17.3: Coping with Death

Learning Objectives

By the end of this section, you will be able to:

• Identify elements and themes of the grieving and mourning process
• Describe common ways to support people who have lost a loved one
• Describe various ways of remembering and honoring loved ones

Dyan is studying to become a counselor because she feels her Ojibwe community needs more mental health resources. She’s currently learning about grief counseling and discovering that grief is more complex than she thought. She always believed everyone went through a specific set of emotional responses after the death of a loved one, but now she’s finding that the emotional reaction to death can vary across people and situations. Dyan realizes that if she wants to be an effective counselor, she must take an individualized and personal approach to supporting people who’ve experienced a loss.

In her studies, Dyan also learns that this support includes helping people find ways to remember and honor their loved ones. She has seen funerals and memorials both in person and in various forms of media. As a creative person, she likes the idea of helping her clients develop meaningful artifacts they can use to help adjust to the loss of their loved one.

Coping with death isn’t a singular process. There are emotional and cognitive aspects of reacting to death—both our own future passing and someone else’s—and behaviors and rituals people use to express their feelings and remember and honor the deceased. Some of these vary by culture, but they may also vary on smaller, more individual dimensions. Thus there is no one “right” way to respond to death. Most people refrain from speaking ill of the deceased or being deliberately disrespectful, but beyond that we all react to death in different ways.

Grief, Mourning, and Bereavement

Coping with the death of a loved one is a deeply personal process, and the grieving process varies for each individual and family, additionally influenced by sociocultural differences. The internal, emotional reaction to loss is referred to as grief, whereas mourning is the outward, behavioral manifestation of grief (Figure 17.16). A related concept is bereavement, the experience of the death of a loved one. Bereavement is different from grief and mourning because it doesn’t indicate anything about how a person feels internally or what they’re doing. It simply means that the person has experienced a loss.

Figure 17.16 (a) Grief is the internal emotional reaction to loss, while mourning includes (b) the behaviors grieving people exhibit. (credit a: modification of work “Khatam funeral of Asadollah Fereydoun, Noor Mosque, Tehran - 5 October 2011 02” by Mohammad Hassanzadeh, Fars Media Corporation/Wikimedia Commons, CC BY 4.0; credit b: modification of work “Military Funeral Honors are Conducted for U.S. Marine Corps Cpl. Spencer Collart in Section 52” by Arlington National Cemetery/Flickr, Public Domain)

There are many aspects of grief and mourning. In addition to cultural factors, we need to consider who is experiencing the grief, the person who’s dying or their family and friends. We also experience grief differently depending on who has died; the death of a child often evokes different grief reactions than the death of an older adult. Grief is a normal, understandable reaction to loss. There are situations in which it lasts an unusually long time and becomes problematic, but mental health professionals generally don’t regard grief as something that needs to be “fixed.”

Themes of Grief

Some of the best-known work on grief was done by Swiss psychiatrist Elisabeth Kübler-Ross. After interviewing hospice patients about their emotional states, Kübler-Ross concluded that a dying person goes through an emotional process in their adjustment to the end of their life. While we often hear the parts of this process described as “stages,” the word “themes” is more appropriate, because they describe the dying person’s emotional and sometimes behavioral priorities rather than specific milestones a person needs to reach. In other words, Kübler-Ross’s themes of grief represent cognitive, emotional, and behavioral reactions to our own impending death. The five themes are denial, anger, bargaining, depression, and acceptance (Table 17.1).

Table 17.1 Kübler-Ross Themes of Grief (source: Kübler-Ross, 1969)

Theme	Description
Denial	A person may react to a diagnosis with disbelief. They may insist the test results are wrong or that someone made a mistake. They may solicit cures or second opinions.
Anger	A person may direct their anger generally or at specific targets such as doctors or a higher power. They may say that life is unfair.
Bargaining	A person may beg a higher power to spare their life. They may promise to be on “good behavior” (such as by donating money to charity) if they get well.
Depression	A person may experience a profound sense of loss, not only for their life, but for associated losses such as missing future family milestones.
Acceptance	A person deals realistically with coming death, neither happy nor giving up.

Kübler-Ross’s theory quickly gained widespread acceptance (Bernau, 2022; Corr, 2020; Daniel, 2023) and has been proposed as a way to describe other types of losses, such as the death of a loved one, changes in the workplace, and addiction recovery (Daniel, 2023). What explains this lasting popularity? First, this theory seems logical and intuitive. Second, Kübler-Ross wrote in plain language that was easy to understand. Third, the theory filled a gap because no others about the psychological adjustment to death were widely used in clinical practice at that time (Bernau, 2022).

Despite it's popularity, the Kubler-Ross's theory does have some limitations. Her research was qualitative and she did not track any of her participants longitudinally to determine whether they actually experienced these themes, and in the order she proposed (Bregman, 2019; Kastenbaum, 2012). These methodological limitations are important because counselors and health-care professionals may regard Kübler-Ross’s themes as a “prescription” for grieving and fail to properly support clients who don’t fit their expectations (McLean et al., 2022; Stroebe et al., 2017).

Although anecdotal reports suggest general support for Kübler-Ross’s themes (Lyckholm, 2019), other research indicates that specific circumstances may influence whether and how people experience them (Corr, 2019, 2020, 2021; Kastenbaum, 2012; Maciejeski et al., 2007; McLean et al, 2022; Schulz & Aderman, 1984). For example, people grieving a stillbirth may not engage in bargaining because they recognize the outcome can’t be changed (Dastidar, 2019). Nor is the experience of grief linear: it may fluctuate, and a person may experience a temporary increase in grief symptoms such as sadness or anger around anniversaries or holidays (American Psychiatric Association, 2022; Stroebe et al., 2017). Some researchers have proposed the existence of middle knowledge, an intermediate stage that represents a simultaneous denial and acceptance of death (Weisman, 1972). Someone in this stage may engage in end-of-life planning but still deny the reality of their impending death (Breitbart, 2017; Polacek et al., 2023).

While Kübler-Ross’s theory does imply a sequential progression, we shouldn’t regard it as a rulebook for how to grieve (Corr, 2020, 2021; Stroebe et al., 2017; Tyrrell et al., 2023). Kübler-Ross herself didn’t propose a timetable for grieving, and acknowledged that people may not experience all the themes or in the same order (Bregman, 2019; Kübler-Ross & Kessler, 2005; Tyrrell et al., 2023). People may skip some themes and revisit earlier themes, such as a person returning to depression or anger upon realizing that they will not see their grandchildren graduate high school. Kübler-Ross believed dying people should be allowed to discuss their feelings openly without being dismissed or told to be optimistic (Kübler-Ross, 1969) (Figure 17.17).

Figure 17.17 Grieving people need support from others in their lives. (credit: modification of work “prs_0061.JPG” by Ewan Topping/Flickr, CC BY 2.0)

Open discussion is generally beneficial for improving emotional well-being and coping (Barlé et al., 2017; McCoyd et al., 2021; Stroebe et al., 2013) and is also part of clinically ethical behavior (Dugan, 2004). This attention to the dying person’s feelings also helps avoid social death because the dying person is still regarded as human (Corr, 2019, 2021).

Other research suggests that experiencing these themes is considered adaptive, although the reason may be that they fit people’s schemas of what grief looks like (Hashim et al., 2013; McLean et al., 2022; Penman et al., 2014). Having a framework for processing different emotions associated with grief may also be comforting or provide structure in an overwhelming situation (Hall, 2014). Regardless of preconceived notions of what grief looks like, health-care providers and others who interact with grieving people need to be flexible and adapt to the needs of the situation (Corr, 2021; Flugelman, 2021; McCoyd et al., 2021). There are different patterns of grieving that vary across individuals, cultures, and the context in which grief occurs. It may not be possible to always accommodate all these variables, but being aware of them is a good first step (Stroebe et al., 2017).

Other Theories of Grief

Kübler-Ross’s model is perhaps the best-known theory of grief, but it’s not the only one. Again, these theories offer not prescriptions for how to grieve, but rather context for understanding the perspective of the person who is grieving.

Neimeyer and colleagues (2006, 2010) and Wolfelt (2005) devised theories that viewed the grieving process as a narrative, story, or journey, with less emphasis on tasks or stages. For Neimeyer, the end goal of the grieving process is to gain a sense of meaning and purpose, which may mean adjusting our worldview (Neimeyer et al., 2006, 2010) through processes similar to Piaget’s mechanisms of assimilation and accommodation. Wolfelt values developing a sense of meaning and places more emphasis on building social networks such as family relationships, friendships, and increased participation in social activities to help compensate for loss (Wolfelt, 2005).

Another theory is the dual-process model, initially proposed by Stroebe and Schut in 1999. Grief has two processes in this model: loss orientation and restoration orientation. During loss orientation, the bereaved person addresses the emotional aspects of the loss by accepting the situation and sharing grief with others. During restoration orientation, the person copes with the changes brought about by their loved one’s death, including changes to or the addition of relationships and roles. These processes aren’t sequential but occur simultaneously, with the bereaved person cycling between them (Stroebe & Schut, 1999, 2015; Stroebe et al., 2013, 2017).

Despite several differences, these theories, including Kübler-Ross’s, have much in common. All treat grief as a process, not an event, and acknowledge that coping with it takes time and effort. They also emphasize that grieving is an individual process; even the theories that propose tasks, stages, or themes avoid prescribing a specific order or timeframe for them. We can use this information to be more compassionate with ourselves and others and not pressure people to move on unrealistically (Harris, 2021).

Contextual Influences on Grief and Mourning

The age at which death occurs, the relationship between the deceased and their survivors, and the specific dying trajectory all also influence the expression of grief. For example, the death of a child or young adult appears to be harder to cope with than the death of an older adult (Morris et al., 2019), perhaps because dying young violates expectations for how the human lifespan should unfold (Neugarten, 1976). When an infant or very young child dies, typical rituals surrounding death may not occur, which may affect the family’s experience of grief (McCoyd et al., 2021; Institute of Medicine Committee for the Study of Health Consequences of the Stress of Bereavement, 1984). It’s easy to assume the child’s parents can turn to each other for support, but parents may each feel they need to be strong and avoid burdening the other, so neither discusses their feelings and everyone’s grief is exacerbated (Barlé et al., 2017; Institute of Medicine Committee for the Study of Health Consequences of the Stress of Bereavement, 1984; Stroebe et al., 2013). Not every family has two parents, and parents may struggle to care for other children in the home while simultaneously processing their own grief (Dastidar, 2019; Howard Sharp et al., 2018; Morris, 2019). They may become overprotective for fear something will happen to their living children (Dastidar, 2019; Kübler-Ross, 2011).

The relationship between the deceased and their survivors may also affect grieving. We typically regard the death of a spouse as one of the most stressful events a person can experience (Holmes & Rahe, 1967; Institute of Medicine Committee for the Study of Health Consequences of the Stress of Bereavement, 1984; Oswald & Powdthavee, 2008). However, other research (Cleiren, 1993; Fujisawa et al., 2010; Maccallum et al., 2015; Morris, 2019) indicates that losing a child is equally difficult or even more so (Aoun et al., 2015; Guldin et al., 2017; Nielsen et al., 2019). Bereaved parents and spouses may also experience different outcomes. For example, loneliness increases for widowed spouses but not for bereaved parents (Barlé et al., 2017).

The closeness of the relationship and/or amount of conflict within the relationship may also be relevant (Currier et al., 2015; Kramer et al., 2010; Shear et al., 2013). However, even people not close to the deceased, such as health-care providers, may experience grief, particularly those who work in fields such as oncology, palliative care, and critical care. Unlike the grief experienced by loved ones, however, the grief of health-care providers may go unacknowledged (Childers & Arnold, 2019), which can be harmful to well-being (Barlé et al., 2017; McCoyd et al., 2021; Stroebe et al., 2013).

The dying trajectory also appears to matter. Perhaps not surprisingly, a sudden death is associated with increased feelings of grief (Aoun et al., 2015; Barlé et al., 2017; Cleiren, 1993; Guldin et al., 2017; Kaplow et al., 2014) because there is less time to emotionally prepare for it. The dying trajectory and cause of death may also differ by age; causes of death for young children are likely to be sudden events like accidents (Centers for Disease Control and Prevention, 2023). Because both a sudden death and the death of a child are associated with heightened grief responses (Aoun et al., 2015; Morris et al., 2019), coping with the death of a child may be especially difficult.

Is cause of death associated with the experience of grief? Some studies indicate that losing a loved one to suicide produces stronger grief reactions than other causes (Cleirin, 1993; Guldin et al., 2017), but this finding isn’t consistent (Kaplow et al., 2014). The sudden trajectory of death in cases of suicide might be more influential than the cause of death. In cases of dementia, caregivers are likely to experience grief in multiple ways. Lindauer and Harvath (2014) identified four sources of grief for dementia caregivers: the uncertain trajectory of the disease, impaired communication with the care recipient, changes in the relationship with them, and their loss of personhood. Many transition points occur in the caregiving relationship as dementia progresses, each of which may bring about new grief. Cognitive impairments also prevent caregivers and care recipients from sharing memories and feelings, which can complicate the experience of grief (Lindauer & Harvath, 2014; Rupp et al., 2023).

Caring for the Bereaved

People who are bereaved need care and support, although they may not all need the same type or degree. One challenge is that bereaved people do not always seek help and do not always regard the help they receive as valuable (Barlé et al., 2017; McCoyd et al., 2021; Morris et al., 2019), possibly because the person trying to help may not truly understand the experiences of the person seeking help. Circumstances such as the dying trajectory and age of the deceased may also affect the survivors’ adjustment. Because there’s no right way to grieve or mourn, and no correct time period in which these things occur, caring for the bereaved requires careful attention to the person’s needs.

As you might expect, bereavement is associated with emotional responses such as sadness, anger, loneliness, and guilt (Aoun et al., 2015; Barlé et al., 2017; Currier et al., 2015; Guldin et al., 2017; McCoyd et al., 2021; Morris et al., 2019;). However, physical responses are also common, such as decreased immune system functioning and increased risk of heart attack and death (Shear et al., 2013; Seiler et al., 2020). Some of these may be caused by increased levels of stress hormones like cortisol (McCoyd et al., 2021), which is associated with health problems such as diabetes and high blood pressure (Iob & Steptoe, 2019; Ortiz et al., 2022; Seiler et al., 2020). Health-care providers, counselors, and other people in the bereaved person’s life need to attend to both the emotional and the physical aspects of well-being, particularly in the first few months after the loss (Figure 17.18). Some cultural communities have built-in practices for doing so. For example, in Kenya and Uganda, friends and family are expected to provide specific support to the bereaved such as arranging the funeral, helping with childcare and housework, and even providing financial assistance. This support is viewed as being crucial for helping the bereaved adjust and cope with their loss (Ayebare et al., 2021).

Figure 17.18 A person experiencing difficulties coping with grief may benefit from psychotherapy. (credit: modification of work “Counselling session” by “tiyowprasetyo”/Wikimedia Commons, CC0 1.0)

One strategy for caring for the bereaved is to identify people with the highest risk for negative long-term outcomes. People who have lost someone to a sudden or traumatic death are at increased risk for mental health problems, self-harm, and suicide, particularly in the first year after death (Aoun et al., 2015; Barlé et al., 2017; Guldin et al., 2017; Morris et al., 2019; Shear et al., 2013). However, there’s much variability in the way people cope (Neimeyer et al., 2010). Some researchers have focused on complicated grief, which lasts longer than typical and is associated with long-term adjustment problems. As the standards and definitions for identifying and classifying psychological disorders evolve, the question of whether complicated grief is a diagnosable psychological disorder has been debated (Cozza et al., 2016; Shear et al., 2011). The addition of prolonged grief disorder to the most recent revision of the DSM (the DSM-V-TR) encompasses the general nature of complicated grief.

When bereaved people begin psychotherapy, it may include treating existing problems such as anxiety disorders or helping the person work through issues from earlier in life. Therapeutic approaches often combine improving coping resources and building social support. Sometimes therapists use formal psychotherapy techniques such as systematic desensitization to deal with anxiety-provoking situations, and cognitive-behavioral therapy to manage self-defeating thoughts and behaviors (Barlé et al., 2017). Helping the bereaved person find meaning in their situation may also be helpful (Barlé et al., 2017; Neimeyer et al., 2010; Ng, 2021; Reischer & Beverley, 2019). This can include creating their own narrative of the loss, sometimes through therapeutic writing such as a letter to the deceased person. A key challenge in this type of therapy is balancing validation of the bereaved person's feelings with helping them to make meaning out of that loss and move forward (Currier et al., 2015; Neimeyer et al., 2010).

Remembering and Honoring Those Who Have Died

Thousands of years ago, Neanderthal humans in Europe began to bury their dead, and centuries later the Romans published obituaries on papyrus sheets. The Taj Mahal, Emperor Shah Jahan’s memorial to one of his wives in Agra, India, was more than twenty years in the making in the mid-1600s. And after Queen Victoria’s beloved husband Albert died in 1861, she wore black for the remaining forty years of her life. Humans have a long and varied history of honoring and memorializing the dead.

Many cultures have rituals to mark someone’s death and build meaning from their passing. Some are secular ceremonies that gather people together, while others have religious significance. Some serve primarily to support the surviving family, while others sustain the memory of ancestors, such as Shinto and Buddhist shrines and the Mexican Day of the Dead (McCoyd et al., 2021). In southern Ghana, some people are buried in elaborate “fantasy coffins” (abebuu adekai) that commemorate aspects of the person’s life, representing the belief that the afterlife is the same as this one (Gundlach, 2017; Potocnik & Adum-Kyeremeh, 2022).

Are people more likely to have unresolved grief if these rituals aren’t performed? Research on this is inconclusive, but it does suggest that planning and participating in grief rituals can have benefits if the rituals allow people to grieve in a way that is meaningful to them (Burrell & Selman, 2020). Some rituals are viewed as essential, and misfortune is associated with omitting them. For example, the Nawfia people of Nigeria routinely hold a second funeral on the one-year anniversary of the first, to finalize the deceased person’s transition to the afterlife (Ugwu, 2023).

Sometimes people participate in death rituals from several cultures. Educator Linita Eapen Mathew (2021) lives in Canada but her ethnic heritage is Indian, so she experienced both cultures’ approaches to mourning following the death of her father. Canadians generally view grief as private, and family members have to make funeral arrangements in a short time frame. The Canadian rituals thus focused on a single event—the funeral—after which the mourning period was considered to be largely over and the bereaved needed to move on. Mathew was left feeling adrift at a time when support was needed most. In contrast, the Indian Christian practices in which she participated after going to India included regular prayer, fasting, charitable contributions, and sacred ceremonies, most done in the company of other mourners. These rituals “offered meaningful and sustaining ways to honour [her] grief …and enhanced [her] ability to heal” (p. 791).

The COVID-19 pandemic reduced funeral attendance in general (Burrell & Selman, 2022), as well as specific practices such as the African American Baptist custom of having a large gathering with a meal after a burial, and the Jewish tradition of nichum aveilim, in which members of the community visit the bereaved family to provide emotional support, prayer, and food (Schuck et al., 2020). Islam and Judaism both have postmortem rituals for handling, washing, and purifying the body (Gabbay & Fins, 2019), which were also curtailed during the pandemic. It remains to be seen whether these changes will have long-term effects on grief rituals, or in what way the pandemic has shaped our approach to communal grieving.

Use of Technology

Technology also influences death rituals. Carlson and Frazer (2015) describe how Aboriginal Australians use social media, particularly Facebook, for “Sorry Business”—participation in death-related activities such as providing comfort to the bereaved and remembering the dead. Given a high mortality rate, large kinship networks, and expectations of participation in funerals and other remembrance activities, conducting Sorry Business in person is expensive and time-consuming and could mean traveling 600 miles or more. However, Aboriginal Australians—and people in many other countries—now commonly use social media to send condolences and pay respects. Some even treat a deceased person’s Facebook page like a memorial or grave site and post photos or sentiments there on important dates, much like visiting a burial place in person (Blanch, 2021; Ryan, 2023). Additionally, funeral homes in many countries now offer the option of a livestreamed or recorded funeral for mourners who can’t attend in person (Bitusikova, 2020; Uriu et al., 2021).

Remembering and honoring the dead does not always involve official rituals from a particular culture or religious belief. For some, a ritual may be gathering friends to share memories and stories of the person's life or toasting to their memory with a small group of close loved ones.

It Depends: What Is the Impact of Losing a Pet?

Pets bring emotional support and companionship to many people, and their death is often highly distressing. However, other people may not take the pet owner’s sorrow seriously. Disenfranchised grief is grief that’s not acknowledged or recognized, and the death of a pet is believed to be a potential instance of this experience (Bussolari et al., 2018; Cordaro, 2012, Green et al., 2018).

Ambiguous loss is unresolved grief that typically occurs in situations lacking closure. Because it is associated with disappearance and/or sudden death, both of which may occur in pet loss, bereaved pet owners are at risk for this outcome (Green et al., 2018). This point may be particularly useful for parents to know, because more than half of children in countries where owning pets is common will experience the loss of at least one before turning seven (Crawford et al., 2020). Caregivers can use this knowledge to be more sensitive and supportive in helping their children navigate this loss.

Do people grieve the same way following a pet’s death and a human’s death? In general, it appears they do. People discussing the loss of a pet tend to describe their feelings with the same language used in discussing the loss of a human (Lyons et al., 2022). Some research indicates that bereaved pet owners experience grief in ways predicted in Kübler-Ross’s model and the dual-process model (Cordaro, 2012).

Bereaved pet owners should be forgiving of themselves and not judge themselves for their grief. This self-care may compensate for possible lack of support from others (Bussolari et al., 2018). If you know a bereaved pet owner, acknowledging the owner’s grief and providing them with support should help their grieving process (Bussolari et al., 2018, Cordaro, 2020).

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