Comparison of theories on death and grief

Death can be defined as the indisputable biological end of life. In order to study and understand this phenomenon, one has to delve into the human perception of it. Woody Allen once said “I don’t mind dying, I just don’t want to be there when it happens”. The experience of such a loss, especially within a group of people as dependent of one another as is the family, is often the cause of grief for the bereaved individuals. The perception of death, nevertheless, seems to differ from culture to culture, as do the rituals encompassing the coping of the family (Kart, and Kinney, 2001).

Zoroastrianism, one of the oldest religions to have ever existed, was characterised by its belief in one God, as well as the need for reservation of the pureness of the elements. Death for the Zoroastrians meant a reuniting of the soul with its guardian and protector, fravashi. The dead were kept in the Tower of Silence, traditionally, to be purified by nature. Life and death were thus not a beginning and an end but parts of a greater hoop of life. East to these Persian grounds survives up-to-day Hinduism, India’s main religion. Hinduism stands for the indestructibility of the soul and hence its cycle from birth to death, before it is reborn. Death again is not regarded as the end, but merely as a stage within a greater loop of meaning. Here, however, cremation is obligatory, minus some exceptions (Garces-Foley, 2005).

Japanese rituals differ in the fact that a bigger part of the community is involved, than the family, mainly due to their collectivistic culture (Kart, and Kinney, 2001). After death, a bedside service is performed where the family is consoled and bathing of the dead body occurs. This is thought to enable the spirit to move on to the next world. The western culture on the contrary, tends to dissociate the living from the dead by allowing as little interaction and exposure to death as possible. A complete stranger is assigned the organising of the funeral, while the hospital cares for the body itself. During the funeral, mourners are to show as little grief as possible in public. Still, the impact of social class is evident here, since the amount of mourning expressed by the family depends on their social and educational background. (Kart, and Kinney, 2001) .

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It becomes evident from the above, that a promise to afterlife and the perpetuation of some part of the current existence (soul, body, chemicals, etc) as well as the idea of a “better place”, was and still is intending to help the family proceed with their everyday lives after the bereavement and grief. Apart from religious factors, the difference between cultures might also demonstrate different attempts of people to cope with the grief of death.

Death can be viewed from a multitude of different standpoints, which contribute to the management and expression of mourning from the family and family members. This makes generalisation of behaviours towards grief hard, if not impossible (Bates et al., 1993).

The philosophical approach to death and bereavement suggests the existence of two types of death; good and bad death. For the family, the distinction of these two, very vague notions, depends on the conditions with which the dying person dies. According to Grosz (2003), the dying person must have his/her pain controlled by the treatment, as far as possible. Other conditions for a good death include the ability of the patient to make conscious decisions of his/her own for the treatment, as well as be handled as an individual, bound with experiences from life, and not as an anonymous patient. Moreover, the dying person must have come to terms with his/her disease and manage any unfinished conflicts such as family, busyness or personal affairs. If these conditions are met, then the semblance of a good death could be acquired, thus permitting the surviving members to access their everyday lives faster and healthier, having dealt with the coping of the bereavement faster and more successfully than if a bad death had occurred.

2. Definitions of Bereavement, Grief and Coping

Bereavement is the condition the family and/or individual are involved with, after the death of an important person (Stroebe et al., 2008). This deprivation is only likely to cause grief, the natural response to a loss. Grief can be defined as the internal manifestation of the strong emotions, raised from bereavement (Stroebe et al., 2008). It is often used interchangeably with the term mourning, which is though the external dealing with grief. That is to say, mourning is the exhibition of grief in public, which eventually leads to the addressing and dealing with the latter state (Stroebe et al., 2008). Because the line between grief and mourning is this slim, the two have come to be used as umbrella terms (Grosz, 2003). Coping is the demanding task of adapting oneself psychosocially, to challenging, threatening and/or harmful circumstances (Moshe, 1996). The stress is managed or even eliminated under behavioural and cognitive endeavours (Lazarus, and Folkman, 1984; Moos, and Schaefer, 1993).

Some people though have been observed to have difficulties in reintegrating themselves within their older daily routines or in pertaining to relations with other persons. Maladaptive coping can hinder the recovery rate of the family and/or individuals, giving rise to feelings of loneliness, depression, hallucinations and even health problems related to stress, as is the abdominal pain and breathing difficulties (Parkes, 1972). People who have suffered bereavement very unexpectedly, or experienced it under shocking conditions, like suicide and homicide, are the ones most likely to acquire maladaptive coping (Grosz, 2003).

How individuals cope with bereavement, grief and mourning, depends on a number of factors. Firstly, as it has already been mentioned, spiritual and religious beliefs or practices and culture of the person, tend to affect their way of viewing death, thus promoting a number of different coping methods, which are to be investigated later on. Again, the way death was experienced as well as the bonding the person had with their important one, before death, seems to also affect the coping. The more dependent the person was to the deceased, the harder it is to let go (Grosz, 2003). Finally, the family itself is a factor pivotal to the dealing with the death of the important one, especially when it comes to children and young adults. If the family is open and caring towards each of its members and is ready to share the pain and experiences, then the whole process of dealing with the death of the deceased is greatly facilitated and rapidly overcome (Walsh, and McGoldrick, 2004). All the above factors are, nevertheless, influenced by the very personality of the mourner, which at the end of the day is the most important of all factors.

Stemming from the aforementioned considerations, related to the impact of one’s death on his/her environment, the ultimate aim of this essay is to investigate how people cope with the death of a family member. Further, a number of relevant theoretical points have been introduced for the better understanding of the issue, along with empirical evidence.

3. Stage Theories of Grief

I. The Five Stages of Death (DABDA)

Back in 1969, top thanatologist Kübler-Ross influenced the viewpoint of medical and health psychology, as she sensitised the world public opinion on terminally ill patients and their treatment, in her book On Death and Dying. There, she describes the five stages of grief people undergo while in loss of their important ones. It is of utmost importance as she has underscored many a times herself, to understand that not all people are the same or experience the five stages in the same sequence, for the same amount of time, or even confront some at all. As she supports, it all depends on the individual and their environment. The stages were first thought to only apply to the patients, but later, their application was broadened to any type of loss as is the case of a divorce, loss of occupation, death of a family member.

Denial is considered to be the first of the five stages put forward by Kübler-Ross (1969). She initially correlated this phenomenon to a number of factors influencing the patient, and in our case, the family. She considered the fact that the way one is told of the irreversibility of the terminal disease, along with the pre-existing experiences with the dying person and dependence on him/her, affects somehow the extend to which one is involved with the particular stage. However, though she suggested that everyone did go through this stage at some point, she only noted a very few cases that had kept the denial barrier up until death. Often, the individuals grew more and more confident of the idea of dying.

Anger is the stage thought to follow denial, even if no real pattern can be identified for all individuals as of the sequence of stages, progression and management. Strong emotions as rage and fury, are said to overwhelm the person who displaces this anger to all directions. This, is what makes this stage the most difficult to be dealt with since ire erupts almost at random. To Kübler-Ross (1969), this stage is again something everyone does go through sometime in their grieving period.

Bargaining, although not quite as famous as the rest of the stages, is thought to be of significant importance to the mourning family. At this point, the person would crave for an amendment of the situation or for the time to go back to when ignorance of the event prevailed. Experiencing the death of an important one is often very painful, disrupting the habitual life of the family. This is enough reason for one to be wishing to go back to what they used to consider normal, before the knowledge of death. Bargaining, the asking of a favour in return for another, could be targeting the very self of the person, or even God, the doctors, or chaplain. These favours are often kept confidential, concealing quite often, unexpressed guilt.

After the family has dealt with the new burden of knowledge and emotional awareness of the death and loss of a family member, depression may be often observed. Along with the person, plagued by his/her disease, the family suffers as well. The emotional burden to bear is huge and frequently fights between the members of the family arise. However, this is only a tip of the family’s problems. Funding the treatment of the dying person is quite the times, responsible for the loss of ability to purchase items and needs that were previously thought commonplace. The tension and depression could grow more rapidly from the absence of the dying person, in case the family was dependent on his/her role before the knowledge of the terminal disease. Such could be the case of a money-making husband/wife or mother/father to children.

Acceptance is the last stage to come, according to Kübler-Ross (1969), and unlike the common belief, it is a stage of no happy emotion. As a matter of fact, it is a stage of no emotions whatsoever, but looks more alike a giving up to the inevitability of the situation, weakened and unable to fight it any longer. The family has gone through many hardships and still does, due to their dying important one. However, at a point, the family understands that they cannot affect the situation or death itself, leaving any type of action to the doctors. After acceptance has been reached, re-assimilation to everyday life begins.

Kübler-Ross’ (1969) stage theory has been formulated via many interviews and case studies on terminally ill patients, which were later generalised to the whole of losses. The sampling she used was relatively limited to the USA, and particularly Chicago, Illinois where she first began. Empirical evidence has demonstrated that this stage theory if partially accurate. The study by Maciejewski et al. (2007) studied 233 bereaved people living in the state of Connecticut, USA and for three years. The results added to the psychology of death, elucidating the five stages of grief. People initially demonstrated disbelief, which had been regarded as similar to the stage of Denial, towards the new information. Disbelief diminished gradually, until it disappeared one month post loss. Yearning was the second stage to be identified as it reached a zenith upon the fourth month post loss, and was characterised by the urge of the individual for the bereaved family member. Anger, the ensuing stage, reached a climax of its own five moths post loss and contained the violent emotions of the individual, displaced toward all directions, as the stage theory suggests. Six months post loss were characterised by depression, which was finally followed by acceptance; a process which has escalated from the initial apprehension of bereavement, 24 months post loss. This evidence agrees with Kübler-Ross (1969) and her stage theory, to some extent. The same pattern of organising the mourning of a bereaved in stages is followed, and even some of them are very much alike the stage theory’s ones. Disbelief and anger could be running parallel to denial and anger. Nonetheless, the theory and study class one another, on the basis of grief display. While Kübler-Ross (1969) seems to position Denial as a first illustrator of grief, the results of Maciejewski et al. (2007), propose Yearning to be the main indication of grief from the first month of loss to the twenty-fourth. Moreover, Acceptance is not thought to be an end-stage, but one which develops throughout the mourning period and reaches a peak at the end of it.

The theory of the five stages of death has been overly criticised based on two major areas of clash. Firstly, the theory is said to be solidly based on Kübler-Ross’ personal experiencing of terminal diseases, bereavement and coping. Since 1969, no further evidence other than the interviews has been put forward to fully explain the existence of the five stages of grief as well as their development. While it is a fact that due to the nature of the subject, empirical evidence is hard to obtain, studies as Maciejewski et al.’s (2007) does not portray or confirm any validity or reliability of the theory. Friedman and James (2008) go as far as saying that the stages are more of a misconception of the public and media, who have come to relentlessly utilise the stages of death, than they can be considered a theory. The interviews and case studies Kübler-Ross (1969) puts forward as evidence of the existence of stages, are thought to be too biased from her own assumptions and expectations, to be considered as support to the theory. Nevertheless, it is important to take them into consideration, since they are among the few ways of studying this particular topic of death and dying, without breaking the ethical code. What could be a limitation to her research though would be the small sampling she used, of people in the USA, thus making generalisations only available to similar cases and not for example, people of collectivistic cultures.

Secondly, Kübler-Ross’ (1969) theory has been criticised of being very broad with its description of stages. Due to her saying that not all five stages have to be completed in any particular order, or duration while mourning, the theory has been criticised of being too vague. Stages are supposed to be having a beginning and an end, a duration, and be characteristic to all individuals from at least a group of similar individuals i.e. dying patients and their families. Since the above conditions are not met, they cannot be considered stages. Additionally, the use of the term ‘stages’ is said to cause more harm than good due to the misconception of time. Once one refers to stages, time is involved and people in mourning are likely to stay inactive, waiting for the ‘symptoms’ of the stage to allay. This can of course give rise to more complex psychological traumas and thus harm the individual (Friedman, and James, 2008). When it comes to stages as Depression, the fluidity of the stages of death can be fully seen, due to the free use of the term. That is to say, depression is more of a psychiatric diagnosis of illness rather than ‘sadness’ or any other such emotion. When is the person considered to be sad and when depressed? Subsequently, how to diagnose depression and treat it when it is imposed as a natural stage in the theory of mourning?

Due to the nature of the subject, not much empirical evidence can be gathered for either fully supporting Kübler-Ross’ (1969) theory or proving it inefficient and harmful. All evidence is partially anecdotal and coloured by the researcher’s interpretations, as was Kübler-Ross’ interviews or Friedman and James’ (2008).

II. Alternative Explanation to Grief

An alternative theoretical approach to grief due to the death of a family member, is Bowlby’s theory of grief (1961), where the psychophysiological components are greatly considered. Here, four main stages are to be considered. Numbness to protest is the first of the stages and consists of the confusion and breakdown of the bereavement paired with the psychological and physical dejection, where elevated blood pressure and heart rate might occur. This seems to be the first reaction to the new lifestyle imposed on the family members due to the loss of the important one, and need to get acquainted with the new life. Bowlby has studied the reactions of the body to the stress and strain of bereavement, only to find they match the stages he has put forward. Such indications include abdominal pain, hallucinations, etc.

Alike the indicators put forward from the study of Maciejewski et al. (2007), yearning is identified as the crave to be closer to the deceased, whether that be with the help of inanimate objects, people or even places that trigger memories of the past live with the person. When this second stage is overcome as well, the third of disorganisation and despair arises.