Developmental Psychology

Chapter #19: Coping with Death and Bereavement

Submitted by: Group 6

Semester: BS 5th (Evening)
Department of Psychology, BZU Multan
Members: Roll #
Wasifa Zafar 17
Asma Aitzaz 21
Laiba Jamil 22
Aleeza Siddiqui 28
Sidra Batool 29
Farheen Bohal 54
Safeen Raza 51

Table of contents:
 Introduction
 Experience of dying
 Meaning of Death across Lifespan
 Process of dying
 Theoretical Perspective on Grieving
 The Experience of Grieving
 Conclusion
  Introduction:

Grief is the process and emotions that we experience when our important
relationships are significantly interrupted or (more frequently) ended, either
through death, divorce, relocation, theft, destruction, or some similar process. A
related term, “bereavement”, has different meanings for different people, but all
meanings refer to the grieving process. While some view bereavement as a specific
subtype of grief that occurs when a loved one (usually a spouse) dies.

Grief starts when someone or something we care about is lost to us. We do not
grieve for all lost relationships; instead, we grieve only for those that have become
important to us over time. These can be relationships with people that we have
strong connections to, such as family members and friends; or things that are
important to us, such as a watch that a grandparent gave us, etc.

 Experience of Dying:

Death is a process as well as state and psysicians have different labels for different
aspects of this process. Experience of Death is shaped by the circumstances
surrounding the end of life

 Characteristics of clinical Death, Brain Death and Social Death:

a period during which vital signs are absent but resuscitation is still possible
 Clinical Death:

Clinical Death is when your heart stops pumping blood. Without CPR

In short, no heartbeat + no breathing + no brain activity = clinical death.

• Brain Death:

Brain death is defined as the irreversible loss of all functions of the brain, including
the brainstem. The three essential findings in brain death are coma, absence of
brainstem reflexes and apnea.

• Social Death
 Social death is distinguished from biological or physical death: when the body is
considered to have died and ceased functioning for life. Social death can occur
before or after physical death.

• Hospice and Hospital difference regarding their effects on terminally ill

patients

Hospice is for anyone living with a serious illness, no longer seeking curative
treatment, and whose remaining lifespan is estimated at six months or
less.Palliative care is for people at any stage of a serious illness from the time of
diagnosis, through treatments, and through end of life. Your condition does not
have to be incurable.

 Meaning of Death Across lifespan

As an adult, you understand that death is irreversible, that it comes to everyone,

and that it means a cessation of all function.But do children and teenagers
understand these aspects of Death? And what does death mean to adults of
different ages?

Children’s understanding of Death

As children have no concept of death until around age of 5 think death can be
reversed through magic prayers or wishful thinking. Around age of 6-7
comprehend death as biological event and have better understanding of Finality
and Irreversibility of death and ideas of death are rooted in their lack of
understanding of death. By age of 9, According to Piaget beginning of concrete
operational stage leads to understanding of universality and Finality of death. By
Middle childhood, most develop realistic concept of death and custom involved
funeral etc.

Factors that affect understanding of Death.

1. Experience with death of loved one or losing any pet

2. Candid and sensitive discussion with adults provides children with scaffolding
they need to achieve a cognitive understanding of death.

Adolescents understanding of Death

They have better understanding of Finality of death than children and are more
pronounced among adults to have personal experience as these experiences tend
to shake adolescents confidence in their own immorality.

What contributes to Adolescents suicide?

• Unrealistic and distorted beliefs

• Temporary escape from stressful personal problems
• Think that death is a pleasurable experience

Meaning of Death for Adults

Ideas about death vary with age. Death seems remote to most young adults. The
notion of personal mortality is a more common focus of thought in middle age,
and by the later years, the idea of death becomes very personally relevant for most
Adults.
Fear of Death across Adulthood:

• Middle Aged Adults – Most fearful of death

• Young Adults – sense of unique in vulnerability that prevents intense
fear of death

Factors that contribute in fear of death:

• Religious Belief
• Personal Worth

Preparation of death:

Preparation of death occur at different levels as:

1. Practical level
2. Deeper level

3. Final preparations

At practical level, such preparations typically include purchasing life insurance,

making a will, and preparing written instructions regarding end-of-life care, often
called an advance directive. Individuals can use advance directives to make clear to
health-care professionals and to their families that they either do or do not wish to
have their lives prolonged with feeding tubes and other device. Researchers found
that older adults are most likely to make such arrangements. At deeper level Adults
may prepare for death through some process of reminiscence. And for final
preparations there may be unconscious changes that occur in the years just before
death, which might be thought of as a type of preparation and there are physical
and mental changes associated with terminal decline. Research has pointed to the
possibility that there may be terminal psychological changes as well.

 Process of Dying:

Dying can be a gradual process, including when someone has a serious illness. If
someone is receiving good care, it can be quite a peaceful time — a time during
which the body lets go of life.

Kubler Ross Theory:

Throughout life, we experience many instances of grief. Children may grieve a

divorce, a wife may grieve the death of her husband, a teenager might grieve the
ending of a relationship, or you might have grieved the loss of a pet.

In 1969, Elisabeth Kübler-Ross described five common stages of grief, popularly

referred to as DABDA. They include:

• Denial
• Anger
• Bargaining
 • Depression
• Acceptance

Denial:

Denial is the stage that can initially help you survive the loss. You might think life
makes no sense, has no meaning, and is too overwhelming. You start to deny the
news and, in effect, go numb. It’s common in this stage to wonder how life will go
on in this different state—you are in a state of shock because life as you once knew
it has changed in an instant. If you receive news of the death of a loved one,
perhaps you cling to false hope that they identified the wrong person. In the denial
stage, you are not living in “actual reality,” rather, you are living in a “preferable”
reality.Once the denial and shock start to fade, the healing process begins. At this
point, those feelings that you were once suppressing are coming to the surface.

Anger:

Once you start to live in “actual” reality again, anger might start to set in. This is a
common stage to think “Why me?” and “Life’s not fair!” You might look to blame
others for the cause of your grief and also may redirect your anger to close friends
and family. You find it incomprehensible how something like this could happen to
you. If you are strong in faith, you might start to question your belief in God:
Where is God? Why didn’t he protect me?

Researchers and mental health professionals agree that this anger is a necessary
stage of grief. And encourage the anger. It’s important to truly feel the anger.

Bargaining:

When something bad happens, have you ever found yourself making a deal with
God? “Please God, if you heal my husband, I will strive to be the best wife I can
ever be, and never complain again.” This is bargaining. In a way, this stage is false
hope. You might falsely make yourself believe that you can avoid the grief through
this type of negotiation. If you change this, I’ll change that. You are so desperate to
get your life back to how it was before the grief event, you are willing to make a
major life change in an attempt toward normality. Guilt is a common wingman of
bergaining.

Depression:

Depression is commonly associated with grief. It can be a reaction to the

emptiness we feel when we are living in reality and realize the person or situation
is gone or over. In this stage, you might withdraw from life, feel numb, live in a fog,
and not want to get out of bed. The world might seem too much and too
overwhelming for you to face. You might not want to be around others or feel like
talking, and you might feel hopeless. You might even experience suicidal thoughts.

Acceptance:

The last stage of grief identified by Kübler-Ross is acceptance. Not in the sense that
“it’s OK my husband died” but rather, “my husband died, but I’m going to be
OK.”In this stage, your emotions may begin to stabilize. You re-enter reality. You
come to terms with the fact that the “new” reality is your partner is never coming
back, or that you are going to succumb to your illness. It’s not a “good” thing, but
it’s something you can move forward from. Understand your loved one can never
be replaced, but you move, grow, and evolve into your new reality.

Criticism and alternative ways:

Kübler-Ross’s model has provided a common language for those who work with
dying patients, and her highly compassionate descriptions have, without doubt,
sensitized health-care workers and families to the complexities of the process of
dying. But Kübler-Ross’s basic thesis—that the dying process necessarily involves
these specific five stages, in this specific order—has been widely criticized (Roos,
2013). Kübler-Ross responded to critics by pointing out that she had not meant the
stages she proposed to be interpreted as rigidly as some researchers and
practitioners suggested they should be. Nevertheless, criticisms of her model go
beyond concerns about its stages.
METHODOLOGICAL PROBLEMS Kübler-Ross’s hypothesized sequence was initially
based on clinical observation of 200 patients, and she did not provide information
about how frequently she talked to them or over how long a period she continued
to assess them. She also did not report the ages of the patients she studied,
although it is clear that many were middle aged or young adults, for whom a
terminal illness was obviously “off time.

CULTURAL SPECIFICITY A related question has to do with whether reactions to

dying are culture specific or universal. Kübler-Ross wrote as if the five stages of
dying were universal human processes. However, cross-cultural studies suggest
that cultures vary considerably in what they believe to be a “good death”. Thus,
certain aspects of KüblerRoss’s theory, such as the concepts associated with the
bargaining stage, may be less important to people in collectivist cultures than they
were to the people who participated in her initial studies.

THE STAGE CONCEPT The most potent criticism of Kübler-Ross’s model, however,
centers on the issue of stages. Many clinicians and researchers who have
attempted to study the process systematically have found that not all dying
patients exhibit these five emotions, let alone in a specific order. Of the five, only
depression seems to be common among Western patients. Edwin Shneidman
(1980, 1983), a major theorist and clinician in the field of thanatology (the scientific
study of death and dying), argues that people who are dying display a wide range
of emotional responses and do not all have the same needs. Instead of stages,
Shneidman suggests that the dying process has many “themes” that can appear,
disappear, and reappear in any one patient in the process of dealing with death.
These themes include terror, pervasive uncertainty, fantasies of being rescued,
incredulity, feelings of unfairness, a concern with reputation after death, and fear
of pain.

Another alternative to Kübler-Ross’s model is a “task-based” approach suggested

by Charles Corr (1991/1992). In his view, coping with dying is like coping with any
other problem or dilemma: You need to take care of certain specific tasks. He
suggests four such tasks for the dying person:
● Satisfying bodily needs and minimizing physical stress

● Maximizing psychological security, autonomy, and richness of life

● Sustaining and enhancing significant interpersonal attachments

● Identifying, developing, or reaffirming sources of spiritual energy, and thereby

fostering hope.

Responses to impending death:

Individual variations in responding to imminent death have themselves been the

subject of a good deal of research interest in recent decades. Some of the most
influential research along these lines has been the work of Steven Greer and his
colleagues (Greer, 1991, 1999; Greer, Morris, & Pettingale, 1979; Pettingale,
Morris, Greer, & Haybittle, 1985). In Greer’s initial study in the 1970s, he followed
a group of 62 women diagnosed in the early stages of breast cancer. Three months
after the original diagnosis, each woman was interviewed at some length, and her
reaction to the diagnosis and to her treatment was classed in one of five groups:

 Denial (positive avoidance): Person rejects evidence about diagnosis; insists

that surgery was just precautionary.
 Fighting spirit: Person maintains an optimistic attitude and searches for
more information about the disease. These patients often see their disease
as a challenge and plan to fight it with every method available.
 Stoic acceptance (fatalism): Person acknowledges the diagnosis but makes
no effort to seek any further information, or person ignores the diagnosis
and carries on normal life as much as possible.
 Helplessness/hopelessness: Person acts overwhelmed by diagnosis; sees
herself as dying or gravely ill and as devoid of hope.
 Anxious preoccupation: Women in this category had originally been included
in the helplessness group, but they were separated out later. The category
includes those whose response to the diagnosis is strong and persistent
anxiety. If they seek information, they interpret it pessimistically; they
 monitor their body sensations carefully, interpreting each ache or pain as a
possible recurrence.

Greer then checked on the survival rates of these five groups after 5, 10, and 15
years. Only 35% of those whose initial reaction had been either denial or fighting
spirit had died of cancer 15 years later, compared with 76% of those whose initial
reaction had been stoic acceptance, anxious preoccupation, or
helplessness/hopelessness. Because those in the five groups did not differ initially
in the stage of their disease or in their treatment, these results support the
hypothesis that psychological responses contribute to disease progress—just as
coping strategies more generally affect the likelihood of disease in the first place.
However, in a subsequent study in the 1990s, Greer reported that the link
between the fighting spirit and cancer survival was likely to have been due to an
absence of an anxious or hopeless approach to the disease (Greer, 1999). That is,
having a fighting spirit does not necessarily increase a cancer patient’s chances of
survival, but an anxious or hopeless attitude reduces it.

Similar results have emerged from studies of patients with melanoma (a form of
skin cancer), as well as other cancers, and from several studies of AIDS
patients.And at least one study of coronary bypass patients showed that men who
had a more optimistic attitude before the surgery recovered more quickly in the 6
months after surgery and returned more fully to their pre-surgery pattern of life.

Despite the consistency of these results, two important cautions are in order
before you leap to the conclusion that a fighting spirit is the optimum response to
any disease. First, some careful studies find no link between depression, stoic
acceptance, or helplessness and more rapid death from cancer (e.g., Cassileth,
Walsh, & Lusk, 1988; Kung et al., 2006; Richardson, Zarnegar, Bisno, & Levine,
1990). Second, it is not clear that the same psychological response is necessarily
appropriate for every disease.

Another important ingredient in an individual’s response to imminent death is the

amount of social support he has. Those with positive and supportive relationships
describe lower levels of pain and less depression during their final months of illness
  Theoretical Perspectives on Grieving:

There are a number of ways of looking at the emotion of grief, but the two that
have had the greatest influence on the way psychologists think about grief are
Freud’s psychoanalytic theory and Bowlby’s attachment theory.

Freud’s Psychoanalytic Theory:

From the psychoanalytic perspective, the death of a loved one is an emotional

trauma. As with any other trauma, the ego, or mind, tries to insulate itself from the
unpleasant emotions such losses induce through the use of defense mechanisms,
including denial and repression. However, Freud believed that defense
mechanisms were only temporary devices for dealing with negative emotions.

Freud’s view has been very influential in grief counseling and in popular notions
about the necessity of “working through” grief in order to avoid its long-term
negative effects. It is generally accepted that bereaved individuals need to talk
openly about their loss. Thus, grief counselors often recommend that friends of a
bereaved person encourage the person to cry or express grief in other ways.

Psychoanalytically based grief therapy for children often emphasizes the use of
defense mechanisms other than denial and repression to cope with grief.
Following two methods can be used to apply this approach.

 Sublimation: to express their feelings through art.

 Identification: to manage their grief.

In addition, the psychoanalytic perspective has shaped grief research by

characterizing the loss of a loved one as a trauma. An important concept in such
research is that the more traumatic the death, the more likely it is to be followed
by physical or mental problems. In fact, researchers have found that people who
lose loved ones in sudden, tragic ways, such as to a drunk-driving accident or a
murder, are more likely to display symptoms of posttraumatic stress disorder.

Bowlby’s Attachment Theory:

John Bowlby and other attachment theorists argue that intense grief reactions are
likely to occur at the loss of any person to whom one is attached, whether a
partner, a parent, or a child. Moreover, their theories predict that the quality of
attachment to the loved one should be related in some way to the experience of
grief. Research seems to confirm this aspect of their view. The stronger the
attachment between a mourner and a lost loved one, the deeper and more
prolonged the grief response.

Bowlby proposed four stages of grief, and Catherine Sanders, another attachment
theorist, proposed five stages, but as you can see in Table, the two systems overlap
a great deal.

Alternative perspective:
A growing set of “revisionist” views of grieving gives a rather different picture from
that of either Freud or the attachment theorists. First, research suggests that,
contrary to psychoanalytic hypotheses, avoiding expressions of grief neither
prolongs the experience of grief nor leads inevitably to physical or mental health
problems.

Second, many researchers and theorists find that grieving simply does not occur in
fixed stages, with everyone following the same pattern.

Psychologists Camille Wortman and Roxane Silver have amassed an impressive

amount of evidence to support such a view. They dispute the traditional view of
grieving expressed in both Freud’s and Bowlby’s theories. First, Wortman and
Silver do not agree that distress is an inevitable response to loss. Second, their
research challenges the notion that failure to experience distress is a sign that the
individual has not grieved “properly.”

Based on their findings, Wortman and Silver conclude that there are at least four
distinct patterns of grieving (Wortman & Silver, 1990):

 Normal: The person feels great distress immediately following the loss, with
relatively rapid recovery.
 Chronic: The person’s distress continues at a high level over several years.
 Delayed: The grieving person feels little distress in the first few months but
high levels of distress some months or years later.
 Absent: The person feels no notable level of distress either immediately or at
any later time.
 The experience of grieving:

When we experience a major loss, grief is the normal and natural way our mind
and body react. Everyone grieves differently. And at the same time there are
common patterns people tend to share. For example, someone experiencing grief
usually moves through a series of emotional stages, such as shock, numbness,
guilt, anger and denial. And physical symptoms of grief are typical also. They can
include: sleeplessness, inability to eat or concentrate, lack of energy, and lack of
interest in activities previously enjoyed.

Psychosocial functions of death rituals:

Funerals, wakes, and other death rituals help family members and friends manage
their grief by giving them a specific set of roles to play. Like all other roles, these
include both expected behaviors and prohibited or discouraged behaviors. The
content of these roles differs markedly from one culture to another, but their
clarity in most cases gives a shape to the days or weeks immediately following the
death of a loved person. Among Tibetan Buddhists, for instance, dead persons are
believed to be unaware of their state for the first 4 days after their deaths.
Mourners are expected to pray that they will realize that they are dead soon
enough to avoid having to be reborn as another human or in another life form.

Death rituals also bring family members together as no other occasion does (with
the possible exception of weddings). Frequently, cousins and other distant
relatives see one another for the first time in many years at funerals. Such
occasions typically inspire shared reminiscences and renew family relationships
that have been inactive for a long time. Death rituals are also designed to help the
survivors understand the meaning of death itself, in part by emphasizing the
meaning of the life of the person who has died.

The process of grieving:

The ritual of a funeral, in whatever form it occurs, can provide structure and
comfort in the days immediately following a death. But what happens when that
structure is gone? How do people handle the sense of loss? Answering that
question requires a look at a number of factors associated with grief

AGE OF THE BEREAVED:

Children express feelings of grief very much the same way teens and adults do
(Auman, 2007). Like adults, children demonstrate grief through sad facial
expressions, crying, loss of appetite, and age-appropriate displays of anger such as
temper tantrums (Oatley & Jenkins, 1996).

Although the behavioral aspects of adolescents’ grief responses vary little from
those of adults, teens may be more likely than children or adults to experience
prolonged grief. One study found that more than 20% of a group of high school
students who had a friend killed in an accident continued to experience intense
feelings of grief 9 months after the death

MODE OF DEATH:

How an individual dies contributes to the grief process of those who are in
mourning. For example, widows who have cared for spouses during a period of
illness prior to death are less likely to become depressed after the death than
those whose spouses die suddenly . Grief-related depression seems to emerge
during the spouse’s illness rather than after the death. However, sudden and
violent deaths, especially those that involve suicide, evoke more intense grief
responses.

Death in the context of a natural disaster is also associated with prolonged grieving
and development of symptoms of PTSD (Kilic & Ulusoy, 2003; Rajkumar, Mohan, &
Tharyan, 2013). Such events bring to mind the inescapable reality of the fragility of
human life.

By contrast, the most frustrating aspect of the grieving process for people who
have lost a loved one through a violent crime is the inability to find meaning in the
event (Currier, Holland, & Neimeyer, 2006; Lichtenthal et al., 2013). In the initial
phases of the grief process, survivors protect themselves against such frustration
through cognitive defenses such as denial and by focusing on tasks that are
immediately necessary (Goodrum, 2005). Next, survivors often channel their grief
and anger into the criminal justice process through which they hope that the
perpetrator of the crime will be justly punished. Ultimately, many survivors
become involved in organizations that support crime victims and survivors of
murdered loved ones or those that seek to prevent violence (Stetson, 2002).
Widowhood:

Widowhood, or the disruption of marriage due to the death of the spouse, is

a source of great emotional pain and stress. Widows (females whose spouse has
died) and widowers (males whose spouse has died) may grieve and mourn their
loss for years. Nearly 3 percent of men and 12 percent of women in all age groups
in the United States are widowed. Among people age 75 and older, nearly 25
percent of men and 66 percent of women are widowed

WIDOWHOOD AND MENTAL HEALTH:

In the year following bereavement, the incidence of depression among widows

and widowers rises substantially, though rates of death and disease rise only
slightly (Onrust & Cuijpers, 2006; Schaan, 2013). In one important longitudinal
study, researchers repeatedly interviewed a sample of 3,000 adults, all age 55 or
older at the beginning of the study (Norris & Murrell, 1990). Forty-eight of these
adults were widowed during the 2½ years of the study, which allowed investigators
to look at depression and health status before and immediately after
bereavement. They found no differences in physical health between widowed and
nonwidowed participants, but they did note a rise in depression among the
widowed immediately following the loss and then a decline within a year after
bereavement. However, other researchers have found that older adults whose
spouses have died differ in mental health for several years following the death
from peers whose spouses are still alive (Bennett, 1997). So it appears that
declines in physical and mental health follow bereavement fairly consistently, but
how long such effects last may be highly variable. Several factors contribute to this
variability.

WIDOWHOOD AND PHYSICAL HEALTH:

The experience of widowhood appears to have both immediate and longer-term

effects on the immune system (Jones, Bartrop, Forcier, & Penny, 2010; Utz,
Caserta, & Lund, 2012). (The term widowhood applies to both men and women;
widow refers to women and widower to men.) In one Norwegian study,
researchers measured immune functioning in widows twice, shortly after their
husbands’ deaths and 1 year later (Lindstrom, 1997). Investigators found that the
widows’ immune systems were suppressed somewhat immediately after the death
but in most cases had returned to normal a year later

PREVENTING LONG-TERM PROBLEMS:

Some research suggests that the “talk it out” approach to managing grief can be
helpful in preventing grief-related depression, especially when feelings are shared
with others who have had similar experiences, in the context of a support group
(Francis, 1997; Schneider, 2006). Research also indicates that developing a
coherent personal narrative of the events surrounding the spouse’s death helps
widows and widowers manage grief (Haase & Johnston, 2012; Neimeyer,
Prigerson, & Davies, 2002; van den Hoonaard, 1999). Participating in support
groups—or even jointly recalling relevant events with close family members—can
facilitate the formation of such stories. Clearly, this kind of psychosocial
management of grief requires time. Mental health professionals advise employers
that providing bereaved employees (especially those whose spouses have died)
with sufficient time off to grieve may be critical to their physical and mental health.
In the long run, illness and depression among bereaved workers who return to
their jobs too soon may be more costly to employers than providing additional
time off.