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Death Anxiety: Paralysis or Provocation?
Senior Project Thesis
By
Michaela Dachovská
Submitted in Partial Fulfillment off the Requirements for the degree of Bachelor of Arts In Psychology
State University of New York Empire State College 2021
Reader: Ronnie Mather, Ph.D. 2
Statutory Declaration / Čestné prohlášení
I, Michaela Dachovská, declare that the paper entitled:
Death Anxiety: Paralysis or Provocation? was written by myself independently, using the sources and information listed in the list of references. I am aware that my work will be published in accordance with § 47b of Act No. 111/1998 Coll., On Higher Education Institutions, as amended, and in accordance with the valid publication guidelines for university graduate theses.
Prohlašuji, že jsem tuto práci vypracoval/a samostatně s použitím uvedené literatury a zdrojů informací. Jsem vědom/a, že moje práce bude zveřejněna v souladu s § 47b zákona č. 111/1998 Sb., o vysokých školách ve znění pozdějších předpisů, a v souladu s platnou Směrnicí o zveřejňování vysokoškolských závěrečných prací.
In Prague, 10. 4. 2021 Michaela Dachovská
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Acknowledgment
I would like to thank my parents for providing me with the opportunity to educate myself.
Especially I thank my mum who was patiently willing to debate my bachelor topic with me.
Also, my gratitude belongs to my mentor, Ronnie Mather, for answering my doubts and his guidance throughout the thesis project.
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Table of Contents
Table of contents 4 Abstract 5 Introduction 6 1. What is death anxiety? 1.1 Death anxiety 7 1.2 Modern advancements: modern age of unnatural dying and greater fear 11 1.3 Negative connotation of death 12 1.4 Death as a subject of avoidance 12 1.5 Defense mechanisms to escape death anxiety 14 1.6 Awakening experience and terminally ill patients 15 1.7 Can death anxiety be eliminated? 17 1.8 Death as meaningful 19 1.9 Quality of life and death anxiety 20 1.10 Perception of death across an individual’s lifespan 21 1.11 Investigating fear of death 23 2. How does death anxiety interact with other psychopathologies? 2.1 The concept of death anxiety in therapeutic intervention 24 2.2 Clinical aspect of death anxiety 26 2.2.1 Death anxiety and psychological conditions 28 2.2.2 Perception and attitude toward death as determinants of pathological behavior 30 2.2.3 Concluding remarks on death anxiety and psychopathology 31 3. How does existential psychology deal with death anxiety? 3.1 Existential questions 32 3.2 Logotherapy 35 3.3 Frankl’s ideology 3.3.1 Holocaust survivors 39 3.3.2 Meaning and suffering 40 3.3.3 Meaninglessness as existential vacuum 43 3.3.4 Spiritual construct 48 3.4 Applicability of logotherapy 49 Conclusion 51 References 54
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Abstract
The paper presents a review and analysis of theoretical and research studies on death anxiety. The paper outlines the modern phenomenon of death avoidance, aspects of death anxiety, and the main conceptualizations of death anxiety. The paper treats death as the root cause of anxiety in humans and traces its interaction with psychopathologies, and examines the possibility of regarding death as a constructive occurrence. The main focus is on a positive conceptualization of the inevitability of death. The primary intention of the study is to depict the theme of death within the context of existential psychology. The study aims to highlight the importance of human meaning that can be provoked by meaning therapy, logotherapy, and how they can assist a more authentic meaningful life despite death awareness.
The inevitability of death can be regarded as one of the greatest existential concerns, an individual can become paralyzed, or develop a maladaptive psychopathological behavior, because of death anxiety depending on the perception of death and discovery of meaning during the life-course. Meaning can play an integral role in the provocation of humans to embrace their own authenticity through discovering meaning in the absurdity of a life undoubtedly leading toward death. Lastly, the present study raises awareness of the importance of discussing existential givens, including death, with a positive outlook guided by Viktor’s Frankl logotherapy. Death will not be repealed by being removed from consciousness, rather death anxiety can only be ameliorated with the revelation of meaning in finitude.
Key words: death anxiety, defense mechanism, pathology, existential, meaning, logotherapy
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Introduction
The theme of this study the taboo of death in modern civilization. Death and dying is not accepted as an integral part of human life, human nature (Rodin & Zimmermann, 2008).
Although people do not accept death through a real awareness of their mortality, they fear death, and the anxiety stemming from the inevitability of death is ubiquitous. This phenomenon can be summarized as follows:
one must avoid-no longer for the sake of the dying person, but for society's sake, for
the sake of those close to the dying person-the disturbance and the overly strong and
unbearable emotion caused by the ugliness of dying and by the very presence of death
in the midst of a happy life, for it is henceforth given that life is always happy or should
always seem to be so. (Aries, 1976, p. 87)
Several explanations can be provided in explaining the human tendency to discard the topic of death including resistance to death, avoidance of death inevitability or simply feeling anxious when thinking about mortality. “It is well recognized that denial, or perhaps more accurately, suppression and psychological defense mechanisms mark the orientation of
Western culture toward death” (Byock, 2002, p. 280).
It cannot be said that the perception of death and dying nowadays is worse or better than in the past. As stated in On Death and Dying “death has always been distasteful to man and will probably always be” (Kübler-Ross, 2013, p.16). However, the displacement of dying can reveal more about our society than people admit. That the absence of thinking about death and dying leads to a taboo, which further causes societal alienation (Jacobsen, 2020).
According to existentialists, humans tend to unconsciously think of themselves as immortal, thereby renouncing responsibility for their actions (Mollinger, 1982; Spillers, 2007). 7
The goal of this study is to investigate how logotherapy and existential psychology address existential themes including the inevitability of death and its being the primary existential concern. In particular, the study examines how logotherapy, the quest for meaning, can facilitate human life despite the consciousness of the inevitability of death existing alongside. Psychology commonly discusses death anxiety as a negative phenomenon. Most recently, as Terror Management Theory. It omits the other side of understanding death as a provocation to finding meaning in life and authentic being (Tomer et al., 2007). Awareness of death can be seen as a critical situation where the individual’s worldview changes, where one is confronted with one’s own death. There can be a shift to a higher state of being, and the acquisition of depth and seriousness of life; or, alternatively, death can be the primary source of anxiety.
In summation, we can perceive death as a threat to the meaningfulness of existence, or, conversely, death as a provocation to live an authentic life; death as pervasive and debilitating as seen by TMT, or as a provocation to attain meaning in spite of finitude.
Chapter 1: What is death anxiety?
1.1 Death anxiety
Becker’s existential view of death regards death anxiety as deeply embedded in the human psyche (Solomon et al., 2000) and that humans are constantly afraid of death (Temple
& Gall, 2018). In other words, the fear of death is permanently present in the psyche. This has been proposed by many philosophers such as Epicurus who said that the fear of death is omnipresent (Yalom, 2010). “We live with death, we think about death, we- even when we do not know it- prepare for death, and we thus constantly live our lives towards death and in the valley of the shadow of death” (Jacobsen, 2020, p. 7). Terror management theory, based on 8
Becker’s ideas (Maxfield et al., 2014) suggests that even though animals fear death, death anxiety is specific to humans because their capacity for self-awareness creates existential fears
(Greenberg et al., 2004). Further, fear of death is comprehended as an adaptation mechanism focused on self-preservation and survival (Pyszczynski, 2004). The will to live and fear of death are complementary in nature (Osborne, 2017); “fear of death is only the obverse of the love of life and together they constitute the struggle to survive” (Hall, 1915, p.550). In this sense, humans strive to assure their survival in the most vital form they possibly can as they are equipped with the will to live.
It has been confirmed by numerous studies that reminders of mortality can cause anxiety and negatively affect subjective well-being (Alexander et al., 1957). Routledge et al.
(2010) conducted many studies on mortality salience and their general finding was that high mortality awareness leads to lowered life satisfaction. When mortality reminders are present, and for a longer period of time, it can subvert life satisfaction (Routledge et al., 2010). Further, their results suggested that it negatively impacts an individual’s adjustment, and that death awareness can be “problematic for psychological functioning” in general (Routledge et al.,
2010, p. 911). Humans feel threatened by death reminders such as seeing a dead body in a picture due to an emotional memory that can anticipate threats (Lehto & Stein, 2009).
According to terror management theory, death thoughts are mostly situated in the unconscious (Hayes et al., 2010). This can be referred to as the distal or symbolic defense where death reminders do not interfere with the conscious mind directly (Bassett, 2007;
Maxfield et al., 2014; Neimeyer et al., 2004). In the distal defense, humans have the urge to stand up for their own worldview and commit to groups, and eliminate potential threats that challenge their commitment (Bassett, 2017; Iverach et al., 2014; Tomer et al., 2007). Becker emphasized that humans need society to alleviate their fears as humans are naturally social animals (Becker, 1985). They need to belong to social groups of shared values including family 9 or religious community (Juhl & Routledge, 2014). Therefore, society and culture play crucial roles in living with the fear of death (Maxfield et al., 2014). Becker states that humans need this platform to make themselves immortal, to conform and obey transference objects embodied in the power of social relationships and belonging, so as to preserve their social self- esteem (Becker, 1985; Iverach et al., 2014). Lehto & Stein (2019) also identified culture as being one of the main defenses against death anxiety, “cultural protection is manifested symbolically in a blend of learned and shared meanings and beliefs, many of which originate in conventional religious dogma and ritual” (Lehto & Stein, 2009, p. 29).
Similarly, as belongingness via culture eliminates mortality salience in humans, self- esteem can also be seen as a pivotal instrument in dealing with death anxiety (Bassett, 2007;
Florian et al., 2001; Maxfield et al., 2014; Routledge et al., 2010; Solomon et al., 2000; Tomer et al., 2007). Humans need self-esteem because they are conscious of “the anticipatory anxiety about death” (Kesebir, 2014). Becker states that mortality causes vulnerability in humans, and such vulnerability prevents humans from embracing their own mortality “if you feel vulnerable it is because you feel bad and inferior, not big or strong enough to face up to the terrors of the universe” (Becker, 1985, p. 180). Self-esteem provides humans with a decrease in vulnerability and “belief that one is living up to standards of value prescribed by the cultural worldview”
(Greenberg, 1994, p. 627). The function of self-esteem is to provide humans with the insight that they are meaningful in and for the world and that when they die, they will not be forgotten
(Iverach et al., 2014; Routledge, 2010). This idea is conveyed in the symbolic immortality that can be attained “by perceiving oneself as part of a culture that endures beyond one’s lifetime, or by creating visible testaments to one’s existence” (Greenberg et al., 2004, p. 18). Humans can create visible symbolic testaments to one’s existence through making arts, living religiously, or having children (Greenberg et al., 2004) as proposed by Lifton (Yalom, 1980). 10
Research has shown that individuals with high self-esteem report being less anxious when reminded of death (Florian et al., 2001). In addition, it has been found that individuals were inclined to conform to their culture when reminded of death (Greenberg, 1994). Research shows that mortality salience worsens individual adjustment while self-esteem helps resist it
(Routledge et al., 2010). People are less anxious about death when they are perceived as powerful since it provides them with a feeling of psychological security, high self-esteem, and an impression of lower vulnerability (Belmi & Pfeffer, 2016). Becker states that defense mechanisms, in the form of culture and self-esteem, are necessary for self-preservation because
“the fear of death cannot be present constantly in one’s mental functioning, else the organism could not function” (Becker, 1985, p. 16). This argument is consistent with the contemporary viewpoint that society does not provide enough space for humans to be persistently “paralysed or stifled by the fear of death” (Jacobsen, 2020, p. 7). Ultimately, it is culture and self-esteem in the terror management theory which constitute the building blocks of meaning in human life
(Feldman & Snyder, 2005).
Moreover, terror management theory believes that death reminders are not always outside of human consciousness, they can enter into conscious awareness. In such cases, death reminders are present in focal attention, but they are moved out of the conscious mind
(Maxfield et al., 2014; Pyszczynski et al., 1999). In such scenarios, humans use the other defense mechanism from the dual-process model (Tomer et al., 2007), called the proximal defense that embodies defenses such as denial, rationalization, or suppression (Neimeyer et al.,
2004). An example can be adapting to the consciousness of one’s mortality by refusing to acknowledge danger factors of premature death (Pyszczynski et al., 1999).
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1.2 Modern advancements: modern age of unnatural dying and greater fear
“The old attitude in which death was both familiar and near, evoking no great fear or awe,
offers too marked a contrast to ours, where death is so frightful that we dare not utter its
name” (Aries, 1976, p.13).
Humans learned to master death not only by coping mechanisms, using euphemisms or ridicule, but also more extensively in the field of science and medicine. It seems that because people cannot accept the reality of finitude, they instead devote their efforts and beliefs in inventing the means to keep themselves alive at all costs via the advancement of medicine.
This can be counterproductive to the acceptance of death as “the more [humans] are making advancements in science, the more [they] seem to fear and deny the reality of death” (Kübler-
Ross, 2003, p. 21). It can be said that technological developments provoke death denial in people since medicine nowadays is capable of curing many diseases, and prolongs life successfully (Rich, 2014). In this regard, people are convinced that “all diseases may be cured and all lives prolonged” (Zimmermann & Rodin, 2004, p. 127). Nowadays, the death of a patient is perceived as a failure of medicine, rather than an expected occurrence in human life
(Kaut, 2002; Sleeman, 2013).
Due to these technological advancements, the meaning of death and dying cannot remain the same over time because “suffering has lost its meaning” (Kübler-Ross, 2003, p. 29).
Fewer people are dying at home (Ariés, 1976; Gomes & Higginson, 2008; Šiklová, 2013). The availability of palliative care removes dying from the domestic (Kübler-Ross, 2003). Since humans do not observe their relatives dying at home, they might perceive death indifferently, as they lack the opportunity to develop appropriate defense strategies to deal with death when it interferes with their reality (Kübler-Ross, 2013). When death and dying take place in the privacy of hospitals, humans start to perceive death as something beyond the norm, something 12 that does not happen in ordinary daily life. For these reasons, Kübler-Ross and many other experts working with the terminally ill would agree with the thought that “curative medicine is death denying” (Zimmermann & Rodin, 2004, p.124). That death is depersonalized due to the medicalisation of death is now a commonly shared argument (Byock, 2002; Connor, 1998;
Jacobsen, 2000; Kübler-Ross, 2003).
1.3 Negative connotation of death, death is mischievous
Historically, evil has been affiliated with death, while good and innocence has been associated with eternal life (Hall, 1915). There is evidence that people have difficulties speaking about death and dying honestly and openly. In particular, language usually provides more socially acceptable words for death that do not evoke such negative reaction and subdue the negative connotation attached to the word death itself. Rawlings et al. (2017) refers to the expression “gone” or “gone to heaven” instead of simply saying that someone has died.
Kirshbaum et al. (2011) reported that individuals rarely used the words “death” or “dying” and replaced these words with “passing away.”
Death is often seen as related to guilt or anger. Mostly, humans are unable to perceive death as natural because “in the unconscious mind [one] can only be killed; it is inconceivable to die of a natural cause or of old age” (Kübler-Ross, 2013, p. 16). Moreover, Razinsky (2010) presents a similar idea that death is external to human perception since external circumstances are responsible for death. For this reason, humans affiliate mortality with mischievous acts and punishment.
1.4 Death as a subject of avoidance
In the book Staring at the sun: Overcoming the terror of death, Yalom draws a parallel between staring at the sun and facing the awareness of one’s mortality as both are subjects of avoidance. Moreover, Yalom proposes death anxiety as a fundamental determinant of other 13 psychological trauma (Yalom, 2010). Freud also identified death anxiety to be the root cause of anxiety in humans (Byock, 2002).
Yalom believes that death anxiety stems from human awareness of the finitude of life and their desire to live forever, as these two ideas are incompatible and essentially refute each other. This results in a cognitive discrepancy that can be threatening to humans because of its inconsistency with their other cognitive structures (Lehto & Stein, 2009). More precisely the conflict between death and life is intimidatory, due to its ambiguous and illogical nature it goes against the human need for order. Referring to the cognitive attribute of death anxiety, “death anxiety is viewed as a multidimensional cognitive construct that stems from attitudes toward death that exist as part of cognitive structure” (Lehto & Stein, 2009, p. 26). Dimensions of the cognitive construct involve thinking about being dead, or speculation on what will happen after death. Schopenhauer stated that humans are not anxious due to the fact that they missed their existence before birth but feel trapped with the idea that they will not be here after death
(Liessmann & Zenaty, 1994; Schopenhauer, 2014). This observation is also shared by Byock, it is “less anxiety provoking to contemplate nonexistence before one’s conception and birth than after one’s death” (Byock, 2002, p. 279).
Yalom acknowledges the notion that all humans apprehend death differently. The same is true that coping with mortality is individual (Temple & Gall, 2018). Nevertheless, Yalom assumes the presence of fatality unavoidably impacts all individuals:
for some of us the fear of death manifests only indirectly, either as generalized unrest
or masqueraded as another psychological symptom; other individuals experience an
explicit and conscious stream of anxiety about death; and for some of us the fear of
death erupts into terror that negates all happiness and fulfillment. (Yalom, 2010, p. 7)
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1.5 Defense mechanisms to escape death anxiety
“Denial, fear, and ambivalence are among the most frequently advanced interpretations of individual and sociocultural orientations toward death” (Kastenbaum & Costa, 1977, p. 229).
Since humans are unable to embrace the awareness of mortality, they incline to confront the fear of death by using several defense mechanisms that help the psyche to suppress negative thoughts connected to death (Osborne, 2017; Yalom, 2002; Yalom, 2010). These make life meaningful (Wolson, 2005). The simplest way is to deny death because it reduces all uncertainties promoting stability and order: “Intrapsychic stability requires that we transcend death- make it a non-issue, live forever” (Strachan et al., 2001, p.11). Moreover, for the purpose of suppressing death anxiety, humans invented a rational means of dealing with the existence of death in a comforting manner such as religion and beliefs in post-death existence. All such comforting rational explanations have the same connection “fear of death and the desire for eternal life” (Sheets- Johnstone, 2003, p. 245). As proposed by Yalom, humans seek an
“ultimate rescuer” such as God who would exempt them from the matter of death (Tomer et al., 2007).
Additionally, Elgee (2003) talks about the evolutionary purpose of humor when humans laugh at the irony of death and simultaneously feel invulnerable and superior to others as a buffering system. However, humans should face the cruelty of death without rational explanations because constant repression deteriorates the quality of living (Osborne, 2017;
Yalom, 2010).
Similarly, dealing with death anxiety should not begin with denying or suppressing death thoughts, but with efforts to suppress the economic mode of life based on ownership and focus on the mode of being, the religious mode. For this reason, more pronounced death anxiety can be observed among individuals oriented toward hedonism and consumerism. Research by 15
Arndt et al. (2004) shows that consumerism can function as a defense mechanism to foster one’s self-esteem in the fight against death as proposed by the terror management theory.
Nevertheless, research by Maxfield et al. (2014) reveals that the orientation toward wealth for the purpose of symbolic immortality is a culture-specific phenomenon. Specifically, cultures oriented toward spirituality sustain self-esteem through means such as modesty or inner stability rather than material sources.
The image of death is often ridiculed for the purpose of defending oneself against the fear of death and its horror. Humans instinctively forget or turn objects of fear into ridiculous and insignificant ones, however deep inside the fear of death cannot be diminished (Osborne,
2017). Defense mechanisms can work as provisional relief to humans that operate on a pseudo- rational basis, however, ultimately defense systems are detrimental (Greenberg et al., 2004;
Mandic, 2008). Specifically, using defense mechanisms is seen as counterproductive in accepting death and preparing for it (Byock, 1998).
1.6 Awakening experience and terminally-ill patients
The constant repression of death inevitability can cause a shock when facing death in reality as one is not mentally reconciled with the fact that death is not only a conceptual phenomenon but can arrive unannounced and unexpectedly. This can be observed in patients suffering from severe illness in palliative care. Illness and closeness to death or confrontation with the death of a loved one, makes people prepare for death and simultaneously initiates their personal growth (Byock, 2002). The dying of a family member is not only an important moment for loved ones when they experience the closure of one human story, but also a process of transformation when people are reminded of their loneliness when their loved ones disappear
(Osborne, 2017). Witnessing the end of life can be a moment that, if handled properly, changes, or modifies one’s current values. The closeness of death brings existential questions about 16 one’s identity or meaning of life: “Forced to live with knowledge of impending death, such questions assume poignant relevance” (Byock, 2002, p. 282).
Many times, the change of the patient’s outlook on death and life is evident (Byock,
1998). Precisely, changing perspective on life due to the existence of death can assign death a transformative aptitude (Tomer et al., 2007). When an individual gets closer to death it is a moment of change when death is finally taken seriously yet obscurely. The moment of change is described as an awakening experience when one’s experience of terminal illness can awaken the realization of the ontological meaning of life and death that was hidden in the everyday mode before the illness (Yalom, 2010). In other words, “in the face of possible loss and annihilation, life takes on new value” (Greenberg et al., 2004, p. 133). Kinnier et al. (2001) conducted a study interviewing individuals who survived extreme life-threatening situations and asked them how they benefitted from the confrontation with death. Questions included topics such as the meaning of life, priorities, or relationships with others. Most participants talked about a lower materialistic focus and a more intense inner spiritual life and better relations with others. Therefore, it can be said that individuals aware of death not only as a distant possibility but as a relatively close fact, live their life more intensely (Šiklová, 2013).
Research findings concerning lower death anxiety in terminally ill patients might be explained by death denial (Iverach et al., 2014). In other words, terminally ill patients might seem that they are reconciled and aware of approaching death, but in fact they are still in a state of denial. Studies indicate that mortality salience increases when an individual’s physical health is at risk (Saleem, 2015). This is not surprizing as an individual has an evident rational reason to fear death because his life is endangered since poor health can lead to death. In other words, sickness can function as a reminder of our own mortality (Lehto & Stein, 2009). Additionally, other stressful circumstances tied to the diagnosis of a physical illness can contribute to increased death anxiety such as uncertainty about how family members handle the death or 17 cope financially after death (Kaut, 2002; Lehto & Stein, 2009). All of these stressful factors that terminally ill individuals might encounter lead to greater death anxiety (Safdar & Rahman,
2016). Therefore, several studies support the connection between physical health and death anxiety particularly in the sense that an unsatisfactory state of health relates to higher death anxiety while a good state of health repeatedly relates to lower death anxiety (Iverach et al.,
2014, Saleem, 2015).
1.7 Can death anxiety be eliminated?
Despite the many defense mechanisms which humans have adopted, the escape from death can only be possible if humans reject a materialistic way of life and enfold authenticity and responsibility (Osborne, 2017). However, this can be problematic for humanity nowadays because modern man is predominantly inclining to disregard values and is focused on external aspects of life (Kundera, 1999). Another way to eliminate death anxiety would be to acknowledge that death does not arrive to punish us but rather fulfills an indispensable role.
“The fact that I must die should not strike me as tragic or unendurable. I should be able to come to terms with the fact that my life is concluding” (Hardwig, 2009, p. 39). In other words, people should discontinue considering death as “disquieting and greedy” (Aries, p. 56).
The prime direction to conquer death anxiety would be indeed acceptance:
Since death is inevitable, accepting it might be the best we can do. Not only do we
thereby avoid the anxiety associated with fear, but we would probably be in such
circumstances best able to provide and prepare for death. (Ray & Najman, 1975, p. 311)
Acceptance can be possible if humans stop using defense mechanisms such as forms of immortality ideologies. Heidegger proposes that humans let themselves be confronted by the finitude of life through withholding immortality ideologies that conceal the existence of death and uncertainty regarding death (Sheets-Johnstone, 2003). Several research studies reveal that 18 individuals not accepting the fact of their mortality suffer from stronger fear related to death and dying (Neimeyer, et al., 2004). Nevertheless, Ray & Najman (1975) indicated that individuals seemingly accepting death are also afraid of death and dying. For this reason, acceptance of death might not ultimately expel the unceasing fear of death.
The last identified suggestion would be open communication about death and dying.
Many contemporary scholars working in mortality studies believe that it is healthy to talk about death because people generally incline to fear unfamiliar topics (Šiklová, 2013). As with other psychological problems, it is found to be therapeutically helpful when people can discuss and share with each other their concerns and doubts including fears connected with death and dying
(Šiklová, 2013). Sleeman (2013) mentions that communicating clearly and openly without euphemisms about death with terminally ill patients is more beneficial for their psychological state than avoiding the topic or providing them with false hope.
Research claims that avoidance and insufficient communication about death and dying in patients further increases suffering and anxiety (Kirshbaum et al., 2011). Also, Buetow
(2009) regarding palliative care remarks that “discussing existential threats may lessen feelings of isolation” (p. 112). A qualitative study by Testoni et al. (2020) focused on educating young people about death revealed positive changes regarding students’ view on death after talking about such existential concerns with psychologists and religious authorities. Specifically, students admitted that discussing death provided them with alleviated fear of death and the prospect of death as an opportunity to reflect upon their own life. Moreover, students said that the acknowledgment of death inevitability provoked them to be more empathetic towards others because death affects everyone.
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1.8 Death as meaningful
“Death does not give meaning to life, but does provide the backdrop against which life is
lived” (Byock, 2002, p. 287).
The fact that the horror of death can bring valuable awareness in humans, Yalom and others suppose that life and death are interdependent because sufficient preparation for the life of self-aware individuals also involves preparation and acceptance of the end of life (Yalom,
1980; Wong, 2011). This unfolds the philosophical interpretation that even though physical death destroys individuals, their outer case of the body, the idea of death can rescue humans as it forces them to take life seriously and embrace own authenticity. Heidegger also assumes that awareness of death can move individuals from everyday unauthentic superficial living to a deeper way of being, the ontological mode of being (Heidegger, 1962; Tomer et al., 2007).
Further, this idea is shared by Emmy Van Duerzen- Smith (1997) who commented on the fierce human effort to forget death despite the fact humans need to be reminded of the end as it can be the substantial motive for living “[humans] flee from death through all the everyday things that [they] do and fail to notice that death is [their] greatest potential” (Van Deurzen-
Smith, 1997, p.41). Yalom argues that death anxiety holds its importance for human life because it provokes humans to ponder the question of meaningfulness in life. Similarly, Frankl often wrote about the positive side of concentration camps that in his eyes resembled an opportunity to find a sense of suffering and eventually the value of life (Frankl, 1992).
For these reasons, death anxiety can be seen as highly motivational for people. In a theoretical study on death anxiety, Lehto & Stein (2009) incorporated source of motivation as an attribute of death anxiety. They mention that the existence of death anxiety among people can be the main responsible factor for productivity including artwork, supportive behavior to others, affiliation in groups, maintenance of romantic relationships, or improvement in self- 20 esteem. Another study by Bassett (2007) suggests that reminders of death and mortality salience motivate individuals to maintain their self-esteem and form interpersonal relationships. In particular, a study by Belmi & Pfeffer (2016) found out that priming mortality salience provoked participants to preoccupy themselves with prosocial behavior.
Therefore, the fidelity of transient life is not only an essential feature of the human life cycle but also constitutive of its meaning.
1.9 Quality of life and death anxiety
Discussing the idea of interdependency between life and death, it can be assumed that the quality of life predetermines the way of dying. A thorough example of this claim can be the character of Ivan Ilyich in the book The Death of Ivan Ilyich by Tolstoy in which the character of an unjust bureaucrat experiences desolate dying since his life was miserable (Yalom, 2002).
Several studies show that an individual who regards his life as meaningless has often greater death anxiety, because he is aware that there are many things he should have done (Safdar &
Rahman, 2016). Such a miserable evaluation of one’s life does not lead to a meaningful death.
Because of this, humans need to have a pragmatic attitude toward death, meaning that they should perceive death as the goal of a spiritual person.
Death anxiety obviously applies to the subject of spirituality. Several research studies show that death is associated with life satisfaction and spirituality to achieve quality of life
(Neimeyer et al., 2004). In particular, spirituality has a positive effect on psychological health
(Schulenberg, 2008). When an individual undergoes situations in life when his autonomy over life is threatened, it is faith and hope that challenge the person to find meaning behind it (Kaut,
2002; Koenig, 2010). Having a spiritual attitude can equip individuals with important themes and resources that help them fight the concept of death, those themes being: “response to 21 mystery, connection to something larger than oneself which endures into an open-ended future, and an experienced source of meaning” (Byock, 2002, p. 282).
1.10 Perception of death across an individual’s lifespan
Studies show that the perception of death and coping strategies differ among the young, adults, and elderly (Maxfield et al., 2014). This is mainly due to the developmental attribute of death anxiety involving developmental stages prototypical for different periods of an individual’s lifespan (Lehto & Stein, 2009). In this way, the developmental stage determines conflicts an individual encounters, and a given standpoint toward death and dying that can vary across the lifespan. While adults are concerned with death and dying, children do not understand death (Kastenbaum & Costa, 1977). Until a certain age, death is overly imaginary for children to rationally comprehend death. They have no grounded sense of time and in their understanding, death is a temporary (Mollinger, 1982) and reversible occurrence (Koocher,
1974; Yalom, 2010).
The subject of death concerns children the most when they lose their sense of safety and assurance because they do not get answers to fundamental questions. Parents protect children from death, which, however, inevitably belongs to life (Yalom, 2010). Kastenbaum &
Costa (1977) further explain the intention of people to keep children away from the death subject, a “child is presumed an innocent in both the realms of death and sexuality and is to be kept in that blessed state as long as possible” (p. 228). For this reason, sexuality and death are often placed under the same category of avoidance as both are considered inappropriate and undignified topics for conversation (Bassett, 2007). Nonetheless, this protective measure of death denial can burden the natural healthy acceptance of life finitude in children as “silence teaches them only that the topic is taboo” (Koocher, 1974, p. 410). Instead of this avoidance, 22 it is more desirable to delve into the child’s ideas and be responsive to them rather than “to allow magical or unspoken fears to play upon a child’s imagination” (Koocher, 1974, p. 410).
Regarding the perception of death among the elderly, it is noted that advancing age enables older people to “accommodate themselves to finitude” (Kastenbaum & Costa, 1977), most likely due to wisdom that can facilitate death preparedness (Ardelt, 2000). Similarly, the research by Neimeyer et al. (2004) mentions that several studies have consistent results that anxiety decreases over adulthood. More precisely, that anxiety decreases from midlife in which death anxiety is higher compared to older ages (Cicirelli, 2006; Lehto & Stein, 2009). Several studies were conducted to examine the discrepancy in mortality salience among the young and elderly. The study by Sinoff (2017) reported that young participants had significantly higher death anxiety compared to elderly participants. The study considers that acceptance of death in the elderly induces lower anxiety, even though older individuals are exposed to more frequent death reminders compared to younger individuals. In this sense, the study does not prove the power of mortality salience hypothesizing that individuals reminded of death fear death more.
Also, the study found out that elderly participants were more afraid of the dying process rather than the subject of death itself (Sinoff, 2017). Nevertheless, some studies call attention to the impact of both the physical and mental state of the elderly. These studies propose the idea that old people suffering physically and emotionally experience higher death anxiety (Fortner &
Neimeyer, 1999; Lehto & Stein, 2009; Osborne, 2017).
Awareness of death among the elderly can be a stimulus for trying to leave something behind after one dies. Hegel argued that the record of history is indirectly a defense against death on both an individual and collective level (Šiklová, 2013). It is an effort by an individual to preserve what he remembers, as well as his conception of the world and society. Referring to the developmental theory, Erikson identified a developmental phase in which older adults either reach generativity or stagnation (Erikson, 1959; Major et al., 2016). This phase of the 23 life cycle when generativity is achieved describes the interest of people to become less selfish and rather care for others and hope for the next generations. Moreover, the older individuals in the last development stage often evaluate their entire life via the retrospective search for meaning in things they have lived for (Erikson, 1959; Šiklová, 2013). For this reason, Osborne
(2017) mentions that retirement can be a critical episode that can potentially influence how death anxiety alters individuals’ identity and life meaning.
1.11 Investigating fear of death
When examining the fear of death in current research, it is important to recognize that fear of death can encompass various forms of fear. Humans can fear death as an abstract event that is awaiting them one day (“being afraid of death”), or the form of fear can be more concrete, such as fear from the process of dying itself due to uncertainty if death is accompanied by pain and suffering (Collet & Lester, 1969; Tomer et al., 2007). Other dimensions of death anxiety include fear of the unknown, fear of conscious death, or fear of premature death
(Benton et al., 2007; Hoelter, 1979). The term death often connects to anxiety, the fear of death further to the fear of pain, suffering, loss of human dignity, fear of loneliness, abandonment, or fear of the unknown (Greenberg et al., 2004; Šiklová, 2013; Tomer et al., 2007). Moreover, fear of death can have a different impact when one distinguishes our own death from the death of others (Collet & Lester, 1969; Hoelter, 1979; Tomer et al., 2007). Greenberg et al. (1994) suggests that even though respondents react more to reminders of their own death, assigning them the task to imagine the death of their loved one also causes strong anxiety, and simultaneously the reminder of other person’s death reminds them of their own mortality.
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Chapter 2: How does death anxiety interact with other psychopathologies?
2.1 The concept of death anxiety in therapeutic intervention
As already mentioned, death thoughts intermingle with many other psychological problems of human mental health and often arise in psychotherapy (Yalom, 2002). Even though the inevitability of death is the major human anxiety, it is neglected in the field of psychology
(Sthalekar, 2000). This reality can be seen in the practice of psychological intervention where clients unconsciously express their suppressed angst regarding death which creates a delicate task for the psychologist to uncover (Osborne, 2017; Temple & Gall, 2018). The reluctance to talk about death directly is also linked to the grief and mourning process (Aries, 1976; Šiklová,
2013). Many times, people encounter difficulties in letting their grief surface and admit their inner sadness. In therapeutic settings, many individuals have experienced the death of a loved one but have not mourned sufficiently, contemporary society does not allow it and sadness is considered a weakness. However, displacing grief can lead to depression as well as pathological avoidance of death as such (Šiklová, 2013).
In The Gift of Therapy Yalom discusses that even though death is an ongoing issue for all clients, and relates to anxiety in general, it is uncommon to uncover the topic of death in psychotherapeutic sessions. The major reason for therapists to avoid the topic of death is because it seems inconvenient to most therapists to bring up such an anxiety-provoking subject in the presence of clients with other anxieties (Yalom, 2002). Moreover, death is avoided because psychologists themselves encounter death anxiety (Birgit et al., 2018). For this reason,
Yalom emphasizes that therapists should endure this difficult and talk about death at a personal level (Temple & Gall, 2018). Yalom mentions that leading a therapeutic group with many oncological patients showed him the importance of facing death issues in the field of psychotherapy (Yalom, 1980). 25
Although the fear of death is natural, people are reluctant to admit they are afraid of dying because it seems to be a weakness to confess their fear of death (Jacobsen, 2020).
Therefore, the human susceptibility to keep quiet about the subject of death being avoided in the psychotherapeutic setting and interpersonal dialogue in general (Šiklová, 2013).
Nevertheless, Yalom dislikes the avoidance of topics related to death and dying because he promotes the importance of working with death thoughts in psychotherapy. Yalom even acknowledges that it is absurd to not include the death topic in therapy because the life of the patient is discussed to which death inevitably belongs (Yalom, 2002). Existential therapy is said to be grounded on “human confrontation with the fundamentals of existence” (Greenberg et al., 2004, p.6). Therefore, clients should be asked about their view on some major existential themes such as finitude, isolation, freedom, or the meaning of life (Greenberg et al., 2004;
Iverach et al., 2014; Yalom, 2002; Yalom, 2010), as these existential themes are interrelated
(Tomer et al., 2007). It is crucial to mention that the problem of death is important in all types of therapeutic intervention beyond existential therapy.
Yalom believes that death anxiety is present in the unconscious mind of individuals in the form of dreams-nightmares (Yalom, 2012) which makes death anxiety hidden (Osborne,
2017). In this sense, clients tend to talk about death via mentioning subjects related to death embodied in dreams, or commenting on their wrinkles for instance (Sthalekar, 2000). The human relationship to death, anxiety, defense mechanisms, images of death in nightmares, the symbolic meaning that death has in the eyes of the individual- all this affects the perception and experience of living by the individual (Temple & Gall, 2018). In other words, how humans respond to the notion of their own mortality determines how they live (Wong, 2011). In this sense, existential therapy does not aim to completely eliminate death anxiety but reduce it to a bearable threshold. The main goal of the therapist is to reduce anxiety in an individual to an 26 acceptable level and then use that existing anxiety to raise awareness of meaning in life (Yalom,
1980).
2.2 Clinical aspect of death anxiety
Death anxiety is a multidisciplinary concept that views death from various fields including psychology, psychiatry, sociology, theology, or anthropology (Šiklová, 2013).
Psychology remains inconclusive when it comes to interpreting death anxiety as psychopathological versus psychologically normal (Tomer et al., 2007). Death anxiety can be described as “significant psychological distress in the form of anxiety about one’s death that contributes to functional impairment in one’s life” (Engelmann et al., 2016, p. 582-583).
However, there are other definitions of death anxiety suggesting that it can be considered a normal human fear that might not necessarily impair one’s life (Lehto & Stein, 2009), despite the fact it does affect individuals even if death anxiety is experienced unconsciously (Iverach et al., 2014). Referring to the distinction between normal death anxiety versus pathological death anxiety, it is convenient to mention Freud and his two types of anxiety. The first type of anxiety involves a neurotic form of anxiety that is persistent over time and paralyzes the individual (similar to pathological death anxiety), while the other form is normal anxiety which serves as an adaptation mechanism that warns an individual against danger and ensures self- preservation (Kastenbaum, 2000), as proposed by the terror management theory (Pyszczynski,
2004). On this account, Kastenbaum (2000) suggests that death anxiety is not always considered maladaptive. It can be considered normal when it is experienced as a response to feelings of threat but should not be present when there is no danger.
When investigating the theme of death anxiety and aspects related to it, one needs to deal with its ambiguous nature. Research frequently happens to “interchange fear and anxiety, each of which implies different approaches to measurement” (Kastenbaum & Costa, 1977, p. 27
233). Many scholars attempt to distinguish between fear and anxiety. In simple terms, fear can be explained as a state of being afraid of a concrete source that is explainable, concrete, or identifiable (Temple & Gall, 2018). Anxiety, on the other hand, is a feeling that cannot be justified by reason (Šiklová, 2013). Anxiety comes to the mind as a response to the awareness that danger can occur at any time (May, 1996; Temple & Gall, 2018). Concretely, death anxiety
“conceptualize[s] the apprehension generated by death awareness” (Lehto & Stein, 2009, p.
23). However, contemporary literature including Yalom (1980) uses both terms interchangeably as synonyms because anxiety and fear are often psychologically understood to intertwine.
Whether individuals develop a psychological problem or even diagnosis due to death anxiety is relative. Primarily, it depends on an individual’s resistance and coping. Numerous factors can hinder an individual’s coping with death anxiety including child trauma, stressful life situation, genetic predisposition, socialization difficulties, or a person’s temperament
(Iverach et al., 2014; Maxfield et al., 2014). Yalom claimed that neurotic individuals exhibit greater death anxiety (Osborne, 2017), the same as anxiety or depression in general (Maxfield et al., 2014). This was also supported by several studies that have commented on death anxiety being closely tied to high levels of neuroticism and compulsivity (Neimeyer et al., 2004;
Strachan et al., 2001; Van Bruggen et al., 2015). Moreover, self-esteem is also known to impact the likelihood of developing a death-related psychopathological problem. While high self- esteem obstructs anxious feelings, unstable or low self-esteem contributes to the development of defensive mechanisms and a maladaptive coping strategy. Insufficient self-esteem relates to maintaining dysfunctional relationships which further increases an individual’s vulnerability and complicates the effective management of death thoughts (Maxfield et al., 2014).
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2.2.1 Death anxiety and psychological conditions
Death anxiety is “considered to be a basic fear underlying the development, maintenance and course of numerous psychological conditions” (Iverach et al., 2014, p. 581).
Anxiety and panic attacks in general can have various triggers including death thoughts.
Individuals with insufficient coping mechanisms against death anxiety can easily develop anxiety disorders or social phobia (Routledge et al., 2010; Yalom, 1980). In other words, the notion that numerous mental problems emerge from the failure to effectively cope with anxiety can also be applied to death anxiety (Maxfield et al., 2014; Strachan et al., 2007). According to Iverach et al. (2014), individuals with a well-founded anxiety-buffering system tend to be more resistant when it comes to anxiety disorders including anxiety linked to existential issues such as the inevitability of death.
Research by Strachan et al. (2007) revealed that death reminders can escalate anxiety in individuals already suffering from anxiety disorders or phobias. In particular, one of their findings was that death reminders increased anxiety in individuals with arachnophobia.
Moreover, this research indicated that participants with obsessive-compulsive disorder oriented towards hand washing were more obsessive when being reminded of death (Strachan et al.,
2007). They state that in individuals with phobias and compulsive tendencies, there is observed a “strong semantic association between death and harmful objects, such as spiders and germs”
(Strachan et al., 2007, p. 1147). Iverach et al. (2014), investigated the transdiagnostic aspect of death anxiety. They reported that the fear of death can manifest itself in individuals with panic disorder or compulsive patients when they report being terrified that they will die due to a panic attack or life-threatening disease due to insufficient hand washing. Death anxiety does contribute to manifestations of potential threats to the psychological well-being of clinical patients (Maxfield et al., 2014). 29
Strachan et al. (2001), suggest that death anxiety is embodied in many psychological fears such as agoraphobia or other phobias. The anxiety is turned to focalized fear because it is more comforting to fear something specific rather than something in general which is more difficult to control (Maxfield et al., 2014). One of their hypotheses is that “existentially anxious individuals search out a source, from the environment, for their problem (ie. anxiety)”
(Strachan et al., 2001, p. 15). The observance that it is better to fear something specific than to fear something abstract and inconceivable is prominent in literature focused on anxiety, including works by Rollo May (Yalom, 2010). For this reason, anxiety related to a particular object can function as a camouflage for death anxiety (Osborne, 2017).
According to several sources, hypochondriac disorder relates to death anxiety (Furer &
Walker, 2008), such patients have developed a pathological dread regarding a somatic suspicion of an illness that eventually results in pathological fear of death (Iverach et al., 2014).
More specifically, death anxiety contributes to the maintenance of hypochondriac disorder
(Birgit et al., 2018). This research examined nine studies and reported a positive association between death anxiety and hypochondriasis in all of the studies. Death anxiety is also associated with post-traumatic stress disorder (Hoelterhoff & Chung, 2017). Individuals with the experience of being threatened and exposed to traumatic death-reminding scenarios tend to lose their trust in their view of the world and this increases their vulnerability in facing life dangers. Survivors of traumatic events with manifestations of PTSD usually encounter a general inability to cope with potential anxiety-provoking stimuli including death awareness
(Maxfield et al., 2014).
There is an extensive literature focused on depression and death anxiety with results which show a predominantly positive correlation between death anxiety and depression scores especially among the elderly. Fear of death positively correlated with depressive attunement
(Frazier & Foss-Goodman, 1988). Among the elderly, fear of death can be part of the 30 depressive syndrome (Templer, 1971). Referring to terror management theory, the development of depression associated with fear of death can originate from the “fragile faith in cultural worldviews and an inefficient capacity to buffer anxiety and to cultivate meaning, self-esteem, and fulfilling relationships” (Iverach et al., 2014, p. 587). This relates to having psychological problems and lower ego integrity that can eventually anticipate death anxiety. In particular, older individuals who accomplished Erikson’s stage of ego integrity demonstrate fewer tendencies to be depressive regarding death (Langs, 2004; Osborne, 2017). However, findings on depression caused by death anxiety are not unvarying as there are other research studies without a recognized correlation between death anxiety and depression (Neimeyer et al., 2004).
2.2.2. Perception and attitude toward death as determinants of pathological behavior
The formation of mental illnesses due to death anxiety depends on one’s perception and attitude toward the meaning of death. Attitudes toward death are very diverse and poorly conceptualized. Even though death is generally perceived as negative, one must acknowledge that death should be discussed through a multidimensional approach due to differing outlooks on death among people (Tomer et al., 2007). Some individuals regard death as “final, others as a natural end-point, others view death as threatening and hostile, while still others believe death serves to give life meaning” (Kirshbaum et al., 2011, p. 33). In simple terms, the literature on death mostly proposes two attitudes toward death; one being death as a threat to human existence, and conversely, death as meaningful (Smith, 1995; Tomer et al., 2007). Moreover, as discussed earlier with the developmental attribute of death anxiety, Kastenbaum (1972) emphasizes that death attitude depends on the age of an individual, and as an individual ages his attitudes toward death do not remain the same. 31
Kast (1998) suggested that individuals who perceive death as a destroyer might have a tendency to engage in violent behavior, and even develop a pathological fascination with dead bodies similar to necrophilic obsession. If no perverted obsessions occur, perceiving death as the destroyer profoundly contributes to the development of depression (Moor, 2004).
Uncontrolled death anxiety can provoke violence in humans (Byock, 2002). The author states that the “fascination with violence and gory death more likely represents an array of defense mechanisms such as reaction-formation or desensitization” accompanied by the inevitability of death (Byock, 2002, p. 280). According to terror management theory, pathological violence in people can be explained by their urge to eliminate all individuals that represent a threat to their worldview (Bassett, 2017; Iverach et al, 2014). Since people feel vulnerable and weak when confronted with death, they often compensate for their fragility by pursuing power (Osborne,
2017), and becoming aggressive or masochistic (Mollinger, 1982). Similarly, Freud’s death drive is a destructive instinct that uniformly affects human behavior mainly in the tendency for destruction turned inward, or onto other organisms, behaving aggressively to strive for self- preservation (Fromm, 1992; Razinsky, 2010). Additionally, the accumulated fear of death can lead to an ironic scenario when an individual begins to feel reluctance toward life and eventually ponders suicide (Yalom, 2010). Apart from violent behavior and suicidal thoughts, uncontrolled death anxiety can lead to other maladaptive forms of hazardous behavior such as drug abuse or sexual promiscuity (Bauman & Waldo, 1998).
2.2.3 Concluding remark on death anxiety and psychopathology
Since death thoughts are not pathological solely because humans naturally experience fear regarding death-provoking reminders, and most people can function in daily life with the death thought on their mind, it is illegitimate to place death anxiety by definition as a psychopathology. In general, “existential frustration[s] [are] neither pathological nor pathogenic” (Frankl, 1992, p. 108). Although there are many tools to detect an individual’s 32 level of death anxiety, and the theme of mortality salience has been extensively studied, research literature concurs that there is a poor theoretical grounding of most scales for measuring death anxiety and fear of death (Osborne, 2017). On the ambiguity of the death anxiety theme, “the concept of death-denial itself needs more conceptual as well as empirical clarification” (Kastenbaum & Costa, 1977, p. 233).
Chapter 3: How does existential psychology deal with death anxiety?
3.1 Existential questions
Existential psychology involves “a broad meta-theoretical perspective that comprises questions that are of fundamental relevance to the entire human race” (Greenberg et al., 2004, p. 507). Referring to existential questions, existential psychology uses expressions such as ultimate concerns, givens of existence, or existential themes.
Existential psychology is essential because it enables inspection into profound questions of human existence, including death, the most fundamental question of existential concern. There is a reasonable connection between existentialism and death (Tomer et al.,
2007). Literary sources consistently refer to key existential themes in human life: death, isolation, meaninglessness and freedom (Greening, 1992; Mollinger, 1982; Spillers, 2007;
Temple & Gall, 2018; Tomer et al., 2007; Yalom, 1980). Such ontological topics are principal for the formation of an individual, his thinking, feelings and behavior (Vos et al., 2015).
Death and isolation can be considered the primary sources of human existential anxiety
(Yalom, 1980). The dread of non-being is the existential fear of extinction or annihilation
(Cicirelli, 2006; Sthalekar, 2000). According to Wong (2011), existential psychology involves
“human existence and the human drama of survival and flourishing in spite of suffering and death” (p. 1). Existential anxiety can be described as “the expression of ultimate concerns about 33 life itself, including things such as meaninglessness, death, fundamental loneliness, and lack of certainty” (Van Bruggen et al., 2015, p. 174). In Frankl’s works, he mentions the “tragic triad” composed of “pain, guilt, and death [and these components] are inevitable and inherent in human existence” (Kimble, 2014, p. 12). Frankl affirmed that throughout the lifetime it is guaranteed that an individual will be hurt, will suffer, and eventually will die (Frankl, 2014).
According to existentialists, humans encounter the following ultimate concerns.
Question of life, death and time- one realizes that s/he is mortal, and that his/her death is inevitable. The desire to live and the fear of death constitute a conflict. Question of loneliness- the realization of loneliness in this world, one is born alone and dies alone. Question of responsibility, choice and freedom- one’s desire for freedom but resistance to accept responsibility for our own choices. Question of meaning and meaninglessness of human existence- humans constantly seek meaning (Spillers, 2007). The loss of meaning derives from the awareness of one’s loneliness, isolation, and the inevitability of death.
Existential anxiety is unrelated to an object, thus people often feel unfulfilled, but their anxiety remains unrecognized (Osborne, 2017). For this reason, existentialists request that people get rid of existential fear through meaning (Osborne, 2017). According to existentialists, meaning is the central concern, so the existential concern of meaning falls under psychotherapy and to some extent psychopathology (Pervin, 1960). The notion that meaning is one of the anxiety-buffering sources is also evident in theories apart from existential psychology including terror management theory (Maxfield et al., 2014).
Existential psychology and logotherapy provoke individuals to contemplate the meaning of life, it can simultaneously activate thoughts related to the finitude of life. However, despite the fact that being reminded of mortality escalates anxiety in the manner suggested by 34 terror management theory, existential psychology promotes the idea of death being desirable rather than desolate (Osborne, 2017).
Existential psychology assumes that a functioning individual is aware of existential issues and is prepared to overcome the existential fear, instead of hiding behind comforting but defective and restrictive coping defenses. Defense mechanisms as reactions to existential anxiety oftentimes prevent individuals from initiating personal growth. For this reason, existential psychology aspires to “liberate people from their responsibility defenses, allowing them to regain volitional control over their own actions” (Greenberg et al., 2004, p. 417). In this regard, existentialists argue that humans are free (Pervin, 1960), and responsible in choosing their standpoints (Spillers, 2007; Vos et al., 2015). That is, the notion that values are not innate but chosen (Greenberg et al., 2004). Existential psychology integrates the
“subjective, phenomenological experience” of individuals (Temple & Gall, 2018, p. 172).
Phenomenology approaches the inner experience of individuals without reductionism or in a deterministic manner (Yalom, 1980).
Greening (1992) presents three possible reactions to the existential concern of death.
He supposes that people might have an oversimplified attitude towards death when they cling to vitality and youth as a means to deny aging and death. Secondly, people can be pessimistic as well as brutal or suicidal as a result of their disdain toward death. With the third reaction, it is possible to acknowledge the reality of the life cycle including death and dying. This is the case when humans are not afraid to fully confront themselves with their own mortality,
Greening describes it as “not afraid or depressed, but aware and choosing life in the face of death” (p. 112). Greening (1992) suggests that the confrontation with the existential challenge of death can also induce other existential challenges such as meaning, freedom or isolation.
This can happen for instance when an individual after a severe illness reconsiders life as 35 meaningful, becomes more valuing of his freedom or cherishes quality relationships with others, or chooses loneliness rather than being with people that betray him.
In sum, when an individual encounters a difficult situation in his life that provokes death awareness, he undergoes an existential call and re-evaluates the purpose of life, its meaning
(Das, 1998; Lantz & Gregoire, 2003; Yalom, 1980). Existential figures including Yalom,
Frankl, and many others suggest that humans can live authentically and meaningfully even though the existential given of human mortality cannot be rationally defeated (Greenberg et al.,
2004).
3.2 Logotherapy: therapy through meaning
Meaning therapy including logotherapy belong to one of the four existential schools
(Vos et al., 2015). Logotherapy is classified as humanistic psychotherapy (Frankl, 1975) and
Viktor Frankl (1905-1997) grounded his theory on roots from existentialism and positive psychology (Kimble, 2014; Murray, 1999; Wong, 2015). With logotherapy, he created an independent approach as a supplement to other psychotherapeutic directions. Specific treatment with logotherapy is only possible for noogenous neuroses. Frankl notes that logotherapy is most relevant for intellectual individuals pondering life meaning, neurotics, and individuals who encounter extreme inalterable circumstances (Pytell, 2001). In other cases, it serves as an extension of therapy or as a part of professional care for the human psyche.
According to Frankl, psychotherapy cannot be effective without logotherapy because the existential vacuum remains unfilled. Therefore, Frankl said that all therapeutic approaches should be complemented by logotherapy (Das, 1998; Frankl, 1954; Längle, 2015), which allows clients to find a specific sense of direction. Through logotherapy, Frankl created a combination between psychology, philosophy (Längle, 2015; Pytell, 2001) and theology
(Längle & Sykes, 2006). Frankl’s position is constructed from classical Western philosophy, 36 from the philosophy of existence and phenomenology, and emphasizes the noetic spiritual dimension of man (Längle & Sykes, 2006).
In contrast to Freud’s overly reductionistic psychoanalysis, Frankl opposed reductionism (Längle & Sykes, 2006), and in his psychotherapeutic direction included a more humanistic element (Pytell, 2001). Humans are not simply guided by instinctive forces but have the ability to actively make decisions and control their own life. Logotherapy does not perceive humans as a result of their intrapsychic dynamics, or environmental influences, but as responsible human beings able to shape their values. Logotherapy is grounded on three conceptual bases, the freedom of will, the will to meaning, and the meaning of life (Frankl,
2014). According to Frankl, meaning is a necessary prerequisite for human existence (Melley,
1998) and eventually imperative for quality of life (Van Deurzen-Smith, 1997). Frankl insisted that the quest for meaning is inherent specifically to humans (Van Bruggen et al., 2015).
Therefore, logotherapy is known as the “therapy through meaning” (Frankl, 2014; Pytell, 2001) or “height psychology” (Pytell, 2001).
Although logotherapy is considered a technique, Frankl highlights the importance of cooperation between the client and therapist rather than a technique (Frankl, 2014). Frankl regards the most crucial mission of therapists to bring about in patients “unconditional faith in unconditional meaning” (Frankl, 2014, p. 120). Unlike some figures of existentialism oriented toward nihilism, Frankl’s philosophy is not pessimistic but actively inspiring self- determination and empowerment (Frankl, 2014). Frankl orients humans toward spirituality, freedom and responsibility (Pervin, 1960).
Logotherapy helps through a didactic technique called the Socratic dialogue (Das, 1998;
Schulenberg et al., 2008) that can be described as “not direct instruction, exhortation, or preaching” (Das, 1998, p. 207). It is an applicable technique for individuals suffering from 37 terminal illnesses, depression, or undergoing a grieving process (Ameli & Dattilio, 2013). This technique provokes individuals to discover all perspectives and among them find the most satisfying viewpoint (Das, 1998). Moreover, the Socratic dialogue stimulates an individual to realize his own resources (Das, 1998). Logotherapy supposes that all individuals have their own internal resources (Schulenberg et al., 2008). Simultaneously, individuals must accept the responsibility that goes along with the moment of the Copernican turn. It represents a moment when the individual realizes that he does not demand life but rather he is the one to whom life assigns challenges (Wong, 2016). For this reason, individuals are accountable for “answering” to life (Pytell, 2001).
The Socratic dialogue (later named attitude modulation) instructs an individual to consider different perspectives (Das, 1998). This is the stage when “attitudes are shifted away from overfocus on the symptoms and shifted toward awareness of remaining options that are in keeping with what the individual perceives as his or her personal meaning, in spite of the symptoms” (Schulenberg et al., 2008, p. 451). Frankl conveys that the therapist should not uncover the life meaning for the individual but rather let the person search for meaning while encouraging conscience and responsibility (Frankl, 2014; Melley, 1998). It is the individual who is the specialist in the given life situation and has the right insight. For this reason, logotherapy is considered a non-directive form of therapeutic intervention (Frankl, 2014).
Another technique of logotherapy is dereflection that Frankl developed specifically for anxiety and depression (Längle, 2015). In simple terms, dereflection can be specified as the opposite of self-reflection. It is crucial that patients turn their attention away from themselves and their source of neurosis and instead find a potential that life offers them (Das, 1998). This method can relieve clients from the preoccupation with their symptoms and eventually the anticipatory anxiety (Schulenberg et al., 2008). The main intention of this technique is to provoke the client to utilize his spiritual abilities of self-transcendence against self- 38 centeredness when the individual keeps himself away from preoccupying with his problems
(Ameli & Dattilio, 2013). The excessive preoccupation with our own self is undesirable since it can lead to hyper-reflection (Schnell, 2010). Frankl believes that humans can self-detach from any extreme situation or problem. He supposes that detachment can be possible due to human heroism and also humor (Frankl, 2014). In the book The will to meaning, Frankl emphasizes that humans should abstain from fixating on the effects of their pursuit because it would mean that their final goal loses its essential intention. To explain this thought, Frankl uses an example when an individual preoccupies himself with the desire to attain health and eventually becomes a hypochondriac (Frankl, 2014).
Additionally, the paradoxical intention is a technique that can effectively target compulsions, phobias (Frankl, 1975) and anticipatory anxiety (Längle & Sykes, 2006) but also recursive anxiety (anxiety recurring overtime) (Ameli & Dattilio, 2013) which might be the case with death anxiety. In this particular technique, a client is encouraged to evoke and experience his symptoms of anxiety intentionally (Frankl, 1975; Schulenberg et al., 2008). For instance, an obsessive-compulsive client that unconsciously fears death and so washes his hands frequently would be instructed to be even more obsessive and wash his hands excessively. This technique reflects Frankl’s assumption that humans can search for meaning in humor or absurdity (Ameli & Dattilio, 2013).
In anxious neurosis, an individual needs a legitimate life goal, and life demands on him that he can cope with. An anxious neurotic can escape from the vicious cycle of anxious thoughts when he manages to divert attention from the manifestation of his anxiety and when he can fix himself on a subject that can make his life meaningful and dignified. Clients need to exempt themselves from symptoms, employ their acquired meaning and adaptive coping stances (Schulenberg et al., 2008). Along with the mentioned techniques, logotherapists widely 39 practice therapeutic intervention with the use of metaphors and anecdotes to promote clients’ change of position (Schulenberg et al., 2008).
3.3 Frankl’s ideology: Meaning through suffering and embracement of responsibility to choose own attitude
3.3.1 Holocaust survivors
“in the last resort man should not ask, what is the meaning of my life, but realize that he himself is the one on trial; life is putting its problems to him, and it is up to him to face the problems by shouldering his responsibility, thus answering for his life” (Frankl, 1954, p. 977)
In Man’s Search for Meaning (1992), Frankl describes moments when he was in the concentration camp and death was a constant threat. He described that “once the meaning of suffering had been revealed to [them], [they] refused to minimize or alleviate the camp’s tortures by ignoring them or harboring false illusions and entertaining artificial optimism”
(Frankl, 1992, p. 86). Such an idea can be applied to death, as death will not be repealed by being moved out of consciousness through ignoring or denying it, but rather will subside with the revelation of meaning. Meaning can serve as a “counterbalance” to death anxiety (Osborne,
2017, p. 249) when meaning can be used as an adaptive construct (Schulenberg et al., 2008).
Frankl reveals that despite the horror of death camps, they all still had spiritual freedom
(Spillers, 2007). Frankl felt that he was free to choose how to approach the extreme environment of the concentration camp as his attitude formation was under his control (Mulley,
1998). It can be said that the will to meaning does not only sustain mental and physical strength, but it also enables the survival of difficult times of agony, suffering, and remorse (Das, 1998;
Frankl, 2014; Shantall, 1999; Tomer et al., 2007). In fact, Frankl’s survival of the concentration camp proves that the sense of meaning can be a self-preserving mechanism. Frankl’s experience of the concentration camp served him as an “experimentum crucis” of his 40 discovered logotherapeutic approach (Längle & Sykes, 2006, p. 4). Further, Frankl’s narration from the death camp conveys his paramount message that “life has a meaning to the last breath”
(Frankl, 1954, p. 976).
Shantall (1999) interviewed Holocaust survivors from different concentration camps discovering the impetus behind the perseverance of survivors. Shantall examined the common themes of all survivor stories including the story of Viktor Frankl. The research identified themes such as spirituality or mental hardiness. The common pattern of behavior among survivors was that they formed their choices based on conscience. This was attainable due to the complete yet cruel acceptance of responsibility. They all perceived suffering as a confrontational possibility. These survivors exempted themselves from self-centered thinking.
They were thoughtful of others, but they were also aware of their own values. They realized that values need a commitment in order to be realized and lived for. And lastly, throughout the time survivors spent in concentration camps, they constantly worked on their mode of the spiritual being to become morally mature.
Similarly, to Frankl’s ideology, the research revealed that the dominant shared attribute among survivors is moral and spiritual heroism which survivors accomplished to transform suffering into the most noble accomplishment.
3.3.2 Meaning and suffering
Frankl believes the inclination to meaning is the central human motivational force (Das,
1998; Smith, 1995), and that meaning is disclosed by the individual rather than external determinants beyond the self (Bauman & Waldo, 1998). The feeling of fulfillment in life is not dependent on what affects an individual, but rather depends on the individual’s attitude towards it (Murray, 1999). Yet, Frankl respects that meaning is relative and unique for all individuals
(Das, 1998; Frankl, 2014), based on moments and situations (Frankl, 2014; Shantall, 1999). In 41 this regard logotherapy strives to teach individuals that life is unique same as goals and the eventual path of all individuals are unique.
Humans do not fear death but their rationalization of death. Through Frankl’s conviction that humans can embrace their responsibility and choose a convenient attitude, it can be said that humans have the “freedom to choose not to fear death” (Buetow, 2009, p. 114).
Similarly, as in Frankl’s logotherapy, the Meaning-Management theory by Wong supposes that death can be represented either as pessimistic or constructive depending on one’s attitude
(Wong, 2011).
Frankl’s concept of logotherapy and the concept of unconditional meaningfulness of life is closely linked to suffering and death. According to Frankl, death does not reduce the meaningfulness of life, but rather is indispensable for the life meaning of all individuals (Tomer et al., 2007). Like many others, Frankl notes that humans are the only beings conscious of mortality (Temple & Gall, 2018). This frame of mind should prompt humans to reflect upon their life, embrace responsibility and avoid denial of human finiteness. Together with Yalom and other existentialist figures, Frankl perceives death to assign human life a substantial direction (Kimble, 2014). Confrontation with death “provides motivation to be one’s creator, to choose how to make life meaningful and to achieve one’s most authentic, spontaneous being in an absurd universe” (Wolson, 2005, p. 677). Frankl proposes that death can be the reason behind the search for meaning as he describes his feelings when he was in the concentration camp “if I had to die there might at least be some sense in my death” (Frankl, 1992, p. 59-60).
The reality that “no human life is free from suffering” (Das, 1998, p. 206) can be according to Frankl and other existentialists constructive in human life (Melley, 1998). Frankl
(1992) supposes that “without suffering and death human life cannot be complete” ( p. 76). An individual can discover meaning through suffering if and only if suffering is imminent and 42 inevitable (Frankl, 1954). Similarly, Wong (2011) suggests that the path toward meaning is most likely not compatible with a life free from suffering. He supposes that in order to live with a purpose, individuals cannot “deny one’s true nature and calling even if it means death”
(p. 3).
Frankl was convinced that suffering can be transformed into a meaningful construct
(Melley, 1998). He proposes that if an individual can achieve such transformation, it is the noblest endowment within him (Frankl, 1954; Shantall, 1999). This is confirmed in logotherapy via three key values being creativity, experience and attitude (Ameli & Dattilio, 2013). The creative value enables individuals to take action, create; the experimental value enables individuals to experience deep feelings via awakening receptiveness (Feldman & Snyder,
2005). In the case when mentioned values cannot be realized, or if they fall apart, the attitudinal value remains (Frankl, 1954; Pytell, 2001). Indeed, Frankl considers the third possibility of meaning discovery as the most important (Frankl, 2014). The moment an individual is unable to change a given condition, he has the choice to convert suffering into strength. Frankl says that humans are capable of such transformation due to the “defiant power of the human spirit”
(Shantall, 1999, p. 103). Humans are responsible for how they choose to suffer (Frankl, 2014).
In this regard, choosing the convenient attitude may in turn “transform, inspire, or liberate
[humans] psychologically and emotionally” (Längle & Sykes, 2006, p. 8).
Searching for meaning is endemic to humans, especially in times of suffering and anticipating death. Finding meaning through logotherapy means discovering a concrete path that corresponds to the given circumstances (Kimble, 2014). In this sense, logotherapy instructs that meaning can be found in every situation including human standpoint when awaiting death and dying one day. 43
Several research studies based on Frankl’s ideas from logotherapy confirm a positive correlation between the meaning of life and death anxiety (Bolt, 1978). Studies show that there is a connection between death-related anxiety and the purpose of life. Individuals with a sense of life meaningfulness have a better adaptive coping strategy. That is to say, meaning plays a central role in the formation of the buffering system against the inevitability of death (Maxfield et al., 2014).
3.3.3 Meaninglessness as existential vacuum
Since it is the central desire for man to strive for meaning, it is problematic if an individual lacks such meaning which leads to an existential vacuum (Das, 1998; Frankl, 2014;
Kimble, 2014; Schnell, 2010). The existential vacuum is manifested by states of anguish, boredom and apathy (Frankl, 2014; Osborne, 2017; Tomer et al., 2007) and ties to symptoms including anxiety, depression (Ameli & Dattilio, 2013; Lantz & Gregoire, 2003) or the absence of self-transcendence (Schnell, 2010). Frankl says that humans commonly repress their existential concerns, but they come back when the human conscience pushes them back on the surface (Frankl, 2014).
Humans tend to escape the search for meaning through means of destructive behavior including material behavior (the will to money) (Temple & Gall, 2018). This is because wealth provides people with a defense mechanism, a sense of control when they can purchase resources to ensure their well-being and safety (Temple & Gall, 2018). However, when an individual lacks personal meaning, but instead inclines to extrinsic aspirations of meaning, existentialism suggests that the individual will eventually suffer from anxiety and meaninglessness (Greenberg et al., 2004).
Frankl supposes that humans are existentially frustrated and search for excitement because society lowered its demands on humans and human existence became effortless 44
(Frankl, 2014). In some of his works, Frankl comments on his notion that anxiety rises as people pursue wealth and undergo what he called “managers disease” (Frankl, 1954). Material excess brings spiritual emptiness and demotivates humans to strive for self-transcendence
(Wong, 2016), thus lowering their capability to live authentically. Frankl describes the phenomenon of collective neurosis by presenting common attitudes of humans such as their resignation to plan (Frankl, 1954). Humans have greater freedom but also more possibilities and risks. And this burden of seemingly unlimited freedom and eventually helplessness is related to the question of meaning. According to Frankl, humans undergo existential frustration because they attempt to liberate themselves from freedom (Tomer et al., 2007). Frankl commonly discussed his notion that existential anxiety is rooted in human fear of existential responsibility (Spillers, 2007) and the inability to accept unlimited freedom (Das, 1998).
Frankl states that suffering and the idea of death are not necessarily neurotic (Frankl,
1992). The absence of meaning in life, the existential frustration, is not pathological according to logotherapy (Pervin, 1960) but rather suggests “spiritual distress” (Das, 1998). Instead, existential anxiety when one lacks meaning is not considered clinical (Frankl, 1954) since it is a natural response to the human need to strive for meaning. In other words, the absence of existential meaning is generally “not indicative of a psychopathological state but rather an overall feeling that the direction of life is missing existential values” (Längle, 2015, p. 74).
Similarly, a purely existentialist characterization of life vanity, means that the individual lacks an “objectively defensible reason to live” rather than a general reason to live (Greenberg et al.,
2004, p. 438). Frankl encourages people not to be ashamed and discuss their existential concerns (Frankl, 2014). Frankl supposes that due to an erroneous interchange of psychological and noological dimensions people assume that an existential vacuum is a mental condition but rather it is spiritual distress since it falls under noological dimension and not the psychological
(Frankl, 2014). Nevertheless, if an individual remains in the state of existential anxiety for a 45 long time, Frankl acknowledges that it can result in noogenic neurosis that does not have a biological origin but occurs when life without meaning becomes chronic (Das, 1998).
Such a maladaptive stage of missing meaning can lead to neuroses. Common signs that an individual lacks meaning include the inability to face suffering and death or be in the present moment. The existential crisis when one does not acquire the sense of meaning tends to be connected to the crisis of aging (Kimble, 2014). An existential vacuum in aging people can be linked to experiencing a crisis of job loss, physical strength, or mental health. Osborne (2017) states that the lack of meaning can be anticipated as death anxiety because both meaninglessness and death anxiety are interrelated (Tomer et al., 2007) and can result in neurosis (Osborne, 2017). The most common reaction to existential frustration is sexual compensation but it can be found in various other forms including alcoholism, suicidal tendencies, drug and alcohol addictions, or criminality (Schulenberg et al., 2008).
Regarding a lack of meaning terminally ill patients in palliative care settings tend to have immense existential distress that is often described as demoralization syndrome (Rich,
2014), and in some sources is known as a “psychiatric diagnosis of existential distress”
(Blinderman & Cherny, 2005, p. 371). The suffering of seriously ill individuals happens when they experience not only physical pain but also spiritual psychological distress including despair, meaninglessness, death anxiety, or identity confusion (Blinderman & Cherny, 2005).
Smith (1995) mentions that individuals awaiting or near death mostly experience anticipatory anxiety that arises from the feeling that they will lose everything meaningful for them. In such cases, the pronounced hopelessness calls for existential psychological intervention to discover meaning in the imminent death (Rich, 2014). For the terminally ill awaiting death, Frankl recommends looking back into the past and remembering all the memories and suffering the individual successfully overcame. Frankl says that the past will remain, and the person can find meaning in it because it cannot be taken away from him (Frankl, 2014). Logotherapy is 46 considered highly efficacious for terminally-ill individuals (Kimble, 2014). Studies agree that existential issues such as death inevitability and life meaning are a fundamental component of palliative care settings (Blinderman & Cherny, 2005; Smith, 1995).
Discussing the loss of meaning in life, humans can live in despair and agony but in extreme cases can also turn to the option of ending their life by committing suicide. Frankl disagrees with suicide or euthanasia (Hoffman, 1995) because suicide does not remove misfortune from the past but only removes the self without providing any solution. Even though suicide confirms human freedom to some extent, committing suicide means that an individual renounces his freedom. Existentialists propose that “meaning is found in living the absurd, not in refusing it” (Tomer et al., 2007, p. 15). Frankl believes the reason behind suicide to be the misguided conscience of suicidal individuals (Frankl, 2014). When the Gestapo practiced euthanasia for mentally ill individuals in death camps, Frankl fought against it and later spoke against physician-assisted suicide (Hoffman, 1995). In the case of assisted suicide in medical settings, Frankl refers to the Hippocratic oath that is violated in the case of the assisted ending of one’s life (Frankl, 2014).
Frankl believes that all individuals must hold onto meaning. Without meaning one could not live. Frankl postulates that “man really could not move a limb unless deep down to the foundations of existence, and out of the depths of being, he is imbued by a basic trust in the ultimate meaning” (Frankl, 2014, p. 115). Often in suffering and anxiety, a person decides whether to take on this difficulty or deny it- commit suicide, behave aggressively, or consume drugs. Frankl uses an example of someone who undergoes bereavement because his loved one died and he can suppress his suffering with antidepressants, however, his reason for suffering will remain existent. Through this example, Frankl presents that the superior concern should be the rationale for existential suffering rather than the removal of the suffering (Frankl, 2014). 47
Frankl mentions that those who approached him with a lack of meaning were individuals distressed by the “transitoriness of life” (Frankl, 2014). Humans have the feeling of meaninglessness since it is definite that they will die, and everything connected with their life will disappear after their death. If this unchangeable destiny brings humans to an inevitable death, it can open up a sense of futility. When talking to individuals who were trapped in the transitoriness of life, Frankl encouraged his clients to ponder what they have achieved throughout their life and if they lived meaningfully. Frankl challenged them with the thought that meaning does not vanish with death because what an individual has done in his lifetime cannot be undone. In other words, once meaning was attained, meaning remains stored even after death. Through this idea, Frankl showed that if humans lived meaningfully and suffered bravely, they can die with relief. On the account of the importance of living a meaningful life,
Wong (2011) says that the greatest uneasiness is not death but the realization before death that one has not lived his life.
Logotherapy teaches that individuals should accept unchangeable occurrences that cannot be prevented. In such cases, humans have the remaining option to transform them into being meaningful which becomes eventually the greatest accomplishment of the individual
(Frankl, 2014). Even though some existential losses are irreversible and out of human control
(such as terminal illness or death), humans have their freedom to choose their attitude to those losses. Despite the fact that destiny cannot be adjusted individuals can adjust themselves, their standpoint (Frankl, 2014). In this sense, logotherapy offers a wide variety of ways individuals can seek meaning. Even though it is not easy logotherapy shows that it is possible.
48
3.3.4 A spiritual construct
A concern with spirituality converges with existential psychology (Frankl, 1992; Kaut,
2002), involving “well-being, life satisfaction, self-transcendence, awe, wonder, or hope”
(Tomer et al., 2007, p. 9). The spiritual nature of humans when they are capable of transcendence beyond physical and psychological nature is part of Frankl’s vision (Das, 1998;
Längle, 2015). In his writings Frankl does not unify the spirituality dimension with the concept of religiosity (Frankl, 2014), rather spirituality represents a special “realm of human existence” where the insistence is on meaning and value (Das, 1998). However, similar to religion, Frankl indisputably believes that faith does drive humans forward (Morgan, 2012). Even in the last moment before death, man hopes to survive, although rationally he knows that no one is immortal and there is no hope in escaping death. Such hope assigns a transcendent sense to life. Frankl says that dispositions to hope in meaning are anchored in the human essence regardless of the religious dogma of an individual (Frankl, 2014).
Frankl outlines a tri-dimensional construct (the tri-dimensional ontology) of humans consisting of physical, psychological and spiritual (Ameli & Dattilio, 2013; Schulenberg et al.,
2008). While physical and psychological dimensions are shared among all living creatures, the spiritual or noetic dimension is human-specific (Ameli & Dattilio, 2013; Frankl, 2014; Längle
& Sykes, 2006; Schulenberg et al., 2008) and represents the essence of human existence
(Frankl, 2014). According to Frankl, spiritual human nature impels us to self-transcendence
(Wong, 2016). What he described as human openness to the world (Frankl, 2014). Self- transcendence is the human facility “to orient [themselves] outward toward another person or toward a cause greater than [themselves]” (Längle & Sykes, 2006, p. 8). Logotherapy can alleviate all of the human dimensions when one can feel physiologically better, psychologically decreases anticipatory anxiety, and spiritually brings near meaning (Schulenberg et al., 2008). 49
3.4 Applicability of logotherapy
Logotherapy is nowadays a recognized psychotherapeutic method (Längle, 2015).
Other psychotherapeutic directions, such as cognitive behavior therapy, are often complemented by logotherapy in psychotherapeutic practice (Ameli & Dattilio, 2013).
Logotherapy is an effective method and research studies demonstrate that the exploration of meaning through logotherapy positively influences anxiety and the general psychological well- being of humans (Schulenberg et al., 2008). Quantitative research by Vos et al. (2015) examined different schools of existential psychology including meaning therapy. They reported higher self-efficacy, and their tendency to maladaptive and psychopathological tendencies were significantly lower. A study by Ameli & Dattilio (2013) on the applicability of logotherapy noted that logotherapy prescription among patients with irreversible suffering may facilitate better toleration of pain and can be effective in “reducing the risk for depression, despair, and suicide” (p. 390).
A number of research studies investigating Frankl’s assumptions have validated a positive correlation between the meaning of life and death anxiety (Bolt, 1978). The search for meaning is imperative for those of old age and approaching death (Das, 1998). Breitbart et al.
(2004) focused on resources of spirituality and meaning among patients in palliative care and describes the applicability of Frankl’s principles of people awaiting death as revolutionary, as it reconstructs the view of death from denial and avoidance to learning about death through purpose and meaning. The authors advise that meaning-centered psychotherapy should become an integral part of care for the seriously ill as it helps them address their personal questions of isolation, fear of death, or individual life purpose. Morgan (2012) discusses the relevance of logotherapy for geriatric patients. Older people have a more limited frame of reference.
Logotherapy can utilize a psychotherapeutic exercise when one is asked to search “existential 50 episodes of happiness”, recalling positive memories when the individual felt happy. The goal of this approach is to create an experience of “reflective happiness” in the present moment.
Zuehlke & Watkins (1977) tested the effectiveness of logotherapy for terminally ill patients with cancer using questionnaires given to subjects prior to and after the treatment exposure. In their study, they incorporated questionnaires including the Purpose in Life Test
(PIL), Death Anxiety Scale (DAS), and Brief Psychiatric Rating Scale (BPRS). Throughout the logotherapeutic treatment, subjects were treated by several techniques such as dereflection or paradoxical intention. The main intent was to implement dereflection in individuals who experienced hyper-reflection and through the technique, patients were instructed to detach from their medical situation by diverting their attention to other thoughts such as family relations. In this regard, the technique not only contributed to detachment from somatic pain but also emphasized the importance of family ties between the patient and his family members. The results indicated that subjects had higher DAS scores since they were trained to eliminate their defense mechanisms, and rather accept the cruel yet true reality which can be acknowledged as a positive effect since it allowed a better realization of inner emotions and outright acceptance of their medical condition. Subjects had significantly higher PIL scores during the post-therapy measurement suggesting their sense of life purpose increased after logotherapy.
The study evaluated that terminally-ill individuals from the experiment were provided with the opportunity to initialize full acceptance of their terminal illness.
51
Conclusion
Death anxiety is a fundamental and universal human response to the finitude of one’s own existence, which is often denied or suppressed. The way humans interpret death and cogitate on their indirect experience with death is reflected in an individual’s position on the subject of death. The inevitability of death might be conquered through distinctive approaches that can result in either adaptive or maladaptive consequences. Notwithstanding this fact, discussion about death in a comfortable manner is of paramount importance and is advisable not only in a psychotherapeutic direction but in palliative settings and other contexts.
Talk concerning finitude opens up new existential questions. One of these questions is the quest for meaning, the search for a meaningful past, and future prospects. In this regard, some individuals might feel helpless since a life with the unchangeable fate of death can seem meaningless. Therefore, the critical point happens in a choice of direction that seems meaningful. The concept of meaning has a crucial influence on the individual’s attitude formation on death.
Logotherapy encompasses meaning and the analysis of being which brings the aspect of spirituality and the ability of self-reflection, conscience, freedom to choose responsibility.
An individual feels satisfied from a fulfilling life if he has something to live for, the reason for psychopathology might be existential emptiness. Particularly, excessive death anxiety is associated with psychopathologies and is often disguised as the absence of meaning in life. The absence of meaning and the search for escape from existential givens exacerbates death anxiety. Yet existential crises can be seen as a natural part of human life. They are not necessarily negative nor pathological. The aim of logotherapy is to find the meaning of life and thus minimize the feeling of this existential vacuum. 52
The inquiry of, and into, meaning is important in logotherapy, especially concerning existential questions that man cannot influence such as death and dying. Even though humans are powerless to annul death and dying, logotherapy leads humans to discover a convenient standpoint and meaning tied to it as an essential psychotherapeutic principle. In this sense, logotherapy offers an approach for individuals holding a viewpoint that death is nonsensical.
The absence of meaning seems to be inevitably associated with efforts to suppress death, suffering and hardship. This human tendency is challenged in logotherapy, its main goal is to provoke the realization of potential and appraisal of life as meaningful despite suffering and the inevitability of death. The feeling of fulfillment, that man has lived his life meaningfully, and suffered responsibly, alleviates the fear of death.
The present study attempted to demonstrate how crucial it is to comprehend death as part of human life. The comprehension of death should go beyond rational death awareness, but, rather, to the integration of death into one’s life. Although existential awareness of death is inevitably linked with anxiety and fear, meaning discovery enables one to perceive the purpose of a finite life. If one is able to achieve this it can make life more satisfying and meaningful. When humans achieve awareness of the fact their lifetime is limited, they take life more seriously and live more intensely. Logotherapy leads to such a view of the phenomenon of death. Coping with the phenomenon of death is to some extent a task given to all humans, existential psychology shows the direction of this internal process. For existential psychologists, including Frankl, finitude is what assigns human life meaning. Such a notion can be a source of inspiration for individuals who reflect on the absurdities of human life.
To conclude, existential psychology through its search for death acceptance offers a more convenient solution to the long-term coping with death anxiety compared to terror management theory. The major difference lies in the approach of logotherapy proposing that death anxiety can be accepted alongside the discovery of a meaningful attitude, while terror 53 management theory argues that anxiety must be fixed. The approach constructed by terror management theory can be seen as further promoting defensive strategies that eventually contribute to death denial, or at least do not promote death acceptance or embracement of authenticity. In contrast to terror management theory, existential psychology supposes that humans can cope with death anxiety without symbolic immortality ideologies. Logotherapy argues that if an individual saw the meaning of one’s own life in its preservation through symbolic immortality, the meaning of life would not be fulfilled, the question of meaning would remain unresolved after his death. Alternatively, Frankl’s idea that what has been done with a meaningful attitude can never be undone seems more comforting compared to other deceitful defense mechanisms, since it relies on active responsibility instead of passive rationalization. Nonetheless, this study does not claim the absolutization of the offered solution through logotherapy to all the psychological problems concerned with death and meaning.
Instead, the goal was to encourage and inspire, when it comes to the struggle with meaninglessness and death anxiety that humans encounter as a result of the postmodern times of death denial.
54
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