12.2 Emotions and Attitudes Related to Death

What are 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 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 between them.

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 with a sense of closure after a loss. These rites and ceremonies send the message that 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 learn to live with loss. 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 and Grief

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 the death of a loved one may cause a young child to become anxious and irritable, cry, or change their sleeping and eating habits.

Dying and Grieving during Infancy (0-2 years) 

Children at this age have no cognitive understanding of death. If they themselves are dying, they are not aware of this fact. Their reactions are based completely on local conditions, including their contact with caregivers and their own current levels of pain and suffering. Infants can be comforted by the presence of secure attachment figures and palliative care to reduce pain. The process of dying is much more psychologically painful for caregivers than for infants, but hospitals and hospice care know how important the active participation of a caring and responsive attachment figure can be, one who is making medical decisions based on the balance between the probability that a treatment will be effective (vs. prolong the dying process) and the pain that treatments cause.

In terms of infants’ reactions to the death of a loved one, even if infants are not cognitively aware of death, they are cognizant of separation and loss, so separation anxiety and grief reactions are possible. Behavioral and developmental regression can occur as children have difficulty identifying and dealing with their loss; they may react in concert with the distress experienced by their caregiver. There is a need to maintain routines and avoid separation from significant others.

If death is the primary attachment figure, the presence of grief and the severity of the infant’s reaction will depend on their age and the quality of care they receive from their new primary caregiver. Before the age of 6 months, the long-term effects of maternal death depend almost entirely on whether a sensitive, responsive substitute caregiver can be found who can take over immediately. For children older than 6 months who have formed a specific attachment to the primary caregiver, expressions of grief and loss are common, but the transition is easier if the new primary caregiver is someone who the infant or toddler knows and with whom they already have a trusting relationship (e.g., father, aunt, grandmother). As mentioned previously, children may repeatedly revisit and re-grieve the loss of a primary caregiver at successive ages as they develop cognitive capacities that allow them to reflect on the loss in qualitatively different ways.

Dying and Grieving during Early Childhood (2-6 years)

Preschool-age children see death as temporary and reversible. They interpret their world in a literal manner and may ask questions reflecting this perspective. When children themselves are facing death, they take their cues about what is happening almost entirely from their caregivers and the other people around them. They have typical developmentally-graded concerns about attachment and abandonment and have a hard time understanding why they have to accept painful treatments and why they can’t just go home and get back to life as usual. They can have tantrums and difficulty regulating their emotions and behaviors, and it can be hard for parents to discipline or set limits with a terminally ill child. However, the same kinds of high-quality parenting are good for children in other circumstances, namely, love (affection, caring, and concern) combined with firm and reasonable limits and autonomy support (validation and opportunities for free expression of preferences and perspectives), are helpful for young children in these situations. Young children should be protected from adult anguish, but they can sense when adults are upset. Small children benefit from familiar routines, assurances that familiar adults are going to be with them the whole time, support for whatever emotions children are actually experiencing, and developmentally attuned explanations and answers to young children’s questions.

When preschool-aged children are dealing with the death of a loved one, especially a central person in their lives, like a mother, father, or sibling, their conception of death makes the process of grieving more difficult. They may believe that death can be caused by thoughts and provide magical explanations, often blaming themselves for the death. The conviction that death is reversible makes it difficult for preschoolers to cognitively accept death as final. They sometimes beg their parents to go get the dead person and bring them back home, and they can become frantic if they are told that the person has been buried. In the context of this conception of death, it is challenging to provide simple and straightforward explanations that emphasize that the child is not to blame, that the loved one cannot return even though they did not want to go, and that the absent person still loves the child.

Even when adults avoid euphemisms and try to correct misperceptions, preschool children often regard death like a kidnapping (with the dead person taken far away against their will) until they reach the concrete operational stage of cognitive development when they rework their understanding of death. It is this combination of developmental characteristics– when a young child has a full-blown attachment to a primary caregiver and a conception of death that makes it impossible to accept death as final– that puts children this age at particular risk for complicated grief and long-term negative neurophysiological and psychological effects. As with infants, the greatest protection against developmental risk is provided by the immediate presence of a loving and stable attachment figure, preferably one to whom the young child is already securely attached.

Dying and Grieving during the Stage of Concrete Operational Development

Middle childhood (6-8 years). When children reach the concrete operational stage of cognitive development, they understand that death is final and irreversible but do not believe that it is universal or could happen to them.  Death is often personalized and/or personified. Expressions of anger towards the deceased or towards those perceived to have been unable to save the deceased can occur. Anxiety, depressive symptoms, and somatic complaints may be present.  The child often has fears about death and concerns about the safety of their other loved ones. In addition to giving clear, realistic information, offer to include the child in funeral ceremonies. Notifying the school will help teachers understand the child’s reaction and provide additional adult support (Amsler, 2015)

Preadolescence (8-12 years). Children at this age have an adult understanding of death – that it is final, irreversible, and universal. They are able to understand the biological aspects of death as well as cause-and-effect relationships. They tend to intellectualize death as many have not yet learned to identify and deal with feelings. They may develop a morbid curiosity and are often interested in the physical details of the dying process as well as religious and cultural traditions surrounding death. The ability to identify causal relationships can lead to feelings of guilt; such feelings should be explored and addressed. To facilitate identification with emotions, it may prove useful to talk about your own emotions surrounding death and to offer opportunities for the child to discuss death. However, they try to hide their feelings and not seem different from their peers; they may seem indifferent, or they may have outbursts (Children’s Developmental Stages Concepts of Death and Responses). As Amsler (2015) noted, children’s and teens’ experiences with death and what adults tell them about death will also influence their comprehension. The child should also be allowed to participate, as much as they feel comfortable, in seeing the dying patient and participating in activities surrounding the death.

During middle childhood and preadolescence, children have a concrete operational understanding of death. When children in this stage are themselves terminally ill and facing their own death, their concrete understanding of death can lead to a relatively matter-of-fact acknowledgment of the actual situation. At this age, adults should still follow the child’s lead in terms of questions and explanations, and share their own grief and sadness only as appropriate. Children may show a wide variety of emotions, but they still have developmentally-graded concerns focused, for example, on keeping up with their friends and their schoolwork. To the extent that the parents of a child’s friends are willing to let them keep the dying child company, the presence of friends can provide both distraction and comfort to the child. Connections with friends can also be maintained through letters, notes, phone conversations, and virtual meetings, where the friends can play games or work together on their homework.

Dying and Grieving during Adolescence (12-18 years) 

Adolescents also have an adult understanding of death. At the same time, however, they are also developing the ability to think abstractly and are often curious about the existential implications of death. They often reject adult rituals and support and feel that no one understands them. They may engage in high-risk activities in order to more fully challenge their own mortality. They often have strong emotional reactions and may have difficulty identifying and expressing feelings. It is important that adults support independence and access to peers but also provide emotional support when needed. adolescents are also tasked with integrating these beliefs into their own identity development (Amsler, 2015).

When adolescents face their own deaths, they also have full-blown emotional and psychological reactions. Like adults, they can grieve the lives and possibilities that are lost with death at a young age. Parents and peers can help them create legacy projects, like blogs, videos, music, or books, that can enable adolescents to feel that they have accomplished at least some parts of their life’s purposes. However, they remain adolescents with developmentally appropriate concerns and problems. For example, the emotional instability and need for autonomy that is characteristic of adolescence can sometimes make it difficult for parents to provide helpful support under such circumstances. Adolescents can get into arguments with parents about whether or not they will accept certain medical treatments, especially if the treatments affect their physical appearance. Adolescents, especially young adolescents, can find life-threatening diseases embarrassing because it makes them different from their peers during a time when they are concerned with peer conformity. However, adults can rest assured that even if they do not always acknowledge it, adolescents count on the presence, wisdom, and support of their parents.

In sum, the generalizations and strategies provided here only serve as a framework when helping a child come to terms with their own death or that of a loved one. The overarching message is that children and adolescents have age-graded conceptions of death and developmentally appropriate concerns and challenges in dealing with grieving and dying. They also need individually and developmentally attuned support during these processes, which can be demanding for their adults. When in doubt, seek help from pediatricians, child-life specialists, mental health professionals, and others specializing in bereavement.

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, research on thanatophobia, or death anxiety, found differences in death anxiety between elderly patients and their adult children (Sinoff, 2017).  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 (Sinoff, 2017).  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.

• Early Adulthood: In adulthood, there are differences in the level of fear and anxiety concerning death experienced by those in different age groups. For those in early adulthood, their overall lower rate of death is a significant factor in their lower rates of death anxiety. Individuals in early adulthood typically expect a long life ahead of them and consequently do not think about nor worry about death.
• Middle Adulthood: Those in middle adulthood report more fear of death than those in either early or late adulthood. The caretaking responsibilities for those in middle adulthood are a significant factor in their fears. As mentioned previously, middle adults often provide assistance for both their children and parents, and they feel anxiety about leaving them to care for themselves.
• Late Adulthood: Contrary to the belief that because they are so close to death, they must fear death, those in late adulthood have lower fears of death than other adults. Why would this occur? First, older adults have fewer caregiving responsibilities and are not worried about leaving family members on their own. They also have more time to complete activities they had planned in their lives, and they realize that the future will not provide as many opportunities for them. Additionally, they have less anxiety because they have already experienced the death of loved ones and have become accustomed to the likelihood of death. It is not death itself that concerns those in late adulthood; rather, it is having control over how they die. (Batts, 2004; Erber & Szuchman, 2015; National Cancer Institute, 2013). 

Grief, Bereavement, and Mourning

The terms grief, bereavement, and mourning are often used interchangeably. However, they have different meanings. Grief is the normal process of reacting to a loss. Grief can be in response to a physical loss, such as a death, or a social loss, including a relationship or job. Bereavement is the period after a loss during which grief and mourning occur. The time spent in bereavement for the loss of a loved one depends on the circumstances of the loss and the level of attachment to the person who died. Mourning is the process by which people adapt to a loss. Mourning is greatly influenced by cultural beliefs, practices, and rituals (Casarett, Kutner, & Abrahm,2001).

Typical grief reactions involve emotional, mental, physical, and social responses. These reactions can include feelings of numbness, anger, guilt, anxiety, sadness, and despair. The individual can experience difficulty concentrating, sleep and eating problems, loss of interest in formerly pleasurable activities, physical problems, and even illness. Research has demonstrated that the immune systems of individuals grieving are suppressed, and their healthy cells behave more sluggishly, resulting in greater susceptibility to illnesses (Parkes & Prigerson, 2010). However, the intensity and duration of typical grief symptoms do not match those seen in severe grief reactions, and symptoms typically diminish within 6-10 weeks (Youdin, 2016).

Prolonged and Complicated Grief. After the loss of a loved one, however, some individuals experience complicated grief, which includes atypical grief reactions (Newson et al., 2011). Symptoms of complicated grief include Feelings of disbelief, a preoccupation with the dead loved one, distressful memories, feeling unable to move on with one’s life, and a yearning for the deceased. Additionally, these symptoms may last six months or longer and mirror those seen in major depressive disorder (Youdin, 2016).

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013), distinguishing between major depressive disorder and complicated grief requires clinical judgment. The psychologist needs to evaluate the client’s individual history and determine whether the symptoms are focused entirely on the loss of the loved one and represent the individual’s cultural norms for grieving, which would be appropriate. Those who seek assistance for complicated grief usually have experienced traumatic forms of bereavement, such as unexpected, multiple, and violent deaths or those due to murders or suicides (Parkes & Prigerson, 2010).

Anticipatory Grief. Grief that occurs when a death is expected and survivors have time to prepare to some extent before the loss is referred to as anticipatory grief. Such anticipation can make adjustment after a loss somewhat easier (Kübler-Ross & Kessler, 2005). Anticipatory grief can include the same denial, anger, bargaining, depression, and acceptance experienced in loss one might experience after death; this can make an adjustment after a loss somewhat easier, although a person may then go through the stages of loss again after the death. 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. At the same time, when a person has organized all their waking hours around the care of a dying loved one, upon their death, the caregiver may experience feelings of emptiness and disorientation in addition to relief.

Survivor’s guilt (also called survivor’s syndrome) is a mental condition that occurs when a person blames themselves for surviving a traumatic event when others did not. It may be found among survivors of combat, natural disasters, and 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.

Disenfranchised Grief. Social support from others plays an important role in the process of grieving. However, grief that is not socially recognized is referred to as disenfranchised grief (Doka, 1989). Examples of disenfranchised grief include death due to AIDS, the suicide of a loved one, perinatal deaths, abortions, the death of a pet, lover, or ex-spouse, and psychological losses, such as divorce or a partner developing Alzheimer’s disease. Due to the type of loss, there are no formal mourning practices or recognition by others that would comfort the grieving individual. Consequently, individuals experiencing disenfranchised grief may suffer intensified symptoms due to the lack of social support (Parkes & Prigerson, 2010).

Patterns of 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. Over time, grief becomes interlaced with gratitude for the presence of the loved one in our lives and the cherished memories that remain.

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 resentment and bitterness 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 all of 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 society. We are asked to grieve privately and 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. 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 unready 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 (Walker et al., 2003). 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.

Factors that Affect Grief and Bereavement

Grief reactions vary depending on whether a loss was anticipated or unexpected (e.g., parents do not expect to lose their children), 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 or overdose (Gibbons et al., 2018). These survivors may torment themselves with endless “what ifs,” even if they know cognitively that there was nothing more that could have been done.

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 complication to the grieving process. Much of this laying of blame 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 and prevent such losses in the future. 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?

Loss of a Child

According to Parkes and Prigerson (2010) the loss of a child at any age is considered “the most distressing and long-lasting of all griefs” (p. 142) Death of a child can take the form of a loss in infancy, such as miscarriage, stillbirth, neonatal death, or SIDS. Alternatively,  death can take an older child, adolescent, or adult child. In most cases, parents find the grief almost unbearably devastating, and the death of a child tends to hold a greater risk for negative psychical and psychological outcomes than any other loss. This loss also begins a lifelong process: One does not “get over” the death but instead must bear, assimilate, and live with it. Intervention and comforting support can make a big difference to the survival of a parent in this type of grief, but the risk for negative outcomes is great and may include family breakup, depression, or suicide. Archer (1999) found that the intensity of grief increased with the child’s age until the age of 17 when it declined. Archer explained that women have a greater chance of having another child when younger, and thus with added age comes greater grief as fertility declines. Certainly, the older the child, the more the mother has bonded with the child and will experience greater grief.

Feelings of guilt, whether legitimate or not, are pervasive, and the dependent nature of the relationship predisposes parents to feelings of responsibility and, hence, 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. And seeing other children who are the age that the child would have had, they lived can be painful and triggering.

Suicide and Drug Overdoses

Suicide rates are growing worldwide, and over the last thirty years, there has been international research to gather knowledge about who is “at risk” and to find out how to successfully intervene to curb this phenomenon. When a parent loses their child through suicide (and suicide is the second leading cause of death during adolescence), it is traumatic, sudden, and impacts all those who love 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 that “a wall of silence” goes up around them that shapes how people interact with them. One of the best ways to grieve and move on from this type of loss is to find a support group of other parents who have suffered a similar loss and to find ways to keep that child as an active part of their lives. It might be private at first, but as parents move away from the silence, they can move into a more proactive healing time.

When adolescents or other family members die from a drug overdose, the grieving process can also be prolonged and complicated, with patterns similar to grieving someone who committed suicide. Survivors may experience feelings of guilt, anger, resentment, and helplessness and may not receive the sympathy and social support from others that they otherwise would. Survivors may worry about the person’s reputation and the value placed on them by society because they committed suicide or died from an accidental overdose, and so may feel defensive, inhibited, or worried about sharing their experience of loss.

Loss of a Spouse

The death of a spouse is usually a particularly powerful loss. A spouse often becomes part of the other in unique ways. Many widows and widowers describe losing “half of themselves” and losing their past selves as well. The days, months, and years after the loss of a spouse can echo with emptiness, and learning to live without them may be harder than the survivor expects. The grief experience is unique to each person. Sharing and building a life with another human being, then learning to live alone, can be an adjustment that is more complex than those providing support may realize. Depression and loneliness are very common. Feeling bitter and resentful are also 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 transition to begin anew; but at younger ages as well, the death of a spouse is unexpected and off-time. A marriage relationship is often a profound anchor around which one’s life is organized, and the loss can completely disrupt the life of 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 is not completed. Changes in insurance, bank accounts, claiming life insurance, and securing childcare are just some of the issues that can be intimidating to someone who is grieving. If there are children still at home, the survivor must take care of them, support them in their grieving processes, and still find time to take care of themselves as well. Social isolation may also become an issue, 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. In fact, seeing other couples still together may be intensely painful. Widows in many cultures, for instance, wear black for the rest of their lives to signify the loss of their spouse and their ongoing grief. Only in more recent decades has this tradition been reduced to shorter periods of time.

Loss of a Parent

In contrast to the loss of a child, the loss of parents in adult life is much more common and results in less suffering. In their literature review, Moss and Moss (1995) found that the loss of a parent in adult life is “rarely pathological.” Those adult children who appear to have the most difficulty dealing with the loss of a parent are adult men who remain unmarried and continue to live with their mothers. In contrast, those who are in satisfying marriages are less likely to require grief assistance (Parkes & Prigerson, 2010). To determine the effects of gender on parental death, Marks, Jun, and Song (2007) analyzed longitudinal data from the National Survey of Families and Households that assessed multiple dimensions of psychological well-being in adulthood, including depression, happiness, self-esteem, mastery, psychological wellness, alcohol abuse, and physical health. Findings indicated that a father’s death led to more negative effects for sons than daughters, and a mother’s death led to more negative effects for daughters.

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 (Marshall, 2004) 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.”

Loss 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. However, the sibling relationship tends to be the longest significant relationship since it can last for 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 (White, 2006).

Loss during Childhood

Loss of a family member. 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 adult caregivers are struggling with their own grief and are psychologically unavailable to the child. The surviving parent or caregiver plays a crucial role in helping the child adapt to a parent’s death. Studies have shown that losing a parent at a young age does not just lead to negative outcomes; there are also some potentially positive effects. Some children showed increased maturity, better coping, and improved communication skills. Adolescents who have lost a parent value other people more than those who have not experienced such a close loss (Ellis & Lloyd-Williams, 2008).

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 six months of age, may have no reaction if a caregiver dies, but older children are typically affected by the loss. This is especially true if the loss occurs during the time when trust and dependency are formed. During critical periods such as 8–12 months, when attachment and separation anxiety are at their height, 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, but strong emotional reactions are still normal.

Worden (2002) identified ten “red flags” displayed by grieving children that may indicate the need for professional assistance:

• Persistent difficulty in talking about the dead person
• Persistent or destructive aggressive behavior
• Persisting anxiety, clinging, or fears
• Somatic complaints (stomachaches, headaches)
• Sleeping difficulties
• Eating disturbance
• Marked social withdrawal
• School difficulties or serious academic reversal
• Persistent self-blame or guilt
• Self-destructive behavior

Loss of a friend or classmate. Children may experience the death of a friend or a classmate through illness, accidents, suicide, or violence. Loss from sudden violence, like drive-by or school shootings, is particularly traumatic. Initial support involves reassuring children that they are safe, that their emotional and physical feelings are normal, and that support is available. Schools are advised to plan for these possibilities in advance. Planning and participating in rituals and memorials may be helpful but will also be challenging. Some children choose to continue visiting with the parents or family of their dead friend or classmate to keep the connection, share the loss, and comfort the family.

Other forms of loss. Children can experience grief as a result of losses due to causes other than death. For example, children may grieve losses connected with divorce and pine for the original family that has been forever lost. As with other losses, they may re-grieve this transition as they get older and have more sophisticated cognitive capacities to reflect on and rework the meaning of the divorce. 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. It is also possible for children who have been physically, psychologically, or sexually abused to grieve over the damage to or the loss of their ability to trust. Since such children usually have no support or acknowledgment from any source outside the family unit, this is likely to be experienced as disenfranchised grief.

Mourning

As a society, are we given the tools and time to adequately mourn? Not all researchers agree that we do. The “death-denying, grief-dismissing world” is the modern world (p. 205) (Kübler-Ross & Kessler, 2005).  We often grieve privately and quickly and medicate our suffering with substances or activities. Employers grant 3 to 5 days for bereavement if the 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 after just a few days. Obviously, life does have to continue, but we need to acknowledge and make more caring accommodations for those who are in grief.

Four Tasks of Mourning

Worden (2008) identified four tasks that facilitate the mourning process. Worden believes that all four tasks must be completed, but they may be completed in any order and for varying amounts of time. These tasks include:

• Acceptance that the loss has occurred
• Working through the pain of grief
• Adjusting to life without the deceased
• Starting a new life while still maintaining a connection with the deceased

Support Groups

Support groups are helpful for grieving individuals of all ages, including those who are sick, terminal, caregiving, or mourning the loss of a loved one. Support groups reduce isolation, connect individuals with others who have similar experiences, and offer those grieving a place to share their pain and learn new ways of coping (Lynn & Harrold, 2011). Support groups are available through religious organizations, hospitals, hospices, nursing homes, mental health facilities, and schools for children.

Viewing death as an integral part of the lifespan will benefit those who are ill, those who are bereaved, and all of us as friends, caregivers, partners, family members, and humans in a global society.

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 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.

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 giving us time to come to grips with what is taking place. A person who receives positive test results for life-threatening conditions may question the results, seek second opinions, or 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, God, or the world in general. 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 oneself to a cause, and 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 is an example 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 ones. 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 include (a) accepting that the loss has occurred, (b) working through and experiencing the pain associated with grief, (c) adjusting to the changes that the loss created in the environment, and (d) moving past the loss on an emotional level.

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.

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.

We no longer think that there is a “right way” to experience grief and loss. People move through a variety of stages with different frequencies 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 (American Psychological Association, 2019).

• 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 a 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 prioritize one’s own and family’s health can help one move through each day effectively. It is important to make a conscious effort to eat well, exercise regularly, and obtain adequate rest.
• 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.

Criticisms of Kübler-Ross’s Five Stages of Grief

Some researchers have been skeptical of the validity of there being stages of grief among the dying (Friedman & James, 2008). As Kübler-Ross (1969) notes in her own work, it is difficult to empirically test the experiences of the dying. “How do you do research on dying,…? When you cannot verify your data and cannot set up experiments?” (p. 19). She and four students from the Chicago Theology Seminary in 1965 decided to listen to the experiences of dying patients, but her ideas about death and dying were based on the interviewers’ collective “feelings” about what the dying were experiencing and needed (Kübler-Ross, 1969).  While she goes on to say in support of her approach that she and her students read nothing about the prior literature on death and dying so as to have no preconceived ideas, later work revealed that her own experiences of grief from childhood undoubtedly colored her perceptions of the grieving process (Kübler-Ross & Kessler, 2005). Kübler-Ross is adamant in her theory that the one stage that all those who are dying go through is anger. It is clear from her 2005 book that anger played a central role in “her” grief and did so for many years (Friedman & James, 2008).

There have been challenges to the notion that denial and acceptance are beneficial to the grieving process (Telford et al., 2006).  Denial can become a barrier between the patient and healthcare specialists and reduce the ability to educate and treat the patient. Similarly, acceptance of a terminal diagnosis may also lead patients to give up and forgo treatments to alleviate their symptoms. In fact, some research suggests that optimism about one’s prognosis may help in one’s adjustment and increase longevity (Taylor et al., 2000).

A third criticism is not so much of Kübler-Ross’s work but how others have assumed that these stages apply to anyone who is grieving. Her research focused only on those who were terminally ill. This does not mean that others who are grieving the loss of someone would necessarily experience grief in the same way. Friedman and James (2008) and Telford et al.(2006) expressed concern that mental health professionals, along with the general public, may assume that grief follows a set pattern, which may create more harm than good.

Lastly, the Yale Bereavement Study, completed between January 2000 and January 2003, did not find support for Kübler-Ross’s five stage theory of grief (Maciejewski et al., 2007). Results indicated that acceptance was the most commonly reported reaction from the start, and yearning was the most common negative feature for the first two years. The other variables, such as disbelief, depression, and anger, were typically absent or minimal.

Attributions

Human Growth and Development by Ryan Newton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License,

Individual and Family Development, Health, and Well-being by Diana Lang, Nick Cone; Laura Overstreet, Stephanie Loalada; Suzanne Valentine-French, Martha Lally; Julie Lazzara, and Jamie Skow is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License,

Human Development by Human Development Teaching & Learning Group under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License,

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