Losing one’s loved one because of death, is an inevitable process for each human being. However, what differs in each human being is the quality and intensity of their reaction regarding their loss and grief process (Bonanno et al., 2002). How the bereaved one copes after losing the loved one affected by personality and coping style, the circumstances of loss and the relationship with the departed (Malkinson, 2007). Although most bereaved people accommodate their loss without any professional help, public health models considered that almost 10 percent of bereaved ones are at risk of developing complex grief reactions and 30 percent are estimated at moderate risk and might benefit from group support (Aoun et al., 2015).

Existence of psychiatric issues, lack of social support, a sudden or a traumatic death, lack of preparedness for the death, a hospital-based death, and a death in the intensive care unit are considered as risk factors for poor bereavement outcomes (Wright, 2010). If family members are unable to say goodbye since the loved lost her life while intubated in an intensive care unit, this situation is referred to as a cause to complicated grief reactions such as prolonged grief disorder (PGD) and post traumatic stress disorder (Kernish et al., 2015). This data has a significant meaning as there is still an ongoing COVID-19 global pandemic where death numbers have reached 3.872.457 globally and 49.293 in Turkey on 22 June 2021 reported by the World Human Organization (WHO).

Obviously, some of these risk factors that are mentioned above are heightened for any death during the COVID-19 time, regardless of whether the death was a direct result of COVID-19 or not. Patients with COVID-19 had a prolonged ICU stay (Morris et al., 2020) and their families are inevitably anxious, afraid, alone, and in need of emotional support, but these are the areas which hospital care has been found lacking (Coimín, 2019). Furthermore, according to Castle and Philips (2003) when deaths are unexpected, there are no traditional grief rituals (saying goodbye, viewing and burial the loved one) and physical social support is lacking (Lobb et al, 2010) there is a high risk of prolonged grief symptoms. Considering the fact that government policies targeting the pandemic has led individuals to have remote conversations, isolation and even dying and being buried alone separated from their loved ones, the potential risk of experiencing a complicated grief which is described as being “essentially frozen or stuck in a state of chronic mourning” is high (Zhang et al., 2006, p. 1191). Morris and colleagues (2020) stated that when rituals that bring comfort and opportunities to access support after a death are not possible, feelings of despair, isolation and loss in bereaved ones are increased.

The research showed that previous pandemics appeared to create multiple losses by disturbing social norms, rituals and mourning practices. The disruption affecting individuals’ ability to connect with the loved one before or after death had an impact on their grief. Particularly, during pandemic times the usual societal and cultural rituals are rushed, altered or absent (Mayland et al., 2020). It is crucial for COVID-19 times to understand the importance of rituals, although a relatively large amount of research regarding loss focuses on attachment bonds and perceived social support (Lobb et al., 2010) and little research has been conducted on the use of rituals after bereavement. Mitima-Verloop and colleagues (2019) considered this scarcity of research as surprising, given that the performance of rituals is frequently linked to coping with loss. Therefore in this article, before mentioning the main theories regarding grief, cultural rituals and traditions will be discussed below.

Through history, the reaction given to the loss has differed greatly across cultures. What remains the same is that each culture has found its unique way to process grief. It is significant to notice the importance of such cultural differences because these differences show the human plasticity and variations in relationships and meanings regarding grief. In each culture, different ways of grieving are embedded in a completely functioning, maintaining systems that are meaningful in their own terms although sometimes it seems meaningless from the perspective of other cultures (Rosenblatt, 2008).

Regardless of which culture, religion or value system it belongs to, death is usually followed by a funeral service (O’Rourke, Spitzberg, & Hannawa, 2011). What differs across cultures and religions is the practice and purpose of a funeral and other death rituals (Walter, 2005). Fulton (1995) stated that a funeral offers a space for bereaved ones to express their loss-related emotions and marks a crossing in which the irreversibility of the death is pronounced. At the same time, a funeral provides a starting point for healing and renewal (Kastenabaum, 2004). Romanoff and Terenzio (1998) stated that rituals are vehicles in the process of transformation, transition and continuity. Also,  experimental studies which illustrated that group coordinated and synchronized activities produce greater cooperativeness and endurance facilitating the achievement of collective goals (Cohen et al., 2010; Wiltermuth & Heath, 2009).

According to Weeks (2004),  rituals enable us “to remain connected with the past, and with each other… They also serve to provide us with comfort and security” (p. 114). Another research showed that these kinds of activities are related to physiological changes that are hypothesized to shape the physiological origin for empathy (Levenson, 2003). This particular evidence about empathy is an important aspect of rituals. In Australia, one remarkable grief ritual was changing the place of glasses in the kitchen after a loved neighbor had passed. When they attempt to reach the glass shelf and see that they are not there, this small surprise used to become a reminder of their neighbor’s pain, a symbolic way of accepting that life is somewhere different after the loss (Köker, 2020). Also, it was an Australian way of believing that remembrance of their grief will keep them together, as poet Khalil Gibran (2011) once had said, “Remembrance is a form of meeting.” Another similar and remarkable grief tradition belongs to some small towns of Turkey, where people come together at the bereaved ones’ home on the first religious festival after the death and call this day “the grief festival”. This ritual aims to give physical and emotional support to the bereaved ones having their first aid without their loved one (Erzurum Review, 24 March 2018). Calling the grief process “festival” was a sign of acknowledging death as the most natural process that deserves recognition, acceptance and remembrance.

These two traditions show that older societies had a capacity to process not only their own loss but also other’s loss and they have found very impressive ways to accompany their pain. However, these traditions and rituals seem to have long been forgotten. Mitima-verloop and colleagues (2019) in the past decades, secularization and individualization have caused reduction of traditional religious rituals. For many people in many societies, surprisingly even for care providers, death is no longer a natural process but it represents a medical failure or defeat. Most of the time it is followed by guilt and self-reproach as part of the grief-response. Therefore, as Jeffreys (2005) said, most of the time it is easier simply not to talk about it, to ignore the topic or distract ourselves.

One particular event occured in Istanbul illustrated this societal degradation very precisely. In 2003, by the wish of a veteran Hasip Uras (1929-2008), a verse from the Holy Quran 3:185 saying “Every soul shall have a taste of death” (Translated by A. Yusuf Ali) had written on the entrance of Zincirlikuyu Graveyard in Istanbul. To this verse, a politician commented as “a very irritating thing”. Furthermore, journalists said that it feels like a threat to read it, it is meaningless to talk about death, and it might even cause a traffic accident to read it (Sabah, 2011). This event, illustrating the great change in society’s perception regarding death, brought up a question: “Are we becoming a society who has forgotten how to grieve?”

In fact, this alienation was global and it happened not only on the societal level, but also at the medical level. As Aries (1981) said, death, which was viewed as natural and expected, has become medicalized and unwelcome in medical care. Accepting the naturalness of dying directly, had opposed the medicalization and legalization of death which characterizes the culture of dying in 21st century America. As Lofland (1985) has said, grief is profoundly affected by social structure and by postmodern culture. In a postmodern world, “mourners do not have to continue their bonds with the dead; it all depends on the individual and their unique relationship with the deceased. People do not work through grief, grief works through the person. It is up to you whether you abandon your dead” (Walter, 2007, pp. 123).

Therefore, when the risk factors for bereaved ones are taken into consideration, societal alienation from the reality of death and degradation of cultural and religious rituals should be considered as well. Bereaved people who lost their loved ones do not only suffer from the governmental policies for COVID-19, but also from the medicalized, legalized, individualized postmodern culture of dying in the 21st century. Researchers said that the development and aftermath of the COVID-19 pandemic, they anticipate prolonged grief disorder will become a major public health concern worldwide (Eisma et al., 2020). Therefore, it is vital for healthcare professionals to understand what grief is as to give support for the bereaved ones. In line with this purpose, five most important theories of loss and grief will be mentioned below respectively Freud, Linemann, Kübler Ross, Worden and Bowlby.

According to Freud (1917), libidinal energy to the loved one draws away with the loss, and libidinal search begins for a new object; and grief is merely the time needed between this transition. In this transitional time, humans may either experience the grief of melancholy. According to clinical findings, there is a meaningful correlation between grief and melancholy. Sometimes, grief reactions turn into melancholy and this is regarded as pathology. In either case, the common feeling is anger; in the grief process this anger is directed towards the outside, and in melancholy, it is directed towards inside the person’s very ownself. Freud regards melancholy as a deviation from the grief process because it includes feelings of guilt and reduction of self-worth, which both do not and must not exist in a healthy grief process. Processes which are important in the grief process goes like this: Withdrawing into oneself, not searching for a new love object as it does not replace the lost loved one, and thus weakening bounds with the outside world. Over time, these reactions reduce, the libidinal energy gradually gets free and the person begins to search for a new object (Freud, 1917). From this aspect, Freud seemed to recognize “time” as a significant healing factor.

Lindemann (1944) regarded grief as a complex process and stated that it might produce emotional, bodily and cognitive reactions. According to his theory, the grief process hardly ever differs in each human being. He expressed six possible symptoms after a loss: Bodily symptoms, mind busy itself with the lost loved one’s imaginative being, guilt, hostile reactions, showing abnormal behaviours, and acquisition of personal qualities of the loved one. Just like Freud (1917), Lindemann also described grief as a time needed to adjust the new situation and regulate interpersonal relationships.

Kübler Ross (1975) regards death as the last stage of development and therefore by the help of the grief process it might become a constructive process for human beings rather than a destructive one. She suggested that a grief process consist of 5 stages: Denial, anger, bargaining, depression and acceptance. In the denial stage, one cannot internalize the fact that a loved one is dying. So in this stage the dominant feeling is mainly denial. In the anger stage, one confronts the fact that the loved one is dead. Sometimes people look for someone who is responsible for the death; it might be the doctor, family members and God. Feeling unfinished and blocked are two dominant feelings of this stage. In the bargaining stage, one expects that a miracle would happen and makes promises about his/her life if this miracle actualizes. Compared to the anger stage, the bargaining stage is an emotionally calmer period. In the depression stage, one looks collapsed because it becomes clear that neither denial or showing anger nor bargaining can change the fact (Kübler-Ross, 1969). Dominant feeling is feeling depressed and sometimes accompanied by unreal shame and guilt. At this stage, social support is crucial. Finally, the last stage of grief is acceptance. At this stage, one confronts the fact of death and accepts it. It is expected for someone who is at this stage to bring a new order to continue without the lost loved one. The physical absence of the loved one is now accepted and it can be seen that the person begins to establish new relationships.

Regarding the view of Elizabeth-Kübler Ross, Jeffreys (2005) mentioned that scientific research has shown that acceptance alone does not make an end to grieving. The bereaved one has to find a way to create personal meaning from the loss. It is also called “repositioning grief” and describes it as not an endpoint but as a start on a profound exploration (Kessler, 2019).

Similarly to Kübler-Ross’s work, Worden (2009) also worked on grief and suggested an explanation for its process. According to Worden (2009), the grief process does not consist of stages to be overcomed but it is a task and he called his theory as “Tasks of Mourning”. The first stage of this model is to accept the reality of the loss, therefore the first task is to realize that the loved one is lost and cannot be seen once again. Second task is to work on the pain that is created by the loss and try to express what is felt. Third task is to produce an ability to accommodate the surroundings where the loved one is no longer a part of. Rich (2002) mentioned that sometimes one might have to take the place of the lost one thus learning new abilities. Apart from this, one might look for a meaning of life and try to give the loss a meaning. At the last stage of the model, the task is to rearrange the emotional relationship with the lost loved one and continue the daily routine. This last stage is the longest one among the other three stages.

Another important scholar who worked on the grief period is John Bowlby. Bowlby (1969) suggested that the grief process consist of four stages. First stage is shock and numbness where one believes that this loss is unreal and feels numb. Second stage is yearning and searching where one feels longing for the lost loved one often accompanied by a deep pain. Third stage is despair and disorganization where one can lose interest in daily activities. The dominant feeling of the third stage is depression and apathy. Last stage is reorganization and recovery where one is ready to turn back to the daily activities, social interactions and enjoy living (Bowlby, 1983).

Although these theories bring insight for the concept of grief, recent studies suggest that these may not be the case for the behaviour of a typical bereaved one (Maciejewski et al., 2007). In the research it is offered to use “states” rather than “stages” for grief, and yearning was found to be the dominant painful sentiment throughout the acute bereavement period (i.e. 1–23 months after the loss). It is also found that less frequently experienced reactions such as sadness, anger and disbelief declined over time from loss (Prigerson & Maciejewski, 2008).

In line with this study, Jeffreys (2005), a psychologist who has a specialization on grief, loss and end-of-life concerns, suggested that there are seven main principles regarding grief which are helpful for care providers to gain further understanding of grief reactions. Principle one is that you cannot fix or cure grief. It is highly crucial for care providers to understand that grief is not an illness that needs medical treatment. Human grief is a combination of physical and emotional feelings, mental thoughts and behaviours that enable us to survive. That is why it is a normal way of reacting when we have already lost or afraid to lose someone or something important to us. Losing a person, physical objects, place, job, dreams or sense of safety and trust” can create a grief response. However, it is also important to consider that if grief is not processed, it is not expressed or shared, it can turn into a traumatic, disenfranchised, and chronic grief. Researchers stated that these pathological forms of grief response are expected to arise in the aftermath of the pandemic outbreak. The pathological forms are called prolonged grief disorder (PGD), which has recently been introduced in the 11th edition of the International Classification of Diseases (World Health Organization, 2018). It is crucial to differentiate a healthy grief from a pathological one.

Jeffreys’ (2005) principal two is that “there is no one right way to grieve.” This principle sheds light to the fact that many cultural traditions process grief in a different way. Each culture has its own norms about how grief is expressed. Castle and Philips (2003) has found that engaging in grief rituals is a way to cope with loss during transitional and traumatic events and in particular, they mentioned the highly ranked ritual of creating scrapbooks that incorporate personal, symbolic objects. It is found that creating scrapbooks is a type of reminiscing that is more helpful than some traditional forms of counseling such as participating in a bereavement support group or individual grief counseling or psychotherapy. (King et al., 2016) They have a role of catalyst for communication and discussion between individuals and provide opportunity for connection and sharing with peers (McCarthy & Sebaugh, 2011). When engaging this ritual in a support group setting, the therapist should encourage participants to share their books with each other. It allows bereaved ones to share their emotions and pain and often promote further sharing and psychological recovery (Kohut, 2011).

The third principle of Jeffreys (2005) is that “there is no universal timetable for the grief journey.” Although older theories ( suggested universal time tables, recent research has shown that there is no universal time table at all. In a Swedish study, authors strive to reach every Swedish parent who had lost their child during a five year period and they contacted 80 percent of the 561 parents asked to participate. In this study which is quite unusual for its sample size and representativeness, it is found that for parents who lost their children the grief process might extend to 9 years (Kreicbergs et al., 2004).

Jeffreys' (2005) fourth principle is that “every loss is a multiple loss”, which suggests when we lose a person or a place, we incur secondary losses. It is not only the body of a deceased we lose, but also the part of ourselves that is bonded in relationship to the loved one, and different roles she played in our life. Regarding COVID times, Selman’s (2020) research also stated that pandemics cause multiple losses both directly related to death and also in terms of reduction to social norms, rituals and mourning practices. Kokou-Kpolou and colleagues (2020) pointed to such multiple loss when the deceased is an elder, the deep pain and distress in the bereaved families could be overlooked by society. In other words, the loved one being an elder does not reduce the pain of a multiple loss of departure of a loved one with tremendous suffering.

Principle five is that “each change brings a loss and each loss brings a grief.” In our daily routine, our physical and social environment changes continuously. In fact, whenever any change occurs in our daily routine, we lose what we left behind and connect with what comes next. In this sense, even a good change brings a natural sense of loss. Every happy transition in life (graduation, wedding, moving, having a baby) may create a grief reaction because we left our previous life behind and step to the new one. However, when the change is death or an illness, the grief reaction might be very intense.

The next and sixth principle of which is highly related with this, is that “we grieve old loss while grieving new loss”. As we move through the stages of life, we accumulate the loss material. In spite of our previous grieving, some unfinished grief might remain. When a new loss emerges in our life, the old grief engages with the new one. And this intensifies the grief reaction. This is especially valid in parents whose children died before the pandemic. The study of Helton and colleagues (2020) aimed to examine how has COVID-19 impacted the bereavement experiences of parents who lost their children to cancer before the pandemic. Many parents commented on feeling more isolated since they are unable to connect with their families or attend support groups and it is said that clinicians should explore innovative ways to connect with and support these parents during this unexampled time (Helton et al., 2020).

And lastly, Jefferys’ (2005) principle seven is that “we grieve when a loss has occurred or is threatened”. Often, the grief process begins before the actual loss event happens with threats: When a loved one is extremely late at home, when the doctor asks for more tests etc. We do not need an actual death to occur to feel a grief response, even the threat of loss is enough to feel it. Which means, during COVID-19 times, even the people who have not literally lost any loved one but felt threatened by losing them, will eventually feel grief as well and might need to be supported. Therefore, to process grief, it is crucial to receive adequate social support, whether it is formal or informal (Bisschop, Kriegsman, Beedman, & Deeg, 2004). This support serves as a way of normalizing and validating the emotions of bereaved ones.

As Love (2007) stated, the aim of helping should be “to ensure that individuals receive appropriate support while they experience and express their grief in their own manner” (p. 80). When the focus is to treat, cure, fix or help them overcome, evidence shows that practitioners provide overly glib and simplistic reassurance to bereaved individuals which make them often feel more isolated and alone (Kouriatis & Brown, 2011). Rather than normalizing the grieving process, individual therapeutic intervention can stigmatize and pathologize it. This is the main reason why researchers found that individual counseling actually may slow down the natural process of grieving for bereaved clients (Knight & Gitterman, 2014).

Similar to this data, Castle and Phillips (2003) found that sharing stories about the loved one with others rated as more helpful than professional counseling. This data might also explain why Death Cafes (cafe mortel), which was first established by Swiss sociologist Bernand Crettaz in 2004, are becoming widespread around the world. These cafes are offering a space for people to talk about mortality, their experiences and grief over tea and cake (New York Times, 2018).

In one manner, sharing stories involves the therapeutic benefit of group membership which is taking its source from mutual aid (Gitterman, 2004; Schwartz, 1974; Shulman, 2008). It is an empowering and validating experience when members are with others who are going through similar life challenges and notice that they are not alone in their feelings, reactions and experiences. This discovery has been referred to as “universality” (Yalom & Leszcz, 2007) and “all-in-the-same-boat-phenomenon” (Shulman, 2008). It is also possible in individual counseling for a practitioner to reassure clients that they are not alone in their thoughts and feelings, however reassurance is more effective when individuals receive it from similarly striving group members. Group members have a keener understanding of each others' difficulties, challenges, distress (Knight & Gitterman, 2014) and this has a great importance in COVID-19 times for people who need for their suffering to be understood.

Once the significance of establishing a group setting is perceived, group leaders should pay attention to some points that are mentioned by Kari and colleagues (2013) who conducted a research on participants’ recommendations for the ideal grief group. Recommendations are mainly under three themes (a) the significance of thorough information before attending to the group (b) screening before participating in groups is a need, and (c) easy access and a flexible organization is necessary. Below, further research is considered regarding these recommendations points.

Regarding the significance of information, Levy and Derby (1992) stressed that sometimes bereaved people hesitate to join support groups because they have negative expectations. Providing information about the aim, structure, organization and possible effects and limitations of group participation shall bring a realistic perspective for participants.

Regarding the importance of the screening, it is a serious fact to consider that when a severe trauma was not treated outside of the group, that traumatic material might be repeatedly brought up by participants which disturbs a healthy group process. Therefore, in order to gain benefit from a group, those in need of trauma-therapeutic help should start with processing the trauma (Cohen et al., 2004).

Lastly, regarding the easy access and flexible organization, the bereaved ones often lack energy to look for grief groups themselves, so they need an automatic offer from the authorities (Dyregrov, 2002). They also need a flexible leader who is knowledgeable about grief and has the strength to manage the group when particular participants begin dominating the group. Group leaders can benefit from these insightful observations from the bereaved ones and improve their groups accordingly to get participants an optimal experience attending a grief group.

Conclusion

Although in many countries it remains a taboo subject, death is a natural and inevitable aspect of life which we all have encountered especially in this COVID-19 period. When grief is not processed naturally, it causes severe symptoms in which the bereaved feels challenged and even more isolated. In this article, this unprocessing of grief is discussed within two contexts. First one is societal alienation and degradation of cultural and religious rituals regarding death. The second is the limitations of the pandemic which prevented people from traditional grief rituals (to say goodbye or to see the body of their loved ones). These are pointed as potential risks to experiencing a complicated grief rather than a natural one.

As to give adequate support for the bereaved, it is crucial to understand the components of grief. In line with this, most important theorists' views are mentioned in the article, namely Freud, Linemann, Kübler Ross, Jeffreys, Kessler, Worden and Bowlby. Jeffreys’ seven main principles regarding grief is considered as helpful for care providers to gain further understanding of grief reactions. It is also suggested that current focus should include creative ways to promote connection and adapt rituals which has a huge potential to send signals of recovery and transformation. Kokou-Kpolou and colleagues (2020) addressed the urgent need for COVID-19 affected countries to implement bereavement focused national mental health programs with qualified health care professionals and we suggest in this article that grief groups should be at the forefront of these programs. In line with the research provided in this article, priority should be given to culturally sensitive interventions and rituals should be involved. And finally, countries may take advantage of this pandemic to activate national bereavement response plans for collective deaths. This could provide insight for health care professionals (Kokou-Kpolou et al., 2020). Obviously the pandemic brought many challenges worldwide, but as Dhranaj and Kohlrieser (2020) said, grief is addressed properly, it can be a creative force which turns loss into inspiration.