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Abstract

This paper proposes that the best way to lead a good life is to pursue a life of meaning, virtue, and happiness through self-transcendence. This meaning hypothesis was developed from the perspective of second wave positive psychology (PP 2.0), which sees mature happiness or well-being as situated in the context of suffering and the dark side of human existence. According to this perspective, the only kind of happiness that can be sustained during adversities is mature happiness, which is based on the psychological and spiritual maturity of learning to be at home with oneself, others, and God or the cosmos—whatever the circumstances. This happiness is characterized by inner peace and harmony.

This paper further proposes that the values and attitudes needed to achieve mature happiness consist of courage, acceptance, self-transcendence, meaning, appreciation, and compassion, or CasMac as the acronym. Finally, the paper focuses on the need for existential courage and practical wisdom (life intelligence) to make the right choices in tough situations as the starting point of developing the CasMac way to live well and die well. After identifying seven common fears, the paper proposes several ways to develop courage, such as self-talk, encouragement, and the experience of having overcome fears.

Introduction

We all go through the same sequence in life—birth, aging, sickness, and death—but we differ vastly in our life’s journey. How we react to the demands of our life and circumstances as well as what kinds of decisions we make determine our character and our destiny.

These variations might be due to differences at birth: some were born in privileged families, while some were born poor and unwanted; some were born in peaceful and prosperous countries, while others were born in war-torn and impoverished regions.

There also might be differences in family history, upbringing, education, cultural traditions, availability of opportunities, the economic/political system of one’s country, and the fate that affects one life course. There is so much we do not know scientifically or personally regarding all the factors that make us decide how to choose our path from birth to death. But one thing we do know—we have the freedom and responsibility, no matter how limited, to the best way to live well and die well.

There may be as many answers as individuals. Some choose to be ordinary people, content to live a simple, peaceful life, while others are more ambitious—they want to stand out and live a magnificent and exciting life; some prefer to eat, drink, and be merry, while yet others choose to risk their lives to serve God or humanity.

Professionals have debated for centuries as to the best way to live a good life. I have proposed the meaning hypothesis, namely, pursuing a meaningful life is the most promising way to live a life of virtue, purpose, and happiness, with no major regrets at the time of death (Wong, 2015).

This hypothesis emphasizes that the good life comes from exercising the personal responsibility, even in a totalitarian state, to choose the path of pursuing meaning and self-transcendence. Both common sense and psychological research have shown that this path of pursuing the ideal of loving God and loving people is the most promising pathway towards flourishing for both individuals and society (Wong, 2016a). In this paper, we focus on the need for courage and practical wisdom (life intelligence) to make the right choices at the crucial points in life. In the final analysis, we are the product of our choices, and courage and wisdom are needed to make the tough right choices.

Second Wave Positive Psychology (PP 2.0)

This meaning hypothesis is based on the yin-yang principle of adaptation, which is at the heart of second wave positive psychology (PP 2.0) (Wong, 2011) and existential positive psychology (Wong, 2009a). Yin represents not just the dark side of human existence, but also the passive mode of coping—this includes acceptance, letting go, reframing, endurance, avoidance, retreat, cooperation, assimilation, embracing, re-authoring, and self-transcendence. Yang represents not just the bright side of life, but also the active, energetic mode of coping—this includes problem-solving, goal-striving, acquisition, expansion, overcoming, conquering, aggression, competition, and control. The first wave of positive psychology (PP 1.0) focuses on the Yang aspects of life, whereas PP 2.0 focuses on the co-existence and interaction between yin and yang; thus, PP 2.0 is capable of providing a complete and balanced account of human well-being and happiness under both desirable and undesirable conditions.

Seligman’s (2004, 2011) positive psychology movement has already transformed the landscape of psychology and has left a remarkable impact on all sectors of society, such as education, healthcare, and business management. I propose that in a turbulent time such as ours, PP 2.0, which incorporates humanistic values, existential insights, and Chinese indigenous psychology (Wong, 2011, 2016b; Wong & Roy, 2017; Wong & Tweed, in press) may be more adaptive than PP 1.0, because it stresses the mature happiness of inner peace and harmony (Delle Fave et al., 2016; Wong, 2017a).

My research on Chinese positive psychology (Wong, 2009b, 2016b) and tragic optimism (Wong, 2009c; 2017a) suggests that mature happiness is derived from the spiritual and psychological maturity of discovering the sweet spot between negatives and positives; it is based on acceptance, faith, and inner integration of both the yin and yang elements of life. As such, it may be called noetic or spiritually-based happiness.

The characteristics of mature happiness may be summarised as follows:

  • It is courageous, capable of laughing at the cruel world and a hard fate with defiance.
  • It is spiritual, capable of trusting in God or a higher power for protection, strength, wisdom, and eventual victory.
  • It is optimistic, capable of maintaining hope in hopeless situations and believing that night is followed by day.
  • It is grateful, capable of giving thanks always, counting one’s blessings for being alive, and being grateful for the strengths and lessons gained in adversities.
  • It is content, capable of feeling at home and satisfied no matter the circumstances.

Future research will determine whether such spiritually-based noetic happiness is more enduring and resistant to traumas and disruptions in life as compared to the other two major types of happiness—hedonic and eudaimonic. Research will also show that the meaning-mindset (Wong, 2012), Self-Transcendence Measure (Wong et al., 2017), and spirituality (Daaleman & Frey, 2004) are better predictors of mature happiness than the traditional contributing factors in happiness research.

Seligman said in one of his early newsletters on happiness that “happiness trumps suffering.” At that time, I reacted negatively to this statement, because I believed then that neither hedonic happiness nor eudaimonic happiness could be sustained in times of suffering. Now, after almost two decades of research on well-being, I have finally discovered that mature or noetic happiness can indeed overcome suffering because suffering provides the fertile soil for the growth of meaning, wisdom, courage, and grit; such growth is capable of both transforming suffering and yielding the fruit of joy. The key to deciding the outcome depends on the choice we make: Saying “Yes” to suffering will lead to the positive spiral of resilience and mature happiness, while saying “No” to suffering will lead to the negative spiral of fear of fears.

In view of the recent developments in well-being research and the current social-political milieu, I propose that that the PP 2.0 framework is better able to achieve mature happiness than positive psychology as usual. More specifically, I propose that the following attitudes and values are needed to create mature happiness and a society of justice and compassion where all people can flourish, regardless of their personal identity, economic status, and nationality. This spiritually-oriented alternative model of well-being may be represented by the acronym CasMac:

  1. Courage to embrace the dark side of human existence, make positive changes in our own lives, and stand for what is right according to our innate conscience and the common good.
  2. Acceptance of the bleak reality and what cannot be changed or is beyond our control.
  3. Self-transcendence to overcome or transform setbacks, obstacles, and internal/external limitations in our strivings to make a significant contribution to others.
  4. Meaning-mindset as a lens to look at life as a whole as well as the present situation in order to discover what is good, beautiful, and the right thing to do.
  5. Appreciative attitude towards life and other people, including unpleasant individuals and uncomfortable situations.
  6. Compassion for all people, living things, and oneself.

One can readily see that this CasMac is heavily influenced by Chinese classics on acceptance (Wong, 2009b, 2016b) and research on self-acceptance (Bernard, 2013); Adler’s (1964) teaching on courage for social interest (Yang, Milliren, & Blagen, 2010); Frankl’s emphasis on the pursuit of a meaning-mindset (Wong, 2012) and self-transcendence (Wong, 2016c); and Buddhist teachings on appreciation and compassion (Gilbert, 2009; also see Wong, 2006). Courage is the deciding factor for my meaning hypothesis of the good life.

The Virtue of Courage

Since courage is essential to making the right decisions and cultivating mature happiness, this paper focuses on this very virtue. It is easy to understand why courage is considered a cardinal virtue by Plato, Aristotle, and Confucius. It not only takes courage to live and become our true self, it also takes courage to be liberated from human bondage and all the deterministic forces.

Adler (1931) was the first psychotherapist that made courage the central theme for psychotherapy and meaningful living. His concept is rooted in the primacy of human community and social interest over individual interest. As Yang et al. (2009) has said, “We cannot help but notice that the acts of courage are characterized by selflessness and other-directedness. Courage is an intrinsic life force that allows us to recognize the goal of the common goodness as we seek our own actualization.”

Frankl (1985) demonstrated that the defiant power of the human spirit is essential in surviving the Holocaust and dangerous times. The courage to take a stand against evil powers is needed to preserve human dignity and respect in oppressive situations. The courage to do the right thing based on one’s intuitive conscience is similar to Alder’s social interest criterion.

Courage is considered as one of the six virtues by Peterson and Seligman (2004); it is defined as the “emotional strengths that involve the exercise of will to accomplish goals in the face of opposition, external or internal” (p. 29) and comprises the strengths of bravery, persistence, integrity, and vitality. Seligman (2011) acknowledged that courage is needed to increase one’s likelihood to flourish throughout life.

Unfortunately, the positive psychology research of courage tends to shy away from existential/spiritual issues. Pury, Brawley, Lopez, and Burnett (2016) defined courage as “voluntarily facing personal risk in pursuit of a worthy goal.” According to Pury and Lopez (2010), the fundamental questions addressed in their edited book on courage were: What is courage? How does it come about? How can understanding it improve individual lives, organizations, and society? Existential courage received little attention in their answers to the above questions.

This article focuses on essential courage—the courage “necessary to make being and becoming possible” (May, 1975, p. 4). Growing up, we can all relate to the following kinds of existential courage:

  1. The courage to grow up in the face of an uncertain future and confusing demands.
  2. The courage to live in the face of inevitable sufferings, such as sickness, loss, or death.
  3. The courage to pursue your dreams or life goals despite obstacles, risks, and failures.
  4. The courage to do the right thing and stand up for your values in the face of threats and real dangers.

I believe that Maddi (2004) is the first psychologist to operationally define existential courage in term of hardiness, which consists of the attitude of commitment (vs. alienation), control (vs. powerlessness), and challenge (vs. security). After reviewing available research, Maddi concluded that hardiness can be measured and trained to increase existential courage.

The most comprehensive treatment of courage can be found in Yang et al. (2010). They identify courage as a spiritual concept “similar to the existential thoughts of the will to power” (p. 13). In their words, “To Adler, the will to power is a process of creative energy or psychological force desiring to exert one’s will in overcoming life problems” (p. 12). Courage is also similar to Frankl’s (1985) defiant power of the human spirit.

When people find themselves feeling inadequate, useless, helpless, or meaningless, they can respond with “Yes” or “No” to the situation. If they have no courage, they will resort to avoidance, giving up, addiction, depression, or aggression, which Frankl called the neurotic triad. However, if the existential courage to say “Yes” to a bleak and threatening situation, they will commit themselves to the challenging task of improving themselves and pursue worthy goals that endow their life with a sense of meaning, purpose, and significance.

Frankl (1985) describes such life-changing goals as self-transcendence, while Adler (1964) refers to them as serving social or community interests. In both cases, there is re-orientation away from self-concern to other-directedness. Only in serving and loving others do we find the courage and strength to move on.

Courage unleashes the hidden strength and optimism in us to forge ahead in spite of the dangers, obstacles, and sufferings; courage is an attitude of affirmation, of saying “Yes” no matter what, an attitude that has been steeled by prior experience of overcoming adversities and hardships (Wong & Worth, in press). For courage to be effective, it needs to be guided by life intelligence or practical wisdom regarding what is right and appropriate.

Existential courage consists of the courage to be true to oneself (authenticity), the courage to belong to a group or serve others (horizontal self-transcendence), and the courage to believe and trust in God or a higher power. Such existential courage encompasses the three vital relations and provides the foundation for all courageous actions.

In sum, courage is a matter of the heart and the will. It is an attitude of affirmation and optimism that enables one to have the true grit to strive towards worthy life goals despite all the dangers and oppositional forces. Courage is not only essential for individual survival and thriving, but also for global well-being and world peace. Thus, the hope for individuals and humanity rests in, first, the courage to believe that good will prevail over evil, happiness will trump suffering, life will drive out darkness, and love will heal all wounds, and, second, the courage to act and strive according to these noble beliefs.

Saying “No” to Seven Fears

Fear is an inevitable aspect of human experience; like pain, it has a very important adaptive function. By alerting us to dangers, fear increases our likelihood of self-preservation and eventual adaptive success. However, this all depends on how we react to fear. On one hand, we ignore fear at our own peril; on the other, if we overact, we may be paralyzed. Thus, our reaction needs to be appropriate and wise. When we say “No” to fear, it does not mean denial, avoidance, or escape from the uncomfortable feeling and situation, but a defiant attitude declaring, “I hear you, but I will not let you control or defeat me. I will stare you in the face and go on living as a fully-functioning human being.”

Here, I identify seven common fears to which we need to say “No.”

1. Fear No Death

Fear of death and anything that endangers our lives is the most basic and universal fear. If we do not learn how to accept death as an inevitable aspect of life, it will have numerous undesirable consequences. On the one hand, such fear can prevent us from pursuing our dreams and actualizing our potentials because of perceived dangers and risks. On the other hand, in repressing our death fear, we may be foolish enough to squander our lives away in misguided ambitions, gambling all as if we will never die. A life calculated to deny or avoid death is no life at all. Learning to accept death is the beginning of wisdom to living a meaningful life.

2. Fear No Evil

Bad things happen to all people. No matter how careful, no one can completely escape from natural and human-made disasters or accidents and sickness. Evil, like bacteria or viruses, is everywhere. However, we need to cultivate the courage and wisdom to not only protect ourselves and society against injustice, oppression, poverty, and violence, but also overcome evil with good and non-violent resistance.

3. Fear No People

We learn to fear people because of the bad experiences of having been hurt, abused, or betrayed by others, especially by those we love and trust. Such wounds are difficult to heal, making it difficult for us to trust others. People need people, and we cannot live a full life without them. We cannot go through life hiding behind fortified walls. We cannot win trust when we wear masks and stay at a safe distance. Other people are hell, but when we have the courage to develop trusting and authentic relationships, we will discover that other people are heaven.

We know that the human heart is deceitful, capable of all kinds of evil schemes and traps. We also know that people are capable of spreading innuendo and malicious rumors to ruin. But we cannot worry too much about what others may think or say about us, nor can we worry too much about what harm they may do to us. Once again, the antidote to such fear is the courage and wisdom to discern what is in people and cultivate communal interests despite past disappointments.

4. Fear No Suffering

The first Noble Truth of Buddhism is “life is full of suffering.” Suffering is an essential part of life. It is impossible to avoid suffering and pain. We have to endure pain when we receive dental treatment or undergo surgery. Similarly, we have to endure suffering, when we see a psychotherapist or psychologist to cure our emotional traumas or addiction.

Even without any tragic accidents, for most people, life is a constant struggle in a very competitive society, especially for the disadvantaged and marginalized underclass. Similarly, for most, stress is part of everyday life. We are stressed out when we do not have the resources to cope with life’s many demands.

Fear of suffering does not help us in any way. When we are armed with mental toughness, we are better able to cope with suffering effectively.

5. Fear No Failure

The danger of avoiding failure is worse than failure itself because to achieve anything worthwhile requires learning how to cope with failures. We end up accomplishing nothing when we take too many precautions to avoid failure. Therefore, an important part of parenting and education is to allow our children to experience setbacks and frustration for them to learn character strengths and resilience.

6. Fear No Face-Losing

Chinese people are particularly concerned about losing face when we do not live up to other people’s expectations or standards, or when we are different from others. Fear of losing face encourages conformity and herd mentality; it also prevents us from being true to our values or pursuing our own path. However, we can also manage such fear in an adaptive, positive way. Recently, I wrote an article about the positive psychology of shame (Wong, 2017b) because the fear of humiliation can become an impetus for us to strive towards self-improvement.

7. Fear of Fear

“The only thing we have to fear is fear itself,” said Franklin D. Roosevelt in his First Inaugural Address. Indeed, fear of fears is the worst of all fears, because it leads to a vicious cycle of generating more fears, resulting in generalized anxiety; it also prevents a more positive response. Unless we learn how to regulate these negative and uncomfortable emotions, they will become our masters and tyrants. Only when we learn to say “No” to fear with courage can we respond in a way that facilitates adaptation and success.

No one can avoid the above seven types of fears, but we don’t have live in a self-mad prison, build walls all around us, or hide behind all kinds of masks. The only way we can be free from the adverse effects of fear is when we face them and react in an adaptive way. We can experience inner peace and mature happiness not by avoiding but by overcoming fears.

Ways of Overcoming Fears

The following methods are helpful in cultivating courage and overcoming fear. Courage is not the absence of fears but the act of moving forward despite fears.

1. Self-Talk

Repeatedly tell yourself, (1) I need courage for everything in life; (2) I already have the capacity for courage; (3) I must use my courage to overcome this current crisis. This existential optimism gives people new grounds for hope and action even in seemingly hopeless situations.

2. Confronting and Overcoming Fears

Freedom is at the other end of fears. Even children need to learn how to confront and overcome the fear of difficulty or failure. In cases of paralyzing fears, paradoxical intention—a logotherapy technique—teaches us to confront and embrace our worst fears by exaggerating them to the point of being laughable.

3. Encouraging and Reinforcing Courage

Adler teaches us that the encouragement and reinforcement client’s effort to face their fears can be very effective. Small victories can reinforce the will to face and overcome fears. Also, encouraging students to cooperate with others or engage in collective coping is another way to gain courage.

4. Building Up Resources

Fear often results from a lack of preparation or resources. According to my resource-congruence model of effective coping (Wong, 1993), by cultivating both social capital (relationships, support networks and being part of a community) and psychological capital (education, wisdom, faith, optimism, and courage), we can be more confident and competent in accepting stress as challenges and employing appropriate coping behaviors.

5. Practicing the CasMac Approach

Courage is just one of the six elements of the CasMac model. Whenever we cultivate other elements in CasMac, we also automatically reinforce courage. Together, the CasMac approach enables us to face the demands of life and unexpected disruptions with equanimity and calm joy. Mindful meditation, perspective shift, practicing compassion, and self-transcendence can all strengthen CasMac and lead to achieving mature happiness, whatever the circumstances (Wong, 2016d, Wong, 2017a).

References

  1. Adler, A. (1931). What life should mean to you. New York, NY: Putnam.
  2. Adler, A. (1964). Social interest, a challenge to mankind. New York, NY: Capricorn Books.
  3. Bernard, M. E. (Ed.). (2013). The strength of self-acceptance. New York, NY: Springer-Verlag.
  4. Daaleman, T. P., & Frey, B. B. (2004). The Spirituality Index of Well-Being: A new instrument for health-related quality of life research. Annals of Family Medicine, 2, 499-503.
  5. Delle Fave, A., Brdar, I., Wissing, M. P., Araujo, U., Solano, A. C., Freire, T., … & Nakamura, J. (2016). Lay definitions of happiness across nations: The primacy of inner harmony and relational connectedness. Frontiers in Psychology7(3), doi:10.3389/fpsyg.2016.00030.
  6. Frankl, V. E. (1985). Man’s search for meaning (Revised & updated ed.). New York, NY: Washington Square Press.
  7. Gilbert, P. (2009). The compassionate mind. London, UK: Constable.
  8. Maddi, S. R. (2004). Hardiness: An operationalization of existential courage. Journal of Humanistic Psychology,44(3), 279-298. doi:10.1177/0022167804266101
  9. May, R. (1975). The courage to create. New York, NY: Bantam Books.
  10. Peterson, C., & Seligman, M. E. P. (2004). Character strengths and virtues: A handbook and classification (Vol. 1). New York, NY: Oxford University Press.
  11. Pury, C. L. S., Brawley, A. M., Lopez, S. J., & Burnett, E. A. (2016). Courage. In C. R. Snyder, S. J. Lopez, L. M. Edwards, and S. C. Marques (Eds.) Oxford handbook of positive psychology (3rd ed.). New York, NY: Oxford. doi:10.1093/oxfordhb/9780199396511.013.30
  12. Pury, C. L. S., & Lopez, S. J. (2010). The psychology of courage: Modern research on an ancient virtue. Washington, DC: American Psychological Association.
  13. Seligman, M. E. P. (2004). Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: Simon & Schuster.
  14. Seligman, M. E. P. (2011). FlourishA visionary new understanding of happiness and well-being. New York, NY: Free Press.
  15. Wong, P. T. P. (1993). Effective management of life stress: The resource-congruence modelStress Medicine, 9(1), 51-60.
  16. Wong, P. T. P. (2006). The nature and practice of compassion: Integrating Western and Eastern positive psychologies [Review of the book Compassion: Conceptualizations, research, and use in psychotherapy]. PsycCRITIQUES, 51(25). doi:10.1037/a0002884
  17. Wong, P. T. P. (2009a). Existential positive psychology. In S. J. Lopez (Ed.), Encyclopedia of positive psychology (Vol. 1, pp. 361-368). Oxford, UK: Wiley Blackwell.
  18. Wong, P. T. P. (2009b). Chinese positive psychology. In S. J. Lopez (Ed.), Encyclopedia of positive psychology (Vol. 1, pp. 148-156). Oxford, UK: Wiley Blackwell.
  19. Wong, P. T. P. (2009c). Viktor Frankl: Prophet of hope for the 21st century. In A. Batthyany, & J. Levinson (Eds.), Existential psychotherapy of meaning: Handbook of logotherapy and existential analysis. Phoenix, AZ: Zeig, Tucker & Theisen. (Early version available here.)
  20. Wong, P. T. P. (2011). Positive psychology 2.0: Towards a balanced interactive model of the good life. Canadian Psychology, 52(2), 69-81.
  21. Wong, P. T. P. (2012). What is the meaning mindset? International Journal of Existential Psychology and Psychotherapy, 4(1), 1-3.
  22. Wong, P. T. P. (2015, December). The meaning hypothesis of living a good life: Virtue, happiness, and meaning. Paper presented at the research working group meeting for Virtue, Happiness, and the Meaning of Life Project, University of South Carolina, Columbia, South Carolina. (Supported by the research grant on Virtue, Happiness, and the Meaning of Life from the John Templeton Foundation in support of the humble approach to positive psychology.)
  23. Wong, P. T. P. (2016a). Self-transcendence: A paradoxical way to become your best. International Journal of Existential Psychology and Psychotherapy, 6(1).
  24. Wong, P. T. P. (2016b). Chinese positive psychology revisitedInternational Journal of Existential Psychology and Psychotherapy, 6(1). Retrieved from http://journal.existentialpsychology.org/index.php/ExPsy/article/view/174/157
  25. Wong, P. T. P. (2016c). Self-transcendence: A paradoxical way to become your bestInternational Journal of Existential Psychology and Psychotherapy, 6(1). Retrieved from http://journal.existentialpsychology.org/index.php/ExPsy/article/view/178/141
  26. Wong, P. T. P. (2016d). Integrative meaning therapy: From logotherapy to existential positive interventions. In P. Russo-Netzer, S. E. Schulenberg, & A. Batthyány (Eds.), Clinical perspectives on meaning: Positive and existential psychotherapy (pp. 323-342). New York, NY: Springer.
  27. Wong, P. T. P. (2017a, May 16). Courage, faith, meaning, and mature happiness. Positive Living Newsletter. Retrieved from http://www.drpaulwong.com/inpm-presidents-report-may-2017
  28. Wong, P. T. P. (2017b). The positive psychology of shame and the theory of PP 2.0 [Review of the book The value of shame: Exploring a health resource in cultural contexts.] PsycCRITIQUES, 62(34). doi:10.1037/a0040971
  29. Wong, P. T. P., Peacock, E., Ivtzan, I., Lomas, T., & Kjell, O. (in progress). Self-Transcendence Measure.
  30. Wong, P. T. P., & Roy, S. (2017). Critique of positive psychology and positive interventions. In N. J. L. Brown, T. Lomas, & F. J. Eiroa-Orosa (Eds.), The Routledge international handbook of critical positive psychology. London, UK: Routledge. (Partially supported by the research grant on Virtue, Happiness, and the Meaning of Life from the John Templeton Foundation in support of the humble approach to positive psychology.)
  31. Wong, P. T. P., & Tweed, R. (in press). Positive psychology in North America. In E. C. Chang, C. A. Downey, H. Yang, I. Zettler, & M. Muyan (Eds.), The international handbook of positive psychology: A global perspective on the science of positive human existence. New York, NY: Springer. (Partially supported by the research grant on Virtue, Happiness, and the Meaning of Life from the John Templeton Foundation in support of the humble approach to positive psychology.)
  32. Wong, P. T. P., & Worth, P. (in press). The deep-and-wide hypothesis in giftedness and creativity [Special issue]. Psychology and Education, 54(3/4).
  33. Yang, J., Milliren, A., & Blagen, M. (2010) The psychology of courage: An Adlerian manual of healthy social living. New York, NY: Routledge.

Cite

Wong, P. T. P. (2017, September 29). The courage to live well and die well. Keynote presented at the 2017 Life Education International Academic Conference at the National Taipei University of Nursing and Health Science, Taipei, Taiwan.