Book Review: Existential and Spiritual Issues in Death Attitudes

Existential and Spiritual Issues in Death Attitudes

Adrian Tomer, Grafton T. Eliason and Paul T. P. Wong (eds). (2008). New York, NY: Lawrence Erlbaum Associates.

Introduction

The editors of Existential and Spiritual Issues in Death Attitudes leave little ground uncovered in the tome of collected works on death, grief, spirituality, end-of-life decisions, suicide, regret, and the application of existential therapy. It is broken up into three parts: I) Theoretical and Methodological Positions, II) Research, and III) Applications. For the sake of brevity, I will address each part separately, and highlight a chapter. I chose this approach specifically in an attempt to parallel this volume in its ability to both provide the reader sufficient detail and, at the same time, ample context.

Part 1 – Theoretical and Methodological Positions

Part I grounds the reader in existential theory. This serves to connect the rest of the book, specifically tying the empirical research into the existential framework on death attitudes.

Chapter one, by Tomer and Eliason, offers the reader a quick but solid starting point by exploring and clarifying what is meant by spirituality, meaning, and death. This brief existential grounding includes covering: Pascal and Kierkegaard, Heidegger, Camus, Sartre, Buber, and Levinas. From there, Tomer and Eliason move to psychological views, and provide similarly concise overviews of Wilber, Tillich, Frankl, Yalom, and Becker. The overview ends with an explication of empirical modes, including Firestone's Approach: The Concept of Microsuicide, Terror Management Theory, and concluding with their own Tomer-Eliason Model of Death Anxiety. While this chapter does not provide an in depth explanation of these topics, it successfully provides the reader with a base to make the connections between these existential theories, and the empirical research provided later.

The chapters in this section succeed exceptionally well at their goal. To give a brief and accessible introduction into existential theories and methodologies. This book is ideal for existential therapists. In addition, I recommend it for professionals who are interested in existential therapy for its foundation in existential theory in plain and accessible language as explicated in Chapter one.

Part 2 – Research

Part 2 is composed of research including topics such as Terror Management Theory, end-of-life-decisions, death attitudes and religiosity of hospice patients, regret and its connection to fear of death, existential and spiritual coping in HIV-positive women, anticipatory grief, meaning-management, phenomenological analysis of bereavement and meaning transformation, and lastly isolation.

A chapter by Gloria Nouel provides Existential-Phenomenological research on the transformation process and bereavement, focusing on mothers who have lost their children in drunk-driving accidents. Nouel begins by indicating that past research on bereaved mothers focuses on the role of participation of bereaved mothers, as opposed to the activities and actions taken by bereaved mothers. Applying existential-phenomenological approaches and cultural-relational theoretical approaches, she attempts to elucidate the process of transformation of bereaved mothers who are engaged in altruistic actions and activism. Nouel defines transcendence from an existential-phenomenological perspective, defining it as 'to rise above, to go beyond, and to surpass' (p 237). In this research, the participants develop a sense of mission, and altruistic actions become part of the transcendence process. She continues by introducing the term empathic activism, which is meant to define the act of attuning to another in a sustained way. Nouel specifically chose this term to include the psychological and social dimensions of the bereaved mothers (and the interrelatedness of feeling, thinking and action) in order to indicate the importance of the interaction between the two, as opposed to the dualistic Western model of separating them. The Existential-Phenomenological methodology explicates the importance of creating a shared narrative from the participants when analyzing the data and, at the same time, focusing on the individual participants. The shared narrative of the bereaved mothers ties together commonalities of each participant's individual narrative, including themes of isolation, hopelessness, loss of illusions of control, and disruptions of daily physical living. The dialectic movement between being helped and being the helper is ongoing through the healing process. The conclusion of the shared narrative is that transcendence is not the removal of pain or getting over loss. Instead, it is the process of commitment to a new meaning of life where there is a 'hole in her heart' (p 244) and a vow to never forget. These convictions led to the importance of the participants to be relational in their transcendence. Concluding, Nouel challenges the pathological view of grief – seeing attachment to memories, things, or acts, as a form of unresolved grief. She instead suggests that research be done in a more holistic understanding of individuals to see the importance of those connections in the process of transformation.

This chapter is the chapter that led me to write this review the way I have. I wished to include both the shared narrative of the book as a whole and the specific story of each chapter. It was refreshing to read research that provided a focus on the bereaved as agents in their transformation in relation to others, as opposed to isolating the individual as an outcome variable to participation in some treatment method. Nouel's insight that clients are agents resonates with the work I have done with clients through the grief process, both with children and adults. I worked with children between the ages of 4 and 6 who had lost a sibling, at the Dougy Center. While working there, the connection between the children in relating to one another, while having their own story of their sibling, led the children to have convictions of how they would advocate and honor their dead siblings. Each week, the children oscillated between helping another to being the one helped, much like Nouel's research found. The Dougy Center in Portland, OR., was founded because Dougy, a dying twelve year old, wrote a letter to Dr. Kubler-Ross asking why no one would talk to him about his own death. An example, even as children, of advocacy and conviction is paramount to the transformation not only in grieving, but in facing one's own death. While Nouel's research was limited to grieving mothers, her findings are paramount in furthering grief work, and I am glad to see it published in a book that can assist in changing grief work away from a pathological model.

Part 3 – Applications

Applications to therapy are provided in this part with an emphasis on: suicide, Regret Therapy, Voice Therapy, Meaning-Centered Counseling for Bereavement, and use of spirituality in meaning making. I began reading this part with trepidation and curiosity. I was intrigued to see how well the editors tied existential work, application, theory, and research.

Chapter 12, by Israel Orbach, critiques the traditional existential view of suicide as a 'less pathological and more rational act' (p 282), making it clear he wishes to critique the view that at the core of suicide is existential meaninglessness. Orbach starts by offering short explanations of existential views on meaning. He covers the general philosophy as well as philosophy of meaninglessness: Camus, Binswanger and Boss, Yalom, Frankl, Antonovsky, and Baumeister. These brief sections provide a reader with enough knowledge to follow Orbach's critique, and provide a clear grounding for someone new to existential psychotherapy and philosophy. The connection between meaninglessness and suicide is examined through the reference of empirical studies that all lead to indicate that suicide is an attempt to escape from meaninglessness. Orbach challenges this position and posits a different interpretation of the research that the meaninglessness and suicide are the consequence of a third factor, and thus existential theory has historically oversimplified the causation of suicide. Orbach's hypothesis is that mental pain is this underlying factor. Distinguishing high order meaning and low order meaning and explicating how trauma is related to existential crisis, Orbach builds his case that ultimately suicide is not about the process of escaping meaninglessness, but an act to project meaning on death and a fortiori the cessation of pain. This chapter feels out of place up to this point as it is theoretical and research based, but the last section places the chapter perfectly in this volume, as clinical implications are explored. Several therapeutic principles are offered at the end, including empathetic dialogue, focusing on suffering from both the client's and therapist's point of view, encountering the full intensity of pain, the roots of self-destruction, restoration of loss and finding a gift in suffering.

In alignment with existential approaches, the principles are not interventions or specific techniques, but rather well thought out and explicated principles and how the principles can be realized with clients. I was pleased to see that the 'applications' were not specific techniques nor specific methods of work; rather, principles that directed how to work. Orbach's principles, in my opinion, were specific enough to instruct me what to focus on. At the same time, the principles are flexible to the extent they avoid becoming mandatory directive interventions. The principles indicate the importance of intersubjectivity between client and therapist. Lastly, Orbach's chapter does not get lost in theory. He ties theory, philosophy, and research to a specific point, which is useful in my office when I talk to clients. I was not left wondering what 'to do' after reading his article.

Conclusion

My first reaction to this book was that it was a grand undertaking. Looking at the Table of Contents, the diverse topics around grief and death seemed vast. The book claimed to be an in-depth examination, but I was skeptical given the breadth of area it was seemingly undertaking. I flipped through the pages, and found bulleted main points at the end of each chapter. I immediately wondered if there would be a quiz after each chapter, and wondered how in-depth main points could be. My skepticism could not have been more wrong. As I read through the book, the layout, the connections, and the content all served to provide both a larger theoretical framework for the reader to understand existential therapy focused on grief work, and the application of these theories in our offices and places of work.

As a grief therapist, I have found most existential therapy books on grief insufficient – either by being too theoretical and thus disconnected from a person's experience of grief, or else a personal account of one's process through grief, and thus too granular. This book suffered from neither. I can confidently say, this book would be an asset to any professional working in grief work, studying grief work, or interested in grief work (though the book is definitely targeted towards counselors and students).

This book as a whole belongs on every grief therapists bookshelf, but only after being well read.

Justin Rock