Article

OMEGA—Journal of Death and Dying

2023, Vol. 87(4) 1088–1108
Mourning During ! The Author(s) 2021
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DOI: 10.1177/00302228211032736
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Study of Grief
Experience Among
Close Relatives During
COVID-19 Pandemics

Seyede Salehe Mortazavi1,2,

Nazanin Shahbazi3, Mozhgan Taban4,
Amirali Alimohammadi3 , and
Mohsen Shati4

Abstract
Considering the need for observing health protocols, the experience of the loss and
the grieving process has changed in nature during this disease. Therefore, this study
aims to gain a deep understanding of the experience of mourning during COVID-19
pandemic by exploring the experiences of survivors of the death of their loved.
During COVID-19 pandemic, the inability to hold the usual ceremonies for mourning
and receive the social support needed in this period, the relatives of the deceased

1
School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of
Medical Sciences, Tehran, Iran
2
Spiritual Health Research Center, Iran University of Medical Sciences, Tehran, Iran
3
Department of Clinical Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of
Psychiatry), Iran University of Medical Sciences, Tehran, Iran
4
Mental Health Research Center, Psychosocial Health Research Institute, Iran University of Medical
Sciences, Tehran, Iran
Corresponding Author:
Amirali Alimohamadi, Department of Clinical Psychology, School of Behavioral Sciences and Mental Health
(Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran.
Email: amiralimohamadi@hotmail.com
Mortazavi et al. 1089

encounter various conditions that disrupt the grieving process and may lead to the
spread of unresolved grief in future.

Keywords
COVID-19, grief, outbreak, pandemic, phenomenological study

The COVID-19 pandemic started in China in December 2020 and spread rapidly
around the world, leading to a rapid and dramatic change in people’s relation-
ships, daily routines, and lifestyle. Phenomena that were previously considered
as a normal part of life (for example, being together) have turned into conditions
in which each human being is considered a potential transmitter of the virus to
another person, and people resort to collective isolation to follow protocols and
social distancing measures.
As a global threat, this pandemic has been an important factor in increasing
the death rate worldwide (Zhai & Du, 2020) so that 185,515,249 patients and
4,012,002 deaths were registered by July 7, 2021 (Covid-19 Coronavirus
Pandemic, 2020). It can be said that this virus has led to the grief and mourning
of many people across the world (Bertuccio & Runion, 2020), and as people try
to keep distance between themselves and others to prevent the spread of the
virus (Bertuccio & Runion., 2020), even the experience of mourning the death of
a loved one has also changed. People experience a kind of unfinished mourning
during COVID-19 pandemic because people who follow the health protocols are
deprived of performing the rituals that are normally performed after the loss
and do not enjoy the presence of others to relieve the grief caused by the loss.
That is why they are left alone to cope with their grief in an unknown way
(Farahmandnia, et al., 2020), which according to studies is a disenfranchised
grief, in which individuals’ grief is not publically acknowledged or socially
supported and they are lonesome in their bereavement and sorrow (Doka, 1999).
Generally, as death is an irreversible process, people must resist the grief
resulting from it and should return to normal life. Freud (1957) referred to
the reaction of people to the loss of a loved one as mourning (Trauer). In
recent decades, various models have been proposed to explain how people
cope with grief, such as Schut and Stroebe’s (2005) dual process model and
Worden’s (2018) task-oriented model.
The dual process model has been developed based on the cognitive stress
perspective and describes grieving as a process of oscillation between two con-
trasting modes of functioning. In the loss-oriented mode, the bereaved person
1090 OMEGA—Journal of Death and Dying 87(4)

responds to the loss with an emotion-focused coping method and achieves

adjustment by focusing on himself/herself and trying to reduce his/her unpleas-
ant feelings. In the restoration-oriented mode, the bereaved responds with a
problem-oriented coping method, focusing on the external requirements of
adjusting to the loss. He/she distracts his/her attention from the loss, responds
to the demands of life, and copes with the event in this way.
Worden’s (2018) model suggests that grieving should be considered as an
active process that involves accomplishing four tasks: 1) accepting the reality
of loss, 2) processing the pain of grief, 3) adjusting to a world without the
deceased (including internal, external, and spiritual adjustment), and 4) finding
an enduring connection with the deceased while accepting a new life.
The grief caused by the experience of bereavement is a natural reaction that
ends over time by accepting the absence of the deceased and transferring libido
to others, and finally, the person passes through this stage. In terms of psycho-
dynamics, Freud (1957) stated that this process also depends on external factors
such as the death due to a chronic and severe illness or internal factors such as
the relationship that the person has with the deceased, and these factors can
affect the mourning process). Since the 1990s, unusual grief persisting with a
high level of acute symptoms has become known as complicated grief. Various
studies have shown that people with complicated grief are at increased risk for
psychological trauma and even suicide. Finally, in 2013, the American
Psychiatric Association (2013) listed complicated grief as a psychiatric disorder
in the DSM-5, which includes severe grief symptoms with high degradation of
the level of performance in social, occupational, or other important areas of
functioning for a period of time longer than usual (at least 6 months) (Nakajima,
2018). Various studies have identified many factors that can affect mourning
and turn it into complicated grief, including the nature of death such as “sudden
death” and its traumatic nature that lead to the lack of preparedness or saying
farewell to the deceased, end-of-life caregiving, needed and available services,
financial issues, the individual’s family and social networks, and the available
cultural context (Burke & Neimeyer, 2013; Burke et al., 2019; Etkind et al.,
2020; Miyajima et al., 2014; Wright et al., 2008). Death due to coronavirus
disease and the actions that communities must take to prevent the risk of getting
COVID-19 cause all of the factors leading to complicated grief to be seen in the
grief resulted from the disease. Some of the factors include the sudden death
following a rapidly progressing and catastrophic disease, uncertainty about dis-
ease and failure to hold the usual mourning rituals, restrictions on funeral rites,
unanswered questions, attempts to accept death, and fear of the future.
Additionally, death due to COVID-19 is usually accompanied by much suffering
and pain. It occurs usually away from the family in the hospital while family
members are not present at the final moments of life and cannot say farewell to
the deceased. In fact, such a death indicates a kind of a “bad death”, and the
grief caused by it can be especially doubled for the relatives of the deceased, who
Mortazavi et al. 1091

may experience social isolation, lack of social and emotional support, financial
problems, concerns for their own health or that of other family members, quar-
antine, and failure to hold the usual mourning rituals. All of these factors can
lead to psychological symptoms such as depression, anger, anxiety, and com-
plicated grief in bereaved individuals (Carr et al., 2020).
In other words, rituals pattern our daily life (Kollar, 1990), and while facil-
itating the assimilation of change, they provide order and strength for groups
(Turner et al., 2017). The rituals and their power are distinguished by the use of
symbols within a performance framework. The symbols may contain personal
excitements or meanings that are socially constructed (Romanoff & Terenzio,
1998). Rituals are a means of expressing and channelizing strong emotions.
Their repetitive and recommended nature reduces feelings of anxiety and dis-
ability (Myerhoff, 1982; Scheff, 1979), and they provide structure and order in
times of chaos and turmoil. It has sometimes been suggested that these charac-
teristics of rituals can have therapeutic functions (McGoldrick & Walsh, 2004;
Rando, 1985). Rituals related to funerals have especially such a healing function
(Loewenthal, 2006).
To better understand the role of the mourning rituals, we can refer to the
three stages of normal grieving, presented by Romanoff and Terenzio (1998).
The first stage occurs in the intra-psychic realm and is called transformation.
The second stage is the transition that occurs in the psychosocial realm and is
complementary to the first stage. The last stage is called the connection which
occurs in the context of society and indicates the maintenance of a productive
bond with the deceased (Romanoff & Terenzio, 1998).
The results of studies show that during the coronavirus pandemic as well as
the previous pandemics, attending the funeral rites provides better conditions
for both adults and children to accept grief and cope with it, especially if attend-
ing these rites is significant for the mourners and indicates a kind of receiving
social support. In contrast, holding special mourning rituals for people who
have died as a result of coronavirus disease has a positive effect on the bereaved
people and is effective in passing through the mourning process in a better way
(Burrell & Selman, 2020; Corpuz, 2021; Lowe et al., 2020; Mayland et al., 2020;
Petryet al., 2021; Wallace et al., 2020).
Given that complicated grief requires professional treatment and it can have
many psychological consequences such as depression, suicide ideation, anxiety,
PTSD, sleep disorders, increased risk of physical diseases, such as heart disease,
cancer, or high blood pressure, impaired performance in relationships or work
activities, and the tobacco, alcohol, and drug use if it is left untreated, the
complicated grief is considered as an important public health concern (Cox et
al., 2015; Gesi et al., 2020; Nakajima, 2018; Shear, 2012).
Challenges arising from the current conditions complicate the grieving pro-
cess (Wallace, et al., 2020), which can cause people to experience severe symp-
toms of prolonged grief that can last for months and years and decrease the
1092 OMEGA—Journal of Death and Dying 87(4)

quality of mental health and life of people (Zhai & Du, 2020). If these challenges
are not recognized timely and a solution is not provided to manage them, they
can lead to many other problems and become a major public health concern
(Eisma et al., 2020). Given the high number of deaths and bereavement of large
numbers in each country, lack of planning in this regard can lead to a crisis. To
help to resolve this problem and prevent it from becoming a disorder, it is firstly
necessary to understand the survivors’ unique experience of mourning in this
condition and take measures on the individual or collective levels. The present
study has been conducted for this purpose.

Methodology
Research Design and Aims
Due to the emergence of the present conditions and the studied phenomenon,
the need to describe and understand these conditions is a priority. Thus,
Colaizzi’s descriptive phenomenological approach has been used in the present
research (Colaizzi, 1978), which is a descriptive phenomenological method con-
sisting of seven steps for exploring the lived experience of individuals. This
method and its interpretation method has been used in this study as it enables
the researchers to achieve a deep understanding of mourning and loss experi-
ences of the survivors following losing their loved ones to Coronavirus. This
study seeks to gain an in-depth understanding of how the mourning process is
experienced by people who have lost their loved ones due to coronavirus disease
during the COVID-19 epidemic and how they go through the mourning process
considering the imposed limitations caused by obligatory physical distancing
and consequent transformations in mourning rituals and traditions. Thus an
exploratory study was carried out to address the research question: “What are
the loss and mourning experiences of people who have lost their loved ones to
Coronavirus?”

Participants and Study Setting

Participants in the study were selected purposefully from the family members of
people who died from coronavirus disease and were willing to participate in the
study. The chosen participants were among those who have lost their loved ones
to Coronavirus and were identified from records provided by organizations
supporting the surviving families.

Patient and Public Involvement

No patient involved.
Mortazavi et al. 1093

Data Collection and Analysis

Data were collected by semi-structured interviews with participants over four
months from April to July 2020. Considering the prevalence of the disease and
the impossibility of conducting face-to-face interviews, all interviews were con-
ducted virtually by clinical psychologists of the research team who are trained
interviewers and have years of experience in conducting interviews and qualita-
tive studies and the interviews were recorded with a digital recorder.
The interviews began with this open-ended question: “can you describe what
happened from the beginning of his/her illness?” The unstructured nature of the
interview allowed the interviewees to present their narratives and thus express
their experiences. Depending on the context of the narratives, the interviewer
then asked such exploratory questions as “can you explain more?” The duration
of the interviews lasted 40–60 minutes, depending on the desire of the participant
and the process of conversation.
Data collection and analysis were performed simultaneously. For this purpose,
following the interviews, the audio files were transcribed word for word after
listening several times. Colaizzi’s interpretation method (Morrow et al., 2015)
was used to undertake the analysis, according to which, interview texts were
studied several times in the first step in order for the researcher to be familiarized
generally with the context of each interview. In the second step, clear and signif-
icant statements that described the interviewee’s experiences of mourning during
the COVID-19 epidemic were identified and the relevant sentences were under-
lined. The “meanings” extracted from significant statements were recorded in the
next step, and the researcher tried to express the formulated meanings in the form
of short sentences and phrases by bracketing (Colaizzi, 1978). In the fourth step,
as indicated in the Colaizzi’s method, the formulated meanings were organized
into clusters of relevant themes. Then, in the next step, the researcher expressed all
the results obtained in the form of an exhaustive description. This exhaustive
description helped to determine the fundamental structure of the experience. In
the sixth step, the exhaustive description was summarized in the form of a dense
description that clearly captured the fundamental structure of the experience
(Polit & Beck, 2004). In the seventh step, according to Colaizzi’s method
(Colaizzi, 1978), the results of the research were returned to the participants to
be verified by them in terms of the degree to which they captured their experiences.
The criterion for completing the sampling was to reach saturation, in which
the new data obtained from the three final interviews did not create any changes
in the existing findings.

Rigor
In the present research, rigor was achieved during the processes of data collec-
tion and analysis (Morrow et al., 2015). To verify the research data, according to
1094 OMEGA—Journal of Death and Dying 87(4)

the seventh step of Colaizzi’s method, the data were returned to the victims’
family members to ensure the validity of the themes and sub-themes (Morrow et
al., 2015), and no change was made in the data. Additionally, a combination of
several data collection methods, including individual interviews and field notes,
was used. In this study, all interviews were coded by two independent individ-
uals (AA and NS), and discrepancies were discussed at research meetings to
make final decisions and the expert review and the peer review were also used to
ensure the acceptability of the study results.

Results
Fifteen Iranian citizens (9 women and 6 men) participated in the study, all of
whom were Muslim, who resided in Iran. Mourning practices and death rituals
as parts of the complex response to loss matter in this regard and must be
understood in their social, cultural, and religious embeddedness. Iranians
follow a schedule in their funerals, which begins with washing the body of de
deceased and wrapping it in a cloth before the burial, and although it is mostly
done privately, the immediate family may attend this part of the service.
Survivors wear black for the funeral and apart from the importance of reading
the Quran together and saying prayers, the post-burial gatherings, presence of
family members and relatives, speeches, and special foods served at the funeral
are of great significance. The mean age of the participants was 39  12.8, and the
demographic information for the study participants is presented in Table 1.

Table 1. Participants’ Demographics.

Relationship with
Participant Gender Age the deceased Marital status Education level

1 F 31 Niece Single Master

2 M 26 Son Single Master
3 F 31 Niece Married Master
4 M 47 Son Married PhD
5 M 55 Brother Married Undergraduate
6 M 32 Cousin-Nephew Single Master
7 M 62 Husband Married Undergraduate
8 F 40 Wife Married Undergraduate
9 F 20 Daughter Married Bachelor
10 F 40 Daughter Married Undergraduate
11 M 28 brother-in-law Married Undergraduate
12 F 55 Wife Married Undergraduate
13 F 55 Wife Married Undergraduate
14 F 33 Daughter Married Bachelor
15 F 30 Daughter Married Bachelor
Mortazavi et al. 1095

Table 2. Themes and Sub-Themes Obtained From the Data Analysis.

Sub-themes Themes

Unknown behavior of the virus Ambiguity and

The rapid onset and spread of the disease desperation
Uncertainty about the effectiveness of therapeutic
interventions
The dichotomy of hope and despair
Fear of the medical staff
Incomplete and hasty encounter with the deterioration Incoherent narrative
process
The distorted and deformed funeral ceremony
Lack of emotional support Feeling lonely
Death in loneliness
Virtual mourning
The family’s ambivalence over the presence of others The conflict between
Family’s isolation as a result of coronavirus stigma fear of and need
The family members’ ambivalence over the support of the
affected person
Turning to the virtual network Becoming relieved by
Turning to religion alternatives

According to the results obtained from data analysis, 16 sub-themes and 5

main themes, including ambiguity and desperation, incoherent narrative, feeling
lonely, conflict between fear and need, and becoming relieved by alternatives,
were finally extracted (Table 2) as explained below.

Ambiguity and Desperation

Ambiguity and desperation were common feelings experienced by the relatives
of a deceased during the COVID-19 epidemic. The unknown function of the
virus, rapid onset and spread of the disease, uncertainty about the effectiveness
of therapeutic interventions, the dichotomy of hope and despair, and fear of the
medical staff caused people to feel that there was no control over any stage of
the disease. Thus, they felt desperate.
The rapid onset and spread of the disease was one of the issues mentioned by
all survivors. In most cases, it did not take more than a month from the onset of
the disease to the patient’s death. As a result, the relatives of the patient expe-
rienced a lack of control over the conditions and felt helpless and desperate.
Participant 4: “In early March, we were talking to my father and he had a
fever, chills, and weakness. Although all of his organs were working very well,
the conditions of his lungs were getting worse day by day. . . and woefully, he
died on 24 March.”
1096 OMEGA—Journal of Death and Dying 87(4)

Additionally, the uncertainty about the effectiveness of therapeutic interven-

tions and the patient’s recovery caused the victims’ family members to fluctuate
between feelings of hope and despair before the death of the patient.
Participant 1: “We rented the ventilator machine from the hospital. . . and
brought it here. . . his blood was purified with this machine for a few days. . . and
the blood plasma from a person who has recovered from COVID-19 was
injected into his body. None of these measures worked. . . we hoped all the
time that new measures had been taken and they might be effective. . . but his
conditions were getting worse. We became disappointed again.”
Participants also reported that the medical staff’s fear of patients with coro-
navirus disease caused them to stay away from patients or to delay interven-
tions. This disrupted the normal treatment process, causing them to feel
desperate for solving the problem in a critical condition.
Participant 11: “unfortunately, there was no good cooperation in the hospi-
tal. . . because they were looking at patients as those with coronavirus disease. . .
and they were afraid to come forward and touch the patient. . . to do some-
thing. . . for example, for the ECG and other similar things. . . we did some of
them ourselves. . .”

An Incoherent Narrative of Mourning

Another common experience of participants was the interrupted/incoherent
experience of demise, deterioration, death, and mourning that prevented them
from believing the loss.
Due to the need to follow health protocols, mourning ceremonies in this
period are held without customs and rituals which make the death of the
deceased unbelievable and cause the psychological experience of disease and
loss to be incoherent.
Participant 13: “If we held a ceremony, we could be soothed. This kind of
bottling up shatters you. . . for we did not see the deceased body, we have not
believed it, neither me nor my child. My son says to me that he thinks his dad is
at work.”
The participants also stated that the impossibility of visiting the patient, the
impossibility of being aware permanently of his/her conditions, and his/her
sudden death in a short period of time caused an interrupted encounter with
the whole process of demise. This led to several fragmented episodes of the
experience of the demise and loss of the deceased person rather than a coherent
narrative of the whole event. They were suspended in accepting or not accepting
the death of a loved one. Accordingly, the statements of the participants were as
follows:
Participant 12: “I was not allowed to see my father at all. . . we only got news
from the nurses by phone. . . when he died, I took the grave-clothes to shroud
him, but they didn’t allow me. At first, we did not believe at all. . . because they
Mortazavi et al. 1097

did not let us see him. . . we didn’t see any corpse. . . any sick person and any-
thing that happened to him. We were just told that he had died. . . they took him
away and buried him. . . this is as if he is a missing veteran. . . he has disappeared
suddenly. Now, they have shown us a place as his grave. . . we do not know even
the things that the others know about their own deceased one. . .”

Feeling Lonely
Participants stated that due to the need to follow health protocols and the fear
of survivors and others of a higher prevalence of coronavirus disease or being
affected by it, very few people attended the funeral, leading to feeling lonely and
the lack of emotional support from relatives. They also believed that the lack of
rituals and the presence of a small number of people at funerals led to the
loneliness of the death of the deceased person, and they expressed grief for it.
Participant 4: “It was very difficult. . . my father was buried in complete
loneliness. . . mourners always expect others to come and comfort them. . .
there was no funeral. . . no ceremony for us. . . it was a complete loneliness. . ..
the conditions were such that we could not even hug and kiss our mother who
was bereaved.”
Due to the lack of emotional supports, some participants used virtual net-
works to share the grief of the loss, to observe the funeral, and to express their
empathy. However, as the participants reported, this virtual mourning was con-
sidered an unreal and unauthentic experience and could not replace the real
encounter with the death of the loved one and the relief by the physical presence
of others.
Participant 1: “they used live video on Instagram to allow the others to attend
the funeral virtually. . . but I do not know why I did not feel burying a deceased
person. It seemed to have not happened while it had happened. . . it was unreal.
When you cannot see anything, you do not believe it. You feel that it is not
real. . . I thought that he would come back again. . . it was not like our usual
mourning at all”.
As an example, the way the code and sub-themes were extracted from the
units of meaning has been presented in Table 3 for the above-mentioned theme.

The Conflict Between Fear of and Need for Others

Participants stated that although they needed the presence of others, they were
afraid of transmitting the virus, its further spread, and being affected by it.
Thus, there was a dichotomy between the need for the physical presence of
the others and the fear of their presence due to the possibility of being affected
by the coronavirus disease.
Participant 9: “We did not hold any ceremony because we were always afraid
that we might be a transmitter of the virus. . . or that the others might be
1098 OMEGA—Journal of Death and Dying 87(4)

Table 3. The Path of Extracting Code for the Theme of Feeling Lonely.

Units of meaning Code Sub-theme Theme

It was very difficult. . . that is, Being deprived of Lack of social Feeling lonely
it was different. . . no one empathy and sup- support
was around to comfort port of relatives in
us. . . and we were all adversity
mourning alone . . .
My father died lonely, it made Mourning ceremonies Death in loneliness
me upset from different with few relatives
points of view. Most of our
relatives, aunts, uncles, etc.
did not even come to
visit us
Yes, I viewed the Instagram Not believing the Virtual mourning
Live video. . . but it was death of the loved
virtual. Although I was fol- one due to the
lowing it and crying, I did impossibility of
not have the same feeling physical presence
that I had when I went to
the cemetery. I actually felt
the death of my uncle just
when I went to the ceme-
tery and saw his grave.

transmitters. As we feared, we told the others not to come. If someone came and
something bad happened to him/her, we would be guilty.”
The participants also stated that many people around them did not approach
them because people believed that they and their place of residence were
infected, and this fear from the victims’ family members led somehow to the
rejection of the family of the deceased person.
Participant 15: “After realizing that my dad was in the hospital, the neighbors
treated us as if we all were sick. We felt rejected, everyone moved away from
us. . . nobody came to our home. . .”
Participants also spoke of a sense of ambivalence about supporting the
person with coronavirus disease and visiting him/her in the hospital. This led
to an internal conflict between caring for and supporting the patient emotionally
by staying physically near him/her and avoiding him/her because of the possi-
bility of being affected.
Participant 5: “I was aching for going. . . but besides myself, I was also
responsible for my family. . . and if I went. . .I would be the carrier of the
virus. . .I would transmit it to my family. . .it would be a problem . . . so I
couldn’t do it out of my selfishness . . .”
Mortazavi et al. 1099

Becoming Relieved by Alternatives

In this regard, participants stated that the victims’ family turned to alternatives
to calm themselves and create a sense of the presence of others due to despair
caused by the lack of control over the conditions and the lack of social support
from others who could not have a physical presence. For example, using fre-
quent or group phone calls, holding a funeral by live videos on Instagram with
the presence of the family, and turning to religion by giving alms or reading the
whole of the Qur’an, they felt hopeful and became relieved.
Participant 1: “ his condition got worse. . . it had a downward trend. The only
thing that we could do was be in a WhatsApp group with the family members to
read collectively the whole of the Qur’an. . . or have prayers and vows. All of our
hopes were that they would have a benefit.”
Participant 4: “virtual space really helped us a lot during this time. . . we did
not gather for the sake of our children and we saw each other virtually through
telecommunications. . . our friends and acquaintances also helped a lot through
telephone and virtual space. We had no other way. . . and the only way to
communicate was it. . .”

Discussion
The results of the present study indicate a different experience of the death of
relatives by survivors during the prevalence of COVID-19 pandemic and the
limitations caused by it. According to the results of the present study, the three
stages of this experience can be identified as 1) before death and during the
disease, 2) death and the initial ceremonies, and finally, 3) after death and the
grieving process.
In the first stage, due to the prevalence of coronavirus and being infected by
it, as well as the unknown nature of the disease and its rapid expansion in the
body, the family members of the patient go through vague and chaotic condi-
tions. After death, due to the impossibility of holding the usual funeral rites and
the lack of social support to share the loss with relatives, loneliness is a prom-
inent feature of this stage. In the later stages, despite the need for the presence of
the other, due to the contagious nature of the virus and the susceptibility of the
deceased’s family members to the stigma, the lack of emotional support con-
tinues and the survivors turn to religion and virtual networks for relief. In all
three stages, the common feature is the inability of the survivors to form a
coherent narrative of the whole process, because the individual does not go
through the usual process of believing and accepting the loss for such reasons
as the lack of accompanying the patient at the final stages of the disease that
prevents going through the anger and bargaining, the impossibility of observing
the course of the patient’s demise, and the impossibility of holding the usual
1100 OMEGA—Journal of Death and Dying 87(4)

ceremonies and burying the deceased as expected that prolongs the denial. In
fact, this cycle hinders a coherent understanding of the event.
In general, the loss creates a gap within the individual’s psychic structure, and
mourning is the process of reconstructing a system of meaning that has been
challenged by the loss. The experience of loss, particularly if it is sudden and
unexpected, can interfere with a person’s ability to rebuild his or her assumptive
world, especially when the death assaults the people’s notion that life is predict-
able (Hall, 2014). During COVID-19 pandemic, mourning imposes some con-
ditions on the bereaved that widen the gap. In practice, the person encounters a
flood of painful events with high speed and the minimal possibility of control-
ling the conditions. The feeling of ambiguity and despair experienced in this type
of mourning is due to such conditions. When mourning, the rituals act as a
mediator to assimilate the event. Historically, people have different understand-
ings of death and the rituals after it in different cultures. The observation of
others when they encounter the death of their loved ones or the general under-
standings of how people respond when experiencing grief leads to the socializa-
tion and prediction of this process. Accordingly, people learn to respond to the
death of a loved one in a certain way, and the beliefs guide people’s responses
when such a thing happens (Alford & Catlin, 1993).
Funeral rituals are symbolic actions that provide meaningful experiences for
the survivors. These rituals mediate the process of the deceased’s transition from
life to death as well as mediate the transition of the bereaved from one social
situation to another (Doka, 1999). During the ritual, members of a social group
try to facilitate this transition by providing social support (Turner et al., 2017).
According to Lacan, a phenomenon such as death that is related to the Real is
symbolized by performing symbolic actions in the form of rituals and attempt is
made to assimilate its traumatic dimensions through symbolic order in the
mental structure of a person. However, this process is disrupted in conditions
with limitations caused by the coronavirus. A part of the process that has been
referred to as the incoherent narrative of grief is concerned with this issue. To
better understand this part, one can refer to the three stages of normal mourning
that are separate but interrelated. The question of how humans both hold on
and let go of those who have died is a worthwhile, Francis et al. (2020) stated,
‘‘When a person dies, his or her social identity will not perish so long as it can be
reconstructed though the memories and actions of the living’’. Reconstructed
social identity is what we have been calling a continuing bond in bereavement
studies, Much attention has focused on the role of the continuing bond to the
deceased (CB) as an integral part of successful adjustment to bereavement
(Klass et al., 1996). Funeral and ancestor rituals are well-developed cultural
forms for managing continuing bonds (Klass, 2001). A continuing connection
may be promoted by talking about the deceased, recalling memories of the
deceased, going over photographs of the deceased, visiting places where the
deceased used to go or visiting the deceased’s gravesite. These interventions
Mortazavi et al. 1101

would also be effective in counteracting these individuals’ tendencies to defen-

sively orient their attention away from the attachment to the deceased and
thereby facilitate the process of working through the loss (Field et al., 2005).
The visits to the cemetery beginning right after the death are an important
element in the construction of the continuing bond both as an inner reality
and as part of the family system. Visitors to the cemetery experience physical
proximity to the deceased. People across the ethnic spectrum talked about the
tomb as the deceased’s home and the physical presence of the body in the home
(Klass, 2006). The physical proximity can serve both the holding on and letting
go aspects of bereavement (Holst-Warhaft, 2000). During COVID-19 pandemic,
the inability to receive the body of the deceased, accompany it to the cemetery,
and bury it physically, which is a symbol of the transition stage, causes the intra-
psychic process of transition not to be facilitated and as a result, the symbolic
process of transition from life to death does not occur. Thus, survivors who have
not been able to meet the deceased in the final stages of the disease face only a
shrouded body whose face they cannot even see for assurance. Accordingly, the
intra-psychic process and preparation for accepting death do not occur. It seems
that during COVID-19 pandemic, due to the absence of rituals, a part of the
death is not symbolized at each stage of the mourning and its traumatic dimen-
sions remain intact.
Survivors suddenly encounter a mere gap in their place of residence and
perceive literally the loss in a harsh way. According to one of the interviewees,
death from coronavirus disease is like the missing of a person and does not
create a sense of death in survivors, because they face only a physical absence of
the person and do not have any coherent narrative of the process of his/her
demise and burial.
In addition to the period of suspension provided by the rituals in the stage of
transition that prepares a person to accept a new condition in the world, the
symbolic and inherently evolving nature of the rituals causes the survivors’
relationship with the deceased to change in the stage of connection by recovering
memories and notions. The survivor is encouraged to symbolize his/her rela-
tionship with the deceased by selecting an object or memory and form a new
intra-mental representation of him/her (Romanoff & Terenzio, 1998).
According to one of the participants, the presence of a group of survivors
together to hold usual ceremonies during the first month after the death of a
loved one is not only limited to mourn and recalling the memories of the
deceased and the psychological connection with him/her facilitate the process
of forming a new symbolic relationship and accepting the new conditions of the
survivor and the deceased. However, the current conditions and the limitations
caused by the coronavirus diseases have hindered such a process. Failure to
mourn and the imposition of rituals specific to the current conditions form
the experiences in the psyche of the bereaved that can lead to complicated or
unresolved grief (Myerhoff, 1982). Furthermore, loneliness and stigma
1102 OMEGA—Journal of Death and Dying 87(4)

experienced by the bereaved, as well as the simultaneous conflict between the

fear of and the need for the presence of others, exacerbate the complicated grief
and affect the individual’s response to these conditions. Based on the dual pro-
cess model, the focus of coping with grief may vary from moment to moment,
person to person, and culture to culture (Stroebe & Schut, 1999).
In conditions with limitations resulting from coronavirus disease, both of
these modes are impaired. Such behaviors as visiting the grave of the deceased
and performing mourning ceremonies together with others are usually the pre-
dominant manifestations of the loss-oriented mode. Detached from the normal
process of life, the person focuses on mourning and emotional responses.
However, it is not currently possible to respond in such a way, and people
just have to be careful to follow the health protocols even when attending the
ceremonies. They should abstain from embracing those around them, which is
the main manifestation of the emotion-focused method. It seems that people are
separated from the grieving process and the present conditions demand cogni-
tive awareness and make it difficult to adopt a loss-oriented mode. Regarding
the restoration-oriented mode, such obstacles as home quarantine and the con-
stant exposure to the absence of the deceased in the place of residence make this
mode less adaptive. It seems that the loss-oriented mode is inevitably imposed
on everyone. However, at the same time, people are not allowed to reveal freely
their emotions as the basis of this mode. A condition is created that lacks any
orientations. Typically, people choose one of these modes based on the individ-
ual differences and the conditions to be more adjusted, but everything is
imposed in the current conditions.
To consider Worden’s model during COVID19 pandemic, one should take
into account the practices that facilitate the acceptance of the loss. For example,
there has been a proverb in the culture of the participants that says “do not
believe the loss until you see the body of the deceased”. This phrase that is used
symbolically in areas other than grieving considers implicitly seeing the body of
the deceased to be the most obvious way of accepting the loss. However, in the
current conditions, this has been impossible for the survivors. In the field of
processing the pain of mourning, one of the participants referred to another
proverb that says “tomb bring coldness with itself”, indicating the importance of
symbolic rituals in easing the pain of the survivors which cannot be held in the
current condition. It appears that the pain is like a tangled web and cannot be
processed. Individuals need information and narrative to process an event and
adjust to it to be able to assimilate it. However, in conditions imposed on
interviewees, this information gap can be seen regarding the process gone
through by the deceased so that one of the survivors stated that “we only
heard the news that the father had died. . . but we did not believe it”. In other
words, when the acceptance and processing of grief encounter with such a con-
siderable obstacle, there cannot be a place for speaking about internal adjust-
ment and finding a connection with the deceased.
Mortazavi et al. 1103

In general, previous studies have shown that the presence of such factors as
the lack of readiness for death, high stress at the time of death, preventable
death, and poor perceived social support after death can be considered as pre-
dictors of unresolved and complicated grief (Lobb et al., 2010). According to the
results of the present study, it seems that all of the above-mentioned factors are
imposed on the survivors due to the limitations caused by COVID-19 pandemic
so that these limitations and death during this period can be considered as
factors contributing to complicated grief. Thus, it can be predicted that in the
coming years, there will be a large number of survivors with this style of griev-
ing. Another factor that is generally a predictor of unresolved grief and has been
seen during COVID-19 pandemic is stigmatized death, which usually occurs for
the survivors of people who have died by suicide (Doka, 2002). However, in the
current conditions, due to the contagious nature of the virus and others’ fear of
survivors, this issue also applies to survivors who suffer a loss that they cannot
express openly and are not socially supported.
As the coronavirus disease is a new one, a short time has passed, and it is not
ending or its ending cannot be predicted, there is a very little knowledge about
the psychological consequences associated with it. Given that we are currently
facing a global challenge, perhaps everyone is looking somehow for a solution to
prevent future consequences of this pandemic and try to facilitate relief, accep-
tance, and improvement of the psychological conditions. According to research,
methods such as writing stories about losing the loved ones on the Internet can
reduce the symptoms of people with unresolved grief and provide an opportu-
nity to express their emotions (Wagner et al., 2006). As the grieving process is a
highly individual experience, offering a variety of options such as online sup-
port, book therapy, personal counseling, group support, and psychoeducational
programs to provide information to individuals can also be helpful (Hall, 2014).
However, according to previous studies, routine preventive measures have not
generally received much support and have not been effective. Early preventive
measures can interfere with the natural grieving process and the therapeutic
measures can be useful only for people who have more complicated grief
(Schut & Stroebe, 2005). Therefore, it seems that the best option at the current
time is to provide as much social support as possible to the survivors, followed
by tolerating and providing a body of knowledge to understand this emerging
phenomenon for planning appropriately in the future for such people. In the
coming months, the generality of this pandemic and the prevalence of this style
of grieving can be used as an opportunity to inform about its consequences and
to manage it by forming small therapy groups or special help lines. Since
Coronavirus disease is an ongoing pandemic, it is not possible to fully under-
stand the effects of this loss and the impossibility of holding mourning rituals on
individuals’ life. Additionally, as the effects of grief, especially complicated grief,
on a person are manifested over time, it is needed to reconsider this issue in the
future. Due to the fact that the present research has been done in a country with
1104 OMEGA—Journal of Death and Dying 87(4)

a specific culture and religion, where special mourning rituals and the funeral
rites are of great importance, the generalizability of the results obtained is
decreased and it is necessary to better understand this phenomenon by conduct-
ing studies in countries with different cultural-religious contexts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding
author, upon reasonable request.

Ethical Considerations
The study was reviewed and approved by the ethics committee of the Iran University of
Medical Sciences (Ethical code: IR.IUMS.REC.1399.284). After explaining the purpose
of the research, those who signed informed consent participated in the research. They
were assured that the information would be confidential and the results of the research
would be published anonymously in a collective manner. Participants could leave the
research whenever they wished.

ORCID iD
Amirali Alimohammadi https://orcid.org/0000-0003-3119-3653

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Author Biographies
Seyede Salehe Mortazavi is an assistant professor of gerontology in the School
of Behavioral Sciences and Mental Health at Iran University of Medical
Sciences (IUMS). She holds a Ph.D. in gerontology and a master of public
health (MPH) and expert in charge of public health, community-based partic-
ipation, and qualitative research and methodology. Her areas of interest and
research are in the health-related issues of older adults and she published several
qualitative articles in this area. She has worked for over 5 years with Vice
Chancellor for Hygiene to support family health.

Nazanin Shahbazi holds a Master’s Degree in Clinical Psychology from Iran

University of Medical Sciences in Tehran, where she practices as a psychoana-
lytic psychotherapist. Her work focuses specifically on the psychoanalytic polit-
ical aspects, understanding the socio-economic origins of the psyche, examining
hegemonic psychodynamics in society, and the resonance of the hegemonic
discourses in the mental space of individuals. Her research interests include
psychopolitics, subjectivity and society, modern subjectivity, cultural studies,
discourse analysis, and psychosocial studies.
1108 OMEGA—Journal of Death and Dying 87(4)

Mozhgan Taban is a Ph.D. by research student in the Mental Health Research

Center at Iran University of Medical Sciences (IUMS). She holds a master of
clinical psychology. Her areas of interest and research are in the mental health
and she published several articles in this area. She has worked for over 10 years
with mental health research center for community-based researches in mental
health.

Amirali Alimohammadi holds a Master’s Degree in Clinical Psychology from

Iran University of Medical Sciences Sciences in Tehran, where he practices as
a psychoanalytic psychotherapist. His research interests include cultural studies,
the psychology of economic transformation, the relation between subjectivity
and modernity, self in differing cultural contexts, discourse analysis, and media
studies.

Mohsen Shati is an assistant professor of Epidemiology in Mental Health

Research Center at Iran University of Medical Sciences (IUMS). He holds a
Ph.D. in Epidemiology and a Master of public health (MPH) after graduating
from school of Medicine as a GP (general practitioner). His areas of interest and
research are Monitoring and evaluation in health care system, Design & analysis
of clinical trials and health-related issues of older adults.