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Abstract

The present paper addresses two aims. Firstly, it provides an approach to the psychological process of dying and how to live meaningfully through the last moments of life. Dying is framed from an existential positive perspective based on Frankl's and Wong's theories of meaning in life. These theories propose self-transcendence as the central element of meaning in life. Therefore, the cultivation of self-transcendence when facing death is presented as the best psychological tool against death anxiety. Secondly, the paper focuses on the utility of death awareness to live meaningfully even when we are not dying. A combination of evidence and personal examples are provided to support this approach. Finally, our existential positive research project with cancer patients and undergraduates at the University of Almeria (Spain) is introduced.
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Existential Positive Psychology Proceedings of the 2018 Meaning Conference
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Learning to Live through Death
David F. Carreño
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Abstract
The present paper addresses two aims. Firstly, it provides an approach to the
psychological process of dying and how to live meaningfully through the last
moments of life. Dying is framed from an existential positive perspective based on
Frankl’s and Wong’s theories of meaning in life. These theories propose self-
transcendence as the central element of meaning in life. Therefore, the cultivation
of self-transcendence when facing death is presented as the best psychological tool
against death anxiety. Secondly, the paper focuses on the utility of death awareness
to live meaningfully even when we are not dying. A combination of evidence and
personal examples are provided to support this approach. Finally, our existential
positive research project with cancer patients and undergraduates at the University
of Almeria (Spain) is introduced.
Keywords: dying, death awareness, meaning in life, existential positive psychology, self-
transcendence
Death is one of the biggest taboos in our culture. Everyone agrees that they are going to die one
day, but only a few feel comfortable to talk about their own death. Although it is one of the only
certainties that human beings have, western cultures normally avoid thinking about mortality.
Generally, it is a topic shunned by society, especially hidden from children. For example, when
my little brother was four years old, he revealed to me that he had realised that one day he would
die as his grandparents died. His logic was simple: “If older people die and I will get older, I will
die too.” My natural response to him was, “Yes, you and I will die one day.” But, he wanted to
hear a different response. He broke into tears, saying that he did not want to die. While I was
trying to normalise his emotions, my aunt heard my brother crying and came to see what was
going on. “David told me that one day I am going to die,” my brother complained. My aunt
looked at me as if I was mad and called me stupid in front of my brother. Immediately, my father
joined my aunt to console my brother by telling him that he would never die. So far, several
years later, he has avoided speaking about death again.
Why do we hide death from our children? Is death essentially something bad? Are we
teaching people in our culture how to face their own death? Is there any worthy lesson in death to
be learned? In comparison to many death-affirming eastern societies (Ivtzan, Lomas, Hefferon,
& Worth, 2016; Rinpoche, 1992), why is death a taboo in western culture? The title of this
article—“Learning to Live through Death”—has a dual meaning that will be addressed
throughout the text. Firstly, the article introduces the psychological experience of dying and how
to live meaningfully through the last moments of one’s own life. Secondly, it discusses how
useful death awareness may be to live meaningfully at all life stages.
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University of Almería
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The Psychological Experience of Dying
Dying might be one of the most difficult experiences in life. The feeling of physical incapacity,
pain, and anxiety are common challenges people pass through. Dying can also be considered for
many people to be the end of one’s existence, at least physically and consciously. It is letting go
of important things and loved ones forever. Worries about the unknown afterlife are also
common. Besides, end-of-life is a stage of making a final judgement about one’s life as a whole.
In a self-centered society like the west, dying can be interpreted as the end of everything.
Nowadays, the major difficulty in dying for many people is accepting the end of their self. If the
individual, the self, is the major focus in life, then death will be more likely considered to be the
end of the world, a chaotic border that produces panic. According to Wong (2014), dying will
probably be experienced as meaningless and worthless if the focus of one’s life has been inward,
only towards personal happiness and individual success. This meaningless of death has been
evidenced in terminal cancer patients. According to several studies, many terminally ill cancer
patients suffer from a loss of dignity and meaning in life, which results in the desire for a faster
death. For instance, about 17% of cancer patients report a strong desire to terminate their lives
due to depression, hopelessness, and loss of meaning rather than pain (Breitbart et al., 2000).
Similarly, Chochinov et al. (2002) observed that 47% of patients in their last months of life
reported a loss of a sense of dignity.
However, is death the end of everything? Should our meaning in life be so self-focused?
Human beings are, by nature, spiritual (Frankl, 1984; Wong, 2014). Spirituality is expressed as
the human propensity toward self-transcendence (Wong, 2014). The only way of becoming fully
human is to redirect focus from self-interest to something bigger and beyond ourselves, towards
others (Wong, 2014). Frankl understood that the question about meaning in life and self-
transcendence is intrinsically the same. When we globally speak of one’s meaning in life, we
refer to what is the mission, the function, of the whole of one’s life in a bigger social context,
how to contribute to others (family, community, society).
In his older years, Abraham Maslow incorporated self-transcendence at the top of the
hierarchy of human needs, above self-actualization. What is more, self-actualization can be
considered as a by-product of self-transcendence. Self-actualization is not possible without
transcending the self for a greater cause than oneself (Frankl, 1969/1981; Wong, 2014). From
this perspective, death is not the end of everything, but rather it is the last step in one’s life to
serve a higher purpose. In other words, death may be the most authentic expression of self-
transcendence. It is for that reason that spiritual care and meaning have been considered to be
essential in palliative end-of-life care (Breitbart & Applebaum, 2011; Chochinov, 2006;
Ellershaw & Ward, 2003).
Positive Dying is to Cultivate Self-Transcendence
A Buddhist maxim is that the best way to have a good death is by having had a good life, having
learned how to transcend the ego and accept the impermanence of things (Rinpoche, 1992). A
life dedicated to following personal values, serving others, and contributing to society and
humanity can facilitate a meaningful death. From this view, dying is a final worthy step towards
complete self-transcendence.
Nevertheless, not everyone has lived a meaningful life. Ware (2011) found that the top
five regrets of people in their last days were (1) not having the courage to live a life true to
themselves, (2) working too hard, (3) not having the courage to express their feelings, (4) staying
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distant from loved ones, and (5) not letting themselves to be happier. Those who live an
egotistical life and ignore the consequences of their actions on others more likely will die alone
without social support, suffering from meaningless death. The question here then is, “How can
we have a meaningful death even if we have not lived a meaningful life?” The answer is: there is
still time to be true to oneself and cultivate self-transcendence. The search for meaning is an
ongoing unending process (Wong, 2014). Meaning and purpose can be discovered in one’s life,
regardless of one’s circumstances and health conditions (Frankl, 1984).
Based on Frankl’s Meaning-Seeking Theory, Wong (2014) recognises that the search for
meaning and self-transcendence has three levels: ultimate meaning, situational meaning, and life
review. These three levels of meaning can also be found during end-of-life, of course, in the
cases in which death is a non-accidental, conscious process.
Ultimate Meaning
Ultimate meaning is based on the belief that life has intrinsic meaning and value regardless of
circumstances. During the last days of life, ultimate meaning can be built on the belief that one’s
existence has had an intrinsic purpose and value. When dying, a clarifying question that one
could ask oneself is: “Am I the most important thing in this world, or am I a part of something
bigger and worthier?” To cultivate ultimate meaning in the face of death is to keep faith and to
accept that one is an expression of something bigger like family, society, humanity, God, nature,
or the universe. To find ultimate meaning in death is also to keep the faith that things are going
to be all right after one dies, that one’s death is only one more step towards that higher value.
Situational Meaning
Situational meaning is based on the belief that each moment has potential emotional, relational,
and moral significance. Situational meaning can be found in the courage and acceptance we
adopt towards suffering and death. Dying can be considered to be the final challenge in one’s
life. In Meaning Management Theory, Wong (2007) maintains that the most effective way to
protect oneself against death anxiety is to focus on living a vibrant, meaningful life. The last
moments in life can be used as an opportunity to teach loved ones about one’s learning in life, to
leave one’s legacy in others’ hands, to say goodbye and express love, and to achieve fusion in a
peaceful connection with the rest of the universe. For example, in Buddhism, death is interpreted
as an opportunity for a final meditation through which to achieve fusion with the rest of things
and the final teaching in this life (Rinpoche, 1992). Many people show an exemplar courage and
meaning cultivation when dying to such an extent that they enhance their legacy through their
attitude towards death.
Life Review
Life review consists of assessing the meaning contents of our life as a whole, considering
personal growth until death. When dying, one might remember one’s achievements and failures,
the positive impact on others, the courage maintained under challenging situations, among other
significant life events. This life review can be shared with loved ones to leave a legacy. If
someone realises on his deathbed that he has made many mistakes and harmed others during his
lifetime, there is still the last opportunity to apologize and help others not to make the same
mistakes. As they say, a good way to honour our ancestors is at least not to make the same
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mistakes that they did. It could also be that someone realises on her deathbed that she has not
been true to herself during her life. In this case, she can try to live the death process as a real
encounter with herself. For example, she could express for the first time her deepest feelings to
others, behave authentically, and accept herself by understanding her life circumstances. Self-
transcendence is intrinsically relational (Wong, 2016a); therefore, having others present to
express one’s final message, leaving one’s legacy, behaving in front of loved ones as a model of
positive dying, is the best way to self-transcend (see Chochinov et al., 2011).
An Example of Positive Dying: My Grandfather
My grandfather was a man dedicated to his family and his community throughout his entire life.
He has been a role model in my maternal family: a good person, cultivated, and a promoter of
social values. I had the luck of living with him during my childhood since both of my parents
used to work for long hours. The motivation towards my studies and profession comes from the
enthusiasm of my grandfather for teaching me about his endless anecdotes full of intelligence
and worth. He passed away seven years ago, at the age of 85. His last years and his death were a
great example of courage and self-transcendence.
A few years before dying, when he started to feel that his energy was already lacking, he
wrote his first book. He spent around two years collecting memories about the family history
(starting from his grandparents until his grandchildren), dedicating a book chapter for each of his
relatives, and the significant events that had occurred in the family within the last century. He
could even remember everything that his grandparents had told him when he was a child, such a
prodigious memory. The reason behind writing this book was to leave his legacy before dying in
order to make the family aware of where we came from, of our values and traditions. His
ultimate purpose was to maintain the union and prosperity of all of us. He did not want to keep
any drop of value and knowledge for the great beyond without it being shared with us. Writing
the book was actually a way of creating his great beyond. Actually, each member of the family
has a copy of the book. When any of us experiences an existential crisis, reading my
grandfather’s book helps us to find meaning in life again. It is impossible to forget my
grandfather; in fact, I visit his grave each time when there is a very happy or very dark event in
my life.
In his last days, he showed huge courage and calm towards death. He never showed any
sign of fear or worries about death in front of the family. Although he was aware that death was
knocking on the door, he always said that everything was okay. He wanted to be a role model
until the end. I remember the last one-on-one conversation I had with him. Taking into account
the difficulties that he suffered during the Spanish post-war in order to study and dedicate
himself to his favorite job, I asked him which profession he would have chosen given optimal
conditions, what he was best at, and what his biggest passion was. After a period of silence, he
answered, “Police inspector,” with a huge smile on his face. Surprised at his response, I asked
him why. His second reply was, “Son, I’m very good at understanding how people are, at
analyzing their behavior, I have a good eye for people.” The last words I said to my grandfather
in life were, “You know, Grandpa, that is what I dedicate myself to.” At that moment, his eyes
shrank, looking at me with such beautiful tears.
This is what we refer to when we speak of self-transcendence. Self-transcendence is to
lose yourself in others, in loved ones, for a greater value. I can affirm that I am the extension of
my grandfather, and each person that carries my grandfather’s values is a part of him. At his
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funeral, hundreds of people went to accompany him for the last time. He is the best example of
self-transcendence and positive dying that I have ever known.
Awareness of Death to Live Meaningfully
After reflecting on the psychological experience of dying and how to live meaningfully and
courageously in the last moments of life, we still have a remaining question to answer: Is death
awareness essentially bad? Should we avoid thinking about our own mortality? I will start with
my personal experience.
Since I was a child, I have been interested in death. Questions such as, “What is the
afterlife like? Do ghosts exist? How old will I be when I die?” were frequent during my
childhood. I remember that I used to frighten my friends and family, talking about death and
dead people. It was fascinating to see the intense emotional impact that this topic used to cause. I
have always wondered, “Why do people avoid awareness of something that is so real and so
human?” In my case, the normalization of death has given me a different life perspective. Death
has acted as a mirror in which I could see the person I want to become. The awareness of my
own mortality has clarified what is essential for me in life, how I want to contribute to society,
and how to self-transcend. Before making important decisions, I have always imagined myself
on my deathbed and asked myself if making that decision would make me feel proud of myself
in that scenario. The answer used to immediately appear.
There is evidence showing that people who reject thinking about their own mortality,
without a spiritual perspective, typically live a more superficial life, act more irresponsibly, are
more disconnected from personal values, and generally are less happy and less resilient (e.g.,
Hoelterhoff & Chung, 2017; Holder, Coleman, & Wallace, 2010; Long, 2012; Purdy, 2004;
Taubman-Ben-Ari, 2011; Wong, 2000). On the other hand, the literature about posttraumatic
growth and near-death experiences provides findings about the positive transformation that many
people experience because of death reminders. For instance, in a review of the posttraumatic
growth and illness-related trauma (mainly in cancer) literature, Hefferon, Grealy, and Mutrie
(2009) found that many patients, after their diagnosis, experienced a reappraisal of life and
personal priorities, a stronger sense of themselves, and a new awareness of their own body. Other
quantitative studies have also shown that a significant number of survivors of a life-threatening
illness, survivors of natural disasters, war veterans, and bereaved spouses and parents reported a
positive change in their personal strength, an opening of new possibilities in their lives, a greater
connection with other people, more appreciation of life, and a spiritual change after such events
(Calhoun & Tedeschi, 2006).
Edward M. Forster (1910/2002) wrote: “Death destroys a man, but the idea of Death
saves him” (p. 171). In death, there seems to be a valuable lesson about life, and vice versa. We
cannot learn it if we turn our face away.
Research Project at the University of Almeria
During the last couple of years, we have carried out a research project in this existential positive
line at the University of Almeria in Spain. The project is linked to my doctoral dissertation. The
aim of this research is to produce new empirical evidence and to fill some gaps in the literature
of mortality awareness, posttraumatic growth, and meaning in life. Overall, we want to study the
role of prosociality and death awareness on meaning in life and personal flourishing empirically.
The investigation is directed towards cancer patients and university students, using both
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qualitative and quantitative methodology. Here we only present the three studies included in our
research proposal and some preliminary findings. We expect to publish the results in 2020.
Impact of Cancer on Personal Values
There is evidence showing that a large amount of cancer survivors perceive a posttraumatic
growth related to increased personal strength, new possibilities, more positive relationships to
others, a reappraisal of life priorities, and a positive spiritual change, among others (e.g.,
Cordova et al., 2007; Thornton, 2002). However, a common limitation of these studies has been
the positive bias of the instruments, mainly that of the Post Traumatic Growth Inventory (PTGI;
Tedeschi & Calhoun, 1996). This instrument only collects items with positive sentences about
the trauma. This sentence format can induce patients to ignore the negative aspects of their
illness and respond only under a positive frame. Besides this limitation, there is still a lack of
quantitative studies that show the in-depth impact of cancer on one’s system of personal values.
Specific studies focused on personal values in cancer survivors could help to understand which
specific life areas become a priority for this population, how relationships change specifically
after diagnosis, as well as to explore potential additional values that can be affected by cancer
(e.g., entertainment, community, physical care, social status, benevolence). This understanding
could be used to enhance current psychological treatments for cancer patients.
After an exhaustive search of the literature, we only found one preliminary quantitative
study by Grezsta and Sieminska (2011) aimed to analyse the perceived change in personal values
in cancer patients. This study served as an opening for future quantitative research on value
change, with results in line to those found in previous qualitative studies of cancer patients.
However, the limitations of this study included that the design was cross-sectional, used a limited
retrospective instrument to assess values, did not compare values with other variables (like
meaning in life, psychological well-being, or quality of life), used a very small sample, and did
not include a control group.
Two years ago, we started a quantitative study to fill this gap in the literature. We have
been collecting data related to personal values, meaning in life, quality of life, and mindfulness
from a sample of 200 cancer patients in the main local public hospital. The sample included
terminal, non-terminal, and survivor patients with the aim of exploring differences of value
change depending on the proximity of death. We used several less biased instruments to analyse
in-depth the shift in the system of values after cancer and the relationship of this change with
mindfulness levels and quality of life. These data have been compared with a healthy group.
Our first hypothesis is that the majority of cancer patients experience a shift in several of
their personal values that is related to an increase of values-based actions in their lives. Based on
the literature and our previous experience with this population, we quantitatively explore which
values and sources of meaning are affected after the diagnosis of cancer. We are also interested
in the demographic and clinical factors that influence this phenomenon. The second hypothesis to
test is whether this existential awakening is beneficial and is related to a higher quality of life
and mindfulness levels.
Teaching the Lesson of Cancer Patients to University Students
The decision to do this second study included two reasons. Firstly, the studies about
posttraumatic growth and change in personal values with cancer patients are cross-sectional and
retrospective. Because of the ethical and resource limitations, it is very difficult to assess values
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in patients before the cancer is diagnosed. Longitudinal and experimental studies are necessary to
provide more reliable causal evidence about the psychological impact of cancer. The easiest
thing for us was to simulate a cancer diagnosis experimentally in university students. The second
reason to carry out this study is that we find it important to communicate and teach to our
psychology students the positive aspects of passing through a cancer diagnosis in terms of
existential awareness, prosociality, meaning in life, and authentic living.
Because of these two reasons, with all ethical restrictions and prudence, we designed a
group focusing exercise with undergraduates in order to mentally induce them to imagine their
own cancer diagnosis and to see the impact on their values and actions. Pre/post qualitative and
quantitative assessments during three weeks were applied and compared with a control group.
We also used this experience in the class of psychotherapy for teaching students the importance
of mortality awareness, prosocial behaviors and values, and their role in meaning in life.
Preliminarily, we have observed a short-term phenomenon similar to the one lived by cancer
patients. Our students seem to increase in values-based actions, particularly in areas related to
close relationships and family.
An Existential Positive Intervention in Undergraduates
The third study proposed is an existential positive 5-session group intervention in university
students. In line with our previous studies, this study aims to explore the role of self-
transcendence and prosociality in meaning in life and psychological well-being. We have created
a novel intervention to promote self-transcendence and prosociality directly. The aim is to
evaluate quantitatively and qualitatively whether students benefit from higher levels of meaning
in life and psychological well-being after the intervention. It is also interesting to see whether
participants experience a reduction of psychological distress because of the intervention. The
protocol includes a psycho-educational session introducing the theories of Wong and Frankl
about meaning in life, a group exercise to imagine a cancer diagnosis, open existential questions
applied in individual sessions to induce self-transcendence, and group dynamics promoting
intimacy and prosocial behaviors among the undergraduates. Existential questions and group
dynamics have been inspired in the meaning-centered positive group intervention by Wong
(2016b) and the questions to generate interpersonal closeness by Aron, Melinat, Aron, Vallone,
and Bator (1997). Results will be compared with a waiting-list group. We have found no
controlled intervention aimed to promote meaning in life, specifically through death awareness
and prosociality in intimate relationships. Our results could be revealing of the important role of
these components of meaning in life.
Conclusions
The present article provides an overview of the crucial role of self-transcendence to live and die
meaningfully. We started by discussing the psychological difficulties encountered among people
in western societies to cope with death. Death is a taboo in our culture, and it typically produces
panic. The underlying problem is that if we both promote an egotistical life and avoid mortality
awareness, death is more likely considered as the end of everything, something chaotic, and very
difficult to accept. However, human beings are spiritual by nature (Frankl, 1984; Wong, 2014).
Spirituality is based on the notion of self-transcendence, the striving for a higher purpose beyond
oneself. The cultivation of self-transcendence is fundamental to experience a positive dying. The
best way to have a meaningful death is to have lived a meaningful life. However, the search for
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meaning is an ongoing, unending process (Wong, 2014). Meaning can be discovered in one’s
life, regardless of one’s circumstances and health conditions (Frankl, 1984). Based on this
perspective, different examples were used to explain how the three levels of meaning proposed
by Frankl (ultimate meaning, situational meaning, and life review) can be cultivated in the last
moments of life.
In the second part of the article, we argued that death awareness is a potent tool to live
meaningfully (see also Wong, 2009). The literature provides evidence that mortality awareness
and spirituality is positively related to a higher meaning in life, authentic living, happiness, and
resilience (Hoelterhoff & Chung, 2017; Holder et al., 2010; Long, 2012; Purdy, 2004; Taubman-
Ben-Ari, 2011; Wong, 2000). Besides, people who have suffered traumas and near-death
experiences, such as survivors of a life-threatening illness, survivors of natural disasters, war
veterans, and bereaved spouses and parents, often report experiencing posttraumatic growth. This
growth consists of a stronger appreciation of life, a shift in life priorities, greater connectedness
with others, a stronger sense of self, new awareness of the body, and a positive spiritual change
(Calhoun & Tedeschi, 2006; Hefferon et al., 2009).
Finally, the proposal for our research project from the University of Almeria in Spain was
presented. Three different studies with cancer survivors and university students are proposed to
provide new evidence in the literature about the central role of death awareness and self-
transcendence (or prosociality) in meaning in life and psychological well-being. This project is
the first one of its kind in our department and one of the few in Spain in the area. We hope that
our investigation serves as a call for future studies in this line of research both in Spain and
worldwide. The results are promising.
A combination of experimental psychology with existential humanistic psychology,
including qualitative and quantitative methodology, can help to bring existential humanistic
psychology to a more privileged place in science. Modern psychology is so focused on studying
areas such as the brain, cognition, emotions, and behavior that it is easy to forget what it means
to be human from a holistic perspective. We often forget that humans are spiritual and social by
nature. These two human aspects should play a more central role in positive research and
interventions than they currently do.
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... En relación con la Terapia Centrada en el Sentido, los trabajos que la han fundamentado en su mayoría han sido los realizados con pacientes con cáncer y paliativos (Breitbart, 2017;Carreno, 2018;Grassi et al., 2022;van der Spek et al., 2013). ...
Thesis
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Este estudio exploratorio investiga cómo el sentido de vida influye en el bienestar psicológico de personas con Esclerosis Múltiple (EM). Con una muestra de 121 participantes, se analizó la relación entre el sentido de vida, la resiliencia, la esperanza y la gratitud, y su impacto en la ansiedad, depresión y satisfacción vital. Los resultados sugieren que fortalecer el sentido de vida podría ser clave para mejorar el bienestar psicológico en pacientes con EM, abriendo nuevas vías para enfoques terapéuticos basados en psicología positiva.
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This chapter describes the Meaningful Living Group as a community-based meaning-centered positive group intervention. This group work is informed by existential positive psychology (EPP; Wong, 2010) and Positive Psychology 2.0 (PP2.0; Wong, 2011). More specifically, it consists of introducing 12 important principles of meaningful living in lay people’s terms to participants in the Meaningful Living Group.
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