As a rule, we humans consider ourselves highly lucky not to have been born as dogs, or pigs, or chickens. Uniquely among the animal kingdom, we are able to summon abstract thoughts about situations, to plan for a range of future possibilities, and to create stories to imbue our past experiences with meaning. We gaze proudly upon the vast civilisations that we have created, and the bewildering range of art, literature, music and science that are born out of the unique creativity of the abstract-thinking human mind.
But this very property of ours is also the one that leads us to extreme states of existential anguish. In its most extreme form, this existential angst relates to our awareness that our existence on this planet is finite; that everything that is born is bound to die, and that all is finite. Many have wondered how, in the face of this certainty, it is possible to make meaning from existence at all; Kirkegaard and Sartre are two examples of philosophers who have explored this.
The Buddhists refer to this phenomenon as anicca, a Pali word whose literal translation is “impermanence”. Anatta, the absence of an abiding self, is another key part of the Buddhist doctrine. Combined with Awareness of Suffering, these concepts make up a core thread of the Buddhist philosophy. It is our human attachment to our corporeal body, combined with our (uniquely human) awareness of impermanence, that leads us to suffer.
All things change, and death is the most extreme example of this. It stands alone in its incomprehensible finality. In being able to contemplate our own non-existence as an abstract concept, we lay ourselves open to anxiety; the thought that one day we will cease to be is a threat that lies over the heads of all humans, regardless of faith, culture or age. Ernest Becker in his seminal book “The Denial of Death” illustrated the ways in which people seem remarkably well-defended against the kind of angst that death awareness might catalyse. Robert Neimeyer explored the psychology of death and dying from this perspective, and Irvin Yalom illustrated through some powerful examples the impact of this death awareness on the human condition, on relationships and hope, regret and grief, in his wonderful book “Existential Psychotherapy”.
Yet in reality we are not paralysed by this knowledge. Life is is paradoxically beautiful, rich and wonderful. We form enduring close relationships, have children, grow careers, plant seeds, make plans for the future and build lives. We lose people that we love; yet instead of turning us into islands, intent on avoiding the pain of loss, we grieve, wail and suffer, and then we grow and find space to connect once again, all in the knowledge that “this too will pass”.
One explanation for this apparent paradox is Terror Management Theory (TMT), initially proposed by Abram Rosenblatt and colleagues in 1989, as an explanation of how humans are psychologically defended against death anxiety, and how this manifests in behaviours and structures of societies around the world. Through an impressive range of existential experiments spanning two decades, TMT has subsequently been tested for range of social behaviours which are attributable to the activation of these defences. In summary, TMT proposes that in the presence of “mortality salience” (i.e. awareness of death) for example through witnessing a news story or receiving a diagnosis of serious illness, we initially invoke a range of so-called proximal defences. These are immediate reactions to the reminder of mortality, and may include denial, repression, distraction, distancing or trivialization. Tightly controlled experiments into proximal defences have shown behaviours such as physical distancing being more likely where participants have been told the “patient” has cancer, as compared to one with arthritis.
If these defences are insufficient to protect against death anxiety, and mortality salience threatens to disturb our equanimity, TMT proposes a second layer of protection, the distal defences. These comprise of more abstract efforts to attain symbolic immortality. Experiments in distal defences have produced some interesting findings; repeated experiments have shown that we are more likely to judge somebody harshly who is from a different “group” (social, religious, ethnic) if we are first exposed to a mortality salience “prime” which makes death thoughts more accessible. In other words, defending ones own world view becomes more pronounced when one is made more aware of death. This has been used to explain the cultural effects that followed the terrorist events of 9/11. Valuing of beauty, youth and self-esteem are also noted to increase following mortality salience primes. A TMT perspective on ageing has suggested that one reason for ageism in a Western culture which values youth and physical beauty so highly is that the elderly remind us of our mortality; they lose control of various faculties, they become vulnerable and dependant, their failing physical systems remind us that we are no different to any animals, and to all things there is a season.
The evidence supporting the existence of both proximal and distal defences is compelling. Greenberg et al 2004 produced a review of over 200 experiments upholding the tenets of TMT, and in the decade since, several hundred more have been undertaken in a variety of countries.
Defences: adaptive or pathological?
Defences in patients are often viewed by healthcare professionals as maladaptive: a doctor may lament how difficult it is to get Harry to make a decision about treatment because he is “in denial” of his cancer diagnosis, or perhaps a community nurse feels frustrated at a family’s repeated attempts to get their dying loved one to eat something “so they can fight this disease”. However, it is important to remember that defences are first and foremost protective; they are a homeostatic device to preserve psychological equanimity. The shock, disbelief and numbness described by those recently bereaved acts as a buffer against the rawness of the emotions were the psychological defences not present.
Why is TMT relevant for health professionals?
As discussed above, under normal circumstances defences against death anxiety are protective. Many healthcare professionals work in clinical areas where death, dying and suffering are commonplace. By definition, anyone requiring input from a healthcare professionals has experienced some degree of loss, whether that loss is of mobility, longevity, independence or dignity, and the role of the healthcare professional is to assist the person to regain or acquire their maximal level of “health” (however that is understood) given the presence of this loss. In the course of this work, healthcare professionals will be exposed to numerous stimuli that have the potential to trigger death anxiety. Whilst denial and distancing may be protective in someone who is driving past the scene of a fatal road accident, the same defences can be detrimental to patient care when they occur in the mind of a healthcare professional. Thus an apparent lack of engagement, flippant attitude or avoidance of difficult issues may not constitute a lack of compassion, but an effort to protect oneself against the psychological stress of mortality salience. Healthcare professionals’ own fear of death may inhibit authentic and compassionate connection with the dying.
Through this lens, the choice appears stark: experience this fully, and suffer from the sorts of existential distress described by Sartre (and more recently labeled as ‘compassion fatigue’), or enlist those robust evolved defences and protect oneself against losing equanimity, with the risk of distancing oneself from the patient at best, and blatant prejudice at worst.
This all sounds rather pessimistic and I do not wish to suggest that we only have two choices, to be open and vulnerable, or closed and hard. There is a third way, which is to be found in the suggestions of Cozzolino (2012) . He points out that TMT has largely been explored in artificial experimental settings and does not encapsulate the experiences of the many people whose lives have actually been enhanced through mortality salience; Wilko Johnson, ex-guitarist from Dr Feelgood, currently on his “goodbye” tour, described his response to his diagnosis of terminal pancreatic cancer thus: “It certainly makes you realise you are alive, it alters your whole perspective. I’m looking outside at the leaves and the sun, thinking ‘this is pretty good’. Let’s see how much I’ve got left of it.”
There is a difference in how we react to unexpected reminders of death and dying, and how we might find opportunities to grow through deliberate contemplation of impermanence. If we are in control of thinking about death and dying, it cannot capture us unawares and trigger us into habitual reflexive patterns of defensive behaviour. Paul Moon suggests that we develop a pedagogy of mortality oin which purposeful reflection on death is utilised in order to enhance the meaningfulness of ones life. The “year to live” groups that are appearing worldwide as a result of Stevine Levine’s work are founded on a similar concept; how would our lives change if we really knew how uncertain the future is.
I often used to talk to patients about the fact that thinking about death is not going to make it happen – it will come when the time is right. We can choose whether to indulge in the illusion of immortality, and continue to react against reminders of our corporeal animals selves, by assuring ourselves that we are different, that we can focus on tasks in order to do our job without exposing our vulnerabilities, to the potential detriment of our patients. Or we can embrace our own fears, worries, doubts and hopes about our future lives and losses, contemplate death and dying, and allow the possibility of authentic, profound connections with patients who are no different to us, except in terms of the fortunes of the present moment. Not me, not thee, but we.