ready for our entrance into the afterlife. However, in addition to being prepared for eternity and judgment, getting one's soul in order has other benefits for the terminally-ill patient, as well.
Overcash, Calhoun, Cann, and Tedeschi (1996) write that religious beliefs can help a person cope with the death of someone else. They write that such beliefs can also comfort the one who is dying. Lindgren and Coursey (1995), in referencing a 1983 Epperly study and a 1978 Gibbs and Achterberg study, support this comment about a positive spiritual focus by stating that terminally-ill individuals are better able to cope with their illness if they hold spiritual beliefs. Finally, Gelo (1995) writes that spirituality is often overlooked as an important aspect of health counseling. He says that "health counseling is most effective when it includes the mastery of facts and skills and also attempts to assess and identify religious and spiritual beliefs that affect decision making."
The counselor, however, must be careful about trying to minister to or preach to the patient. As Kubler-Ross, Nichols, and others have already stated, the terminally-ill patient goes through several stages during their terminal illness. If the counselor becomes involved with the terminally-ill patient and tries to be too evangelistic, he or she might do more harm than good. Dr. David Miller (1988) says that the terminally-ill person needs to be allowed the time to complete each stage of their grieving process. He says that much of what the counselor does is listen rather than try to argue or rationalize the patient into a particular state of mind. If the patient is in the denial stage, then the counselor must understand that the terminally-ill individual needs to be able to grasp at straws. If the patient has entered the anger stage, then the counselor must realize that this person is about to lose everything. He or she has a reason to be angry. If the patient feels the need to try to bargain with God, as King Hezekiah had done when faced with his death, then the counselor should not try to discourage the patient's attempts to buy time. Helping the unprepared patient prepare for the spiritual aspects of death is important, but the counselor must be careful to allow the patient to initiate such discussions. In some cases, simply reading selected passages from the Bible might provide important comfort to the terminally-ill patient and also initiate a spiritual conversation. However, even something as innocent as Bible reading must be done with the welfare of the patient still as the top priority.
Getting One's House In Order. Another service which the counselor might be able to provide is to help the terminally-ill patient get his or her house in order. This, too, can be a useful function. The patient might desire to make or discuss making a living will. Rex Ahdar (1996) writes that "the Death with Dignity Bill provides choice and opportunities to persons suffering from terminal or incurable illnesses, and who believe their quality of life to be seriously and permanently impaired, to manage their own inevitable death." The Christian counselor might be reluctant to deal with this topic, but the patient may still wish to at least talk about such a thing.
Another topic which might arise that will require attention is the matter of assisted suicide. As of March 1995, Dr. Jack Kevorkian had helped twenty-one terminally-ill patients take their own life (Osgood, 1995). As Christians, we should never help someone end their life, nor should we even help someone find a doctor who will help them end their life. However, as counselors and Christian counselors, we may have to discuss this issue with our terminally-ill patient. When someone realizes that their life is almost over and if that person is experiencing or faced with experiencing severe pain, then a quick, assisted death might seem like a good solution.
In this situation, the Christian counselor might be able to encourage the discouraged patient by sharing the truth of Psalms 116:15, which says that the death of His saints is precious in the sight of the Lord. In many situations, however, the counselor may not be able to share this truth. Much will depend on the spiritual maturity of the patient, on their current stage in the grieving process, and on the counselor's ability to recognize these factors. Dr. Miller (1988) pointed out that religious affiliation is a major factor to the person who is about to die. Those who are or have been strong in their faith will probably be more comforted by Psalms 116:15 than those who are or have been less strong. If the counselor does not feel the liberty to speak in this manner to the patient, then he or she may have to just listen and allow the patient to express their fears, hurts, and frustrations.
Helping the client deal with their condition. Another part of the counselor's function may be to help the client deal with their condition. It has already been stated that Dr. Miller sees much of the counselor's duty as listening, but added to that might also be the responsibility of informing. In his dealing with AIDS patients, Brandon Hunt (1994) writes that maintaining one's quality of life is very important. He says that the counselor might have to become involved in medical issues such as pain management, maintenance of strength and endurance, and independent self-care. In this regard, the counselor may be able to help the patient find a support group which can help ease them through some of their concerns (Hunt, 1994). Hunt points out, however, that the counselor should investigate the group ahead of time to ensure that his or her patient will not feel out of place with the other group members. He says that a woman with AIDS probably will not feel comfortable in a group with AIDS-infected men or even bisexuals.
Dr. Miller (1988) suggests some additional areas relating to the patient's condition where the counselor may have to be involved, and these areas are an extension of those already mentioned by Hunt. Dr. Miller states that the terminally-ill patient, in many cases, may have a fear of being overly-dependent on someone else. The patient may be afraid of having to experience pain, or he or she may already be experiencing the fears of being alone, rejected and/or isolated. These emotions are all forms of death anxiety. Rasmussen and Brems (1996), in reporting on a Lonetto and Templer study performed in 1986, state that existential adjustment and social adequacy are significantly and negatively related to death anxiety. In their own study of one hundred and thirty-two women and sixty-four men, Rasmussen and Brems concluded that age and psychosocial maturity are also significantly and inversely related to death anxiety. Of special significance was psychosocial maturity because while aging might serve to lessen death anxiety, it was a combination of aging and greater psychosocial maturity that served best to decrease death anxiety (Rasmussen and Brems, 1996).
Erik Erikson developed a list of eight psychosocial stages which describe how a person's personality develops (Craig, 1996). Based on the findings of Rasmussen and Brems, the counselor may be able to help the patient achieve a more positive attitude at Stage Eight, which is the Psychosocial Maturity stage. During this phase of personality development, the individual questions whether or not he or she has found contentment and satisfaction through the handling of their life. If they decide that they have not, then they will probably begin to despair and feel a lack of completeness about their life. If the counselor can somehow help the patient get through this condition of despair, then the patient might be able to achieve a greater sense of closure, unity, and direction about their life. These feelings probably will not eliminate or lessen the approach of death, but they will give the patient a brighter, more positive outlook.
Another area of concern which relates to the patient's condition is that of independence. Hunt and Dr. Miller point out that the patient may have anxiety over their inability to care for themselves. Concerning this focus towards independent self-care, Dr. Miller indicates that one of the goals of Hospice Care is to make the patient's remaining days as comfortable and pleasant as possible. The counselor might be able to bring the patient and Hospice together.
Conclusions
Trying to help someone face the end of their life is a difficult and serious task for the counselor because so many variables are involved. The counselor must be able to assess which stage of the grieving process the client is in. Then, the counselor must be able to adapt to that stage. As Dr. Miller (1988) points out, much of the counselors work is in being a good listener. It is not like the counselor can wave a magic wand and remove the patient's problem. It is also not like the counselor or any other living person has ever been where the patient is at. We only die once. Therefore, the counselor must always be sensitive to the current feelings and situation of the terminally-ill patient.
Based on the findings of Brandon Hunt (1996), the counselor can assist the patient in finding a support group which tries to help those with the patient's particular condition. Especially important for a person with AIDS, the counselor can try to inform or educate the patient about some of the treatments which are available and also about what to expect. The counselor may also be able to help with certain medical issues like pain management, maintenance of strength and endurance, and independent self-care.
Based on the findings of Rasmussen and Brems, the counselor can try to help the patient bring their life to closure. Where the patient might be suffering from despair and death anxiety over what may seem like a failed life, the counselor can try to comfort the patient and help him or her bring their life to a more satisfactory conclusion. Everyone has had their share of bad experiences, but most everyone has also had their share of good. By helping the terminally-ill patient focus on their good experiences and on their positive achievements, the counselor may be able to lessen a big psychological burden from off the back of the patient.
Another important finding which can help the counselor work with the terminally ill is that of religion. Overcash, Calhoun, Cann, and Tedeschi (1996), Lindgren and Coursey (1995), and Gelo (1995) all indicate that religious beliefs can help the dying person face their ordeal. While this is a true statement, the Christian counselor can also look for opportunities to help the patient who does not have a personal relationship with the Lord. Getting through the ordeal of death is important. It is part of the battle which the counselor helps the patient fight. But much more important than that battle is the fact that physical death is not the end. As Christians and as those who try to do the work of a counselor, we should always remember that our patients, terminally ill or not, are eternity-bound creatures. Therefore, wherever and whenever possible, we should always be trying to point them towards a saving knowledge of the Lord Jesus Christ.
A final task where the counselor might be able to help is in bringing the patient into contact with Hospice Support. Hospice is a voluntary organization which tries to comfort those who are about to die. When a person is about to leave this life, the presence of a loving, caring individual by the bedside might be the very touch that that person needs, plus with Hospice, the patient will not have to feel alone, rejected, or isolated.
Ahdar, Rex. (1 Jun 1996). Religious parliamentarians and euthanasia: A window into church and state in New Zealand. Journal of Church & State [On-line]. Available: http://www.elibrary.com.
Craig, Grace J. (1996). Human Development. Upper Saddle River, New Jersey: Prentice Hall, 666-672.
Gelo, Florence. (1 Jul 1995). Spirituality: A vital component of health counseling. Journal of American College Health [On-line]. Available: http://www.elibrary.com.
Hacker, Douglas. (1 Aug 1994). An existential view of adolescence. Journal of Early Adolescence [On-line]. Available: http://www.elibrary.com.
Hunt, Brandon. (18 Jul 1996). Rehabilitation counseling for people with HIV disease. The Journal of Rehabilitation [On-line]. Available: http://www.elibrary.com.
Kottler, Jeffrey A. & Brown, Robert W. (1992). Introduction to Therapeutic Counseling (2nd ed.). Pacific Grove, CA: Brooks/Cole Publishing Company, 277-279.
Lindgren, Karen & Coursey, Robert. (1 Jan 1995). Spirituality and serious mental illness: A two-part study. Psychosocial Rehabilitation Journal [On-line]. Available: http://www.elibrary.com.
Mannino, J. Davis. (1997). Grieving Days, Healing Days. Santa Rosa, California: Santa Rosa Junior College, preface.
Miller, David. (1988). A Worktext For Personality Development. Lynchburg, VA: School of Lifelong Learning, Liberty University, 120, 125.
Osgood, Nancy J. (1 March 1995). Assisted suicide and older poeple - a deadly combination: ethical problems in permitting assisted suicide. Issues in Law & Medicine [On-line]. Available: http://www.elibrary.com.
Overcash, Wendy S.; Calhoun, Lawrence G.; Cann, Arnie; & Tedeschi, Richard G. (1 Dec 1996). Coping with crises: an examination of the impact of traumatic events on religious beliefs. Journal of Genetic Psychology [On-line]. Available: http://www.elibrary.com.
Rasmussen, Christina A. & Brems, Christiane. (1 March 1996). The relationship of death anxiety with age and psychosocial maturity. The Journal of Psychology [On-line]. Available: http://www.elibrary.com.
Tom of Spotswood"He that hath the Son hath life; and he that hath not the Son of God hath not life." (I John 5:12)
"And ye shall seek me, and find me, when ye shall search for me with all your heart." (Jeremiah 29:13)
Index to Selected Essays And Book Reviews
Study 2 - Study Notes For The Final Exam (short essay)
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