d
Chapter 13
Sociocultural Definitions of Death
Key Topics
Cultural Understandings of Death
•Death is a universal experience but defined differently across cultures.
•Melanesians:
•Term mate includes the sick, very old, and dead.
•Term toa refers to all other living people.
•South Pacific Cultures:
•Life force may leave during sleep, illness, or with age.
•Ghana:
•“Good death” occurs when a person completes unfinished business and makes peace with others.
Beliefs About Death
•Death as a transition to another type of existence (e.g., spirits interacting with the living).
•Some cultures believe in rebirth or a circular pattern of life and death.
•Ancestor veneration is significant in many Asian cultures.
Mourning Rituals and Grief
•United States and other countries:
• Lower flags to half-staff during mourning periods.
•Orthodox Jews:
• Cover mirrors, recite prayers, men slash ties.
•Papua New Guinea:
• Defined time periods for phases of grief.
•Muskogee Creek tribe:
• Hand-dig graves, farewell handshakes with dirt.
Cross-Cultural Mourning
•Global grief occurs for major figures (e.g., Queen Elizabeth II, Nelson Mandela).
•Death can feel personal and public.
Funeral Customs
•Range from private rituals (e.g., scattering ashes) to large community events (e.g., Black church home-going
services).
•Iconic structures reflect customs of death:
•Pyramids (Egypt)
•Taj Mahal (India)
Legal and Medical Definitions of Death
Key Topics
Historical Criteria
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Clinical Death: Historically defined by the absence of heartbeat and respiration.
Modern definition: Whole-brain death is now the standard in most countries.
Whole-Brain Death Criteria
(American Academy of Neurology, 2019):
1.
Irreversible loss of all brain functions (entire brain).
2.
Brainstem reflexes have permanently ceased.
3. Permanent cessation of breathing, requiring a ventilator for bodily functions.
Additional Notes:
•Diagnosis involves complex steps by physicians trained in determining brain death.
Variability in Definitions
•United States: Brain death criteria can vary state by state.
•Religious perspectives:
• Muslim scholars: Majority accept brain death; some debate remains.
• Roman Catholics: Emphasize “natural death” as part of moral teachings.
Persistent Vegetative State (PVS)
Definition:
• Cortical function ceases, but brainstem activity continues.
• Allows spontaneous heartbeat and respiration but no consciousness.
•Causes:
• Blood flow disruption, severe head injury, or drug overdose.
•Important distinction:
• PVS is not classified as death under the whole-brain standard.
•Ethical dilemmas:
• Families often face difficult decisions regarding life support.
Ethical Issues Concerning Death
Key Topics:
 Bioethics and Ethical Dilemmas
 Bioethics – the study of the intersection between human values and technological advances in
healthcare.
 Core Principles:
1. Respect for Individual Freedom
2. Minimizing harm rather than maximizing good
 Examples:
 Aggressive cancer treatment with severe side effects
 Decisions to withdraw life support
 Euthanasia
 Definition: Ending life for reasons of mercy
 Type of Euthanasia:
1. Active: deliberately ending life (i.e., drug overdose, mercy killing)
2. Passive: withholding treatment (i.e.., stopping nutrition, disconnecting ventilator.
 Debate: active vs passive distinction is controversial; outcome (death) is the same
 Public Opinion:
 Most Americans support passive in cases of terminal illness but are divided on religious
and moral grounds.
 Global variation:
 Netherlands: more support for euthanasia
 Jordan: strong opposition due to religious beliefs
 Legal Landmark: Nancy Cruzan Case (1990) court required clear evidence (i.e., living will)
for passive euthanasia
 Physician-Assisted Suicide (PAS)
 Definition: physician provides a patient with a lethal dose of medication, which the patient selfadministers
 Legal status:
 Permitted in parts of Australia, Belgium, Canada, Colombia, Luxembourg, Netherlands,
Switzerland, and several U.S. states.
 Requirements:

 Intolerable, hopeless condition
 No relief available
 Patient is competent
 Repeated requests
 Agreement by two physicians
 Key case: Brittany Maynard (2014)  sparked debates over ethics, quality of life, and death
with dignity
 Opposition: often based on religious/moral grounds or family objections.
Financial and Ethical Costs of Life-Sustaining Care
 Debate: should life support care be continued for terminally ill individuals?
 Pro: life is precious, all means should be used
 Con: care is costly, prolongs sufferings, burden society
 End-of-life care expenses:
 25% of Medicare spending is for end-of-life care
 Lower costs for individuals with advance directives or in hospice/palliative care.
A Life-Course Approach to Dying
Key Topics
 Feelings about dying:
 Vary with age and culture
 Learning about terminal diagnosis often causes distress but can also lead to setting personal goals
to complete before death
 Cognitive Development and Perceptions of Death:
 Adolescents often feel immortal, but adults develop postformal thinking, integrating emotions and
thoughts to better accept mortality
 Midlife and Death Awareness:
 Death of parents:
 A turning point when people begin to confront their own mortality
 Realizing they may now be the oldest generation in the family.
 Shift in time perspective:
 Focus changes from “how long I’ve lived” to how long I have left”.
 May lead:
 Occupational changes
 Improving deteriorated relationships
 Supports socioemotional selectivity theory: prioritize emotionally meaningful goals.
 Older Adults and Death Anxiety
 Older adults are generally less anxious about death.
 Young-old (65-75)
 More anxiety about death due to a larger gap between desired and expected remaining
meanings
 Old-old (85+)
 Less anxiety, more acceptance of death.
 Acceptance of Death:
 Ego integrity: a key factor in older adults’ acceptance of mortality
 Some older adults may feel
 Joy of living has diminished
 Losses (family, friends, and health) have accumulated
 They’ve completed their life goals or bucket list
Dealing with One’s Own Death
Key Topics:
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Dying Trajectories:
o Definition: duration and course from terminal diagnosis to death
o Examples:
 Lung cancer: clear, rapid terminal phase (often used for hospice eligibility)
 Congestive heart failure: no distinct terminal phase, more gradual decline

Kübler-Ross’s Five Reactions to Death
o Reactions/Stages (not sequential or universal):
 Denial: Refusal to accept reality.
 Anger: Frustration and resentment.
 Bargaining: Trying to negotiate for more time or a cure.
 Depression: Deep sadness about impending loss.
 Acceptance: Coming to terms with death.
o Emotional reactions may overlap or occur in any order
o Not everyone experiences all stages
o Goal: help people achieve an “appropriate death” that meets their individual needs.
Corr’s Contextual Theory of Dying:
o Identifies four dimensions of issues/tasks for dying individuals
1. Bodily needs: managing physical symptoms and comfort
2. Psychological security: coping with emotional and mental challenges
3. Interpersonal attachments: maintaining important relationships
4. Spiritual energy and hope: finding meaning and peace
o Holistic Approach:
 Acknowledges individual differences in dying experience
 Includes coping efforts of family, friends and caregivers
Broader Contextual Approaches:
o Kastenbaum and Thuell (1995)
 Suggest broader theory considering:
 Variety of terminal illnesses
 Dying person’s perspectives and values
 Changing socio-environmental context (i.e., moving from home to long-term
care)
 Purpose:
 Improve quality of life and end-of-life care
 Prepare caregivers and family for supporting the dying process
 Create research questions about acceptance of death and coping strategies.
Narrative Perspective
o View dying as dynamic, individualized process
o Encourages writing narratives from multiple viewpoints
 Patients, family members, and care providers
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What is a “Good Death?”
1. Minimizes pain and suffering
2. Maximizes psychological security
and control, minimizes fear and
anxiety
3. Be close emotionally to the people
we care about
4. Have the sense that there was
integrity and purpose in our lives
Death Anxiety
Key Topics
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What is Death Anxiety
o Definition: anxiety or fear of death and dying, rooted in the unknown nature of death
o Components:
 Concerns about pain, body malfunction, humiliation, rejection, nonbeing, punishment,
interruption of goals, being destroyed, and negative impact on survivor
 Assessed at public, private and non-conscious levels
Terror Management Theory (TMT)
o Explains behaviours driven by mortality concerns
o Key ideas:
 Primary motive  ensuring continuation of life
 Health-related decisions focus on reducing vulnerability (i.e., wearing masks during
Covid-19).
o Neuroimaging research:
 Death-related thoughts activate brain region like amygdala and caudate nucleus
 Younger adults show stronger brain responses to death-related terms than older adults.
o
Demographics and Cultural Differences
Age  older adults have lower death anxiety due to life review, perspective on time, religious
motivation
o Gender  men – greater fear of the unknown; women – more specific fear of the dying process
o Culture  death anxiety expression varies globally; i.e., Taiwan – higher anxiety among cancer
patients linked to lack of life purpose and fear of relapse.
Benefit of Death Anxiety:
o Motivates survival behaviours, ensuring the continuation and socialization of the species
o Can encourage having and raising children to ensure future generations
Ways to deal with death anxiety:
1. Living life to the fullest
o Emphasize enjoying life with minimal regrets
2. Death awareness exercises:
o Writing your own obituary
o Planning your own death and funeral
o Ask reflective questions like:
 What circumstances would make my death acceptable
 Could death happen to me right now
3. Death education:
o Combines factual knowledge with sensitivity to dying’s people’s emotions
o Covers topics like grief, bereavement, and cultural diversity
4. Experiential Program:
i.e., death over dinner: safe, uplifting discussions about death
- research show these programs reduce death anxiety, and increase end-of-life awareness
o
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Creating a final Scenario
Key points:
What is a Final Scenario?
- Planning for the final phase of life, including:
 Medical care preferences
 After-death body disposition (i.e., burial, cremation)
 Memorial service plans
 Distributions of assets and personal effects.
- Purpose: helps dying individuals take control over end-of-life decisions and aids family and
friends in coping and achieving closure
- Key Elements of a Final Scenario
1. Advanced Directives:
 Legal documents specifying healthcare decisions
 Example: healthcare power of attorney, living will
2. End-of-Life Care preferences:
 Choices between traditional care (hospital/long-term care ) and alternatives (i.e., hospice)
 Assisted suicide as an option for some
3. Memorialization
 Preferences for funeral/memorial service timing and method (i.e., traditional burial vs cremation)
 Often influenced by cultural and religious beliefs.
4. Asset Distribution:
 Importance of creating a will to prevent disputes
 Informal distribution of personal effects to minimize family conflicts
5. Relationship closure:
 Affirming love, resolving conflicts, and achieving peace in relationships
 Covid-19 Impact: highlighted the emotional toll when closure is not possible.
 Benefits of a Final Scenario:
 Provides clarity and direction for family and friends
 Facilitates open and honest communication between loved ones
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 Reduces anxiety by allowing individuals to take control of their dying process
 Ensure respect for personal beliefs and preferences
 Healthcare Worker’s Role
 Facilitate Communication encourages discussion between patients and families about end-of-life
decisions.
 Recognize each patient’s unique life experiences and how they influence preferences
 Support pain management through palliative care and emotional support.
 Cultural Shifts:
 Global trends – increasing emphasis on personal control over dying, even in traditionally
physician-led-cultures (i.e., Japan).
 Demographic changes – different groups are redefining end-of-life rituals
 More focus on involving younger generations and addressing diverse cultural needs
 Key Challenges:
 Family members may avoid discussing final scenarios due to death anxiety
 Without clear communication, conflicts may arise, leaving survivors without closure
 Balancing multiple perspectives requires mutual respect and understanding
Palliative Topics
Key Topics:
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What is Palliative Care?
 Definition: An approach that focuses on relieving pain and symptoms, not curing illness
 Goal: prolong meaningful life, maintain awareness and cognitive function, and ensure a pain-free
process.
What is Hospice?
 A form of palliative care emphasizing quality of life and death with dignity for terminally ill
individuals with a life expectancy of 6 months or less
 Key Principles:
 Treat clients and families as a unit of care
 Keep clients free of pain and minimize emotional/social distress
 Support client Autonomy (i.e., starting or ending relationships)
 Provide holistic care, addressing physical, emotional and spiritual needs
 Types of Hospices
 Inpatient Hospice  combines skilled care with a home-like settings
 Outpatient Hospice  preferred for many, especially families of terminally ill children.
 Roles in Hospice Care:
 Hospice team – focuses on being with the client, maintaining dignity, and providing
emotional support
 Death doulas – offer non-medical support to dying individuals (i.e., holding hands,
playing music)
 Support for families – includes bereavement counselling and help during and after the
dying process
 Benefits of Hospice Care:
 Clients are more mobile, less anxious, and less depressed compared to hospital care
 Families are more involved in care
 Hospice teams are perceived as more accessible
 Significant improvements in quality of life after starting hospice care
 Key Considerations for choosing Hospice:
1. Accreditation – ensure the hospice meets national standards.
2. Client’s understanding – full knowledge of their condition and prognosis is crucial
3. Expectations, fear and hopes
4. Care plan timeline – rapid implementation helps clients and families adjust
5. Family participation
6. Inclusivity – hospice should serve marginalized groups
7. Insurance coverage
 Challenges to Hospice Care:
 Barriers:
 Family reluctance to accept terminal illness
 Misconceptions about hospice care
 Language and cultural barriers
 Limited healthcare providers referrals
 Key goal  ensure the dying person’s wishes are honored with state-of-the-art pain
management and treatment
Making Your End-of-Life Intentions Known
Key Topics:
Importance of Making Intentions Known
 Without clear instructions, medical personnel may default to life-sustaining interventions (e.g., CPR).
 Advance directives prevent ethical dilemmas and ensure patient preferences are honored.
Ways to Document End-of-Life Wishes
1. Living Will:
o States preferences about life support and medical interventions.
o Covers situations where the individual is unable to express decisions.
2. Healthcare Power of Attorney:
o Appoints a trusted individual to make healthcare decisions on one’s behalf.
o Includes authority for decisions about life-support and other treatments.
3. Do Not Resuscitate (DNR) Order:
o Directs medical personnel not to perform CPR if the heart or breathing stops.
o Must be clearly communicated to all healthcare providers.
Challenges to Advance Directives
 State-specific laws: Documents may not be applicable across states.
 Failure to inform: Family or physicians may be unaware of directives.
 Historical barriers: DNR orders were often ignored in operating rooms, though this is changing.
 Miscommunication: Families and surrogates may misinterpret a person’s wishes.
Medicare Coverage for Advance Care Planning
 Medicare reimburses discussions about advance care planning with healthcare professionals.
 Facilitates informed decision-making and documentation of wishes.
Patient Self-Determination Act (1990)
- Right to provided to patients:
 Make their own healthcare decisions
 Accept or refuse medical treatment
 Create an advance directive
- Healthcare facilities must:
 Provide written information about these rights
 Document existing advance directives in medical records
 Train staff on advance directives
 Avoid basing treatment decisions on the presence of directives
Competency and Capacity Determinations
1. Capacity (Clinical):
o Evaluates whether the individual can make specific healthcare decisions.
o Measured clinically (e.g., cognitive or psychological assessments).
2. Competency (Legal):
o
o
Determined by the court for specific tasks or general decision-making.
Can be subjective and doesn’t always require formal assessment.
Challenges in Competency and Capacity
 Family reluctance: Conversations about end-of-life preferences are often avoided.
 Surrogates’ accuracy: Surrogates may misunderstand or misinterpret a loved one’s preferences.
 Guidelines for professionals: Exist to evaluate psychological and legal aspects of competence.
Best Practices for End-of-Life Planning
 Discuss wishes with family and healthcare providers early.
 Ensure appropriate advance directives are in place.
 Communicate wishes clearly to surrogates and key individuals.
The Grieving Process:
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Bereavement: state or condition caused by loss through death.
Grief: the sorrow, hurt, anger, guilt, confusion, and other feelings that arise after suffering a loss
Mourning: the ways in which we express our grief
What is Grief?
 Definition: The process of coping with the emotional, social, and practical challenges following a loss.
 Grieving is personal and highly individual—there is no “right” way to grieve.
 Grief involves actively coping with loss, as opposed to bereavement, which is the state of having lost
someone.
The Grief Process (Worden’s Model)
1. Acknowledge the reality of the loss:
o Overcome denial and accept the full impact of the loss.
2. Work through emotional turmoil:
o Confront and express emotions; avoid repressing them.
3. Adjust to an environment without the deceased:
o Create new routines and find meaning in life without the person.
4. Loosen ties to the deceased:
o Say goodbye and reengage with life and social networks.
Key Points About Grief
 Grief is active: Requires addressing emotional, social, spiritual, and practical aspects of life.
 Time frame:
o Recovery often begins after 1–2 years, though grief’s impact may last a lifetime.
o A return to normal activities doesn’t always reflect emotional recovery—it may be due to societal
pressures.
 Moving forward: Most people eventually adapt, though grief often becomes something one learns to live
with rather than fully “recovering” from.
Risk Factors in Grief
1. Mode of Death:
o Sudden death vs. anticipated death affects coping:
 Anticipatory grief (before death) may help or complicate the grieving process.
 Strong attachments make sudden deaths harder but may lessen guilt or regret over
unresolved issues.
2. Personal Factors:
o Age: Older adults cope better with bereavement than middle-aged adults.
o Gender: Bereavement effects may differ across genders.
o Personality: No consistent traits identified that reliably buffer or worsen grief.
3. Social Support:
o Strong social networks, including virtual ones, lessen the impact of bereavement.
o Weak or absent support systems increase the difficulty of grieving.
Attachment Theory and Grief
 Secure attachment styles:
o Tend to reduce depression post-loss due to fewer unresolved issues.
 Strong attachments:
o Increase grief severity but can also provide a framework for healthy coping.
Helpful Responses to Grief
 Simply acknowledge the loss (e.g., “I’m sorry for your loss”).
 Offer support and mean it—be available for the grieving person.
Typical Grief Reactions
Grief and Its Challenges
 Grief involves intense feelings such as sadness, denial, anger, loneliness, and guilt.
 People need time and space to grieve, but societal pressure often demands they move on quickly.
Themes of Grief (Muller & Thompson)
1. Coping: Strategies people use to deal with their loss.
2. Affect: Emotional triggers and reactions tied to the deceased.
3. Change: Life changes after loss, often accompanied by personal growth.
4. Narrative: Stories about the deceased and the death process.
5. Relationship: Nature of the bond between the deceased and the survivor.
Cultural Variations in Grief
 Expression of grief varies widely across racial, ethnic, and cultural groups.
o KwaZulu-Natal, South Africa: Emphasis on closure and addressing loneliness.
o Latino/a groups: Differing grief rituals across Mexican, Puerto Rican, and Central American
communities.
o Black communities: Distinctions between African American and Caribbean grief practices.
 Many cultures maintain a relationship with the deceased through dreams, prayer, ancestor veneration, or
spiritual connections.
Physical Reactions to Grief
 Grief can affect physical health, leading to:
o Illness or increased healthcare use.
o Sleep disturbances and issues in the neuroendocrine, neurological, or circulatory systems.
 Anniversary reaction: Emotional and behavioral changes tied to significant dates (e.g., death
anniversaries, holidays).
Social Expectations and Grief
 Grieving has no standard timeline.
o Widows may grieve intensely even 5 years post-loss.
o People may feel the effects of a loss even 50 years later.
 Societal pressure: Grief is often expected to resolve within a "reasonable" time, but this varies widely
based on perceived closeness of the loss.
Key Points About the Grief Process
1. Grieving is personal and varies in intensity and duration.
2. Psychological and physiological effects of grief often intertwine.
3. Social pressure can complicate grieving by enforcing unrealistic timelines.
4. Over time, most people learn to integrate their loss and move forward, but feelings of sadness can reemerge
occasionally.
Coping with Grief
Integrative Model of Grief
1.
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2.
3.
Four-Component Model:
 Context of the loss – risk factors such as whether the death was expected
 Subjective meaning – personal evaluations of the loss and life’s meaning
 Changing relationships – evolution of how the decreased is remembered over time
 Coping and emotion regulation – strategies to manage grief emotions
Grief processing may not always help; excessive rumination can worsen distress
Grief work as rumination hypothesis: an approach that not only rejects the necessity of grief processing for
recovery from loss but views extensive grief processing as a form of rumination that may actually increase
distress
Dual Process Model (DPM):
 Two type of stressors:
 Loss-orientated stressors: focus on grieving the loss
 Restoration-orientated stressors: adapt to new life (i.e., building relationships)
 Dynamic Process: people alternative between grief and moving forward, eventually finding a balance.

Model of Adaptive Grieving Dynamics (MAGD)
 Four dynamics:
 Lamenting: painful grieving experiences
 Heartening: uplifting and joyful memories of the deceased
 Integrating: assimilating changes due to the loss
 Tampering: avoiding overwhelming attempts to integrate loss
 Grieving involves a blend of joy and sorrow simultaneously, unlike DPM’s back-and-fort oscillation

Key Insights from Grief Models
 Grief is highly individual and nonlinear; it doesn’t follow a predictable path
 Excessive focus on grief (“rumination”) can lead to chronic distress rather than resolution
 Adaptive grieving involves reconciling distress and joy, integrating loss into life, and finding
ongoing balance
Difference between Models:
-
Four-Component Model: focuses on meaning-making and emotional regulation; challenges traditional grief
work.
DPM: emphasizes oscillation between grief and adaptation
MAGD: highlights simultaneity of grief dynamics
Practical Implications for Coping
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Minimize rumination
Balance task – shift between grief-focused and life-focused activities (DPM)
Acknowledge mixed emotions – joy and sorrow coexists in the grieving process (MAGD)
Recognize individuality.
Ambiguous Loss
Definition of Ambiguous Loss
 Ambiguous Loss: Loss where there is no resolution or closure.
 Coined by Boss (2010, 2015), this type of loss involves uncertainty about the fate or identity of the lost
person, making closure impossible
Types of Ambiguous Loss
1. Physically Absent but Psychologically Present:
A missing person whose fate is unknown.
Examples:
 Missing after disasters (e.g., tsunamis).
 Kidnappings, disappearances by oppressive governments.
o Challenges:
 Families endure constant pain due to the lack of answers.
 Grief is indefinitely postponed, preventing closure and moving on.
 Hope for the loved one’s return often motivates families.
Physically Present but Psychologically Absent:
o A person is physically alive but no longer mentally or emotionally present.
o Examples:
 Alzheimer’s disease or dementia.
 Severe mental illness or coma.
o Challenges:
 Families grieve as the person loses their identity over time.
 Loved ones are thought of as "dead" even though they are physically alive.
o
o
2.
Common Challenges in Ambiguous Loss
 No certainty:
o Families struggle with the unending pain of not knowing.
o Closure in the usual sense is impossible.
 Social pressure:
o Families may feel pressure to "let go" or be accused of being cold.
 Impact on Generations:
o Effects can persist across generations, particularly in cases of unresolved disappearances.
Prolonged Grief
What is Prolonged Grief?
 Definition: Persistent, intense grief lasting beyond the expected period of adaptation, interfering with daily
functioning.
 Associated with separation distress (longing/yearning) and traumatic distress (pain, disbelief).
Diagnostic Criteria for Prolonged Grief Disorder (APA, 2022)
1. Timing:
o The death occurred at least 12 months ago.
2. Core Symptoms (present most days, nearly every day for at least 1 month):
o Intense yearning/longing for the deceased.
o Preoccupation with thoughts or memories of the deceased.
3. Additional Symptoms (at least 3 present most days for at least 1 month):
o Identity disruption: Feeling part of oneself has died.
o Disbelief about the death.
o Avoidance of reminders of the death.
o Intense emotional pain (e.g., sorrow, anger, bitterness).
o Difficulty reintegrating into life (e.g., social or occupational activities).
o Emotional numbness.
o Feeling life is meaningless.
o Intense loneliness.
4. Impact:
o Causes significant distress or impairment in social, occupational, or other areas of functioning.
Exclusions:
o Not better explained by other mental disorders (e.g., depression, PTSD).
o Symptoms exceed cultural, social, or religious norms.
Key Features of Prolonged Grief
 Prolonged grief involves many typical grief reactions, but the duration and intensity are much greater.
 Evidence suggests differences in brain processing:
o Individuals with prolonged grief may struggle with emotion regulation and engage different brain
areas than those with typical grief.
Risk Factors for Prolonged Grief
 Type of loss:
o Sudden or unexpected deaths are more likely to result in prolonged grief.
 Social support:
o A lack of supportive networks may increase the risk of prolonged grief.
Disenfranchised Grief
5.
What is Disenfranchised Grief?
 Definition: Grief that is not openly acknowledged, publicly mourned, or socially supported.
 Coined by Doka (1989).
 Twofold nature:
1. Denial of one’s right to grieve, complicating the bereavement process.
2. Lack of social support to help the bereaved cope.
Common Situations of Disenfranchised Grief
1. Hidden relationships:
o Examples:
 Secret intimate relationships.
 LGBTQIA+ partnerships that are not publicly recognized.
2. Non-traditional losses:
o Examples:
 Loss of a pet.
 Losses deemed "less valid" by societal norms.
Impact of Social Expectations
 Society often pressures individuals to move on quickly after a loss.
 Failure to recognize the personal impact of certain losses leads to:
o Lack of empathy for the grieving individual.
o Bias and stereotypes regarding whose losses are “legitimate.”
Eliminating Disenfranchised Grief
 Affirm the right to grieve any loss that holds personal significance.
 Recognize that all losses, regardless of societal perceptions, deserve empathy and support.
Dying and Bereavement Experiences across the Life Span
Childhood
Children’s Understanding of Death
 Preschoolers:
o View death as temporary and magical.
o May think of death as something dramatic, like a ghost or burglar.
 Ages 5–7:
o Begin to understand death is permanent, universal, and biological functions cease.
Children’s Grief Reactions
 Young children (preschoolers):
o Common behaviors:
 Regression, guilt (believing they caused the death), denial, repression, displacement, and
wishful thinking.
 Older children (later childhood):
o Common behaviors:
 Problems at school, anger, physical ailments, and grief triggers.
o Begin to shift to problem-focused coping as they develop more coping skills.
 Children often alternate between grieving and normal activity, modeling patterns they see in adults.
Supporting Children Through Grief
 Avoid shielding children from the reality of death.
 Avoid euphemisms (e.g., “Mommy is sleeping”)—these can confuse children.
 Use simple, age-appropriate explanations to help children understand death.
 Reassure children that:
o Their feelings are normal (e.g., sadness, crying).
o They are not to blame for the death.
 Encourage participation in rituals:
o Attending funerals or private viewings helps children process death.
Impact of Grief on Children
 Typical bereavement does not usually lead to long-term effects like depression.
 Long-lasting impacts may occur if:
o The child lacks adequate care and attention following the death.
o Grief is left unaddressed, affecting attachment and future relationships.
Adolescence
Adolescents’ Experience with Death
 Prevalence:
o 40%–70% of college students experience the death of someone close during college years.
 Challenges:
o Adolescents are in a phase of personal and physical change, trying to develop their identity.
o Bereavement can be especially difficult to process, particularly if it is their first experience with
death.
Impact of Bereavement on Adolescents
 Severe Effects:
o Chronic illness, enduring guilt, low self-esteem.
o Poor academic/job performance.
o Substance abuse and interpersonal relationship issues.
o Suicidal thinking.
 Peer Pressure:
o Younger adolescents may avoid discussing grief to fit in with their peer group.
o This reluctance can lead to psychosomatic symptoms (e.g., headaches, stomach pains).
 Prolonged Grief:
o Adolescents often continue missing and loving their deceased loved ones.
o May use tools like social media to maintain a connection.
 Social Isolation:
o Nonbereaved peers may avoid or feel uncomfortable supporting bereaved adolescents.
Helping Adolescents Cope
 Resilience Songwriting Program:
o A structured program using music therapy to process grief and build resilience.
o Key Features:
 Eight sessions, 90 minutes each, in a school setting.
 Excludes participants’ siblings.
 Enhances self-esteem, coping skills, emotional expression, and meaning-making.
 Uses cognitive behavior therapy (CBT) strategies:
 Psychoeducation, cognitive reframing, positive appraisals.
 Flexibility in songwriting to accommodate group dynamics and emotional needs.
 Encourages participant agency and collaboration
Adulthood and Grief
Adults and Grief Experience
 First encounters with death:
o For many adults, the death of a close friend or family member occurs for the first time in
adulthood.
o Adults often feel unprepared for the emotional impact.
 Emerging adults:
o Just starting to build families, careers, and personal goals.
o Tend to feel that death at this stage is "unfair" or a loss of potential.
o Prolonged grief and mental health issues are more common.
Challenges for Bereaved Adults
1. Social Pressure:
o Adults, including college students, are often told to “move on” or not dwell on grief.
o This dismissiveness can hinder emotional healing.
2. Romantic Relationships:
o Grief for romantic partners not officially recognized (e.g., unmarried partners or LGBTQIA+
relationships).
o Military example: Girlfriends of fallen soldiers often feel isolated and unsupported.
3. Peer Support:
o Social media and peers are common outlets for bereaved adults.
o Peers may lack the knowledge or skills to provide effective support.
Specific Types of Loss
1. Death of a Child:
o Profound and often considered the most devastating loss.
2. Death of a Parent:
o Often marks a turning point in adulthood, bringing awareness of mortality.
3. Death of a Partner:
o Creates emotional, social, and financial challenges.
Death of One’s Child
Impact on Parents
 Unimaginable grief:
o The death of a child is seen as a violation of the natural order.
o Intense mourning and relationship stress often result.
 Parent–child bond:
o A unique and enduring bond that begins before birth makes this loss particularly devastating.
Young Parents and Unexpected Loss
 Experience high anxiety, guilt, and a more negative view of the world.
 Losses through stillbirth, miscarriage, abortion, or neonatal death are often overlooked.
 Attachment before birth:
o Mothers in particular form strong bonds, making these losses deeply painful.
 Role of rituals:
o Rituals are essential for acknowledging the loss and validating grief.
Middle-Aged Parents and Adult Children
 The loss of an adult child is equally devastating, especially in cases like:
o Drug overdoses or other traumatic circumstances.
 Prolonged grief:
o More common in parents due to the unique parent–child dynamic.
Challenges and Societal Expectations
 Pressure to recover quickly:
o Society often expects parents to move on, leading to unfeeling comments and a lack of support.
 Parents describe the loss as a life-changing event, with deep and enduring pain.
Cultural Perspectives
 Parents in Northern India, for instance, face profound grief from stillbirth, perinatal, or childhood death,
compounded by cultural and societal expectations.
Death of One’s Parents
Significance of Parental Loss
 A common rite of passage:
o Losing a parent transforms adult children, making them feel "orphaned."
o It symbolizes being "next in line" to face mortality.
 Profound emotional impact:
o Even in adulthood, losing a parent often brings significant emotional changes.
Loss During Different Life Stages
1. Emerging Adults:
o Women becoming mothers:
 Feel deep loss when unable to share pregnancies with their deceased mothers.
 Fear of dying young themselves.
2. Adults Losing Older Parents:
o Common feelings:
 Letting go and accepting mortality.
 Relief from seeing the parent’s suffering end.
 Reflection on one’s relationship with the deceased parent.
o Unique cases:
 Loss of a parent to Alzheimer’s disease:
 Bodily death can feel like a "second loss", as the parent–child connection was
often lost earlier.
Impact on Adult Children
 Marriage and relationships:
o Effects on the child’s marriage depend on the quality of the relationship with the deceased parent.
 Psychological adjustment:
Adult children may either:
 Find comfort in memories of the parent.
 Attempt to separate from expectations set by the deceased parent.
Death of One’s Partner
The Loss of a Partner
 Deep personal loss:
o The death of a partner feels like losing a part of oneself.
o Especially profound in long and close relationships.
 Social expectations:
o Mourning is expected for a culturally defined period (e.g., about a year in the U.S.).
o Survivors may face criticism if they seek a new partner too soon.
Young Adults
 Traumatic and unexpected:
o Young widows and widowers often feel isolated.
o They must cope with their grief while supporting grieving children.
 Unique challenges:
o Feeling out of place with the label "widow/widower" at a young age.
o Pressure to "move on" can intensify grief.
Older Adults
 Grieving process:
o Grief can persist for years, especially in long-term partnerships.
 Social support:
o Mixed findings on its impact:
 Quality of support matters more than quantity.
 Support networks may shrink after bereavement.
 Unfinished aspects of relationships:
o Regret over unresolved issues in the marriage makes grief more difficult.
 Therapeutic interventions:
o Cognitive-behavioral therapy (CBT) and meaning-making strategies help reduce depression and
aid coping.
Challenges Specific to Queer Relationships
 Disenfranchised grief:
o LGBTQIA+ partners may face discrimination in healthcare or funeral settings.
o This can hinder closure and exacerbate grief.
 Caregiver identity loss:
o Caregiving roles tied to identity may amplify grief after a partner's death.
o
Key Challenges in Widowhood
1. Loneliness:
o Widowed individuals may feel isolated as friends and family withdraw.
2. Financial struggles:
o Particularly affects women without pensions or savings.
3. Repartnering:
o Addresses loneliness but faces challenges:
 Family objections (e.g., adult children).
 Social pressures (e.g., estate concerns).
 Functional limitations (e.g., health issues).
4. Living Alone Together:
o
A romantic relationship where partners maintain separate residences is an emerging arrangement.
Late Adulthood
Death Anxiety in Late Adulthood
 Acceptance of death:
o Older adults are generally less anxious and more accepting of death than younger age groups.
o Belief that major life tasks are completed contributes to this acceptance.
Loss of a Child
 Long-lasting grief:
o Older adults feel the loss of a child even decades later (e.g., 30+ years).
o Accompanied by:
 Guilt over its effects on relationships with surviving children.
 Difficulty coming to terms with the loss.
 Cognitive effects:
o Loss of a young adult child may lower cognitive functioning in late life.
 Racial disparities:
o Black parents are at greater risk of child loss due to systemic factors like lack of access to quality
healthcare
Loss of a Grandchild
 Emotional impact:
o Intense grief, survivor guilt, and regrets about the relationship with the grandchild.
o Need to restructure family relationships after the loss.
 Hidden grief:
o Bereaved grandparents may suppress their emotions to protect the bereaved parent.
 Primary caregivers:
o Grandparents who were custodial caregivers (e.g., in cases of AIDS-related deaths in South Africa)
experience compounded grief due to stigma and caregiving loss.
Chapter 14.2 Healthy Aging
What is Healthy Aging:
Definition of Healthy Aging
 Goal: Achieving physical, cognitive, and emotional well-being, avoiding disease, and staying engaged with
life.
 Key Elements:
o Avoiding disease.
o Staying active and engaged.
o Maintaining cognitive and physical functioning.
o Achieving personal goals with dignity and independence.
Global Initiatives
 United Nations Decade of Healthy Ageing (2021–2030):
o Focus areas:
1. Combatting ageism.
2. Promoting age-friendly environments.
3. Ensuring integrated care.
4. Providing long-term care.
5. Addressing social isolation and loneliness (added after COVID-19 pandemic).
o PAHO's life course approach: Framework for achieving healthy aging globally.
Research and Theories
1. Life-Span Perspective:
o Healthy aging involves managing biopsychosocial factors throughout life.
o Key aspects: Balancing gains and losses, addressing internal and external factors.
o Model Components:
 Antecedents: Changes across the lifespan.
 Mechanisms: Selection, optimization, and compensation (SOC).
 Outcomes: Enhanced competence, quality of life, and adaptability.
2. Selective Optimization with Compensation (SOC) Model:
o Helps individuals optimize strengths and compensate for losses.
o Interventions can focus on personal goals, tasks, and environments
Interventions for Healthy Aging
1. Focus on Individual Goals:
o Interventions should address personal goals rather than generic objectives.
2. Example: Technology Training for Older Adults
o Strategies for effective learning:
 Collaborative learning: Group discussions, interactive activities, workshops.
 Intergenerational learning: Reduces anxiety, fosters mutual understanding.
 Experience-based learning: Active, real-world training.
 Informal settings: Personalized and flexible curricula.
Salutogenesis and Healthy Aging
Definition of Salutogenesis
 Focus: Emphasizes factors that support and promote health rather than those causing disease.
 Introduced by Aaron Antonovsky (1979) as a framework for creating wellness-based interventions.
Key Components of Salutogenesis
1. Sense of Coherence (SOC):
A global orientation toward life, helping people cope with stress and life’s challenges.
Three elements:
 Comprehensibility: Seeing the world as structured and predictable.
 Manageability: Believing resources are available to meet challenges.
 Meaningfulness: Feeling life has purpose and challenges are worth facing.
Health-Ease/Dis-Ease Continuum:
o Health exists on a spectrum between “total health” and “total absence of health.”
o Movement along this continuum depends on how stressors are managed.
Generalized Resistance Resources (GRRs):
o Internal and external resources to counteract stressors, such as:
 Internal: Attitudes, self-efficacy, knowledge.
 External: Social support, cultural stability.
o GRRs help people avoid, redefine, or manage stressors.
o
o
2.
3.
How Salutogenesis Promotes Healthy Aging
1. Role of Sense of Coherence (SOC):
o Strengthening SOC helps older adults impose structure on stressful situations and search for
resources to overcome challenges.
o Higher SOC leads to better stress management, quality of life, and perceived health.
2. Positive Lifestyle Emphasis:
o Focuses on proactive steps to enhance well-being in:
 Workplaces: Reducing stress and improving performance.
 Communities: Empowering residents to use available resources and make communities
age-friendly.
3. Person-Centered Approach:
o Emphasizes adaptability, self-management, independence, and connectedness.
o Aligns with the concept of aging in place, which prioritizes older adults living independently and
resourcefully in their preferred environment.
Applications of Salutogenesis
 Workplace:
o Encourages practices to reduce employee stress and promote wellness.


Community:
o Focuses on empowering residents to build supportive, age-friendly environments.
Healthy Aging:
o Encourages independence, decision-making, and use of resources among older adults.
Positive Psychology and Healthy Aging
Definition of Positive Psychology
 Introduced by Martin Seligman (1999):
o Shifted psychology's focus from problems to building positive qualities.
o Emphasizes optimism, hope, gratitude, self-esteem, emotional intelligence, empathy, humor, and
creativity.
Impact on Healthy Aging
 Influence on Aging Research:
o Optimism linked to longer telomeres, which are indicators of slower biological aging.
o Positive behaviors and attitudes reduce depression, anxiety, and stress in older adults.
 Connection to Salutogenesis:
o Both emphasize positive resources, coping strategies, and promoting health rather than focusing
on illness.
Mental Fitness Program for Positive Aging (MFPPA)
 Structure:
o A 12-session journey focusing on positive psychology strategies for older adults.
o Topics include:
 Exploring personal strengths.
 Improving relationships.
 Practicing mindfulness and gratitude.
 Engaging in activities that create "flow."
 Visualizing one’s best self.
 Goals:
o Plan for the future.
o Enhance personal strengths.
o Address areas needing improvement (e.g., self-esteem, decision-making, emotional support).
Integration with Salutogenesis
 Combination Benefits:
o Supports autonomy, environmental mastery, and life purpose.
o Focuses on wellness and reserve capacities rather than deficits.
 Intervention Goals:
o Increase older adults' engagement in family and community.
o Identify and strengthen resources (e.g., social networks).
o Promote active lifestyles tailored to individual needs.
Challenges and Responsibilities
1. Older Adults’ Role:
o Maintain health and resources to reduce reliance on societal support.
o Stay engaged in family, community, and personal growth.
2. Societal Role:
3.
o Remove structural barriers to healthy aging.
o Provide opportunities for continued personal growth and social engagement.
Helping Professionals’ Role:
o Shift from ageist stereotypes to creating wellness-focused interventions.
o Incorporate positive psychology and salutogenesis into treatment plans.
Technology and Aging
Role of Technology in Healthy Aging
1. Enhancing Competence:
o Helps older adults stay connected (e.g., video-calling, social networking).
o Assists in daily tasks (e.g., online shopping, managing finances).
o Supports independence (e.g., mapping apps for navigation).
2. Telemedicine:
o Increased use during COVID-19 for pain management and therapy adherence.
o Barriers: Limited comfort and trust in telemedicine for initial appointments.
3. Assistive Apps and Tools:
o Apps for visually or cognitively impaired individuals.
o Tools for caregivers to monitor wandering behavior.
Barriers to Technology Adoption
1. Challenges for Older Adults:
o Privacy and security concerns.
o Difficulty understanding or accessing tools.
o Affordability and cost concerns.
2. Solutions:
o Design synchronized product ecosystems.
o Simplify privacy and security settings.
o Develop user-friendly interfaces with clear instructions.
o Provide affordable options and personalized support.
Robotics in Aging
1. Social Robots (e.g., ElliQ):
o Encourage social interaction and reduce loneliness.
o Provide health prompts, reminders, and simple companionship.
o Use AI to learn and adapt to user preferences.
2. Therapeutic Benefits:
o Enhance communication and mood.
o Assist with daily tasks (e.g., medication reminders).
o Reduce caregiver burden.
3. Acceptance:
o Better received when older adults are introduced to robots beforehand.
o Users often form bonds, viewing robots as companions or friends.
Driverless Cars and Healthy Aging
1. Autonomous Vehicles:
o Promote independence and aging in place.
o Society for Automotive Engineers (SAE) defines six levels of automation:
 Level 0: No automation.
 Level 5: Full vehicle autonomy.
Cooperative driving automation (CDA) enables interactions between human drivers and
autonomous systems.
Future Potential:
o Safer and more accessible transportation for older adults.
o Increased independence for those unable to drive.
o
2.
Applications in Positive Psychology and Salutogenesis
1. Salutogenesis:
o Technology serves as a generalized resistance resource (GRR) to reduce stress.
o Promotes comprehensibility, manageability, and meaningfulness in life.
2. Positive Psychology:
o Social robots and telemedicine enhance emotional well-being.
o Autonomous vehicles and assistive tools encourage independence and optimism.
Healthy Aging, Health Promotion, Disease Prevention
Frameworks for Healthy Aging
 Prominent Models:
o National Institute on Aging: Focus on quality of life through disease prevention and health
promotion.
o United Nations Decade of Healthy Ageing (2021–2030): Key focus areas include ageism,
creating age-friendly environments, integrated care, and addressing social isolation.
Prevention Strategies
1. Four Levels of Prevention:
o Primary: Prevent disease before it occurs (e.g., vaccinations, avoiding smoking).
o Secondary: Early detection and intervention (e.g., cancer screening, routine medical exams).
o Tertiary: Managing chronic conditions to avoid complications (e.g., physical therapy, pain
management).
o Quaternary: Improving quality of life and avoiding overmedication (e.g., occupational therapy,
cognitive interventions for dementia).
2. Focus Areas:
o Increased use of secondary prevention for early diagnoses.
o Quaternary strategies to enhance functionality and life quality in chronic conditions.
Lifestyle Factors in Health Promotion
1. Smoking:
o Single largest contributor to health issues (480,000 U.S. deaths annually).
o Risks: Cancer, cardiovascular disease, cognitive decline.
o Quitting: Improves lung function, reduces stroke and coronary disease risks, even in late life.
2. Exercise:
o Benefits: Improved cardiovascular health, brain function, immune system, mood, and life
expectancy.
o Aerobic Exercise:
 Targets heart health (pulse rate 60–90% of maximum).
 Examples: Jogging, swimming, wheelchair aerobics.
 Recommended: 150 minutes/week of moderate intensity.
3. Nutrition:
o
o
o
Essential for physical and mental health.
Guidelines: Balanced intake from all food groups, limit added sugars, saturated fats, and sodium.
Addressing challenges: Initiatives for urban "food deserts" and Native American communities.
Cholesterol and Cardiovascular Health
1. Lipoproteins:
o LDL ("bad"): Increases fatty deposits in arteries; optimal level <100 mg/dL.
o VLDL: Carries triglycerides; should be <150 mg/dL.
o HDL ("good"): Helps clear arteries; optimal level >60 mg/dL.
2. Management:
o Lifestyle changes (healthy diet, exercise, weight management).
o Medications: Statins (e.g., Lipitor, Crestor) to lower LDL and raise HDL.
Healthy Aging through Lifestyle Interventions
 Exercise and Brain Health:
o Reduces cortical atrophy, enhances gray matter, improves hippocampal function.
o Possible to slow cognitive decline in aging and mild cognitive impairment.
 Nutrition’s Role:
o Affects metabolism, changes across the life span.
o Specific attention to dietary needs reduces risks for major chronic illnesses.
Government and Community Programs
 Older Americans Act Programs:
o Free services such as health screenings, nutrition education, and physical fitness programs.
o Aims to improve awareness of chronic conditions and promote early diagnosis.