I consider the following four issues important for a death and dying workshop and for policy making on palliative care:
1. We Need a Culture of Death Acceptance Rather than Death Denial or Death Avoidance
When I first did research on death attitude in the 80s, I met strong resistance from my department. I could not get ethical clearance until I threatened to appeal to the Ministry of University Affairs, for the lack of academic freedom.
My department’s main objection was based on the fear that participants might be upset by questions regarding death. To me, it was more a projection of their own fear and discomfort with the subject matter of death. I am gratified that my Death Attitude Profile-Revised (DAP-R; Wong et al., 1994) has been used widely with more than 900 citations and translated into many languages. The literature has provided ample empirical support (e.g., Wong & Tomer, 2011; Wong et al., 2018) that cultivating death acceptance is the antidote to death anxiety, which is considered as the “worm at the core of mental health” (Menzies & Menzies, 2018).
There are three types of death acceptance according to Wong et al. (1994) – Neutral acceptance considers death as a biological fact of life; Approach acceptance considers death as a gateway to a better afterlife; and Escape acceptance considers death a better alternative than a miserable existence. Most of the health benefits are associated with the first two types of death acceptance.
Some people still question the need for death acceptance in spite of all the empirical support for its benefits. My answer to these skeptics is that the alternatives are death denial, death avoidance or death anxiety. Death denial may provide the positive illusion that one can enjoy life forever, but sooner or later, the day of rude awakening will come.
2. We Need a Culture of Ending Suffering Rather than Pursuing Happiness
The end of suffering marks the beginning of true happiness, and the single-minded pursuit of happiness is the source of our suffering. There is now increasing evidence regarding the downside of pursuing happiness (Gruber, 2012; Robson, 2021).
For palliative care patients and for people with chronic pain, their primary concern is not happiness but the reduction or end of their pain. I can attest to this because I am still living with aches and pains 24/7. I have also gone through days with excruciating pain; that’s when I discovered the need for mature happiness (Wong & Bowers, 2018).
From the perspective of Buddhist psychology, ending suffering is necessary for happiness and wellbeing because the craving for worldly happiness and the ignorance of the impermanence of life are the major sources of suffering (Hanh, n.d.; Targ & Hurtak, 2006; Thera, 2004). There is much empirical support that mindful meditation reduces suffering (Harvard Health Publishing, 2019; Kabat-Zinn, 1990) and increases health and wellbeing (Davis & Hayes, 2012; Keng et al., 2011).
Likewise, from the perspective of existential positive psychology (EPP; Wong, 2019; Wong, Mayer, & Arslan, 2021), human flourishing comes from overcoming or transcending suffering. Here is my vision of EPP (or PP2.0): Human flourishing is about learning how to end all suffering and enjoy life together by co-creating a better world. This paradigm shift is necessary in view of all the major disasters in the 21st century – 9/11, COVID-19, and now the Russian-Ukraine war that threatens to escalate into a broader conflict.
The positive psychology as championed by Martin Seligman (1995, 2002; Seligman, & Csikszentmihalyi, 2000) may work quite well in times of peace and prosperity, but for those living in pain and terror in the war zone, what they desire more than anything else is an end to bombing and violence so that they can rebuild their broken lives.
The significance of this paradigm shift is that by aiming to eradicate suffering, we are more likely to overcome the systemic problem of poverty, injustice, and discrimination. This demands virtues such as compassion, altruism, justice, and self-transcendence, which serve as an antidote to selfishness, greed, anger, and aggression. In addition, the need for collective coping and collaboration between the government and individuals remind us that each person is just a small part of the huge web of life, and all human beings are interconnected. Thus, individual flourishing is linked to co-creating a kinder and fairer world.
Even at the individual level, the ability to manage the inescapable negative experiences and emotions enables one to have greater likelihood of success in achieving PERMA – positive emotion, engagement, relationships, meaning and accomplishment/achievement (Seligman, 2011) and sustainable wellbeing. The advantage of EPP is that it seeks to navigate a dynamic balance between the Yin of suffering and Yang of happiness simultaneously (Wong, 2012), resulting in mature happiness (Wong & Bowers, 2018).
3. In Terms of Interventions, Meaning and Spiritual are the Two Pillars
Meaning is important for a good death and a good life in many ways: (a) The sense of meaninglessness and absurdity of human existence motivates us to seeking a meaningful life, (b) only meaning can transform suffering and death into positive energy for living, (c) meaning provides a buffer against suffering and death, and (d) suffering is no longer suffering when there is meaning in the suffering, such as suffering seen as a willing sacrifice for a loved one or as a necessary step for reaching a worthy goal. The new science of suffering revolves around the centrality of meaning and self-transcendence.
Spirituality or religiousness is another factor important for good death and good life: (a) It gives us a sense of hope and security in hopeless situations beyond our control, (b) it enables use to connect and access the invisible but powerful spiritual resources, (c) it creates miracles by making impossible things possible, and (d) the fear of God or a higher power provides the necessary deterrent to individuals drunk with power and ambition. There will be fewer Hitlers or Stalins if people fear God more than men.
Integrative meaning therapy (Wong, 2010, 2020) is based on Frankl’s (1949/1986) logotherapy and positive psychology research. The ABCDE intervention is an example of how to become stronger by facing death and suffering with a meaning-mindset and spirituality: A stands for accepting reality with gratitude, no matter how painful it is; B stands for believing in a better future by believing in both self-efficacy and God’s help; C stands for committing oneself to pursuing a worthy life goal; D stands for discovering hidden treasures in oneself, in God, and other people and in God or some higher power, and E stands for enjoying life every moment in a deeper way such as peace and calmness in the midst of a storm.
4. With Respect to Policy Making for Mental Health, Palliative Care, and Education, We Need to Focus on How to Reduce Suffering
This shift in focus is important in addressing poverty, discrimination, and racial injustice as the main cause of suffering, as I have mentioned earlier. Death education should be part of life education because living well and dying well are inextricably connected – you can die well only when you have lived fully without major regrets. The idea of death can save many lives because it teaches people make the best use of their limited time on earth. The reality that the world is full of suffering and overcoming reminds us the need to arm our young people with the mental toughness to embrace the hardships in life as a necessary suffering for survival and thriving.
The present Russian-Ukraine war makes us realize that how important life intelligence (LQ) is. Knowing about how to live and die well is needed for both education and mental health because without any fear of God and any respect for the sanctity or sacredness of life, people can destroy the whole world with nuclear weapons.
As an 85-year-old man, I feel like a lone voice in the wilderness, but I will never stop proclaiming the truth as I see it based on Eastern wisdom and Christian teaching. I will speak until my last breath, even without any recognition from the psychology establishment. I work day and night with aches and pains, 24/7, because I believe that the world needs to understand that what is personal is also universal and vice versa. One cannot really enjoy a banquet when all the people around them are dying of hunger. My last word is: We need to co-create a better world by learning how to stop all suffering and how to live together in peace and happiness.
- Davis, D. M., & Hayes, J. A. (2012). What are the benefits of mindfulness. APA Monitor, 43(7), 64. https://www.apa.org/monitor/2012/07-08/ce-corner
- Frankl, V. E. (1986). The doctor and the soul: From psychotherapy to logotherapy. Second Vintage Books. (Originally published in 1949)
- Gruber, J. (2012, May 3). Four ways happiness can hurt you. Greater Good Magazine. https://greatergood.berkeley.edu/article/item/four_ways_happiness_can_hurt_you/
- Hanh, T. N. (n.d.). The end of suffering. Science and Nonduality. https://www.scienceandnonduality.com/article/the-end-of-suffering
- Harvard Health Publishing. (2019, June 15). Mindfulness meditation to control pain. Harvard Medical School. https://www.health.harvard.edu/pain/mindfulness-meditation-to-control-pain/
- Kabat-Zinn J. (1990). Full catastrophe living: How to cope with stress, pain and illness using mindfulness meditation. Bantam Dell.
- Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: a review of empirical studies. Clinical psychology review, 31(6), 1041–1056. https://doi.org/10.1016/j.cpr.2011.04.006
- Menzies, R. E., & Menzies, R. G. (2018). Death anxiety. The worm at the core of mental health. InPsych, 40(6). https://psychology.org.au/for-members/publications/inpsych/2018/december-issue-6/death-anxiety-the-worm-at-the-core-of-mental-heal
- Robson, D. (2021, January 10). Why it’s time to stop pursuing happiness. The Guardian. https://www.theguardian.com/science/2021/jan/10/why-its-time-to-stop-pursuing-happiness
- Seligman, M. E. P. (1995). The optimistic child. Houghton Mifflin.
- Seligman, M. E.P. (2002). Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. Free Press.
- Seligman, M. E. P. (2011). Flourish: A visionary new understanding of happiness and well-being. Free Press.
- Seligman, M. E. P., Csikszentmihalyi, M. (2000). Positive Psychology: An introduction. American Psychologist, 55(1), 5–14. Doi:10.1037/0003-066x.55.1.5.
- Targ, R., & Hurtak, J. J. (2006). The end of suffering: Fearless living in troubled times…or, how to get out of hell free. Hampton Roads Publishing.
- Thera, N. (2004). Why end suffering? Access to Insight. https://www.accesstoinsight.org/lib/authors/nyanaponika/whyend.html
- Wong, P. T. P. (2010). Meaning therapy: An integrative and positive existential psychotherapy. Journal of Contemporary Psychotherapy, 40(2), 85-93. https://doi.org/10.1007/s10879-009-9132-6
- Wong, P. T. P. (2012). Toward a dual-systems model of what makes life worth living. In P. T. P. Wong (Ed.), The human quest for meaning: Theories, research, and applications (2nd ed., pp. 3-22). Routledge.
- Wong, P. T. P. (2019). Second wave positive psychology’s (PP 2.0) contribution to counselling psychology. Counselling Psychology Quarterly [Special Issue]. https://doi.org/10.1080/09515070.2019.1671320
- Wong, P. T. P. (2020). Existential Positive Psychology and Integrative Meaning Therapy. International Review of Psychiatry. Doi:10.1080/09540261.2020.1814703
- Wong, P. T. P., & Bowers, V. (2018). Mature happiness and global wellbeing in difficult times. In N. R. Silton (Ed.), Scientific concepts behind happiness, kindness, and empathy in contemporary society. IGI Global.
- Wong, P. T. P., & Tomer, A. (2011). Beyond terror and denial: The positive psychology of death acceptance [Editorial]. Death Studies, 35(2), 99–106. https://doi.org/10.1080/07481187.2011.535377
- Wong, P. T. P., Carreno, D. F., & Gongora Oliver, B. (2018). Death acceptance and the meaning-centered approach to end-of-life care. In R. E. Menzies, R. G. Menzies, & L. Iverach (Eds.), Curing the dread of death: Theory, research, and practice (pp. 185-202). Australian Academic Press.
- Wong, P. T. P., Mayer, C.-H., & Arslan, G. (2021). Existential Positive Psychology (PP2.0) and the New Science of Flourishing Through Suffering [Editorial]. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyg.2021.800308/full
- Wong, P. T. P., Reker, G. T., & Gesser, G. (1994). Death Attitude Profile – Revised: A multidimensional measure of attitudes toward death. In R. A. Neimeyer (Ed.), Death anxiety handbook: Research instrumentation and application (pp.121-148). Taylor and Francis.
Wong, P. T. P. (2022 March 14). My Conversation with the National Institute of Aging regarding their Death and Dying Workshop [Invited Talk]. US National Institute on Aging. http://www.drpaulwong.com/national-institute-of-aging-death-and-dying-workshop