For much of its 125-year history, psychology, the study of human behavior, could not find a place for death and dying among the topics that it considered worthy of scientific attention. Although psychology was derived from philosophy, a system that gives death a central role in shaping human thought and conduct, early on there was a schism between those who wanted to study behavior from an experimental, physiological perspective and those who wanted to keep a broader, person-based focus. In Europe during the late 1800s, experimental psychology was advanced by such pioneers as Wilhelm Wundt, Francis Galton, and Alfred Binet, and in the United States by E. L. Thorndike, G. Stanley Hall, James McKeen Cattell, and John Dewey. A more encompassing, holistic approach was advanced in Europe by Sigmund Freud and in America by William James.
With late-nineteenth-century science dominated by Charles Darwin's theory of evolution, it was perhaps inevitable that the fledgling science of psychology steered itself toward the experimental, psychophysiological side of investigation and away from philosophy. Although there were voices in the field hinting at the importance of death for understanding human behavior, psychology as a whole paid little attention.
Logical positivism, a method of inquiry that rejects transcendental metaphysics and requires as proof verifiable consequences in experience, held center stage in psychology until the events of World War II fundamentally changed the way psychologists considered their task. Many of the early experimental theories of behavior emphasized evolutionary (genetic) determinism. However, nothing in the psychologist's laboratory manual could predict or explain the wholesale human destruction of two world wars in fewer than thirty years. Science the savior turned out to be the specter of death in the guise of Nazi Germany and the atomic bomb.
In the wake of World War II, psychology turned its attention to social and organizational behavior, as well as to explanations of racism and violence in the development of malignant personality patterns. It was again willing to consider philosophical approaches to behavior that emphasized the whole person. Logical positivism was eclipsed by existential and humanistic philosophies that grappled with the nature of humanity and the meaning of behavior.
In this context, psychology's first organized approach to death was a symposium titled "The Concept of Death and Its Relation to Behavior," chaired by clinical psychologist Herman Feifel and presented at the 1956 annual meeting of the American Psychological Association in Chicago. The symposium served as the basis for the 1959 book The Meaning of Death, edited by Feifel, which is widely recognized as the single most important influence in galvanizing what has since become the multidisciplinary field of thanatology (the study of death, dying, and bereavement).
During the two decades that followed publication of Feifel's book, psychologists began to fully participate in the thanatological community by making important contributions to theory, research, education, and service delivery. Empirical and clinical advances were made in understanding how people construct their ideas and attitudes about death, how ideas about death change from childhood through old age, the nature and meaning of death anxiety, the biological basis of attachment and grieving, and why people commit suicide. Psychologists such as Daniel Leviton and Robert Kastenbaum helped spearhead the death education movement, and the latter built one of the first university centers devoted to the study of death at Wayne State University in Detroit, Michigan. Two of the premier research journals devoted to this topic area were created by psychologists: Omega: The Journal of Death and Dying edited by Robert Kastenbaum, and Death Education, now called Death Studies, edited by Hannelore Wass.
The last two decades of the twentieth century saw a maturing of the field of thanatology, the role played by psychologists in shaping the future of death studies, and the treatment of dying and bereaved persons. During this time psychologists were at the forefront in research on death attitudes and death anxiety; coping with life-threatening illnesses such as cancer, heart disease, and AIDS; grief and bereavement; and the study of suicide. Psychologists helped build and staff hospices for terminally ill patients. Many colleges and universities hired psychologists who made death studies a major focus of their work as part of an expansion of research and coursework in thanatology for students in developmental, clinical, counseling, and school psychology programs.
Empirical and Clinical Findings
From its inception, thanatology has been a multi-disciplinary field encompassing anthropology, education, medicine, nursing, philosophy, psychiatry, religion, social work, sociology, the arts, and the humanities. In contrast to this ecumenical trend, research on death attitudes and death anxiety has been conducted mostly by psychologists. Perhaps this is why the literature has shown a strong focus on methodological issues rather than broader sociocultural and applied concerns. By 1995 there were more than 1,000 published studies in this field that addressed diverse subjects, including children, adolescents, adults, the elderly, and the mentally ill. Almost all of these studies involved descriptive, atheoretical, single-assessment designs and used self-report questionnaires. In spite of the limitations inherent in these studies, four themes have emerged from their findings:
- Most people think about death to some extent and report some fear of death, but only a small subset exhibit a strong preoccupation with death or fear of death.
- Women consistently report more fear of death than men, but the difference is typically minor to moderate.
- Fear of death does not increase with age among most people.
- When considering their own death, people are more concerned with potential pain, help-lessness, dependency, and the well-being of loved ones than with their own demise.
Studies have also demonstrated that fear of death is not a unidimensional variable. Various subcomponents are evident in fear of a painful or unpleasant afterlife, fear of the unknown, and fear of a loss of dignity or individuality. In addition, some research has shown that fear of death may take different forms on the conscious and unconscious levels. For example, low levels of self-reported death anxiety may be an outright aversion and avoidance at an unconscious level.
Death possesses many meanings for people and is an important psychological element for all persons, not just the elderly, dying persons, and those facing potential death in their daily activities (e.g., military and police). People think about death and experience the deaths of others throughout life. Adult conceptions of death can be quite complex and involve multiple abstractions, among them the concepts of futurity, inevitability, temporal uncertainty, universality, personal inclusion, and permanence. As humans develop from early childhood into adulthood, their ability to think abstractly also increases. Research has confirmed that among children and adolescents, comprehension of death is related to general levels of cognitive development and personal experiences with death-related phenomena.
The pioneering work of the Hungarian psychologist Maria Nagy identified three stages of development in children's ideas about death. In children from three to five years old she found great curiosity about death and a widespread view of death as a separation where the dead are not as alive as the rest of us but can come back to normal living status. From ages five to nine children begin to understand that death is final but they persist in believing that one might avoid it. Death also becomes personified at this age. From age nine into adulthood there is recognition of death as personal, universal, final, and inevitable.
Research on the death attitudes of children and adolescents demonstrate that they must not be shielded from knowledge of death and should be included in discussions about death at appropriate times. Even the youngest children are aware of separation and its threat to their well being. Young people are inquisitive about death. Adults who exclude children from death-related conversations and experiences do them a disservice by removing them from important sources of information and thus reinforcing anxiety and fear. Adults who wish to participate in educating their children about death must be aware of their own attitudes and values, be prepared to share their feelings and experiences, and serve as models for a healthy appreciation of the importance of death.
Treatment of the Dying and Bereaved
Medical advances have extended the human life span, yet created a growing population of persons (particularly the elderly) who die with chronic diseases. Too often the focus of professionals has been on the physical disease rather than the experiences of the victims. Both clinical and research findings underscore that dying is not just a biological process but also a psychological one. There is an essential need for open and honest communication between the dying person, health-care providers, family, and friends.
The attitudes and fears of caregivers strongly influence the way in which they view and treat the dying and bereaved. Most dying persons and their families want to be apprised of the processes of death, communicate about death and its consequences, and be included in decision-making as it applies to treatment and end-of-life issues. Unless health-care providers can become aware of their own feelings and attitudes, receive education about dying and grief, and become comfortable with the knowledge of death as a multifaceted process that has many derivatives and outcomes, their patients will often be ill-served or even harmed.
The psychiatrist Elisabeth Kübler-Ross conceived a five-stage model of dying and grief that has helped to increase death awareness in the general public and has spawned numerous research investigations. She proposed that as individuals respond to awareness of impending death (their own or that of a loved one), they move through stages of denial, anger, bargaining, depression, and acceptance.
Empirical and clinical investigations inform us that grief unfolds in many different ways and demonstrates not weakness but rather a necessary and deep human need most of us have in reacting to the loss of our own life and that of a loved one. Hard data do not support the existence of stages or schedules through which all persons move as they experience and respond to death. For example, studies of Kübler-Ross's model have shown a simultaneity, omission, or reversal of stages in some individuals.
Because of a lack of precise clinical criteria, healthy and unhealthy grief can be difficult to distinguish. Hence practitioners must be cautious in encouraging survivors to abandon grief prematurely or to wallow in it. They must be alert to signs of personal denial, avoidance, or antipathy among the dying and bereaved so that meaningful interventions can be considered early enough to have the greatest positive impact.
Current and Future Directions
Among the areas of current interest and importance to psychologists are the development of comprehensive theories of dying and bereavement; studies of death and dying among children; theory-based, experimental, longitudinal, and cross-cultural investigations of how death attitudes are related to diverse human behaviors; and development of empirically-validated models and methods for treating the dying and bereaved.
Although thanatology is still waiting for a compelling, realistic framework for understanding death, progress is being made by psychologists in conceptualizing dying and bereavement. People in the field have moved away from viewing grief as a series of predictable stages to seeing it from a task-based perspective. Charles Corr identified four dimensions of tasks: physical, psychological, social, and spiritual. Kenneth Doka suggested a five-phase model of life-threatening illness: prediagnostic, acute, chronic, terminal, and recovery. Clinical psychologist Therese Rando advanced the concept of anticipatory grief to include not only one's reactions to an impending death but also all of the losses experienced throughout one's life. Robert Neimeyer, clinical psychologist, and colleagues have developed their view of bereavement as a task of meaning reconstruction. Robert Kastenbaum has argued for a life-span-developmental approach to death and dying that incorporates a biopsychosocial perspective, stressing an awareness of what anthropologists call etic and emic frames of reference; that is, viewing death from the outside (as observer) and inside (from the point of view of the dying person). He has drawn attention to deathbed scenes as a way of developing a more complete understanding of dying at what is arguably the single most critical point in the process. The social psychologists Tom Pyszczynski, Jeff Greenberg, and Sheldon Solomon applied terror management theory to the fear of death. They argued that a wide variety of behaviors, many of them seemingly unrelated to death, guard against conscious and unconscious fear of personal death.
Since 1956 psychology has moved from its original ostrich approach to death to a recognition of death studies as among the most important in the field. The bounty of books and hundreds of research articles published each year portend a continued flourishing of thanatology in the twenty-first century.
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Kastenbaum, Robert. The Psychology of Death, 3rd edition. New York: Springer, 2000.
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Neimeyer, Robert A., and David Van Brunt. "Death Anxiety." In Hannelore Wass and Robert A. Neimeyer eds., Dying: Facing the Facts, 3rd edition. Philadelphia: Taylor & Francis, 1995.
Pyszczynski, Tom, Jeff Greenberg, and Sheldon Solomon. "A Dual-Process Model of Defense against Conscious and Unconscious Death-Related Thoughts: An Extension of Terror Management Theory." Psychological Review 106 (1999):835–845.
Rando, Therese A., ed. Loss and Anticipatory Grief. Lexington, MA: Lexington Books, 1986.
Shneidman, Edwin S. The Suicidal Mind. New York: Oxford University Press, 1996.
Strack, Stephen, ed. Death and the Quest for Meaning. Northvale, NJ: Jason Aronson, 1997.
Wass, Hannelore, and Robert A. Neimeyer, eds. Dying: Facing the Facts, 3rd edition. Philadelphia: Taylor & Francis, 1995.
STEPHEN STRACK HERMAN FEIFEL
See D EATHBED V ISIONS AND E SCORTS .