Endings Are Reframed Beginnings: An Exploration of Death Positivity

Death is both a personal and social experience. From death doulas to obituaries and in memoriam rituals, people use various tools to process and honor the end of life. Of those left behind, many are able to move through the stages of grief and heal from the loss of their loved ones. However, some invite the assistance of mental health professionals for bereavement support as they work to rebuild their lives. As board-certified practitioners, there is an advantage to viewing our client’s needs from a natural and holistic perspective. By incorporating a balanced and celebratory framework for integrated care, we foster whole person healing and reframe loss to the transcendent honor of loved ones. This clinical approach validates one’s emotional, physical, intellectual, and spiritual experience while advancing the notion that the continuum of life does not end with death. 

The inclusion of Kubler-Ross’s stages of grief (denial, anger, bargaining, depression, acceptance) often appear around the rituals of remembrance. On Death and Dying (1969) by Dr. Kübler-Ross provided explicit, previously elusive guidance on how to openly broach the topic of death at the bedside. She wrote “It might be helpful if more people were to talk about death and dying as an intrinsic part of life just as they do not hesitate to mention when someone is expecting a new baby” (p. 126).

Continuing bonds theory suggests that people don’t “move on” from grief, but instead maintain a relationship with the deceased in new forms (e.g., through memorials or personal rituals). Thus, it is important to explore how cultures cope with loss which can tell professionals about their values and mental health frameworks. Maintaining a connection with the deceased may be beneficial for the bereaved by providing a source of solace for survivors (Klass, Silverman, & Nickman, 1996). The continuation of the connection to the deceased may provide structure and comfort for the bereaved attempting to cope with the changes the death has brought. Continuing bonds therefore may act as grief-specific coping strategies that provide the bereaved a link to his or her loved one that may help temper the pain associated with the death (Asai et al., 2010).

Given that death is a part of life’s continuum, there is a need to shift toward death positivity—the idea that talking openly about death can improve our experience of life.  By incorporating talks around death and dying, we can help reduce death anxiety through promoting open conversation and preparation. More specifically, we provide emotional validation and exemplify human valuing by holding space for grief, fear, and hope. Perhaps, more importantly, we normalize death as part of life, reducing isolation and medicalization at end-of-life and encourage legacy projects, life reviews, or rituals that support healing and closure.

There are a few clinical approaches that therapists can take in having an open and transparent dialogue about death and dying. One is dignity therapy (DT). It is  one of the first manualized psychotherapy interventions developed specifically for use in palliative care settings (Chochinov et al., 2005a; 2011). In DT, patients with a terminal illness or otherwise (i.e., across a range of conditions, not only those with cancer) are invited to discuss aspects of their life they would most want recorded and remembered. This therapeutic approach embodies reflective processing and incorporates choice. Another approach is Meaning Centered Group Psychotherapy (MCGP). It draws heavily from Frankl’s concepts, by identifying the sources of meaning as a resource to help patients develop or sustain a sense of meaning and purpose, even while in the midst of suffering. In addition, MCGP incorporates a number of fundamental existential concepts and concerns related to the search, connection, and creation of meaning (Park & Folkman, 1997). In short, enhanced meaning is conceptualized as the catalyst for improved psychosocial outcomes, such as improved quality of life, reduced psychological distress, and a decreased sense of despair. Hence, meaning is viewed as both an intermediary outcome, as well as a mediator of changes in these important psychosocial outcomes (Rosenfeld et al., 2018).

It is important to acknowledge the differences in how perception of death and dying can vary across cultures around the world. There are significant differences in Western and Eastern countries pertaining to the bereavement of death, how we process death, and the perception on the cycle of death. Western cultures in places such as the United States, Canada, and western European countries, often perceive death as occurring only once (Gire, 2014), while South Pacific cultures believe that life leaves the body at different times throughout our life including when one becomes ill, or one is asleep. Additionally, Hindu traditions envision the death and life cycle as cyclical where death and being reborn occur multiple times. This idea contrasts with the Christian belief that one only dies once and, if one is faithful, they are rewarded in heaven.

Across different cultures and countries those grieving a death of a loved one, often report bereavement related hallucinations. This phenomenon occurs when a bereaved individual describes seeing, hearing, or feeling the deceased individual after they have passed. Although in medical or Western cultures, this experience may be viewed as pathological or clinically significant, many cultures welcome these experiences and view them as an important part of the grieving process (Sabucedo et al., 2023). These mourning hallucinations often occur and are reported frequently in the Hopi tradition, Latin American cultures, and Hawaiian cultures. Additionally, cultures in South America, specifically in the Amazon Basin, will use hallucinogens or psychedelics such as ayahuasca to encourage the communication between the living and the dead. While Western cultures often rely on mental health practitioners to assist in the difficulties of grieving, collectivist societies rely on their community, spiritual practitioners, and religious leaders as a means of support during the bereavement process. (Sabucedo et al., 2023).

Additionally, the perception of death as an anxiety inducing phenomenon has found to be more prevalent in collectivist countries such as Japan and China than in Western countries (Plusnin et al., 2021). Despite the increasing availability in mental health resources and education, death anxiety has found to be chronically elevated in collectivist countries. It has been hypothesized that this is due to a multitude of factors. It is largely taboo to openly and publicly discuss the concept of dying in East-Asian cultures, and thus the presence of the taboo increases the anxiety about death due to the forbidden nature of the topic and the avoidance of exploring this topic within their community. Another supporting factor to this elevation is the collective nature of China and Japan. Due to the importance of community and closeness within these cultures, they are more likely to think about how death can impact others and the community. Conversely, suicidal ideation and completion due to grieving a loved one are found to occur more often in individualist, Western countries rather than collectivist countries due to the collectivist cultures’ concern for those affected by an action or how their action can create suffering for the group (Ariapooran et al., 2018). Another protective factor for collectivist cultures in this case is the connection to community as a means of support and collective process of grief. The complexity of death perception is influenced by a variety of cultural factors (Western/Eastern orientation, religious/spiritual background, and racial heritage), social mores, and afterlife beliefs. 

Whether we believe in reincarnation or an afterlife in heaven/hell (Buddhist/Christian ideology), deferred happiness until the cross-over (legacy of racial oppression), or time-limited bereavement (social customs), there is a connection from this life to what comes afterwards. “Human beings know that they will die: death is not simply something that happens in the world but something that will happen to me” (Lammers & Verhey, 1987). 

As psychologists, we have a prime opportunity to support client development from negative perceptions of death that are based in fear towards death positivity. Challenging inherited beliefs about death in favor of personal belief exploration is a first step in dismantling the negative connotations surrounding death. Looking to biblical scripture, there are key converging themes – to be absent from the body is to be one with the Lord (2 Corinthians 5:8) and my faith/works in life have consequences in death. Thus, death can bring peace and be viewed as a reward for a life well-lived. Life experiences shape who we are and ultimately, who we will become after our demise. From this outlook, death not only can be expected, but celebrated as a natural, culminating rite-of-passage.