Death, dying and

bereavement
HETAL PATEL
Learning Outcomes
By the end of the lecture you should have some
understanding of:

1. Some different ways to define death

2. How we may understand death differently at
different life stages
3. Kubler-Ross’ stage theory of death and dying
Defining death
Defining death is important for many medical and legal
reasons

Different ways to define death:

• Functional Death: Absence of heartbeat and
breathing
• Brain Death: All signs of brain activity have ceased
• Psychological Death? Some people argue that once
someone has suffered irreversible brain damage they
can be considered dead
http://www.independent.co.uk/news/science/what-happens-die-brain-activity-life-heart-beating-death-after-eeg-study-research-a7620131.html
Understanding of death is
based on 5 ideas
(Berk, 2014:642)

1. Permanence
2. Inevitability
3. Cessation
4. Applicability
5. Causation
Children’s understanding of
death – Maria Nagy (1948)
Wanted to understand children’s comprehension of death
N=378. Aged 3-10 years
Methods:
1. Written compositions – used with 7-10 year olds. Asked them
to write about ‘everything that comes into your minds about
death’. Had 1 hour to do this and were not allowed to ask
questions.
2. Drawings – used with 6-10 year olds. Children began to make
drawings of death of their own accord after the written
composition task.
3. Discussions – used with all year groups. Used varying method
with 3-6 and 7-10 year olds.
Maria Nagy (1948) – first
stage
First stage (3-5 years) – there is no definitive death

A. Death is a sleep – this denies death

“Its eyes were closed, it lay there, so dead. No matter what one does, it
doesn’t say a word.
After 10 years will it be the same as when it was buried?
It will be older then, it will always be older and older…” [5 year old]
B. Death is gradual or temporary
“…He can’t speak. He can’t move. Can’t see. Can’t open his eyes. He lies
for four days.
Why for four days?
Because the angels don’t know yet where he is. The angels dig him out,
take him with them. They give him wings and fly away.” [5 year old]
Maria Nagy (1948) – second
stage
Second stage (5-9 years) – Death = a man

“Death is a living being and takes people’s souls

away. Gives them over to God, death is the king of
the dead. Death lives in the cemetery and can be seen
only when he carries off some person’s soul. There is
a soul in death.” [7 year old]

Death can be avoided if you can get away from the

death man and not be caught
Maria Nagy (1948) – final
stage
Third stage (9+ years) – death the cessation of
corporal activities

“Death is the termination of life. Death is destiny.

Then we finish our earthly life. Death is the end of
life on earth.” [9 year old participant]

Understanding that death is a cessation of life; it is

inevitable and universal.
 Development of a conception
of death
(Berk, 2014:642)

Early adulthood:
Adolescence: Unique Middle/late
invulnerability adulthood:
Abstract
but are still
conception of Changes in roles
realistic about
death and relationships
personal
mortality
Death Education
Many people have argued for education around death and dying to
help young people to remove the taboo

Current Death Education programmes:

1. Crisis intervention education
◦ Used around key national events (e.g. 9/11) and local events
(Sandoval et al., 2009)
2. Routine death education
◦ Rare at infant school level, but seen at high school and increasingly
HE (Eckherd, 2009)
3. Death education for helping professionals
◦ Essential for medical training (Haas-Thompson et al., 2008)
Death Education goals
(Berk, 2014: 665)

1. Increase understanding of the physical and

psychological changes that accompany dying
2. Helping students learn how to cope with the
death of a loved one
3. Preparing students to be informed consumers of
medical and funeral services
4. Promoting understanding of social and ethical
issue involved in death
 Facing your own death: Terminal
illness
Middle Late
Childhood Adolescence Young adults adulthood adulthood
Children with Feelings of Similar Increased Death can be
terminal being reaction to fears of more ‘real’
illness can vulnerable adolescents death generally as
show good lead to anger (but less (Levinson, friends and
awareness of Often make parental 1992) and siblings start
their own poor patients control) increasing to reach the
situation Challenges years end of their
(Bluebond- with planning life
Langner, Withdrawal
2000) (Turner &
Helms, 1994)
Suicide (esp.
>85, M)
Should you always tell
someone they are
dying?
Awareness and interaction
(Glaser and Strauss, 1966, 1968)
1. Closed awareness – dying person does not know they are dying
and the care provider or relative is not going to tell them. About
keeping this information a secret rather than non-communication.
2. Suspected awareness – the patient surmises they are not being
told the truth. They attempt to check that they disease can't be
reverse or halted.
3. Open awareness – both patient and others share knowledge and
concerns. They feel free to bring up the subject if necessary or
useful but don’t have extensive discussions about it. There is less
tension and conflict
4. Mutual pretence – the patient and visitor knows he/she is dying.
They pretend they don’t know and are aware the other person is
pretending too. The pretence is difficult to sustain and they may be
caught off guard and let the truth escape.
(cited in O’Brien, 2016:186)
 Stages of dying and bereavement
(Kubler-Ross 1969, 1982)

Denial Anger Bargaining Depression Acceptance

Denial – no, not me, it
cannot be true
Resistance of the idea that death is coming
◦ Flat out denial
◦ Seeking second opinions

Defence mechanism?
◦ Allows acceptance at one’s own pace

Can fluctuate (Smith 1993; Teutsch 2003)

Health professionals advised to be sympathetic but not to distort

reality
(O’Brien, 2016: 187)
Anger – Life is not fair! Why
me?
Anger directed at several sources
◦ Others in good health
◦ Family members
◦ Health professionals
◦ ‘God’

Can be very difficult for loved ones and those

providing treatment

(O’Brien, 2016: 187)

Bargaining – if you’ll just let
me live until my grandchild
is born
Attempts to bargain for extra time related to:
Milestones
◦ “If I can just make it to Christmas I’ll….”
◦ Evidence that death rates fall just before important
holidays and rise just after (Phillips & Smith, 1990)

• Altruism
– Wanting extra time to make
things easier for loved ones
(Komp, 1996)
(O’Brien, 2016: 187)
Depression – what difference
does it make anyway?
Depression about the end of life and the process of
dying

Phases of depression:
◦ Reactive: Sadness based on what has already been,
or things that have ended
◦ Preparatory: Sadness over future losses

(O’Brien, 2016: 187)

Acceptance – I’ve lived a
good life, I’m ready to go
Awareness that death is coming

Lack of emotional reactions to death

State of “peace”

Some withdrawal (Samarel, 1995)

(O’Brien, 2016: 187)
Evaluation of Kubler-Ross’
theory
(Boyd and Bee, 2015:476)

Help health professions by identifying when they should

leave someone alone, provide hope or encouragement

Universal human process – cultural differences

Methodological problems:
• How often did she speak to participants?
• How long a period was the assessment??
• How old were the patients?
• Type of diagnosis?
Evaluation of Kubler-Ross’
theory
(Boyd and Bee, 2015:477)

Should be viewed as coping strategies – often viewed as

fixed-order stages

Shneidman (1980, 1983) – based on emotions. Many

themes that appear, disappear and reappear in any one
patient
• Include: terror, pervasive uncertainty, fantasies of
being rescued, incredulity, feelings of unfairness, a
concern with reputation after death, and fear of pain
Evaluation of Kubler-Ross’
theory
https://
www.psychologytoday.com/blog/notes-self/2012
10/real-stages-grief

Real stage of grief?

https://www.psychology.org.au/publications/inps
ych/2011/december/hall
/
Responses to impending
death
(Boyd and Bee, 2015:477)

Greer 1970s followed 62 females with diagnosis of early

stage breast cancer:
1. Denial (positive avoidance) – rejects evidence
regarding diagnosis
2. Fighting spirit – optimistic attitude
3. Stoic acceptance (fatalism) – accepts diagnosis, or
ignores diagnosis
4. Helplessness/hopelessness – overwhelmed by
diagnosis
5. Anxious preoccupation – strong and persistent anxiety
Coping with the death of a
loved one
(Berk, 2014: 659)

Bereavement – experience of losing a loved one by

death

Grief – intense physical and psychological distress

Mourning – culturally specified expression of the

bereaved person’s thought and feelings
Bereavement
Can also be explained by Kubler Ross’ theory, though
acceptance can be more difficult for the bereaved

Also thought of as a set of tasks to fully grieve (Worden 2009,

cited in Berk 2010, p. 660):
1. Accept the reality of the loss
2. Work through the pain of grief
3. Adjust to a world without the loved one
4. Develop an ‘inner bond’ with the deceased and move
on
Bereavement reactions (Parkes,
1998 cited in O’Brien, 2016:198)
1. Trauma response – anxiety, restlessness, fear. Anger
and guilt towards those who want them to accept
their loss. PTSD
2. Grief response – urge to search for lost person. Grief
reaction maybe excessive, prolonged, uninhibited.
3. Psychosocial response – sense of dislocation between
this world and the world that should be. Sense of
emptiness. There is a process where the bereaved
person moves from denial to acceptance and adoption
of a new model of the world. The process may be
impaired by feelings of helplessness and
hopelessness.
Attachment type predicts
bereavement style?
According to Parkes (2010:16/17) –
1. Secure – show less grief and distress
2. Anxious/ambivalent – suffer grief and tendency
to cling following bereavement
3. Avoidance – difficulty expressing affection and
grief
4. Disorganised – are anxious, panicky and/or
depressed
Dual process model of
coping with loss
Often two parallel types of adjustment
• Practical
• Emotional

Dual-process model of coping with loss (Hansson & Stroebe,

2007) argues that we must deal with both

Moving between dealing with the two types of can distract and
give the bereaved a ‘break’

Continued confrontation of grief can have negative

consequences (Corr & Corr, 2007)
Bereavement research
Richardson (2007)
Followed widowed older adults 6, 18 and 48 months after loss of
spouse
Those that engaged in ‘restoration’ activities (practical) had
reduced stress

Lund et al., (2004)

Tested an intervention for older adults which moved between
practical and emotional coping
Found that bereavement did not come in stages but was compared
to a ‘rollercoaster’ of ups and downs
Individual differences in
bereavement
Gender
◦ Men are less likely to express grief openly and seek support (McGoldrick,
2004)

End of life experiences

◦ Painful deaths lead to more anxiety, and yearning for the loved one (Carr,
2003)

Sudden versus prolonged

◦ Unexpected deaths can be most stressful due to lack of anticipatory
grieving (Breslau et al., 1998)

Relationship to the deceased

◦ Nature of relationship (e.g. parent-child versus spouse etc.)
◦ Quality of relationship
 Cultural
differences in
bereavement

http://ideas.ted.com/11-fascinating-funeral-traditions-from-around-the-globe/

https://commons.wikimedia.org/wiki/File:Gaben_balinese_funeral_2007-06-10.jpg
Ghana's funeral dancers
To summarise
1. There are different ways to describe death and
which definition you use may depend on the
purpose of the definition
2. Kubler-Ross’ stage theory of death and dying
has been very influential but there are
limitations to the theory
3. Bereavement is a complex process which needs
to be considered in the context of individual and
cultural differences
Examples of exam questions
Discuss how Kubler-Ross’ model helps
us to understand dying and
bereavement.

Describe and evaluate Kubler-Ross’

model of dying and bereavement
References
Berk, L. (2014) Development through the lifespan. 6th ed.,
Boston: Pearson
Boyd, D. and Bee, H. (2015) Lifespan development. New Jersey:
Pearson.
Nagy, M. (1948) ‘The child’s theories concerning death.’ The
Journal of Genetic Psychology 73 pp.3-27.
O’Brien, E. (2016) Psychology for Social Work: A Comprehensive
Guide to Human Growth and Development. London: MacMillan
Education.
Parkes, C. (2010) ‘Grief: lessons from the past, visions for the
future.’ Psychologica Belgica, 50(1) p.7-26.