What you’ll learn to do: examine emotions related to death and dying

While death is inevitable, our emotional responses and reactions to it vary dramatically. In this section, we’ll take a closer look at the emotions that are involved in death, both for the individual who is dying as well as their family and friends. We’ll also learn more about the stages of grief and how to cope with death.

Attitudes about Death

Bereavement refers to outward expressions of grief. Mourning and funeral rites are expressions of loss that reflect personal and cultural beliefs about the meaning of death and the afterlife. When asked what type of funeral they would like to have, students responded in a variety of ways; each expressing both their personal beliefs and values and those of their culture.

I would like the service to be at a Baptist church, preferably my Uncle Ike’s small church. The service should be a celebration of life . . .I would like there to be hymns sung by my family members, including my favorite one, “It is Well With my Soul”. . .At the end, I would like the message of salvation to be given to the attendees and an alter call for anyone who would like to give their life to Christ. . .

I want a very inexpensive funeral-the bare minimum, only one vase of flowers, no viewing of the remains and no long period of mourning from my remaining family . . . funeral expenses are extremely overpriced and out of hand. . .

When I die, I would want my family members, friends, and other relatives to dress my body as it is usually done in my country, Ghana. Lay my dressed body in an open space in my house at the night prior to the funeral ceremony for my loved ones to walk around my body and mourn for me. . .

I would like to be buried right away after I die because I don’t want my family and friends to see my dead body and to be scared.

In my family we have always had the traditional ceremony-coffin, grave, tombstone, etc. But I have considered cremation and still ponder which method is more favorable. Unlike cremation, when you are ‘buried’ somewhere and family members have to make a special trip to visit, cremation is a little more personal because you can still be in the home with your loved ones . . .

I would like to have some of my favorite songs played . . .I will have a list made ahead of time. I want a peaceful and joyful ceremony and I want my family and close friends to gather to support one another. At the end of the celebration, I want everyone to go to the Thirsty Whale for a beer and Spang’s for pizza!

When I die, I want to be cremated . . . I want it the way we do it in our culture. I want to have a three day funeral and on the 4th day, it would be my burial/cremation day . . .I want everyone to wear white instead of black, which means they already let go of me. I also want to have a mass on my cremation day.

When I die, I would like to have a befitting burial ceremony as it is done in my Igbo customs. I chose this kind of funeral ceremony because that is what every average person wishes to have. 

I want to be cremated . . . I want all attendees wearing their favorite color and I would like the song “Riders on the Storm” to be played . . .I truly hope all the attendees will appreciate the bass. At the end of this simple, short service, attendees will be given multi-colored helium filled balloons . . . released to signify my release from this earth. . .They will be invited back to the house for ice cream cones, cheese popcorn and a wide variety of other treats and much, much, much rock music . . .

I want to be cremated when I die. To me, it’s not just my culture to do so but it’s more peaceful to put my remains or ashes to the world. Let it free and not stuck in a casket.

These statements reflect a wide variety of conceptions and attitudes toward death. Culture plays a key role in the development of these conceptions and attitudes, and it also provides a framework within which they are expressed. However, it is important to note that culture does not provide set rules for how death is viewed and experienced, and there tends to be as much variation within cultures as well as between.

Another important consideration related to conceptions and attitudes toward death involves social attitudes. Death, in many cases, can be the “elephant in the room,” a concept that remains ever present but continues to be taboo for most individuals. Talking openly about death tends to be viewed negatively, or even as socially inappropriate. Specific social norms and standards regarding death vary between groups, but on a larger societal level, death is usually a topic reserved only for when it becomes absolutely necessary to bring up.

Regardless of variations in conceptions and attitudes toward death, ceremonies provide survivors a sense of closure after a loss. These rites and ceremonies send the message that the death is real and allow friends and loved ones to express their love and duty to those who die. Under circumstances in which a person has been lost and presumed dead or when family members were unable to attend a funeral, there can continue to be a lack of closure that makes it difficult to grieve and to learn to live with loss. And although many people are still in shock when they attend funerals, the ceremony still provides a marker of the beginning of a new period of one’s life as a survivor.

Developmental Perspectives on Death

Another key factor in individuals’ attitudes towards death and dying is where they are in their own lifespan development. First of all, individuals’ attitudes are linked to their cognitive ability to understand death and dying. Infants and toddlers cannot understand death. They function in the present and are aware of loss and separation, as well as disruptions in their routines. They are also attuned to the emotions and behaviors of significant adults in their lives, so a death of a loved one may cause a young child to become anxious and irritable, cry, or change their sleeping and eating habits.

A preschooler may approach death by asking when a deceased person is coming back and might search for them, thinking that death is temporary and reversible. They may experience brief but intense reactions, such as tantrums, or other behaviors like frightening dreams and disrupted sleep, bedwetting, clinging, and thumbsucking. Similarly, those in early childhood (age 4-7), might also ask where the deceased person is and search for them, as well as regress to younger behaviors. They might also think that the person’s death is their own fault, as per their belief in the power of their own thoughts and “magical thinking.” Their grief might be expressed through play, rather than verbally.^[1]

Those in middle childhood (ages 7-10) begin to see death as final, not reversible, and universal. Developing Piaget’s concrete operational thinking, they may engage in personification, seeing death as a human figure who carried their loved one away. They may not really believe that death could happen to them or their family, maybe only to the very old or sick—they may also view death as a punishment. They might act out in school or they might try to keep a bond with the deceased by taking on that person’s role or behaviors.^[2]

Preadolescents (ages 10-12) try to understand both biological and emotional processes of death. But they try to hide their feelings and not seem different from their peers; they may seem indifferent, or they may have outbursts.^[3]  As Amsler (2015) noted, children’s and teens’ experiences with death and what adults tell them about death will also influence their comprehension. As teens develop formal operational thinking (ages 12-18), they can apply logic to abstractions; they spend more time pondering the meaning of life and death and what comes after death. Their understanding of death becomes more complex as they move from a binary logical concept (alive or dead) to a fuzzy logical concept with potential life after death, for instance. Adolescents are also tasked with integrating these beliefs into their own identity development.^[4]

What about attitudes toward death in adulthood? We’ve learned about adults becoming more concerned with their own mortality during middle adulthood, particularly as they experience the deaths of their own parents. Recently, (Sinoff, 2017) research on thanatophobia, or death anxiety, found differences in death anxiety between elderly patients and their adult children. Death anxiety may entail two different parts—being anxious about death and being anxious about the process of dying. The elderly were only anxious about the process of dying (i.e., suffering), but their adult children were very anxious about death itself and mistakenly believed that their parents were also anxious about death itself. This is an important distinction and can make a significant difference in how medical information and end-of-life decisions are communicated within families.^[5] Consistent with this, if elders resolve Erikson’s final psychosocial crisis, ego integrity versus despair, in a positive way, they may not fear death, but gain the virtue of wisdom. If they are not feeling desperate (“despair” with time running out), then they may not be anxious or fearful about death.

Bereavement and Grief

Grief is the psychological, physical, and emotional experience and reaction to loss. People may experience grief in various ways, but several theories, such as Kübler-Ross’ stages of loss theory, attempt to explain and understand the way people deal with grief. Kübler-Ross’ famous theory, which we’ll examine in more detail soon, describes five stages of grief: denial, anger, bargaining, depression, and acceptance.

Grief reactions vary depending on whether a loss was anticipated or unexpected, (parents do not expect to lose their children, for example), and whether or not it occurred suddenly or after a long illness, and whether or not the survivor feels responsible for the death. Struggling with the question of responsibility is particularly felt by those who lose a loved one to suicide. ^[6] These survivors may torment themselves with endless “what ifs” in order to make sense of the loss and reduce feelings of guilt. And family members may also hold one another responsible for the loss. The same may be true for any sudden or unexpected death, making conflict an added dimension to grief. Much of this laying of responsibility is an effort to think that we have some control over these losses; the assumption being that if we do not repeat the same mistakes, we can control what happens in our life. While grief describes the response to loss, bereavement describes the state of being following the death of someone.

As we’ve already learned in terms of attitudes toward death, individuals’ own lifespan developmental stage and cognitive level can influence their emotional and behavioral reactions to the death of someone they know. But what about the impact of the type of death or age of the deceased or relationship to the deceased upon bereavement?

Death of a child

Death of a child can take the form of a loss in infancy such as miscarriage or stillbirth or neonatal death, SIDS, or the death of an older child. In most cases, parents find the grief almost unbearably devastating, and it tends to hold greater risk factors than any other loss. This loss also bears a lifelong process: one does not get ‘over’ the death but instead must assimilate and live with it. Intervention and comforting support can make all the difference to the survival of a parent in this type of grief but the risk factors are great and may include family breakup or suicide. Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship disposes parents to a variety of problems as they seek to cope with this great loss. Parents who suffer miscarriage or a regretful or coerced abortion may experience resentment towards others who experience successful pregnancies.

Suicide

Suicide rates are growing worldwide and over the last thirty years there has been international research trying to curb this phenomenon and gather knowledge about who is “at-risk”. When a parent loses their child through suicide it is traumatic, sudden, and affects all loved ones impacted by this child. Suicide leaves many unanswered questions and leaves most parents feeling hurt, angry and deeply saddened by such a loss. Parents may feel they can’t openly discuss their grief and feel their emotions because of how their child died and how the people around them may perceive the situation. Parents, family members and service providers have all confirmed the unique nature of suicide-related bereavement following the loss of a child. They report a wall of silence that goes up around them and how people interact towards them. One of the best ways to grieve and move on from this type of loss is to find ways to keep that child as an active part of their lives. It might be privately at first but as parents move away from the silence they can move into a more proactive healing time.

Death of a spouse

The death of a spouse is usually a particularly powerful loss. A spouse often becomes part of the other in a unique way: many widows and widowers describe losing ‘half’ of themselves. The days, months and years after the loss of a spouse will never be the same and learning to live without them may be harder than one would expect. The grief experience is unique to each person. Sharing and building a life with another human being, then learning to live singularly, can be an adjustment that is more complex than a person could ever expect. Depression and loneliness are very common. Feeling bitter and resentful are normal feelings for the spouse who is “left behind”. Oftentimes, the widow/widower may feel it necessary to seek professional help in dealing with their new life.

After a long marriage, at older ages, the elderly may find it a very difficult assimilation to begin anew; but at younger ages as well, a marriage relationship was often a profound one for the survivor.

Furthermore, most couples have a division of ‘tasks’ or ‘labor’, e.g., the husband mows the yard, the wife pays the bills, etc. which, in addition to dealing with great grief and life changes, means added responsibilities for the bereaved. Immediately after the death of a spouse, there are tasks that must be completed. Planning and financing a funeral can be very difficult if pre-planning was not completed. Changes in insurance, bank accounts, claiming of life insurance, securing childcare are just some of the issues that can be intimidating to someone who is grieving. Social isolation may also become imminent, as many groups composed of couples find it difficult to adjust to the new identity of the bereaved, and the bereaved themselves have great challenges in reconnecting with others. Widows of many cultures, for instance, wear black for the rest of their lives to signify the loss of their spouse and their grief. Only in more recent decades has this tradition been reduced to shorter periods of time.

Death of a parent

For a child, the death of a parent, without support to manage the effects of the grief, may result in long-term psychological harm. This is more likely if the adult carers are struggling with their own grief and are psychologically unavailable to the child. There is a critical role of the surviving parent or caregiver in helping the children adapt to a parent’s death. Studies have shown that losing a parent at a young age did not just lead to negative outcomes; there are some positive effects. Some children had an increased maturity, better coping skills and improved communication. Adolescents valued other people more than those who have not experienced such a close loss.^[7]

When an adult child loses a parent in later adulthood, it is considered to be “timely” and to be a normative life course event. This allows the adult children to feel a permitted level of grief. However, research shows that the death of a parent in an adult’s midlife is not a normative event by any measure, but is a major life transition causing an evaluation of one’s own life or mortality. Others may shut out friends and family in processing the loss of someone with whom they have had the longest relationship.^[8]

Death of a sibling

The loss of a sibling can be a devastating life event. Despite this, sibling grief is often the most disenfranchised or overlooked of the four main forms of grief, especially with regard to adult siblings. Grieving siblings are often referred to as the ‘forgotten mourners’ who are made to feel as if their grief is not as severe as their parents grief (N.a., 2015). However, the sibling relationship tends to be the longest significant relationship of the lifespan and siblings who have been part of each other’s lives since birth, such as twins, help form and sustain each other’s identities; with the death of one sibling comes the loss of that part of the survivor’s identity because “your identity is based on having them there.”

The sibling relationship is a unique one, as they share a special bond and a common history from birth, have a certain role and place in the family, often complement each other, and share genetic traits. Siblings who enjoy a close relationship participate in each other’s daily lives and special events, confide in each other, share joys, spend leisure time together (whether they are children or adults), and have a relationship that not only exists in the present but often looks toward a future together (even into retirement). Surviving siblings lose this “companionship and a future” with their deceased siblings.^[9]

Loss during childhood

When a parent or caregiver dies or leaves, children may have symptoms of psychopathology, but they are less severe than in children with major depression. The loss of a parent, grandparent or sibling can be very troubling in childhood, but even in childhood there are age differences in relation to the loss. A very young child, under one or two, may be found to have no reaction if a carer dies, but other children may be affected by the loss.

At a time when trust and dependency are formed, a break even of no more than separation can cause problems in well-being; this is especially true if the loss is around critical periods such as 8–12 months, when attachment and separation are at their height information, and even a brief separation from a parent or other person who cares for the child can cause distress.

Even as a child grows older, death is still difficult to fathom and this affects how a child responds. For example, younger children see death more as a separation, and may believe death is curable or temporary. Reactions can manifest themselves in “acting out” behaviors: a return to earlier behaviors such as sucking thumbs, clinging to a toy or angry behavior; though they do not have the maturity to mourn as an adult, they feel the same intensity. As children enter pre-teen and teen years, there is a more mature understanding.

Children can experience grief as a result of losses due to causes other than death. For example, children who have been physically, psychologically or sexually abused often grieve over the damage to or the loss of their ability to trust. Since such children usually have no support or acknowledgement from any source outside the family unit, this is likely to be experienced as disenfranchised grief.

Relocations can also cause children significant grief particularly if they are combined with other difficult circumstances such as neglectful or abusive parental behaviors, other significant losses, etc.

Loss of a friend or classmate

Children may experience the death of a friend or a classmate through illness, accidents, suicide, or violence. Initial support involves reassuring children that their emotional and physical feelings are normal. Schools are advised to plan for these possibilities in advance.

Survivor guilt (or survivor’s guilt; also called survivor syndrome or survivor’s syndrome) is a mental condition that occurs when a person perceives themselves to have done wrong by surviving a traumatic event when others did not. It may be found among survivors of combat, natural disasters, epidemics, among the friends and family of those who have died by suicide, and in non-mortal situations such as among those whose colleagues are laid off.

Anticipatory grief occurs when a death is expected and survivors have time to prepare to some extent before the loss. Anticipatory grief can include the same denial, anger, bargaining, depression, and acceptance experienced in loss one might experience after a death; this can make adjustment after a loss somewhat easier, although a person may then go through the stages of loss again after the death. A death after a long-term, painful illness may bring family members a sense of relief that the suffering is over or the exhausting process of caring for someone who is ill is over.

Complicated grief involves a distinct set of maladaptive or self-defeating thoughts, emotions, and behaviors that occur as a negative response to a loss. ^[10] From a cognitive and emotional perspective, these individuals tend to experience extreme bitterness over the loss, intense preoccupation with the deceased, and a need to feel connected to the deceased. These feelings often lead the grieving individual to engage in problematic behaviors that further prevent positive coping and delay the return to normalcy. He or she may spend excessive amounts of time visiting the deceased person’s grave, talking to the deceased person, or trying to connect with the deceased person on a spiritual level, often forgoing other responsibilities or tasks to do so. The extreme nature of these thoughts, emotions, and behaviors separate this type of grief from the normal grieving process.

Disenfranchised grief may be experienced by those who have to hide the circumstances of their loss or whose grief goes unrecognized by others. Loss of an ex-spouse, lover, or pet may be examples of disenfranchised grief.

It has been said that intense grief lasts about two years or less, but grief is felt throughout life. One loss triggers the feelings that surround another. People grieve with varied intensity throughout the remainder of their lives. It does not end. But it eventually becomes something that a person has learned to live with. As long as we experience loss, we experience grief.

There are layers of grief. Initial denial, marked by shock and disbelief in the weeks following a loss may become an expectation that the loved one will walk in the door. And anger directed toward those who could not save our loved one’s life, may become anger that life did not turn out as we expected. There is no right way to grieve. A bereavement counselor expressed it well by saying that grief touches us on the shoulder from time to time throughout life.

Grief and mixed emotions go hand in hand. A sense of relief is accompanied by regrets and periods of reminiscing about our loved ones are interspersed with feeling haunted by them in death. Our outward expressions of loss are also sometimes contradictory. We want to move on but at the same time are saddened by going through a loved one’s possessions and giving them away. We may no longer feel sexual arousal or we may want sex to feel connected and alive. We need others to befriend us but may get angry at their attempts to console us. These contradictions are normal and we need to allow ourselves and others to grieve in their own time and in their own ways.

The “death-denying, grief-dismissing world” is often the approach to grief in our modern world. We are asked to grieve privately, quickly, and to medicate our suffering. Employers grant us 3 to 5 days for bereavement, if our loss is that of an immediate family member. And such leaves are sometimes limited to no more than one per year. Yet grief takes much longer and the bereaved are seldom ready to perform well on the job. It becomes a clash between life having to continue, and the individual being ready for it to do so. One coping mechanism that can help smooth out this conflict is called the fading affect bias. Based on a collection of similar findings, the fading affect bias suggests that negative events, such as the death of a loved one, tend to lose their emotional intensity at a faster rate than pleasant events. ^[11] This is believed to help enhance pleasant experiences and avoid the negative emotions associated with unpleasant ones, thus helping the individual return to his or her normal daily routines following a loss.

Stages of Loss

The complex construct of death is associated with a variety of thoughts, emotions, and behaviors, that vary between individuals and groups. To some, death is the final end, when the body ceases to function, with nothing occurring next. To others, death is the start of a new journey, and is its own beginning. These varying viewpoints are shaped by numerous factors related to culture, religion, social norms, personal experiences, and more. It is no surprise then that multiple theories have been created to understand the occurrence of death on cognitive, emotional, and behavioral levels; each offering different explanations for what individuals go through during death.

Kübler-Ross’ Stages of Loss

Kübler-Ross (1965) described five stages of loss experienced by someone who faces the news of their impending death (based on her work and interviews with terminally ill patients). These “stages” are not really stages that a person goes through in order or only once; nor are they stages that occur with the same intensity. Indeed, the process of death is influenced by a person’s life experiences, the timing of their death in relation to life events, the predictability of their death based on health or illness, their belief system, and their assessment of the quality of their own life. Nevertheless, these stages provide a framework to help us to understand and recognize some of what a dying person experiences psychologically. And by understanding, we are more equipped to support that person as they die.^[12]

Denial is often the first reaction to overwhelming, unimaginable news. Denial, or disbelief or shock, protects us by allowing such news to enter slowly and to give us time to come to grips with what is taking place. The person who receives positive test results for life-threatening conditions may question the results, seek second opinions, or may simply feel a sense of disbelief psychologically even though they know that the results are true.

Anger also provides us with protection in that being angry energizes us to fight against something and gives structure to a situation that may be thrusting us into the unknown. It is much easier to be angry than to be sad or in pain or depressed. It helps us to temporarily believe that we have a sense of control over our future and to feel that we have at least expressed our rage about how unfair life can be. Anger can be focused on a person, a health care provider, at God, or at the world in general. And it can be expressed over issues that have nothing to do with our death; consequently, being in this stage of loss is not always obvious.

Bargaining involves trying to think of what could be done to turn the situation around. Living better, devoting self to a cause, being a better friend, parent, or spouse, are all agreements one might willingly commit to if doing so would lengthen life. Asking to just live long enough to witness a family event or finish a task are examples of bargaining.

Depression is sadness and sadness is appropriate for such an event. Feeling the full weight of loss, crying, and losing interest in the outside world is an important part of the process of dying. This depression makes others feel very uncomfortable and family members may try to console their loved one. Sometimes hospice care may include the use of antidepressants to reduce depression during this stage.

Acceptance involves learning how to carry on and to incorporate this aspect of the life span into daily existence. Reaching acceptance does not in any way imply that people who are dying are happy about it or content with it. It means that they are facing it and continuing to make arrangements and to say what they wish to say to others. Some terminally ill people find that they live life more fully than ever before after they come to this stage.

In some ways, these five stages serve as cognitive defense mechanisms, allowing the individual to make sense of the situation while coming to terms with what is happening. They are, in other words, the mind’s way of gradually recognizing the implications of one’s impending death and giving him or her the chance to process it. These stages provide a type of framework in which dying is experienced, although it is not exactly the same for every individual in every case.

Since Kübler-Ross presented these stages of loss, several other models have been developed. These subsequent models, in many ways, build on that of Kübler-Ross, offering expanded views of how individuals process loss and grief. While Kübler-Ross’ model was restricted to dying individuals, subsequent theories tended to focus on loss as a more general construct. This ultimately suggests that facing one’s own death is just one example of the grief and loss that human beings can experience, and that other loss or grief-related situations tend to be processed in a similar way.

Other Models on Grief

One such model was presented by Worden (1991), which explained the process of grief through a set of four different tasks that the individual must complete in order to resolve the grief. These tasks included: (a) accepting that the loss has occurred, (b) working through and experiencing the pain associated with grief, (c) adjusting the the changes that the loss created in the environment, and (d) moving past the loss on an emotional level.^[13]

Another model is that of Parkes (1998), which broke down grief into four stages, including: (a) shock, (b) yearning, (c) despair, and (d) recovery. Although comprised of somewhat different stages than those of Kübler-Ross’ model, Parkes’ stages still reflected an ongoing process that the individual goes through, each of which was characterized by different thoughts, emotions, and behaviors. Throughout this process, the individual gradually moves closer to accepting the situation, and being able to continue with his or her daily life to the greatest extent possible.^[14]

A different approach was proposed by Strobe and Shut (1999), which suggested that individuals cope with grief through an ongoing set of processes related to both loss and restoration. The loss-oriented processes included: (a) grief work, (b) intrusion on grief, (c) denying or avoiding changes toward restoration, and (d) the breaking of bonds or ties. The restoration-oriented processes included: (a) attending to life changes, (b) distracting oneself from grief, (c) doing new things, and (d) establishing new roles, identities, and relationships. Since each individual experiences grief and loss differently, in light of personal, cultural, and environmental factors, these processes often occur simultaneously, and not in a set order.^[15]

We no longer think that there is a “right way” to experience grief and loss. People move through a variety of stages with different frequency and in different ways. The theories that have been developed to help explain and understand this complex process have shifted over time to encompass a wider variety of situations, as well as to present implications for helping and supporting the individual(s) who are going through it. The following strategies have been identified as effective in the support of healthy grieving:^[16].

• Talk about the death. This will help the surviving individuals understand what happened and remember the deceased in a positive way. When coping with death, it can be easy to get wrapped up in denial, which can lead to isolation and lack of a solid support system.
• Accept the multitude of feelings. The death of a loved one can, and almost always does, trigger numerous emotions. It is normal for sadness, frustration, and in some cases exhaustion to be experienced.
• Take care of yourself and your family. Remembering to keep one’s own health and the health of their family a priority can help with moving through each day effectively. Making an conscious effort to eat well, exercise regularly, and obtain adequate rest is important.
• Reach out and help others dealing with the loss. It has long been recognized that helping others can enhance one’s own mood and general mental state. Helping others as they cope with the loss can have this effect, as can sharing stories of the deceased.
• Remember and celebrate the lives of your loved ones. This can be a great way to honor the relationship that was once had with the deceased. Possibilities can include donating to a charity that the deceased supported, framing photos of fun experiences with the deceased, planting a tree or garden in memory of the deceased, or anything else that feels right for the particular situation.