Itive Psychology of Death Acceptance Paul T. P. Wong Toronto, Ontario Life

International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010

Meaning Making and the Pos- Death is like an unfathomable black hole, itive Psychology of Death capable of destroying all our dreams, achieve- Acceptance ments, and happiness. But at the same time, the idea of death can save many lives by chal- Paul t. p. wong lenging us to fill the huge void by living a life Toronto, Ontario of significance. The challenge for psycholo- gists and death educators is to discover pathways to death acceptance. This essay focuses Life is what lies between birth and death. on meaning-making as a promising way to What makes this journey so difficult is that free us from the terror of death to self-actual- from the very outset, life moves relentlessly ization. towards death like an unstoppable train rac- ing towards a crushing end. TheT error of Death

Nothing in life can really prepare us Death remains the biggest threat as well for the inevitable and singular event of per- as the greatest challenge to humanity. It is sonal death. The human mind is not capable the single universal event that affects all of us of comprehending the full enormity and in ways more than we care to know (Green- the horror of biting the dust after a lifelong berg, Koole, & Pyszczynski, 2004; Wass & struggle to make life enjoyable. How can the Neimeyer, 1990; Yalom, 2008). mind defend itself against its own capacity to foresee one’s own demise? Because of the unique human capacity of meaning-making and social construction, Confucius said: “If we don’t know life, death has evolved into a very complex and how can we know death?” But I say: “If we dynamic system, involving biological, psycho- don’t know death, how can we know life?” logical, spiritual, societal and cultural compo- nents (Kastenbaum, 2000). Whatever mean- We cannot even begin to understand the ings we attach to death may have important meaning of life, until we stare at death un- implications for our well being. Thus, at a flinchingly. Paradoxically, death holds the key personal level, death attitudes matter: Death to life. We cannot truly live without aware- defines personal meaning and determines ness of life’s inevitable end. How can we live how we live (Neimeyer, 2005; Tomer, 2000; fully and vitally, if we spend a life time run- Tomer, Eliason, & Wong, 2008). ning away from death? In a strange way, life is defined by it fragility and finiteness and death From a larger perspective, death attitudes holds the key to authentic living. Only fools also play vital role in national security: Death live as if there is no tomorrow. Only fools defying suicide bombers have changed the think that they can avoid death anxiety by landscape of geopolitical warfare, and vic- immersing themselves in pursuing pleasures tory in the war on terror depends in part on and worldly success. our ability to live with death threat and our www.ExistentialPsychology.org 73 International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010

willingness to accept the ultimate sacrifice in our own demise? Whatever the answer, death defending our freedoms. has moved from its dark closet into the glar- ing light of public space. Lifting the taboo In the post 9/11 era, the ever present may have paved the way for death to emerge threat of terrorist attacks has injected into our as a popular subject for both psychological collective awareness the unpredictable nature research and public death education. of mortal danger and mass destruction. In a wired global village, our death attitudes are From Death Denial to Death Acceptance further affected by the 24-hour news coverage of natural and men-made disasters around In spite of its pervasive and profound the world, from catastrophic earthquakes to impact and its power to engage the human genocides, from scenes of corpses on Haiti minds since antiquity, death remains shroud- streets to images of carnage in Iraq and Af- ed in mystery— an imponderable, blinding ghanistan. reality that is at once terrorizing and tantaliz- ing. Death has invaded our living rooms in gory details on a daily basis. Our passive ac- All through history, human beings have ceptance of the endless coverage on carnage developed elaborate defense mechanisms and atrocity betrays a love-hate relationship against the terror of death both at the in- with death – we are simultaneously repelled dividual and cultural levels. We now have a by its terror and seduced by its mysteries. The huge literature on death denial and terror popular appeal of violent video games and management (Pyszczynski, Greenberg, & Hollywood horror movies provides further Solomon, 2002). proof of our morbid fascination with death. In short, our relationship with death is more The medical profession has made it its complicated than we realize; a complete psy- mission to keep death at bay and save lives. chology of death needs to move beyond terror When death occurs, it is often viewed as a and denial to studying our multifaceted rela- failure of medicine or the attending physician. tionships with death. An aversion towards death also makes it difficult for physicians to communicate the “bad The above development also raise ques- news” to patients and their family members in tions about the effects of over-exposure to an honest and caring manner. images and messages of death. Does it de- sensitize us to the terror of death and make At the cultural level, death also makes its us more tolerant of violence? Does it trivial- ubiquitous presence felt in a broad spectrum ize the human tragedy of senseless killings? of social functions, from family, religion, en- Does the prevalence of mortality salient tertainment industry to medical care (Kearl, images overtax our psychological defense 1989). How we relate to our own mortality is mechanisms? Or, does our familiarity with in turn mediated by family, society and cul- the Grim Reaper make it easier for us to face ture (Kastenbaum, 2000). All human activi- www.ExistentialPsychology.org 74 International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010

ties are framed by death anxiety and colored ness and death anxiety. Therefore, we all need by our collective and individual efforts to to come to our senses and consider our desti- resolve this inescapable and intractable exis- ny. To be prepared for this eventuality enables tential given. us to live wisely and die without regrets.

All our defenses fall apart, when death Secondly, there are cultural as well as sneaks up on us, often unexpectedly. The individual differences in death attitudes. Our death of a loved one, a near fatal accident, understanding of the good death and our or life-threatening illness can stop us on our preferred pathways to death acceptance may track and thrust death right in our face. The impact how we address various end-of-life predicament of patients with terminal ill- issues. nesses brings to sharp focus the critical issue of how to confront and accept personal mor- Thirdly, research on the good death con- tality with courage, serenity and hope. When stitutes a new frontier of the current positive does one give up the heroic but futile battle psychology movement. The interdependence against cancer and accept the inevitable out- between living and dying well makes it an come with serenity? On a personal level, how important topic for advancing the scientific do we react when we receive the bad news study of the good life. that cancer has reached the final stage. As a cancer survivor, this question is never too far Finally, we need to learn how to talk from my mind. about death in a way that is liberating, hu- manizing and life-enhancing. We hope that In sum, we cannot live indefinitely in a through an increased understanding of death culturally and psychologically induced state of acceptance, we may learn to treat each other denial. The fact is that death is all around us, with respect and compassion not only in the above us, below us and inside us. Death is you medical context but also in daily interactions. and death is me. Death lies dormant in every human being. We all need to confront the The Different Meanings of Death unsettling reality of personal mortality, the Acceptance sooner the better. There are numerous reasons for embarking on this exploration of death Elisabeth Kuber-Ross (1969, 2009) was acceptance. largely responsible for making death a legiti- mate topic for research and medicine. Her Firstly, we cannot live authentically and stage-model of coping with death (denial, meaningfully without embracing death. So anger, bargaining, depression and acceptance) much wasted time, self-inflicted miseries and has left a lasting impact on our understand- human tragedies happen because of greed, ing of the psychological reactions to death. envy, and misguided ambitions. Addiction, She has identified some defense mecha- depression and aggression can also be related nisms (denial and bargaining), and negative to desperate attempts to escape meaningless- emotional reactions (anger and depression) www.ExistentialPsychology.org 75 International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010 involved in coming to terms with the reality About two decades ago, when my associ- of death. In the final stage, denial, fear and ates and I undertook a comprehensive study hostility give way to embracing the inevitable of death acceptance, we met with resistance end. Her sequential stage concept has widely from both within our own psychology de- been criticized. For example, Bonanno (2009) partment and rejection from journal editors has recently found that in coping with be- as if death acceptance were not worthy of reavement, most people can come to death research. Eventually, we were able to publish acceptance without going through the previ- our research findings (Gesser, Wong, & Re- ous stages; however, that does not mean the ker, 1987-88). In addition to death fear and absence of inner struggles with the complex death avoidance, we identified three distinct emotions involved in bereavement. Only types of death acceptance: (1) Neutral death direct research on death acceptance will reveal acceptance – facing death rationally as an the pathways and mechanisms of coming to inevitable end of every life, (2) Approach ac- terms with death in a constructive way. ceptance – accepting death as a gateway to a better afterlife, and (3) Escape acceptance In the last fifty years, the psychology of – choosing death as a better alternative to a death has been dominated by research on painful existence. The Death Attitude Profile death anxiety (Kastenbaum, 2000; Neimeyer, (DAP) was later revised as DAP-R (Wong, 1994a, b) and terror management theory Reker, & Gesser, 1994). Both scales have (Pyszczynski, Greenberg, Solomon,1999; been widely used and evidence is accumulat- Solomon, Greenberg, & Pyszczynski, 2004). ing regarding the validity and reliability of There was only a scant literature on death DAP (Gesser et al., 1987-1988) and DAP-R acceptance. Ray and Najman (1974) were the (Wong at al., 1994). For example, Neimeyer, first ones to develop a new scale to measure Moser and Wittkowski (2003) confirm that death acceptance, and found that it had a DAP-R remains the main instrument to as- small but significant positive correction with sess death acceptance. two death anxiety scales. The discovery of the co-existence of death anxiety and death ac- ThreeT ypes of Death Acceptance ceptance is important because it reveals a basic ambivalent and conflicted attitude towards Approach acceptance is rooted in reli- death: It is never easy to resolve the issue of gious/spiritual beliefs in a desirable afterlife. death anxiety regarding our personal demise. For those who embrace such beliefs, afterlife No matter how remote and vague, the pros- is more than symbolic immortality, because it pect of death of self or a loved one will always typically associates with theistic religious faith be unsettling because it disrupts the flow of or belief in a transcendental reality. Approach life as we know it. However, a well developed acceptance is based on the social construction system of death acceptance can keep death of life beyond the grave, thus, offering hope anxiety at bay and prevent it from interfering and comfort to the dying as well as the be- with our daily functioning. reaved. More specifically, Harding, Flannelly,

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Weaver, and Costa (2005) reported that scales terlife, Motivator and Legacy. Belief in After- that measure Belief in God’s existence and life is similar to Approach Acceptance; Ex- Belief in the Afterlife were both negatively tinction, Motivator and Legacy can all come correlated with death anxiety but positively under the umbrella of Neutral Acceptance. correlated with death acceptance. The Dual-System Model Escape acceptance is primarily based on the perception that life is so painful and Imagine yourself a marine serving in miserable that death offers a welcome relief. Afghanistan. Knowing that every time you Suicide and assisted suicide are expressions of are on patrol, you and your fellow soldiers Escape acceptance. Cicirelli (2006) observed could be blown to pieces by an improvised that when individuals experience intractable explosive device, how would you manage the pain or loss of function, they want to end constant death threat and carry out the dan- their own lives. In such cases, the terror of gerous mission? How would you maintain a death seems less fearful than the terror of liv- positive attitude towards life in this environ- ing. ment? Any professional soldier knows that it does not pay to live in terror everyday, because The construct of neutral acceptance needs excessive fear will reduce your combat effec- closer examination. Clements and Rooda tiveness and increase the likelihood of getting (1999-2000) examined the factor structure, killed. He would reveal that the best one can reliability, and validity of DAP-R using a do in such a dangerous situation is to accept sample of 403 hospital and hospice nurses. the dangerous situation and live as normally They were able to replicate four of the five as you can. Wong’s (2010) dual-system model factors reported by Wong et al. (1994): Fear of achieving the good life provides a useful of Death, Death Avoidance, Approach Ac- conceptual framework to manage the co-exis- ceptance, and Escape Acceptance. However, tence of death acceptance and death fear. the items which loaded on the Neutral Ac- ceptance subscale were split across two fac- According to this model, one needs to tors. This finding seems to suggest that the depend on the cooperation and interaction Neutral Acceptance subscale may measure between approach and avoidance systems. different pathways to death acceptance with- These two complementary tendencies repre- out believing in an afterlife. For example, sent two different motivations and life orien- some may be resigned to the fact that death tations. The defensive tendency to avoid pain, is simply a biological fact of all living things, suffering, dangers, anxieties and death, serves while others may feel that they are ready to a protective function. It is the tendency to die because they have completed their life seek security and self-preservation in a cha- mission and left a worthy legacy. In fact, otic and often dangerous world. It involves Cicirelli (2001) has identified four different both unconscious and conscious defense Personal Meanings of Death: Extinction, Af- mechanisms to safeguard our psychological

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and physical integrity. It also involves coping maintains that the most effective way to pro- behaviors to reduce the threat and negative tect oneself against death anxiety is to focus affective reactions. Those who prefer a defen- on the immediate task and live a meaningful sive stance would be very cautious and timid, life. afraid of making change or taking risk. But we cannot experience the positive aspects of According to this model, soldiers on life if we live in constant fear and anxiety. patrol duties in the war zone are confronted with two choices. If they focus on how to The approach system is primarily con- dodge bullets or how to avoid improvised cerned with pursuing worthwhile life goals, explosive devices so that one can return home such as career success, raising a happy and to enjoy the salary and benefits, they would healthy family, or doing something that live on edge, constantly worrying that the makes a difference in the world. The approach next step might be the fatal one. However, if system is also involved in seeking and creat- their identity is built around a sense a calling pleasant moments, such as enjoying a ing and the honor and pride of serving one’s beautiful sunset or sharing a joke. While en- country, and if the primary focus is on how to gaged in life enhancing activities, one has to complete the patrol duties without an acci- deal with the intrusion of negative thoughts, dent, courage will keep fear at bay. When one such as fear of failure and fear of untimely has found something worth dying for, one death. is no longer afraid of death. The excitement of doing something significant and beautiful Optimal functioning depends on our can be so overwhelming that one is totally ability to confront the negatives and trans- engaged in doing what one loves, leaving no form them in service of the positive goals. room for death anxiety. Thus, whether we fo- This ability can be developed through prac- cus on avoidance or approach will determine tice and training. The positive individuals are how we live and how we die. willing to confront the crisis and create op- portunities for growth. Their tendency is to Death Acceptance Through Meaning- take on the difficult tasks, and risk even death making in order to achieve some significant life goals. They are primarily motivated by their desire The same cognitive capacity that terroriz- to accomplish their life missions, whatever es us about the prospect of death can also res- the risks, because they have found something cue us from this terror. Our capacity of mean- worth dying for. In other words, the sting of ing seeking and meaning making can discover death is swallowed up by the hope and mean- something so beautiful and powerful that ing of positive living. it expels all fears. Elsewhere, I have defined meaning in terms of purpose, understanding, According to this dual-system model, responsibility and enjoyment (Wong, 2010). the best defense is offense. While recognizing I have also described how meaning manage- the value of defensive mechanisms, the model ment theory (MMT) (Wong, 2008) provides www.ExistentialPsychology.org 78 International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010

a conceptual framework to understand death it easier to cope with the traumas and dangers acceptance. Simply put, meaning manage- in combat situations. ment offers us the best protection against fear of death and dying, because other defense Primacy of Death Avoidance vs. Primacy of mechanisms seem inadequate in coping with Quest for Meaning death anxiety (Palmer, 1993). At the same time, meaning management motivates us to According to terror management theory embrace life and do what matters most to (TMT), avoidance of death anxiety is the us. Meaning management is not simply ra- primary motive, and the quest for meaning is tionalization or cognitive reframing, because secondary, because it is triggered by the terror it demands actual transformation of values, of death. According to MMT, the quest for beliefs and life goals. meaning is a primary motive, because we are meaning-seeking and meaning-making crea- Meaning management is involved in tures living in a world of meanings. Meaning both approach and avoidance systems. For is important for both survival and resilience. example, knowing who you are, what really We need to understand and comprehend matters, and why you are in military services what is going on in order to adapt and sur- will give you a sense of purpose and satisfac- vive, but we also need reasons for living when tion even when engaged in the most danger- the situations become very difficult. ous and difficult mission. Meaning-making can also help you rise above what is beyond Both avoidance and approach systems your control and transform fears into faith, are necessary, but an approach life orienta- trust, altruism and courage. tion sets us free to love and work, while an avoidance life orientation condemns us to the A truly transcendental meaning system prison of fear. When we learn to focus on the can lift the person above preoccupations with positives, and accept the inevitable negatives, self-preservation and death anxiety, because we are free to take risks and live vitally. Re- self is lost in something larger. For instance, gardless of the circumstances, a positive bias the psalmist prays: “The Lord will fulfill his always connects us with the forces of life. purpose for me; your love, O Lord, endures forever -- do not abandon the works of your Yalom (2008) recognizes that “Everyone hands” (Psalm 138:8). A sense of purpose and is destined to experience both the exhilaration calling imbues the psalmist’s life with mean- of life and the fear of mortality” (p.273). The ing, but here the responsibility for success no secret is how to keep our mind on life rather longer rests entirely with the individual. There than on death. Kahlil Gibran (1997) expresses is a strong sense of partnership between God this idea well: “It is life in quest of life in and the psalmist. To live or die is to fulfill bodies that fear the grave” (p.104). When the God’s purpose in his life. According to an old human quest for meaning and spirituality oc- saying, “There are no atheists in foxholes.” cupies the center stage, fear of the grave will Soldiers with a strong faith in God may find retreat to the background. Meaning therapy www.ExistentialPsychology.org 79 International Journal of Existential Volume 3, Number 2 Psychology & Psychotherapy December, 2010

(Wong, 2010) attempts to squeeze out every ounce of positive meaning and happiness from the destructive forces of human existence.

Conclusion

One of the objectives of the International Conference on Personal Meaning in 2008 was to illuminate the mystery of death so that the terror and denial of death would give way to enlightenment and death acceptance. The path to death acceptance is often full of twists and turns, mountains and valleys; education and support are needed to go through this difficult process.

The special issue of Death Studies Jour- nal (Wong & Tomer, in press) and the death acceptance papers from the Meaning Confer- ence 2008 published here have brought death acceptance to the forefront of the psychology of death and death education. The conference proceedings, to be published shortly, will further reinforce the message that to live fully, we need to accept death through meaning making. Yes, we can make life better for every one and make this world a much better place to live, only if we can teach people the profound and practical wisdom of death acceptance.

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