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4
Death, Dying, and
Grief in Families
Colleen I. Murray, Katalin Toth,
and Samantha S. Clinkinbeard

On September 11, 2001, Kate was working in New York City when she
received a call from her elderly fathers nursing home upstate and learned that
her father had only hours to live. Her efforts to leave the city were slowed
by the chaos of that tragic day, and her father died before she arrived at the
nursing home. She thinks of her grief over missing her chance to say good-bye
to him as selfish and insignificant compared with the losses others suffered
that day.
On the afternoon of September 11, 2001, 16-year-old Dan was killed in
Ohio as he was walking home from school. He was run down by a drunk driver who, despite a history of drunk driving, claimed he had been drinking that
afternoon in response to the days events. Dans family believes that Dans
death has gone unnoticed.
A Manhattan psychotherapist observes that the initial increases in compassion and existential consciousness he saw in his clients soon after 9/11 have

Authors Note: Additional material related to this chapter, including suggestions

for clinical, public policy, and educational interventions as well as directions for
research, can be found online at http://equinox.unr.edu/homepage/cimurray/.
75

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shifted to narcissistic, angry preoccupations. Meanwhile, the mass media
continue to present heroic images of New Yorkers, not the detached people he
sees in his neighborhood (Alper, 2002).
Months after the 9/11 terrorist attacks, Ricardo, who lives in Nevada, learns
that his firefighter uncle has died 2,000 miles away while responding to an act
of environmental terrorism in which a luxury car dealership was bombed.
Everyone talks of his uncle as a young hero, and of the familys patriotism.
Then the family is left to grieve alone, as the rest of the nation moves on. Two
years later, Ricardos neighbor dies in the war in Iraq; Ricardo notices that
there are similarities in how people respond to the neighbors family and how
they responded to his family when his uncle died.

espite terrorism and war, dying and grief have changed little since the
previous edition of Families and Change was published. Most adults
in industrialized countries still die from degenerative illnesses, and most
young people die from sudden or violent causes. Death still poses the most
painful adaptational challenges for families (Walsh & McGoldrick, 1991,
p. 25). Changes in the cultural paradigm from narcissistic materialism to
compassion and from a sense of security to vulnerability seem limited in
scope, reflecting most Americans experience with single acute tragic events
rather than with recurring large public tragedies. The mass media speedily
convey the details of wartime danger, natural disasters, high-profile accidents, and purposive public acts of violence and provide marathon coverage
of events through technologically enhanced reporting (Blondheim & Liebes,
2002). We live in an environment where death is invisible and denied, yet we
have become desensitized to it. These inconsistencies appear in the extent to
which families are personally affected by deathwhether they define loss as
happening to one of us or to one of them. In this chapter, we address
enduring processes related to death in the family as well as some changes
that have occurred since the terrorist attacks of September 11, 2001.
Annually, there are more than 2.9 million deaths in the United States,
affecting 8 to 10 million surviving immediate family members, including
2 million children and adolescents (Hoyert, Arias, Smith, Murphy, &
Kochanek, 2001). Death is a crisis that all families encounter, and it is recognized as the most stressful life event families face, although most do not
need counseling to cope (Parkes, 2001). Research that examines loss as a
family system phenomenon has only recently gained visibility (e.g., Shapiro,
1994; Walsh & McGoldrick, 1991), with increased attention paralleling
movement into midlife of baby boomers.

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Death, Dying, and Grief in Families77

Etiology of Invisible Death

and Its Consequences
At least from the Middle Ages through the 17th century, death was viewed as
natural and inevitable (Aris, 1974). A movement to deny the realities of death
occurred during the 18th and 19th centuries, and by the 20th century a lack
of firsthand familiarity with death in Western culture fostered an era in which
death became sequestered, privatized, and invisible. Factors contributing to
this lack of familiarity with death included increased life expectancy, changes
in leading causes of death from communicable diseases to chronic and degenerative diseases (although there is currently some concern about increases in
communicable diseases such as West Nile virus, meningitis, and drug-resistant
tuberculosis, and about the use of smallpox as a bioweapon), redistribution of
death from the young to the old, decreased mortality rates, and increased duration of chronic illnesses (Miller, Engelberg, & Broad, 2001; U.S. Bureau of the
Census, 1975). In industrialized Western nations, geographic mobility and
social reorganization of families also resulted in reduced intergenerational contact and thus fewer opportunities for younger family members to participate
in death-related experiences (Rando, 1993). In addition, the development of
life-extending medical technologies has had several effects on Americans experiences with death: (a) It has moved most dying from peoples homes to institutions (National Center for Health Statistics, 2001), (b) it has resulted in care
dominated by efforts to delay death by all means available, (c) it has led us to
question our assumptions about what constitutes life and death, and (d) it has
confronted families with decisions about whether to prolong the process of
dying or terminate the lives of loved ones.
Although Western families are distanced from the intimacies of death,
they are bombarded by public presentations of death through the news and
entertainment media (Dolan, 2003; Murray & Gilbert, 1997). These frequent, sensationalized, violent portrayals of death as unnatural contribute to
desensitization, repression, and personal traumatization of bereaved individuals (Alper, 2002; Rando, 1993). Media-orchestrated emotional invigilation
in reporting on the deaths of famous individuals and mass tragedies leave
consumers with illusions of intimacy and grieving (Walter, Littlewood, &
Pickering, 1995). Individuals who did not personally know the deceased can
go through rituals of mourning and virtually attend the funeral through
television or the Internet, without feeling the depth of pain and depression
of actual grief. Viewers may confuse their emotional responses (i.e., virtual
grief) with the actual grief experienced by the deceased persons loved ones

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(Cose, 1999). Recovery from virtual grief is quick, so individuals who have
experienced only virtual grief may be insensitive regarding the amount of
time that others need to return to normal when actual grief occurs.
The changes described above have increased the stress that families experience when coping with death. Westerners generally do not view dying and
bereavement as normal life-span experiences; rather, they compartmentalize
death, frequently excluding children from family death-related experiences
(Hurd, 1999). Families adaptation to losses through death has been hampered by the lack of cultural supports that could assist family systems in
integrating the fact of death with ongoing life (Walsh & McGoldrick,
1991, p. 2) and the lack of instrumental social supports to help them manage disruptions in their daily lives, such as assistance with child care, housework, and finances (Shapiro, 2001). For many Americans, a minimum of
rituals exist surrounding death, the roles of chronically ill or bereaved individuals are not clearly defined, and geographic distance hinders the completion of unfinished business (Harvey, 2000; Shapiro, 1994).
Although death and grieving are normal, survivors can experience physical, psychological, and social consequences that can be viewed either as
stressor experiences (Burnell & Burnell, 1989) or as part of the coping
process (Hall & Irwin, 2001). Bereavement can result in negative consequences for physical health (Prigerson et al., 1997), including physical illness, aggravation of existing medical conditions, increased use of medical
facilities, and the presence of new symptoms and complaints (Burnell &
Burnell, 1989). During anticipatory bereavement and the months following
a loss through death, physiological changes in survivors are indicative of
acute heightened arousal (i.e., increased levels of cortisol and cathecholamines, change in immune system competence, and sleep complaints);
however, changes in neuroendocrine function, immune system competence
and sleep may endure for years in survivors (Goodkin et al., 2001; Hall &
Irwin, 2001). Intrusive thoughts and avoidance behaviors are correlated
with sleep disturbances, which appear to intensify the effects of grief, resulting in decreased numbers and functioning of natural killer cells (Ironson
et al., 1997). Bereavement also appears to be related to increased adrenocortical activity, long-lasting brain changes, and possible long-term changes in
gene expression (Biondi & Picardi, 1996). It should be noted, however, that
Rosenblatt (2000) found sparse reference to any personal health problems in
the narratives of bereaved parents regarding their childrens deaths or dying.
Epidemiological studies cannot assess a direct causal relationship between
bereavement and physical ailments, but researchers have found bereavement
to be an antecedent of disease (Goodkin et al., 2001; Hall & Irwin, 2001).
Risk factors for increased morbidity and mortality during bereavement

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include self-damaging or neglectful behaviors, additional stress symptoms,

elevated physiological arousal, and depression. Physiological resilience appears
to be related to coping strategies, social support networks, and healthy
sleep profile.
The consequences of bereavement for mental health also are difficult to
measure (Attig, 2001). Characteristics typically associated with grief are ones
that would evoke concern in other circumstances. High rates of depression,
insomnia, suicide, and anorexia may exist in conjunction with consumption
of drugs, alcohol, and tobacco (Stroebe, 2000). Individuals with personality
disorders are more likely to exhibit complications (Rando, 1993). Lack of
differentiation among grief, depression, and somatization (Wayment &
Vierthaler, 2002), as well as researchers failure to examine traumatic or complicated grief reactions separately from normal grief, hinder determination
of mental health consequences (Wortman & Silver, 2001).
Research has suggested that bereaved individuals identify bereavement
as a social stressor, reporting lack of role clarity and support (Rando, 1993;
Rosenblatt, 2000). The changes in social status, conflicts in identity, disputes
over inheritance, and loss of roles, income, or retirement funds that may
result when a family member dies can contribute to social isolation. Changes
in family communication patterns and relationships with people outside the
family are common.
Paradoxically, a body of literature is currently emerging that emphasizes
growth as an outcome of loss. Posttraumatic growth is both a process and an
outcome in which, following trauma, growth occurs beyond the individuals
previous level of functioning (Schaefer & Moos, 2001; Tedeschi, Park, &
Calhoun, 1998). Growth outcomes may occur in the individuals perception of
self (e.g., as survivor rather than victim, or as self-reliant yet with heightened
vulnerability), interpersonal relationships (e.g., increased ability to be compassionate or intimate, to self-disclose important information, and to express
emotions), and philosophy of life (e.g., reorganization of priorities, greater
appreciation of life, grappling with the meaning and purpose of life, spiritual
change, and sense of wisdom). In contrast, terror management theory
(Pyszcznski, Solomon, & Greenberg, 2003) suggests that what appears to be
posttraumatic growth is actually cognitive coping, which protects or distances
the individual from traumatic events and buffers his or her fear of death.

Theories of Grieving
Theories of grieving have moved beyond bereaved individuals to the interpersonal study of the group or societal influences and impacts of grief. They

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include developmental stage and process-based theories focused on individuals

experiences as family members as well as theories based on the family system.

Individual-Based Theories
Scholars have proposed theories of grieving that focus on developmental
stages or trajectories for the dying (e.g., Kbler-Ross, 1969; Pattison, 1977)
and for survivors (e.g., Rando, 1988; Worden, 1991) derived from the
works of Freud (1917/1957) and Bowlby (1980). Such theories differ in the
numbers of stages they describe, but they all assume that grieving consists of
three basic phases: (a) a period of shock, denial, and disorganization; (b) a
period of extremes including intense separation pain, volatile emotions, and
active grief work; and (c) a period of resolution, acceptance, and (for the
bereaved) withdrawal of energy from the deceased and reinvestment. Critics
of developmental theories question the definition of normal grief and
these theories assumptions about how people should respond, including
the following: (a) Intense emotional distress or depression is inevitable;
(b) failure to experience distress is indicative of pathology; (c) working
through loss is importantintense distress will end with recovery; and (d) by
working through loss, individuals can achieve a state of resolution, including intellectual acceptance (Wortman & Silver, 2001).
Stage theories have been criticized for being population specific and for
representing progress toward adjustment as linear (Corr, 1993). Critics contend that progress is not always forward and that grief processes may have
no definite ending (Rosenblatt, 2000; Wortman & Silver, 2001). They assert
that the emphasis should not be on recovery or closure, but on continuing
bonds, relearning relationships, and renegotiating the meaning of loss over
time (Attig, 2001; Klass, 2001). Rather than dichotomizing relinquishing
and retaining bonds, Boerner and Heckhausen (2003) suggest that transformation involves both disengagement from the deceaseds physical absence
and connection with the deceased through mental representations.
Scholars have also argued that developmental theories view grief as passive, with few choices for grievers (Attig, 2001). Critics of these theories
contend that grieving is active, presenting bereaved individuals with challenges, choices, and opportunities. They question the necessity of grief
worktraditionally accepted as an essential cognitive process of confronting loss (Bowlby, 1980; Freud, 1917/1957; Lindemann, 1944; Parkes,
2001). Margaret Stroebe and her colleagues suggest that grief work is not a
universal concept and that the definitions and operationalizations of the concept that researchers have used have been problematic. They note that few
studies have yielded substantial conclusions regarding the effectiveness of

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grief work, and researchers have approached these studies with the aim of
understanding the processes of grief rather than developing prescriptions for
recovery (Stroebe et al., 2000).
Models based on varied tasks of grieving have begun to emerge in recent
years. Worden (1991) has moved away from grief as illness to delineate a
model based on the following tasks: (a) acknowledging the reality of loss,
(b) working through emotional turmoil, (c) adjusting to the environment
where the deceased is absent, and (d) loosening ties to the deceased. Horaceks
(1995) heuristic model identifies tasks related to high-grief deaths and views
grief responses as both reactive and proactive. Attig (2001) presents a model
of grief as active in which the task of the bereaved person is to relearn the
world in terms of physical surroundings, relationships, and who he or she is.
Among individual-centered process-based models is Randos (1993) 6 R
model, which assumes the need to accommodate loss. The 6 R processes
are recognizing the loss, reacting to separation from the deceased, recollecting (and reexperiencing) the deceased and the relationship, relinquishing old
attachments and the assumptive world, readjusting to move into a new
world without forgetting the old, and reinvesting (p. 45). In contrast, the
dual-process model of coping (M. S. Stroebe & Schut, 2001) suggests that
active confrontation of loss is not necessary for a positive outcome; there
may be circumstances when denial, avoidance of reminders, and repressive
strategies are essential. The dual-process model concurs with the findings of
social-functional research that minimizing expression of negative emotions
and using laughter as a dissociation from distress may improve functioning
(Bonanno, 2001). This model assumes that most individuals experience
ongoing oscillation between loss orientation (coping with loss through grief
work, dealing with denial, and avoiding changes) and restoration orientation
(adjusting to various life changes triggered by death, changing routines, transitioning to a new equilibrium, avoiding or taking time off from grief). There
is movement between coping with loss and moving forward, with the need
for each orientation differing from individual to individual depending on
such factors as type of loss, culture, and gender.

Family Theories of Coping With Death

Although scholars have focused on dying or bereaved individuals, death
does not occur in isolation. An estimated 70% of deaths in the United States
involve end-of-life decision making negotiated among family members, physicians, and (when competent) dying family members (American Psychological
Association, 2000). Individual process models have not been broadened to
aid in our understanding of families, except for psychoanalytic models, which

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some have argued are suited for dealing with family bereavement because of
their emphasis on ambivalent relationships (Blake-Mortimer, Koopman,
Spiegel, Field, & Horowitz, 2003). Work on grief from a family perspective
has typically utilized elements of systems theories, particularly through integrative approaches to complex issues. Refinement of systemic models recognizes that multiple griefs exist simultaneously for individuals, couples,
families, and communities, and, although some thoughts and feelings are
shared, others are not (Gilbert, 1996).

Family Systems Theory

Family systems theory focuses on dynamics and provides concepts that
are useful for describing relationships (e.g., Jackson, 1965; Kantor & Lehr,
1975), offering a nonpathologizing conceptualization of grief as a natural
process (Nadeau, 2001). The following premises of systems theory can be
useful in examining families adaptations to dying and death:
1. A family reacts to loss as a system. Although we grieve as individuals, the
family system has qualities beyond those of individual members (Jackson,
1965), and all members participate in mutually reinforcing interactions
(Walsh & McGoldrick, 1991).
2. Actions and reactions of a family member affect others and their functioning. This interdependence exists because causality in systems is circular
rather than linear (Shapiro, 2001).
3. Death disrupts a family systems equilibrium, modifies the structure, and
requires system reorganization in feedback processes, role distribution, and
functions (Bowen, 1976; Jackson, 1965).
4. Death may produce emotional shock waves of serious life events that can
occur anywhere in the extended family in years following a death (Bowen,
1976). Such waves exist in an environment of denied emotional dependence
and may seem unrelated to the death. They may trigger additional stressor
events and increasingly rigid strategies to maintain stability (Shapiro, 2001).
5. There is no single outcome from death of a member that characterizes all
family systems. Various family characteristics, such as feedback processes
(Jackson, 1965), patterns of relationship (Shapiro, 2001), family schema, and
family paradigm (McCubbin, Thompson, Thompson, Elver, & McCubbin,
1998), influence the outcome.

Scholars have applied systems theory infrequently in examining deathrelated reorganization (Shapiro, 2001). Loss has traditionally been identified

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as a historical, individual, or content issue and inappropriate for traditional

family systems work (which focuses on process, homeostasis, differentiation of
self from family, current interaction, and the present) (Nadeau, 2001; Walsh
& McGoldrick, 1991). Recent versions of systems theory have focused on the
balance of change and continuity as well as the negotiated inclusion of differences to balance self-assertion and cohesion. The application of family systems
theory to the study of grief is now discussed in a framework that includes
intergenerational and family life-cycle perspectives (Walsh & McGoldrick,
1991), focusing on change in structural factors such as boundaries, and family
dynamics such as roles and rules, as well as meaning making and communication (Nadeau, 2001). In a recent examination of the relationship between individual grief and family system characteristics, Traylor, Hayslip, Kaminski, and
York (2003) found that grief symptomatology at 4 to 5 weeks postloss did not
predict any family system characteristics or grief symptomatology 6 months
later. However, individuals perceptions of family system cohesion, family
expressions of affect, and communication were predictors of later grief.

Integrative Models
Particularly useful models are those that simultaneously consider individual, family, and cultural dimensions. Rather than relying on traditional
family systems, these models integrate family systems concepts with other
perspectives. Rollands (1994) family systemsillness model examines the
interface of individual, family, illness, and health care team. Rather than
taking the ill individual in a family as the central unit of care, it focuses on
the family or caregiving system as a resource that both is affected by and
influences the course of illness. This model can be useful for understanding
the experiences of the ill individual and family members during the terminal
phase of chronic illness, in multiple contexts and across time.
Mooss (1995) model of the interrelationship of processes involving grief
tasks of individuals and those of their families highlights the interdependence
of family processes and individual perceptions. This model addresses relationships between individual and family grief symptoms, the influence of each
family member on a family systems coping strategies and grief reactions, and
the mediating roles of family history, cultural constraints, feedback, and
nuclear family functioning. Shapiro (1994, 2001) has applied a systemic
developmental approach in examining grief as family process. This clinical
model views grief as a developmental crisis influenced by family history,
sociocultural context, and family and individual life-cycle stages. A crisis of
identity and attachment, grief disrupts family equilibrium but makes possible
the development of growth-enhancing stability (Shapiro, 1994, p. 17).

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Popular interactionist approaches account for context by incorporating

life-course, social constructionist, and systems concepts. These models recognize the unique interpretation of internal and external worlds of individuals and families dealing with loss (Harvey, Carlson, Huff, & Green, 2001;
Nadeau, 2001; Neimeyer, 2002; Rosenblatt, 2000). They utilize narrative
methods, focus on meaning making or account making, and recognize
intimate losses as part of changing identity. Such models assume that the
accuracy of the meaning given to any particular event is of limited importance, because it is meaning itself that influences family interactions.
Interactionist counseling can help families not only to understand and manage grief symptomatology, but also to reconstruct meaningful narratives of
self, family, and world.

Factors Related to Family

Adaptation to Death
Characteristics of the Loss
Below, we discuss briefly a number of factors that have been identified as
related to death itself and to how societys interpretation of a loss influences
family adaptation.
Timing of illness or death. When the duration of time before death is far
longer or shorter than expected, or the sequence of death in a family differs
from the expected order, problems may occur. Elderly individuals are
assumed to experience timely deaths. Early parental loss, death of a young
spouse, and death of a child or grandchild of any age are considered tragic
and evoke searches for explanations (Murphy, Johnson, & Lohan, 2003).
Nature of death. Initial grief reaction to sudden or unexpected death may be
more intense than reaction to death related to protracted illness (Bowlby,
1980), with survivors experiencing a shattered normal world and a series of
concurrent stressors and secondary losses (Murray, 2001), with unfinished
business more likely to remain (Lindemann, 1944). Factors existing along a
continuum that can affect coping include (a) whether the loss was natural or
human made; (b) degree of intentionality/premeditation; (c) degree of preventability; (d) amount of suffering, anxiety, or physical pain the deceased
experienced while dying; (e) number of people killed or affected; (f) degree
of expectedness (Doka, 1996, pp. 1213); (g) senselessness; and (h) the survivors having witnessed the death or its aftermath or having found out

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about the death through the media. Differences related to suddenness of

death appear to be short-term when internal control beliefs and self-esteem
are taken into consideration (W. Stroebe & Schut, 2001) and are lessened
when families are present during emergency medical procedures, such as
efforts to resuscitate (Kamienski, 2004).
According to the National Center for Health Statistics (2000), 80% of
deaths to adolescents and young adults in the United States result from sudden violent accidents, homicide, and suicide. In a longitudinal study of
parents surviving a childs sudden death, Murphy, Johnson, Wu, Fan, and
Lohan (2003) found that marital satisfaction decreased among the parents
during the 5 years following the death; nearly 70% said that it took them
3 to 4 years to put their childrens deaths in perspective, and at 5 years postdeath, 43% said they still had not found meaning in their childrens deaths.
Although popular works often discuss suicide of a loved one as the most
difficult loss, there is little empirical evidence to support this contention
(W. Stroebe & Schut, 2001). Homicide appears to be most directly related
to posttraumatic stress disorder and grief marked by despair. In a mass
trauma (a potentially life-threatening event experienced by a large number of
people), adaptation appears to be influenced by whether it is a single event
or recurring/ongoing, by emotional or geographic distance (with vicarious
traumatization possible through viewing of media coverage, particularly for
those who have experienced other, unrelated losses), by attribution of
causality, and by the interaction of personal, community, and symbolic
losses (Webb, 2004).
Death following protracted illness can also be stressful. In such cases,
family members have experienced a series of stressors before the death,
including increased time commitments for caring, financial strain as a result
of cost of care and lost employment, emotional exhaustion, interruption of
career and family routines, sense of social isolation, and lack of time for self
or other family members (Rabow, Hauser, & Adams, 2004; Rolland, 1994).
Although research findings on the existence, role, and multidimensionality
of anticipatory grief have been inconsistent, protracted illness appears to be
associated with trauma and secondary morbiditythat is, difficulties in physical, emotional, cognitive, and social functioning of those closely involved
with the terminally ill person (Rando, 1993). Deaths following chronic illness
may still be perceived as sudden or unexpected by surviving adults who are
not yet ready, by children whose developmental stages inhibit their understanding that the death is inevitable, and following multiple cycles of relapse
and improvement. Deaths from trauma and illness have much in common.
Similar to families who have witnessed or experienced death through violence, families experiencing prolonged or complicated grief, multiple deaths

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simultaneously, or a series of deaths in close proximity may display signs of

posttraumatic stress disorder, with family caregivers experiencing secondary
traumatic stress (Bucholz, 2002; Figley, 1999; Rando, 1993).
Losses unacknowledged by society. Recently, scholars have devoted
increasing attention to disenfranchised griefthat is, grief that exists
although society does not recognize the bereaved persons right, need, or
capacity to grieve (Doka, 2002). Examples include grief over the loss of
unrecognized or unacknowledged family and other relationships (i.e., relationships not recognized as significant), such as the loss of a former spouse,
lover, cohabitor, or extramarital lover; a foster child or foster parent; a
stepparent or stepchild; a coworker; a partner in a gay or lesbian relationship; or a companion animal. In addition, deaths related to pregnancy (i.e.,
miscarriage, elective abortion, stillbirth, neonatal death) may result in disenfranchised grief. Professional caretakers and emergency first responders,
especially those labeled as heroes or those who are competently focused
on tasks of rescue and recovery, also may suffer unacknowledged grief
when they lose those for whom they provide care. Bereaved grandparents,
men in general (Gilbert, 1996), and families of deceased addicts may also
experience disenfranchised grief. Many people see others, such as young
children, older adults, and mentally disabled persons, as incapable of grief
or without a need to grieve (Doka, 2002). Disenfranchisement also occurs
when it is assumed that the circumstances of particular deaths do not warrant grief, and when bereaved persons are told that they are experiencing or
expressing grief in inappropriate ways.
Stigmatized losses. People grieving various types of deaths have reported
feeling as though their grief has been stigmatized (Walter, 2003). They feel
that others are uncomfortable around them and so distance themselves, and
they experience direct or indirect social pressure to become invisible
mourners (Rosaldo, 1989). Disenfranchised grief often results from stigmatized losses, particularly when there is an assumption that the death was
caused by the deceaseds disturbed or immoral behavior (Shapiro, 1994) or
a fear of contagion, such as with AIDS- and cancer-related deaths (Doka,
2002). AIDS-related deaths have been stigmatized because of their concentration in the homosexual community and, more recently, in poor inner-city
Latino and African American neighborhoods. Survivors of AIDS-related
deaths may be experiencing multiple losses among family and friends, lack
of legal standing in relation to their deceased loved ones, denial of death
benefits, and isolation. In inner-city neighborhoods many of those infected
with HIV are women, some with infected children, and many have already

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lost companions, siblings, children, and friends. Although the disclosure of

HIV-positive status may sometimes bring relationship partners closer
together, mothers coping with HIV infection must also deal with finding
caregivers for their children and negotiating safer-sex practices with partners reluctant to use condoms. Stigma also occurs in families that have lost
members to suicide or homicide, resulting in altered identities, provoking
feelings of anger and guilt, and leading to isolation, blame, and injustice
characteristics of revictimization (Bucholz, 2002). The resulting secrecy and
blame can distort family communication, isolate family members, and
diminish social support (Walsh & McGoldrick, 1991).

Factors Affecting Family Vulnerability

Timing and concurrent stressors in the family life cycle. Death-related loss
involves many secondary losses, including personal, interpersonal, material,
and symbolic losses. Families have more difficulty adapting to death if other
stressors are present, as dealing with a loss does not abrogate other family
needs (Murray, 2001). When normative events associated with family life
cycle (e.g., new marriage, birth of child, an adolescents move toward
increased independence) are concurrent with illness or death, they may pose
incompatible tasks (Shapiro, 2001).
Function and position of the deceased prior to death. The centrality of the
deceaseds role in the family and the degree of the familys emotional dependence on that individual influence family adaptation (Shapiro, 2001).
Shock waves rarely follow the deaths of well-liked people who played
peripheral roles or of dysfunctional members unless dysfunction played a
central role in maintaining family equilibrium (Bowen, 1976).
Conflicted relationship with the deceased. Complications in family adaptation can occur when intense and continuous ambivalence, estrangement, or
conflict exists (Elison & McGonigle, 2003). High levels of grief and depression have been reported by those with anxious-ambivalent attachments;
somatization is more common among those with avoidant attachment styles
(Wayment & Vierthaler, 2002). Grief after the death of an abuser can result
in ambivalence, rage, secrecy, sadness, and shame (Monahan, 2003). During
illness, there may be time to repair relationships, but family members may
hesitate, fearing that confrontation may increase risk of death. Surrogate
end-of-life decision makers report greater ability to resolve family disagreements when they perceive a family as psychologically close or open to
communication (Mick, Medvene, & Strunk, 2003).

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Family Resources, Capabilities, and Strengths

Resources that assist families in meeting demands may be tangible (e.g.,
money or health) or intangible (e.g., friendship, self-esteem, role accumulation, or a sense of mastery) (McCubbin & McCubbin, 1989). The disruption
a bereaved family experiences also is related to the familys degree of openness (Mick et al., 2003) and is mediated by the intensity and chronicity of
family stress. Adaptation is facilitated by members emotional regulation
capacity, nonreactivity to emotional intensity in the system, cohesion and
adaptability, and marital intimacy (Nadeau, 2001; Shapiro, 2001; Znoj &
Keller, 2002). Research findings concerning the importance of open communication about loss are mixed. Pennebaker, Zech, and Rime (2001) suggest that confiding in others is related to health after a loss. Other scholars
assert that the best predictor of emotional well-being is emotional regulation, not emotion-focused coping (Bonanno, 2001; Znoj & Keller, 2002).
Social support networks appear to simultaneously complicate and facilitate grieving. Supporters may listen, but they may also hold unrealistic
expectations. The availability of formal or informal networks does not guarantee support, especially in a society that does not sanction the expression of
emotions surrounding loss. Some bereaved family members turn to self-help
groups composed of persons who have experienced similar types of losses
a practice that may be predictive of finding meaning in death during the
years that follow (Murphy, Johnson, & Lohan, 2003). However, the rules
of some family systems discourage members from sharing intimate information and feelings with persons outside the family. Religious beliefs also may
simultaneously complicate and facilitate grieving. Belief in Gods plan can
help a bereaved individual create meaning from loss, but it can also lead to
anger toward God for unfairly allowing the death, which can isolate the
individual from his or her spiritual roots.

Family Belief System, Definition, and Appraisal

Family paradigm. To understand fully how a family perceives a death or
uses coping strategies following a death, one must determine the familys
worldview (Boss, 1999). A common paradigm is the belief in a just
world, which posits that the self is worthy and the world is benevolent,
just, and meaningful (Janoff-Bulman, 1992; Lerner, 1980). This paradigm
values control and mastery and assumes fit between efforts and outcomes:
One gets what one deserves. Such a view is functional only when something
can be done to change a situation. Challenges to the just world assumption make the world seem less predictable and can lead to cognitive efforts
to manage fear of death. Such efforts can lead to blaming chronically ill

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persons for their conditions and lack of recovery, or to linking adolescent

deaths to drug use or reckless behavior as a way of affirming, It cant happen to my child. In contrast, for those dealing with loss, understanding the
complexities, multiple levels of context, and short- or long-term effects of
the event will facilitate grief (Murray, 2001).
Deaths legacy. Family members share some beliefs that are unintentionally
but collectively constructed. Family history and experiences with death
provide a legacy (a way of looking at loss that has been received from
ancestors) that is related to how the family will adapt to subsequent loss
(McGoldrick, 1991). Particularly in relation to several traumatic untimely
deaths, a family may have a legacy of empowerment (family members see
themselves as survivors who can be hurt, but not defeated) or a legacy of
trauma (family member feel cursed and unable to rise above their
losses)either of which can inhibit openness of the system. Families may
not recognize transgenerational anniversary patterns or concurrence of a
death with other life events, and members may lack emotional memory or
have discrepant memories regarding a death (Shapiro, 2001). Family
members may make unconscious efforts to block, promote, or shift beliefs
to maintain consistency with the legacy.
Family meaning making. Grief can be viewed as a process of meaning construction that evolves throughout the life of the bereaved. Several factors
appear to influence families construction of the meaning of their losses,
including family schema, contact, cutoffs, interdependence, rituals, secrets,
coherence, paradigms, divergent beliefs, tolerance for differences, rules
about sharing, and situational and stressor appraisals (McCubbin et al.,
1998; Nadeau, 2001). Researchers are increasingly noting the importance
of making sense of the event, finding benefits from the experience, and
shaping ones new identity to include the loss (Neimeyer, 2002). Violent
death that is irrational and meaningless may result in meaning making
expressed through activism or intense pursuit of numerous small actions.

Boundary Ambiguity
Boundary ambiguity is the confusion a family experiences when it is not
clear who is in and who is out of the system (Boss, 1999). Ambiguity rises
when (a) facts surrounding a death are unclear, (b) a person is missing but
it is unclear whether death has occurred, and (c) the family denies the loss.
Degree of boundary ambiguity may be more important for explaining
adaptation and coping than the presence of coping skills or resources. Both
denial and boundary ambiguity initially may be functional because they give

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a shocked family time to first deny the loss and then reorganize itself before
it accepts the fact that the loss is real. If a high degree of ambiguity exists
over time, the family is at risk for maladaptation. However, reports that
bonds continue to exist after death, and that conversations with the dead
may be replacing rituals as the normative way of maintaining such bonds
(Klass, 2001), may challenge the notion of boundary ambiguity, suggesting
that individuals can recognize loss while holding psychological, emotional,
and spiritual connections to deceased loved ones.

Factors of Diversity
Gender. Despite Western cultural expectations, most marital couples experience incongruent grieving, often with one adult whose grief could be
called cognitive and solitary and the other whose grief is more social and
emotional (Gilbert, 1996). Perhaps this incongruence can be understood as
a family systemlevel manifestation of M. S. Stroebe and Schuts (2001)
dual-process model. A functional system would require loss orientation and
restoration orientation.
Studies of incongruent grieving have suggested that women display an
intuitive grieving style, with more sorrow, guilt, and depression than men
(Doka & Martin, 2001). Men are socialized to manage instrumental tasks,
such as those related to the funeral, burial, finances, and property. Women
are more likely to take on caregiving roles, which require them to engage in
both of the dual processes. However, men are more able to immerse themselves in work and thus block other intuitive tasks. Reasons for genderrelated differences in grieving are not well understood, but they seem to be
influenced by expectations and socialization. Research in this area has been
hampered by reliance on studies completed during acute stages of grief and
a lack of nonbereaved control groups. When bereaved persons who have suffered violent or traumatic losses are examined in longitudinal studies, few
gender differences appear (Boelen & Van Den Bout, 20022003).
With gender controls, despite differences in social support, widowers have
been found to experience greater depression and health consequences than
widows (W. Stroebe & Schut, 2001). It has been thought that men have unrecognized problems because their socialization interferes with active grief
processes (Doka & Martin, 2001). Mens responses to grief typically include
coping styles that mask fear and insecurity, including remaining silent; taking
physical or legal action in order to express anger and exert control; immersion
in work, domestic, recreational, or sexual activity; engaging in solitary or
secret mourning; and exhibiting addictive behavior, such as alcoholism. Cook
(1988) has identified a double bind that bereaved fathers experience: Societal
expectations are that they will contain their emotions in order to protect and

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comfort their wives, but they cannot heal their own grief without sharing their
feelings. Similarly, Doka and Martin (2001) have identified a third pattern of
grief involving dissonance between the way an individual experiences grief and
the way in which he or she expresses it. For example, some males may experience internal grief feelings but are constrained from expressing them. Much of
the problem may not be in mens grieving, but in our understanding of the
mourning process (Cook, 1988), which largely has been formulated through
the study of women. As such, concepts of meaning making (Gilbert, 1996) and
the dual-process model (M. S. Stroebe & Schut, 2001) may be more relevant
than concepts of grief work for research with men.
Culture, religion, and ethnicity. Grief is a socially constructed, malleable
phenomenon, and given current levels of immigration and contact among
various cultural and ethnic groups, mourning patterns in the United States
can be expected to change. In addition to commonalities, group differences
in values and practices continue to exist and present a wide range of normal
responses to death. General areas in which differences exist include the following: (a) extent of ritual attached to death (e.g., importance of attending
funerals, degree to which funerals should be costly, and types of acceptable
emotional displays); (b) need to see a dying relative; (c) openness and type of
display of emotion; (d) emphasis on verbal expression of feelings and public
versus private (i.e., solitary or family) expression of grief; (e) appropriate
length of the mourning period; (f) importance of anniversary events; (g) roles
of men and women; (h) role of extended family; (i) beliefs about what happens after death, particularly related to ideas of suffering, fate, and destiny;
(j) value of autonomy/dependence in relation to bonds after death; (k) coping strategies; (l) social support for hospice patients; (m) whether certain
deaths are stigmatized; (n) definition of when death actually occurs; (o) barriers to trusting professionals; and (p) interweaving of religious and political
narratives (McGoldrick et al., 1991; Rosenblatt, 2001).

Specific Losses
Death of a Child
The death of ones child is viewed as the most difficult loss, for it is contrary
to expected developmental progression and thrusts one into a marginal social
role that has unclear role expectations (Klass, 2001; Rubin & Malkinson,
2001). Deaths of offspring ranging from fetal loss to the loss of an adult child
who may also be a grandparent or a caregiver to older parents can cause
reactions similar to posttraumatic stress (Znoj & Keller, 2002). From an

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Eriksonian perspective, young-adult parents grapple with death-related issues

of identity as a parent and spousal intimacy, middle-aged parents deal with
loss of generativity, and elderly parents deal with loss in terms of ego integrity
versus despair. Attachment and psychoanalytic models appear to be inadequate to address the experiences of a parent who loses a child to death. Newer
models focus on integrating the deceased child into the parents psychic and
social worlds (Klass, 2001; Rubin & Malkinson, 2001).
Society expects spouses to provide support and comfort to each other during times of stress; however, this may not be possible for bereaved parents,
who are both experiencing intense grief as individuals, with unique timetables, and may not be in sync (Rando, 1993). Sexual expression between
bereaved spouses can serve as a reminder of the child and elicit additional
distress (Rosenblatt, 2000). However, previous reports of high divorce rates
among bereaved parents appear to be erroneous; the research on which they
were based has been shown to lack longitudinal value and to confuse marital distress and divorce (Schwab, 1998).

Death of a Sibling
Most research on sibling death is recent, focused on children and adolescents. Prior work on sibling loss generally was confined to clinical studies;
recent work differentiates between normal and complicated sibling grief patterns (Silverman, Baker, Cait, & Boerner, 2003). Even in the same family, sibling grief reactions are not uniform or the same as those of parents; rather,
they can be understood best in relation to individual characteristics (e.g., sex,
developmental stage, relationship to the deceased sibling). Scholars have not
found behavioral or at-risk differences in school-age children who have experienced parental death or sibling death, but they have found gender differences, with boys more affected by loss of a parent and girls more affected by
death of a sibling, especially a sister (Worden, Davies, & McCown, 1999).
Initial negative outcomes and grief reactions of siblings include drop in
school performance, anger, sense that parents are unreachable, survivor
guilt, and guilt stemming from sibling rivalry (even when survivor siblings
recognize the irrationality of their beliefs) (Rando, 1988; Schaefer &
Moos, 2001). Parents report more frequent and negative symptoms in
adolescents than in younger children, with mothers and fathers reporting
different problem behaviors (Lohan & Murphy, 2002). Although siblings
report more family conflict than do parents, siblings rarely direct their anger
toward parents, who they perceive to be vulnerable and hence in need of
protection from additional pain. Long-term changes appear to be positive,
especially in terms of maturity, which adolescents relate to appreciation

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for life, coping successfully, and negotiating role changes. Adults who lost
siblings in childhood have reported that these losses fostered greater insights
into life and death (Schaefer & Moos, 2001).
Deceased siblings still play an identity function for triangulated survivors
who may feel a need to fulfill roles the deceased children played for parents
or to act in an opposite manner in an attempt to show that they are different (Bank & Kahn, 1975). In later adulthood, sibling death is the most
frequent death of close family members, yet researchers have largely overlooked this form of loss. Surviving siblings appear to experience functioning
and cognitive states similar to those of surviving spouses (Moss, Moss, &
Hansson, 2001).
Unfortunately, research on sibling grief to date has consisted primarily of
cross-sectional investigations that rely on retrospective data, data no more
than 2 years beyond the loss, and longitudinal data treated as cross-sectional
due to small sample sizes. Research is needed to determine how siblings grief
may change over time, particularly in the context of stigmatized losses such
as AIDS-related deaths.

Death of a Parent
Death of a parent can occur during childhood or adulthood. Childrens reactions to parental death vary and are influenced by emotional and cognitive development, closeness to the deceased parent, and responses of/interactions with the
surviving parent (Rando, 1988). A recent research trend has been to identify grief
responses and perceptions of social support among children who have lost parents
(Rask, Kaunonen, & Paunonen-Limonen, 2002). Adolescents grieving the death
of a parent appear to have a heightened interpersonal sensitivity, characterized by
uneasiness and negative expectations regarding personal exchanges (Servaty-Sieb
& Hayslip, 2003). Comparisons of retrospective data from adults who experienced a parents death during adolescence with data from adults who experienced
parental divorce suggest that both groups received comfort-intended communication, but bereaved adolescents were more accepting of comments that highlighted the lost parents positive attributes (Marwit & Carusa, 1998). Adolescents
tend to flee grieving peers, thus family support may be especially important and
instrumental in preventing maladaptive behavior (Balk, 2001; Silverman et al.,
2003). Although many adolescents live in single-parent, divorced, or blended
families, researchers have largely ignored the topic of parental death in those contexts or have focused on surviving parents grief and adjustment (Scott, 2000).
Death of a parent is the most common form of family loss in middle
age. Adult response to this loss is influenced by the meaning of the
relationship, the roles the parent played at the time of death, anticipation,

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disenfranchisement, circumstances of the death, the impact of the death on

the surviving adult child, and maintenance of the parent-child bond while
letting go (Moss et al., 2001; Rando, 1988). Adults whose parents experienced protracted illness or lived in nursing homes prior to death exhibit
multidimensional responses to their parents deaths, including sadness, grief,
relief, persistence of memories about the parents, and a sense that the
protection against death provided by the parents has vanished (Elison &
McGonigle, 2003). Adults who are orphaned through parental death may
find their identities as well as their remaining relationships affected.
Adults with mental disabilities who experience parental death have some
aspects of grief in common with others, but they also have unique concerns.
When individuals with psychiatric disabilities are faced in midlife with the
death of a parent, they often have had no preparation for this event. They
may suddenly find themselves faced with making funeral arrangements and
somehow dealing with the financial repercussions of the death as well as
possible residential relocation (Jones et al., 2003).

Death of a Spouse or Life Partner

Death of a spouse is the adulthood loss that scholars have studied most
intensively, although they have paid less attention to spousal death in early or
middle adulthood, including widowed parents with dependent children, and to
death of any other life partner, such as one member of a committed homosexual couple. Loneliness and emotional adjustment are major concerns of a
spouse who has lost a companion and source of emotional support, particularly in a long, interdependent relationship in which both members had a
shared identity based on systems of roles and traditions (Moss et al., 2001).
Conjugal bereavement can be especially difficult for individuals whose relationships assumed a sharp division of traditional sex roles, leaving them unprepared to assume the full range of tasks required to maintain a household.
Death of ones spouse brings up issues of self-definition and prompts the need
to develop a new identity. Despite these problems, many bereaved spouses
adjust very well (Schaefer & Moos, 2001). Some derive pleasure from their
new independent lifestyle, feeling more competent than when they were wed.

Conclusion
Dealing with death is a process, not an event. It is an experience that all
families will encounter. As Klass (1987) notes, Bereavement is complex, for

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it reaches to the heart of what it means to be human and what it means

to have a relationship (p. 31). Despite its importance in the experiences of
individuals and families, death still appears to be a taboo subject in Western
cultures. Research and theory have focused on the experiences of dying
individuals and on dyadic relationships between bereaved and deceased.
A contextualized multigenerational approach to family systems theory is
well suited to addressing issues of loss and needs further application to
research and clinical practice. Families adaptations to death vary; factors
that influence the process include characteristics of the death, family vulnerability, history of past losses, incompatible life-cycle demands, resources,
belief systems, and the sociocultural context in which a family lives.
Although loss is a normal experience, theorists and researchers have treated
it as a problem. At this point, scholars need to increase their focus on processes
and strengths associated with loss, such as processes of coping (rather than
problems), and factors that facilitate growth from loss (rather than those that
inhibit growth). Examination of posttraumatic growth is a first step, but this
concept warrants application beyond individuals to entire families.

Suggested Internet Resources

Association for Death Education and Counseling (342 N. Main St., West
Hartford, CT 06117): http://www.adec.org
Center for Loss and Life Transition (3725 Broken Bow Rd., Fort Collins, CO
80526): http://www.centerforloss.com
The Compassionate Friends (P.O. Box 3696, Oak Brook, IL 60522), a nondenominational support group for bereaved parents and siblings: http://
www.compassionatefriends.org
The Dougy Center: The National Center for Grieving Children and Families
(P.O. Box 86852, Portland, OR 97286): http://www.dougy.org
Grief in a Family Context (online course): http://www.indiana.edu/~famlygrf
GriefNet (online grief support): http://www.griefnet.org
Tragedy Assistance Program for Survivors (2001 S Street SW, Suite 300,
Washington, DC 20009), offers support for all members of the armed services
who have been affected by death: http://www.taps.org
Widowed Persons Service of AARP (601 E Street NW, Washington, DC 20049):
http://www.aarp.org

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