International Journal of Existential Psychology and Psychotherapy, Vol 3, No 2 (2010)

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Meaning Making and the Positive Psychology of Death Acceptance

Paul T. P. Wong

Life is what lies between birth and death. What makes this journey so difficult is that from the very outset, life moves relentlessly towards death like an unstoppable train racing towards a crushing end.

Nothing in life can really prepare us for the inevitable and singular event of personal death. The human mind is not capable of comprehending the full enormity and the horror of biting the dust after a lifelong struggle to make life enjoyable. How can the mind defend itself against its own capacity to foresee one’s own demise?

Confucius said: “If we don’t know life, how can we know death?” But I say: “If we don’t know death, how can we know life?”

We cannot even begin to understand the meaning of life, until we stare at death unflinchingly. Paradoxically, death holds the key to life. We cannot truly live without awareness of life’s inevitable end. How can we live fully and vitally, if we spend a life time running away from death? In a strange way, life is defined by its fragility and finiteness, and death holds the key to authentic living. Only fools live as if there is no tomorrow. Only fools think that they can avoid death anxiety by immersing themselves in pursuing pleasures and worldly success.

Death is like an unfathomable black hole, capable of destroying all our dreams, achievements, and happiness. But at the same time, the idea of death can save many lives by challenging us to fill the huge void by living a life of significance. The challenge for psychologists and death educators is to discover pathways to death acceptance. This essay focuses on meaning-making as a promising way to free us from the terror of death to self-actualization.

The Terror of Death

Death remains the biggest threat as well as the greatest challenge to humanity. It is the single universal event that affects all of us in ways more than we care to know (Greenberg, Koole, & Pyszczynski, 2004; Wass & Neimeyer, 1990; Yalom, 2008).

Because of the unique human capacity of meaning-making and social construction, death has evolved into a very complex and dynamic system, involving biological, psychological, spiritual, societal and cultural components (Kastenbaum, 2000). Whatever meanings we attach to death may have important implications for our well being. Thus, at a personal level, death attitudes matter: Death defines personal meaning and determines how we live (Neimeyer, 2005; Tomer, 2000; Tomer, Eliason, & Wong, 2008).

From a larger perspective, death attitudes also play a vital role in national security: Death defying suicide bombers have changed the landscape of geopolitical warfare, and victory in the war on terror depends in part on our ability to live with death threat and our willingness to accept the ultimate sacrifice in defending our freedoms.

In the post 9/11 era, the ever present threat of terrorist attacks has injected into our collective awareness the unpredictable nature of mortal danger and mass destruction. In a wired global village, our death attitudes are further affected by the 24-hour news coverage of natural and men-made disasters around the world, from catastrophic earthquakes to genocides, from scenes of corpses on Haiti streets to images of carnage in Iraq and Afghanistan.

Death has invaded our living rooms in gory details on a daily basis. Our passive acceptance of the endless coverage on carnage and atrocity betrays a love-hate relationship with death – we are simultaneously repelled by its terror and seduced by its mysteries. The popular appeal of violent video games and Hollywood horror movies provides further proof of our morbid fascination with death. In short, our relationship with death is more complicated than we realize; a complete psychology of death needs to move beyond terror and denial to studying our multifaceted relationships with death.

The above development also raise questions about the effects of over-exposure to images and messages of death. Does it desensitize us to the terror of death and make us more tolerant of violence? Does it trivialize the human tragedy of senseless killings? Does the prevalence of mortality salient images overtax our psychological defense mechanisms? Or, does our familiarity with the Grim Reaper make it easier for us to face our own demise? Whatever the answer, death has moved from its dark closet into the glaring light of public space. Lifting the taboo may have paved the way for death to emerge as a popular subject for both psychological research and public death education.

From Death Denial to Death Acceptance

In spite of its pervasive and profound impact and its power to engage the human minds since antiquity, death remains shrouded in mystery— an imponderable, blinding reality that is at once terrorizing and tantalizing.

All through history, human beings have developed elaborate defense mechanisms against the terror of death both at the individual and cultural levels. We now have a huge literature on death denial and terror management (Pyszczynski, Greenberg, & Solomon, 2002).

The medical profession has made it its mission to keep death at bay and save lives. When death occurs, it is often viewed as a failure of medicine or the attending physician. An aversion towards death also makes it difficult for physicians to communicate the “bad news” to patients and their family members in an honest and caring manner.

At the cultural level, death also makes its ubiquitous presence felt in a broad spectrum of social functions, from family, religion, and entertainment to medical care (Kearl, 1989). How we relate to our own mortality is in turn mediated by family, society and culture (Kastenbaum, 2000). All human activities are framed by death anxiety and colored by our collective and individual efforts to resolve this inescapable and intractable existential given.
All our defenses fall apart, when death sneaks up on us, often unexpectedly. The death of a loved one, a near fatal accident, or life-threatening illness can stop us in our track and thrust death right in our faces. The predicament of patients with terminal illnesses brings to sharp focus the critical issue of how to confront and accept personal mortality with courage, serenity and hope. When does one give up the heroic but futile battle against cancer and accept the inevitable outcome with serenity? On a personal level, how do we react when we receive the bad news that cancer has reached the final stage. As a cancer survivor, this question is never too far from my mind.

In sum, we cannot live indefinitely in a culturally and psychologically induced state of denial. The fact is that death is all around us, above us, below us and inside us. Death is you and death is me. Death lies dormant in every human being. We all need to confront the unsettling reality of personal mortality, the sooner the better. There are numerous reasons for embarking on this exploration of death acceptance.

Firstly, we cannot live authentically and meaningfully without embracing death. So much wasted time, self-inflicted miseries and human tragedies happen because of greed, envy, and misguided ambitions. Addiction, depression and aggression can also be related to desperate attempts to escape meaninglessness and death anxiety. Therefore, we all need to come to our senses and consider our destiny. To be prepared for this eventuality enables us to live wisely and die without regrets.

Secondly, there are cultural as well as individual differences in death attitudes. Our understanding of the good death and our preferred pathways to death acceptance may impact how we address various end-of-life issues.

Thirdly, research on the good death constitutes a new frontier of the current positive psychology movement. The interdependence between living and dying well makes it an important topic for advancing the scientific study of the good life.

Finally, we need to learn how to talk about death in a way that is liberating, humanizing and life-enhancing. We hope that through an increased understanding of death acceptance, we may learn to treat each other with respect and compassion not only in the medical context but also in daily interactions.

The Different Meanings of Death Acceptance

Elisabeth Kuber-Ross (1969, 2009) was largely responsible for making death a legitimate topic for research and medicine. Her stage-model of coping with death (denial, anger, bargaining, depression and acceptance) has left a lasting impact on our understanding of the psychological reactions to death. She has identified some defense mechanisms (denial and bargaining), and negative emotional reactions (anger and depression) involved in coming to terms with the reality of death. In the final stage, denial, fear and hostility give way to embracing the inevitable end. Her sequential stage concept has been widely criticized. For example, Bonanno (2009) has recently found that in coping with bereavement, most people can come to death acceptance without going through the previous stages; however, that does not mean the absence of inner struggles with the complex emotions involved in bereavement. Only direct research on death acceptance will reveal the pathways and mechanisms of coming to terms with death in a constructive way.

In the last fifty years, the psychology of death has been dominated by research on death anxiety (Kastenbaum, 2000; Neimeyer, 1994a, b) and terror management theory (Pyszczynski, Greenberg, Solomon,1999; Solomon, Greenberg, & Pyszczynski, 2004). There was only a scant literature on death acceptance. Ray and Najman (1974) were the first ones to develop a new scale to measure death acceptance, and found that it had a small but significant positive correction with two death anxiety scales. The discovery of the co-existence of death anxiety and death acceptance is important because it reveals a basic ambivalent and conflicted attitude towards death: It is never easy to resolve the issue of death anxiety regarding our personal demise. No matter how remote and vague, the prospect of death of self or a loved one will always be unsettling because it disrupts the flow of life as we know it. However, a well developed system of death acceptance can keep death anxiety at bay and prevent it from interfering with our daily functioning.

About two decades ago, when my associates and I undertook a comprehensive study of death acceptance, we were met with resistance from both within our own psychology department and rejection from journal editors as if death acceptance were not worthy of research. Eventually, we were able to publish our research findings (Gesser, Wong, & Reker, 1987-88). In addition to death fear and death avoidance, we identified three distinct types of death acceptance: (1) Neutral death acceptance – facing death rationally as an inevitable end of every life, (2) Approach acceptance – accepting death as a gateway to a better afterlife, and (3) Escape acceptance – choosing death as a better alternative to a painful existence. The Death Attitude Profile (DAP) was later revised as DAP-R (Wong, Reker, & Gesser, 1994). Both scales have been widely used and evidence is accumulating regarding the validity and reliability of DAP (Gesser et al., 1987-1988) and DAP-R (Wong at al., 1994). For example, Neimeyer, Moser and Wittkowski (2003) confirm that DAP-R remains the main instrument to assess death acceptance.

Three Types of Death Acceptance

Approach acceptance is rooted in religious/spiritual beliefs in a desirable afterlife. For those who embrace such beliefs, afterlife is more than symbolic immortality, because it typically associates with theistic religious faith or belief in a transcendental reality. Approach acceptance is based on the social construction of life beyond the grave, thus, offering hope and comfort to the dying as well as the bereaved. More specifically, Harding, Flannelly, Weaver, and Costa (2005) reported that scales that measure Belief in God’s existence and Belief in the Afterlife were both negatively correlated with death anxiety but positively correlated with death acceptance.

Escape acceptance is primarily based on the perception that life is so painful and miserable that death offers a welcome relief. Suicide and assisted suicide are expressions of Escape acceptance. Cicirelli (2006) observed that when individuals experience intractable pain or loss of function, they want to end their own lives. In such cases, the terror of death seems less fearful than the terror of living.

The construct of neutral acceptance needs closer examination. Clements and Rooda (1999-2000) examined the factor structure, reliability, and validity of DAP-R using a sample of 403 hospital and hospice nurses. They were able to replicate four of the five factors reported by Wong et al. (1994): Fear of Death, Death Avoidance, Approach Acceptance, and Escape Acceptance. However, the items which loaded on the Neutral Acceptance subscale were split across two factors. This finding seems to suggest that the Neutral Acceptance subscale may measure different pathways to death acceptance without believing in an afterlife. For example, some may be resigned to the fact that death is simply a biological fact of all living things, while others may feel that they are ready to die because they have completed their life mission and left a worthy legacy. In fact, Cicirelli (2001) has identified four different Personal Meanings of Death: Extinction, Afterlife, Motivator and Legacy. Belief in Afterlife is similar to Approach Acceptance; Extinction, Motivator and Legacy can all come under the umbrella of Neutral Acceptance.

The Dual-System Model

Imagine yourself a marine serving in Afghanistan. Knowing that every time you are on patrol, you and your fellow soldiers could be blown to pieces by an improvised explosive device, how would you manage the constant death threat and carry out the dangerous mission? How would you maintain a positive attitude towards life in this environment? Any professional soldier knows that it does not pay to live in terror everyday, because excessive fear will reduce your combat effectiveness and increase the likelihood of getting killed. He would reveal that the best one can do in such a dangerous situation is to accept the dangerous situation and live as normally as you can. Wong’s (2010) dual-system model of achieving the good life provides a useful conceptual framework to manage the co-existence of death acceptance and death fear.

According to this model, one needs to depend on the cooperation and interaction between approach and avoidance systems. These two complementary tendencies represent two different motivations and life orientations. The defensive tendency to avoid pain, suffering, dangers, anxieties and death, serves a protective function. It is the tendency to seek security and self-preservation in a chaotic and often dangerous world. It involves both unconscious and conscious defense mechanisms to safeguard our psychological and physical integrity. It also involves coping behaviors to reduce the threat and negative affective reactions. Those who prefer a defensive stance would be very cautious and timid, afraid of making changes or taking risks. But we cannot experience the positive aspects of life if we live in constant fear and anxiety.

The approach system is primarily concerned with pursuing worthwhile life goals, such as career success, raising a happy and healthy family, or doing something that makes a difference in the world. The approach system is also involved in seeking and creating pleasant moments, such as enjoying a beautiful sunset or sharing a joke. While engaged in life enhancing activities, one has to deal with the intrusion of negative thoughts, such as fear of failure and fear of untimely death.

Optimal functioning depends on our ability to confront the negatives and transform them in service of the positive goals. This ability can be developed through practice and training. The positive individuals are willing to confront the crisis and create opportunities for growth. Their tendency is to take on the difficult tasks, and risk even death in order to achieve some significant life goals. They are primarily motivated by their desire to accomplish their life missions, whatever the risks, because they have found something worth dying for. In other words, the sting of death is swallowed up by the hope and meaning of positive living.

According to this dual-system model, the best defense is offense. While recognizing the value of defensive mechanisms, the model maintains that the most effective way to protect oneself against death anxiety is to focus on the immediate task and live a meaningful life.

According to this model, soldiers on patrol duties in the war zone are confronted with two choices. If they focus on how to dodge bullets or how to avoid improvised explosive devices so that one can return home to enjoy the salary and benefits, they would live on edge, constantly worrying that the next step might be the fatal one. However, if their identity is built around a sense of calling and the honor and pride of serving one’s country, and if the primary focus is on how to complete the patrol duties without an accident, courage will keep fear at bay. When one has found something worth dying for, one is no longer afraid of death. The excitement of doing something significant and beautiful can be so overwhelming that one is totally engaged in doing what one loves, leaving no room for death anxiety. Thus, whether we focus on avoidance or approach will determine how we live and how we die.

Death Acceptance Through Meaning-making

The same cognitive capacity that terrorizes us about the prospect of death can also rescue us from this terror. Our capacity for meaning seeking and meaning-making can discover something so beautiful and powerful that it expels all fears. Elsewhere, I have defined meaning in terms of purpose, understanding, responsibility and enjoyment (Wong, 2010). I have also described how meaning management theory (MMT) (Wong, 2008) provides a conceptual framework to understand death acceptance. Simply put, meaning management offers us the best protection against fear of death and dying, because other defense mechanisms seem inadequate in coping with death anxiety (Palmer, 1993). At the same time, meaning management motivates us to embrace life and do what matters most to us. Meaning management is not simply rationalization or cognitive reframing, because it demands actual transformation of values, beliefs and life goals.

Meaning management is involved in both approach and avoidance systems. For example, knowing who you are, what really matters, and why you are in military services will give you a sense of purpose and satisfaction even when engaged in the most dangerous and difficult mission. Meaning-making can also help you rise above what is beyond your control and transform fears into faith, trust, altruism and courage.

A truly transcendental meaning system can lift the person above preoccupations with self-preservation and death anxiety, because self is lost in something larger. For instance, the psalmist prays: “The Lord will fulfill his purpose for me; your love, O Lord, endures forever -- do not abandon the works of your hands” (Psalm 138:8). A sense of purpose and calling imbues the psalmist’s life with meaning, but here the responsibility for success no longer rests entirely with the individual. There is a strong sense of partnership between God and the psalmist. To live or die is to fulfill God’s purpose in his life. According to an old saying, “There are no atheists in foxholes.” Soldiers with a strong faith in God may find it easier to cope with the traumas and dangers in combat situations.

Primacy of Death Avoidance vs. Primacy of Quest for Meaning

According to terror management theory (TMT), avoidance of death anxiety is the primary motive, and the quest for meaning is secondary, because it is triggered by the terror of death. According to MMT, the quest for meaning is a primary motive, because we are meaning-seeking and meaning-making creatures living in a world of meanings. Meaning is important for both survival and resilience. We need to understand and comprehend what is going on in order to adapt and survive, but we also need reasons for living when the situations become very difficult.

Both avoidance and approach systems are necessary, but an approach life orientation sets us free to love and work, while an avoidance life orientation condemns us to the prison of fear. When we learn to focus on the positives, and accept the inevitable negatives, we are free to take risks and live vitally. Regardless of the circumstances, a positive bias always connects us with the forces of life.

Yalom (2008) recognizes that “Everyone is destined to experience both the exhilaration of life and the fear of mortality” (p. 273). The secret is how to keep our mind on life rather than on death. Kahlil Gibran (1997) expresses this idea well: “It is life in quest of life in bodies that fear the grave” (p. 104). When the human quest for meaning and spirituality occupies the center stage, fear of the grave will retreat to the background. Meaning therapy (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 Journal (Wong & Tomer, in press) and the death acceptance papers from the Meaning Conference 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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