Death Anxiety and the Relational

Abstract

Despite Ernest Becker’s claim, nearly 40 years ago, that the denial of death has relevance to the depth of the individual psyche as well as to human bonding behaviors, death anxiety continues to be heavily denied in its clinical application. This denial largely persists in the field of psychology and the practice of psychotherapy as death anxiety is reserved for comprehensive, philosophical, and ontological concerns but rarely informs the organization of the therapeutic dyad or the treatment of patients. The purpose of this article is to illustrate that death anxiety acts as a bonding agent to the close psychotherapeutic relationship and that mortality salient dyadic encounters can be assessed and used by the psychotherapy practitioner. This article introduces death anxiety experiments and theories (mostly contributions of Terror Management Theory) that have more recently demonstrated the buffering and mitigating potential of close relationships on an individual’s death fears. Additionally, this article illuminates the significance of the close relationship, which is a commonly accepted psychotherapeutic agent of change and also, paradoxically, produces death fears. The article concludes by suggesting that death anxiety plays a dominant role in the socially constructed mind and should therefore play a prevalent role in clinical depth work.

Keywords

death anxiety terror management theory psychotherapy close relationships Ernest Becker

Ernest Becker, a cultural and psychological anthropologist, published his seminal work, The Denial of Death, in 1973, thereby changing the way psychology considers the role of mortality in understanding human existence. Becker suggests that elaborate societal structures are the work of a human race motivated by the need to deny death’s numerous and intricate threats against the human psyche. He refers to many of humanity’s psychological and sociological constructs as illusions, as well as a necessary response to the ontological, paradoxical dilemma of a limited body and an unlimited mind:

[Humanity] literally drives [it]self into a blind obliviousness with social games, psychological tricks, personal preoccupations so far removed from the reality of [the human] situation that they are forms of madness—agreed madness, shared madness, disguised and dignified madness, but madness all the same. (p. 27)

The “games” and “tricks” used to deny human mortality include the creation of culture, bolstered modes of self-identity, and a preoccupation with heroism. To assuage death anxiety and deny death’s presence, people have long constructed hierarchical systems of people groups separated by means (e.g., the wealthy and poor) and symbols (e.g., national flags and religious signs and images). Engendering a feeling of specialness in relevance to another group of people (out-groups), according to Becker, provides psychological reprieve from humanity’s shared fate. Rather than admit to the certainty of death, its unpredictable timing, and its prelude to the unknowable, people instead distance themselves from one another and refer to their own group as special, thereby garnering a sense of superiority that symbolically aligns the in-group with immortality. The unconscious rationale is that death is reserved for the inferior and not for the group with overwhelming significance.

Though typically marginalized to the Existential-Humanistic movement, death anxiety is considered by some to have a dominant impact on the human psyche, and the denial of death is considered to be central to the development of psychologically theory. For instance, Irvin Yalom (1980) asserts that “the terror of death is ubiquitous and of such magnitude that a considerable portion of one’s life energy is consumed in the denial of death” (p. 41). Robert Langs (2004) agrees, “Death anxiety is . . . the most powerful unconscious psychodynamic dynamism in present-day emotional life” (p. 32). Rollo May (1981) also holds that death fears are deeply significant, as he places death anxiety within a paradoxical interplay with free will—so that if one is denied then so is the other. In other words, without recognition of death, humans cannot be free. Additionally, in his trauma work, Robert Stolorow (2007, 2011) describes trauma as forced and unchosen plunges into death anxiety that both devastate one’s previously held assumptions about reality and experientially isolates the victim from everyone else. Likewise, Kirk Schneider’s (2013) most recent research points to polarized, black-and-white thinking and the resultant wars, traumas, and diverse forms of bullying, tyranny, bigotry, and arrogance all as consequences of widely unacknowledged existential and death fears. Schneider considers the 9/11 attacks, the overprescription of antidepressants, and the latest Newtown Massacre as just a few examples of tragedy that are intimately linked to fundamental human fears—one of which is the fear of death.

Furthermore, there are consequences for denying the certainty of death. Despite efforts to suppress death thoughts and fears from conscious awareness by means of psychological defenses (e.g., distraction and minimization), human beings fail to eliminate death anxiety and, in fact, increase its accessibility to consciousness each time it is repressed (Hayes, Schimel, Arndt, & Faucher, 2010). Efforts to rationalize away thoughts about one’s own death, for instance, temporarily relieve mortality fears but also assure that future death thoughts will be brought into consciousness with greater ease.

The topic of death anxiety is also heavily denied in clinical literature (Hoffman, 1979). For instance, some of my colleagues will deny its impact altogether claiming, “I never think about death. . . . I don’t believe many of my patients do either.” Others will admit that death anxiety is worth considering and that it should be talked about in therapy but that there is little good that can be derived from it. Additionally, the current literature, especially mainstream psychological writings, will not often guide a clinician through the application of death fears as they may apply to case conceptualization and therapeutic technique. Therapists, in turn, feel unable to address death directly or believe that addressing it will make them out to be a maverick at best and unethical at worst, thereby practicing outside the purview of their training, comprehension, and ability. Those therapists who do acknowledge the existence of death anxiety, including its psychic dominance, are inadequately equipped to consider it in case conceptualization or an element of treatment to be interpreted and discussed along with sex, aggression, historical events, self-actualization, cultural identity, context, spirituality, relationships, and a myriad of other factors that affect every potential patient (Razinsky, 2012).

Death Anxiety and Relationships

Becker (1973) asserts that when Westerners’ use of religion fails to offer psychological mergence with God, there is instead a turn to sentimentalism and to the mergence with another person. Evidence of such a move to merging relationships can be found in American pop culture and romance movies wherein love conquers all, and the romantic partner provides a type of rescue or salvation for another. Of course, such relational mergence serves the same purpose that religion still does—to transcend the self and provide robustly meaningful connections with others. Being in a relationship is central to escaping the existential problems found in isolation. Facing one’s own limitations, both physical and ontological, for instance, diminish on symbolic mergence with another person or group of people. Close relationships, intimacy, and attachment all offer loss of one’s sense of individuality, which is ultimately accompanied by death anxiety (Firestone, 1984; Firestone & Catlett, 2009).

Here, I define close relationships as encompassing all the multiple forms of interpersonal connection. These forms include variances on genuine intimacy and fantasized connection (transference). Genuine intimacy is an exchange of love or an impassioned, typically long-term, deep care and concern for someone, which is predicated on a more exclusive knowledge of another person than is typically sustained in the majority of an individual’s human relations. Genuine intimacy also helps define romantic relations, though it is also found in parent–child bonds, friendships, and, as I explain later, clinician–patient relationships. Fantasized, or transference connection, is the redirection of feelings attributed to one person toward another. Put differently, transference is the mergence of images and meanings of one relationship onto another (e.g., the projection of images of a father or mother onto a romantic partner). Becker (1973) uniquely considers the transference phenomenon as the spiritual and moral longings of people who are taken up in close relationships. He claims, “The love partner becomes the divine ideal within which to fulfill one’s life” (p. 160).

These close relationships offer multiple modes of escaping ontological concerns. The genuine intimacy and fantasized transference connection allow the person more than one avenue of connection, which means that the person has multiple modes of existing with just one person. Multiple modes are used and necessary, in fact, as genuine intimacy and transference relationships can each evoke death threats. Genuine intimacy induces death anxiety because it reflects the nature of the decaying individual as the partner acts as a symbolic mirror. Transference relationships induce death anxiety because they leave the individual alone with their decaying self—a self who is only ascribing old, self-produced images and meanings instead of opening to the new experience of another. Genuine intimacy and transference connection, however, also offer relief from the death anxiety induced by the other. For instance, to avoid death anxiety induced by genuine intimacy the person can relive a more familiar and protective past by unconsciously ascribing the transference relationship. The couple can therefore escape the authentic mode and move into a transference mode when genuine intimacy stirs up death anxiety.

Also playing a role in the manifestation of death anxiety is attachment. Attachment is the basis of close relationships because it is a basic form of security from isolation. Bowlby (1973) used attachment to illustrate the importance of the caregiver—infant relationship in the development of normal social and emotional habits and to account for the infant’s distress on separation from the caregiver. The Boston Process Change Study Group (2010) says that a secure form of attachment with the infant necessitates the mother’s attunement, derived through implicit relational communication. Consistently, caregiver–infant observation and attachment experimentation demonstrate that secure attachments associate with infant dependability on the caregiver and that an insecure attachment fails to contain dependable expectations that the caregiver will return after leaving for short periods of time. Typically, the insecure infant experiences more severe forms of distress on these separations from the primary caregiver.

Later, during childhood, the separation anxiety is replaced by the child’s fear of ultimate separation through death (Firestone & Catlett, 2009). Most children begin to grasp their own mortality between the ages of 3 and 5 (Kastenbaum, 2006; Yalom, 1980), creating a stirring death terror that affects the psyche throughout the lifespan. Robert Firestone (1984, 1987, 1993) claims that the death-fearing child, once distressed by short periods of separation from the caregiver, now experiences distress at the thought of a permanent separation through death. Having learned to quell previous short-term separation anxiety from the caregiver by fantasizing the presence of his caregiver, the death-fearing child later uses a fantasized connection (i.e., a Fantasy Bond) throughout his life to mitigate death fears. Therefore, a child’s death anxiety solidifies and enhances the previously established need to form both imagined (when the caregiver is not there) and authentic (when the caregiver is present) human bonds. Later, the adult’s fear of death sometimes creates the need to distort the image of the other (i.e., transference relationships). Such shifts of perception of the other person are exemplified in romantic connections, wherein there are distortions of the authentic relationship, exaggeration of particular partner qualities, or provocation of one member to act like someone they are not. These psychological defenses are rooted in the need to buffer against the death anxiety present in the authentic and intimate relationship (Firestone & Catlett, 2009).

Martin Buber (1958) referred to these authentic and intimate connections as I-Thou relationships; while the distorted I-It relationships he referred to as a false and irrelevant connection. Buber also fully embraced the transition from the Freudian version of a closed, internal system of the psyche (one-person psychology), to the open, interactive mind as a dynamic field (two-person psychology). Buber asserts, in fact, that “all real living is meeting” (p. 11) and therefore undermines the enclosed version of the mind and transference relationships in favor of the authentic I-Thou relationship (i.e., genuine intimacy). Buber maintains that connections other than the genuine relationship “are merely following the uneternal division that springs from the lust of the human race to whittle away the secret of death” (p. 5), but new Terror Management research demonstrates that authentic and intimate I-Thou relationships are also created in resistance to our death anxiety.

Terror Management Theory

Terror management theory (TMT) was inspired by the works of Becker (1973) and Otto Rank (1941/1978) and has been used to better understand the particular psychological mechanisms that buffer and mitigate death anxiety. TMT researchers (Pyszczynski, Greenberg, & Solomon, 1999; Pyszczynski, Greenberg, Solomon, & Hamilton, 1991; Pyszczynski, Solomon, & Greenberg, 1986) state that the awareness of death is a primary source of anxiety and that culture and self-esteem are the primary mechanisms used to buffer and mitigate death fears.

Culture as a Death Anxiety Buffer

Culture is considered a psychologically distal defense, or an unconscious defense, against death terror and has been demonstrated to successfully shield against and diminish death fears on participants from more than 200 different cultural backgrounds (Greenberg, Pyszczynski, Solomon, Simon, & Breus, 1994; Pyszczynski et al., 1999). In some of these studies (e.g., Greenberg et al., 1994), participants are asked open-ended questions about their own death, administered fear of death scales, and shown gory footage of car accidents (for example) to create a Mortality Salient (MS) situation. The MS situation hypothesis states that to the extent that a psychological structure provides protection from death anxiety, then reminding people of death anxiety should lead to an increased favorability of those things that support that psychological structure and a negative reaction toward things that threaten that structure. For instance, some TMT participants exposed to MS situations claim a stronger allegiance to their nation and to that nation’s cultural norms than those participants whose death fears have not been stimulated. The reason for this is that a person’s national allegiance (Greenberg et al., 1990), following social and moral norms (Florian & Mikulincer, 1997), and finding other ways of grouping the self with other people allow a person to symbolically transcend the experience of a limited and decaying body. A TMT participant’s ability to favor particular culture groups and reject others in order to mitigate death anxiety is interconnected with the second TMT defense, that is, an individual’s self-esteem.

Self-Esteem as a Death Anxiety Buffer

Self-esteem, unlike cultural groups, serves as a psychological proximal defense, operating typically on a conscious level, and is maintained by a person’s ability to consistently embody cultural norms. TMT studies (Pyszczynski et al., 1986; Pyszczynski et al., 1999) demonstrate that participant’s feelings of acceptance into a cultural group is validating and therefore increases the feelings of pride, specialness, and a sense of superiority in comparison to those that do not meet cultural norms (i.e., the out-group). This special feeling of pride also buffers and mitigates death anxiety. The self-esteem hypothesis states that to the extent that one’s self-esteem protects against death anxiety, the individual’s death fear will be minimized. In other words, the individual with high self-esteem is less prone to death anxiety and the individual with low self-esteem, who is less aligned with cultural norms, is more prone to death anxiety. TMT studies that demonstrate the effectiveness of self-esteem as a death anxiety buffer (Hayes et al., 2010; Pyszczynski et al., 1986; Pyszczynski et al., 1999) control for the anxiety associated with physical pain, fear of failure, test fears, and performance anxiety. Later developments of TMT bring examination of close relationships, intimacy, and attachment as additional buffers to death anxiety.

Close Relationships as a Death Anxiety Buffer

In a little over the past decade, the exploration of TMT studies has evolved into the introduction of close relationships as an anxiety-buffering and mitigating mechanism of death anxiety (Hayes et al., 2010). A close relationship with another individual is now considered a psychological mechanism that can become activated during MS situations. Close relationships are a buffering factor for much the same reason that groups (e.g., racial and religious groups) mitigate death anxiety—they provide a greater sense of meaning and a symbolic sense of longevity to one’s life (Florian, Mikulincer, & Hirschberger, 2002; Mikulincer & Florian, 2000).

TMT studies examining close relationships as a death-anxiety buffer are executed in much the same way that previous TMT research has been conducted, with the use of MS situations and measurements of participant death anxiety (Cox et al., 2008; Florian et al., 2002; Mikulincer, Florian, & Hirschberger, 2003). Close relationships of several different types have been tested for their death anxiety–buffering potency, including attachment to parental figures (Mikulincer et al., 2003), maternal love (Fritsche et al., 2007; Taubman-Ben-Ari & Katz-Ben-Ami, 2008), couples with the desire to procreate (Fritsche et al., 2007; Taubman-Ben-Ari & Katz-Ben-Ami, 2008; Zhou, Lei, Marley, & Chen, 2009), and romantic relationships (Florian et al., 2002). Marriage is also a death-anxiety buffer (Bassett, 2005), and even if such long-term, committed relationships are strained by conflict and criticism, the relationship still acts to buffer and mitigate death fears (Hirschberger, Florian, & Mikulincer, 2003). Connection between the couple does not have to be congenial and pleasant to relieve existential concerns, but the depth of intimacy is a significant factor in gauging the degree that the relationship shields the couple from death threats.

One particular study by Mikulincer, Florian, Birnbaum, and Malishkevich (2002), for instance, demonstrates that different degrees of intimacy buffer and mitigate death anxiety on different levels. In this study, TMT participants were exposed to threats of separation from people with whom they had differing degrees of connection. Death thoughts were assessed before and after the induction of separation threats to determine the presence and strength of death anxiety. The participants were asked to imagine separation from acquaintances as well as from someone with whom they were romantically involved. The induced threats of separation from acquaintances and partners were also categorized into short-term separations, long-term separations, or permanent splits. Participant death anxiety was lowest during the threat of short-term separations from acquaintances whereas death anxiety was highest among participants imagining long-term or final separations from more intimately attached partners.

Gaining and maintaining close, intimate relationships becomes of primary importance to an individual threatened by the presence of death anxiety. As has already been stated, relationships do not necessarily have to be pleasurable to protect from death fears. In fact, intense feelings of guilt and shame are just as durable a relational bonding agent as kindness and admiration. Studies that support negative relationships as death anxiety buffers (Florian et al., 2002; Mikulincer et al., 2002) suggest that the maintenance of close relationships may be more important than the individual’s level of personal satisfaction with that relationship. These findings are somewhat contrary to the original assertion of TMT, which states that self-esteem is a primary mode of defense against death anxiety. In response, Hirschberger et al. (2003) suggest that self-esteem may instead be a secondary anxiety-buffering mechanism to a primary striving for close relationships. On the other hand, Cox and Arndt (2012) provide evidence that relationships buffer against death anxiety depending on whether one perceives their partner as regarding them in a positive or negative way. Those participants who claim their partner’s positive regard for them were better shielded from death threats than those participants who believed their partner carried disdain for them. Further studies still need to be conducted in order to illuminate the nuances of different types of relationships and their ability to buffer and mitigate death anxiety. Nevertheless, substantial evidence exists to conclude that creating and maintaining a relationship serves as a central psychological mechanism against death anxiety, not only due to the transcendent nature of relationships but also because the majority of societies highly value coupling; and a person’s self-esteem, in turn, is highly dependent on their ability to embody and preserve this social value.

Close relationships, whether sexual, romantic, familial, or platonic, have also been central to art, literature, music, philosophy, and science. In fact, many disciplines throughout history have considered coupling to be sacred. Aristotle, for instance, spoke of friendship and love as a single soul occupying two bodies (Laertius, 2012), considering the couple bond as something other than that which a single person could possess. The Bible also contains narrations and moral teachings that hold sacred the relational bond: “No one has greater love than this, to lay down one’s life for one’s friends” (John 15:13, New Revised Standard Version). This verse, in particular, denotes love as superior to the individual life. Family ties, friendship, connection, and love relationships have long been valued as significant to human life, but it is only recently that close relationships are becoming accepted as the psychotherapeutic vehicle of change.

Close Relationship as Central to Psychotherapeutic Encounter

Examination of the relationally psychotherapeutic, or dyadic, field has been central to a two-person psychology that emphasizes the cocreation of meaning and the patient’s emotional experience of that relationship. Extensive quantitative and qualitative reviews and analyses of thousands of studies (Lambert & Ogles, 2004; Norcross, 2011) demonstrate that while many factors contribute to the effectiveness of psychotherapy, the fit between patient and therapist is of primary importance for a positive, long-term outcome. This includes the building of an alliance or emotional bond defined by trust, mutual inclination toward one another, and a general sense of respect. The important dyadic relationship also represents a microcosm of the patient’s relational patterns and therefore serves as an environment where those patterns can be analyzed in the here-and-now. The use of the relationship and the analysis of this microcosm have been recently, widely considered the therapeutic change agent for the patient.

Relationship as Agent of Change

The agent of change in the psychotherapeutic process, regardless of length or type of depth-oriented treatment is, according to this author, the novel relational exchange through authentic and implicit communication that imparts creative space to pilot new ways of existence. In other words, the new close relationship creates an opportunity for change. Brain development across the lifespan, as well as psychodynamic experimentation, both suggest that human connection is fundamental to health, growth, and recovery.

Dan Siegel (2010, 2012), an interpersonal neurobiologist, provides evidence that there is a connection between interpersonal dynamics, neural-brain integration, and health. Siegel pioneers a field in which close relationships are central to the healthy development of an individual body, brain, and mind.

Because the circuits responsible for social perception are the same as or tightly linked to those that integrate the important functions controlling the creation of meaning, the regulation of bodily states, the modulation of emotion, the organization of memory, and the capacity for interpersonal communication. (Siegel, 2012, p. 33)

Grey matter physically changes, neurological circuits rewire, and the creation of meaning alters, Siegel suggests, as a result of interpersonal connection. Furthermore, the relationships that promote physical and psychological health, creativity, flexibility, happiness, recovery, and longevity of life are those secure attachments made available by the parent, lover, friend, or therapist who is respectful, compassionate, loving, and is therefore willing and able to see the subjective experience that hides behind behavior. Additionally, Siegel emphasizes, such a profoundly attuned and brain-changing relationship is not due to another’s use of the correct words but requires an exchange of a bodily flow of energy, or implicit communications. Powerful relationships as agents of change are also the area of increased interest within the field of relational psychoanalysis.

As neurobiology emphasizes the influence of a two-person bond as the primary source of psychic life, so also is the field of psychoanalysis evolving into the analysis of the relational or the examination of the space between the object and subject. Stephen Mitchell (1988) generated a compelling theoretical shift in the concept of the mind. Mitchell helped thrust psychoanalysis from a predominately fixed notion of the mind as internally produced and instead introduces the mind as “a social product” (p. 18). Analyst Robert Stolorow (Socarides & Stolorow, 1984/1985; Stolorow, 2011) has similarly dedicated his work and career to moving psychoanalysis away from a Cartesian, Freudian, and drives-based version of the mind to a post-Cartesian, affect- and intersubjective-based context. In other words, Stolorow recognizes that the mind is relationally constructed and that effective therapy thereby requires a meaningful relationship to heal, recover, or change. Mitchell and Stolorow caution against the psychotherapeutic principle of neutrality and empathy and instead insist that a genuine meeting is what makes psychotherapy work. Stolorow, Atwood, and Ross (1978) demonstrate that internal emotional experiences are inseparable from the intersubjective and that traumas necessitate a genuine relationship or “a relational home” (Stolorow, 2007, 2011, p. 50) in order to be integrated into the mind for healing. Accordingly, a patient’s psychological health is less and less in need of the right intervention but instead requires a close relationship.

Therapeutic Relationship as Death Anxiety Buffer

As was previously explained, TMT research shows that close relationships are a mitigating factor against death anxiety. While researchers have not yet examined the therapy relationship as a death anxiety buffer, it stands to reason that the influential close relationship in psychotherapy can also buffer and mitigate death anxiety. The confidential and intimate nature of the close therapy relationship permits a transcendence of the limits of time; allowing the patient to comb through their childhood, their latent memories, their repressed emotions, and discover fresh ways of describing their past as well as rehearsing and imagining their future. Time spent in the depth work of a therapeutic hour quickens and intensifies a relationship in a way that bypasses the closeness typical of even long-lasting nontherapy relationships (Mann, 1973). A couple can spend years together, for instance, and not acquire the intimacy that a therapist and patient may experience with one another in just the initial sessions. Parental, spousal, romantic, and friendly relationships act as buffering mechanisms against death anxiety (Cox et al., 2008; Florian et al., 2002; Mikulincer et al., 2003), so it is reasonable to assume that the therapeutic dyad also acts as a potential factor in the diminishment of death anxiety.

To further apply death anxiety research to the dyadic psychotherapy relationship: death anxiety acts as a binding agent to the therapy relationship. The dyad is in constant relational motion between a newly authentic relationship and a fantasy bond (or transference relationship) (Firestone, 1984; Firestone & Catlett, 2009). The authentic relationship, though preferable to a fantasized bond, presents an I-Thou meeting wherein two unique individuals mirror one another’s isolated existence and therefore mirror a life-toward-death. Additionally, the newly acquired and authentic therapy relationship connotes progress, which is also a reminder of time’s passage toward its inevitable end. The patient escapes, therefore, to a bonded dyad in which they transfer the image of past relationships onto the new one. The patient lives out the past and the therapist, attempting to meet the patient on his or her own perceptive ground, sometimes enters into this fantasized relationship as well. Inevitably, while reliving the past through transference relieves immediate death fears, it paradoxically leaves a person feeling lost, alone, and in need of an authentic connection. This place of lost-ness and aloneness is also isolating and death anxiety inducing, so the patient and therapist move back to moments of authentic connection in order to escape death’s resurfacing. All the while, this cycle of trying to escape death anxiety serves to actually strengthen death anxiety’s accessibility to the conscious mind with greater intensity (Hayes et al., 2010). While the therapist is typically trained to monitor and analyze these movements between coupled reality and fantasy, she is simultaneously engaged in the authentic or fantasized connection and, consequently, is also occupied in a death denial of her own. To continue the application of TMT research to the close therapy relationship, consider that even attachments filled with negative emotion (i.e., hate, anger, and shame) also successfully diminish death fears (Florian et al., 2002; Mikulincer et al., 2002). Therefore, a negative relationship between patient and therapist should still serve to buffer and mitigate death anxiety. Whether the close relationship between patient and therapist is positive or negative, the participants in a close relationship experience an increase in death anxiety on threats to that close relationship. Consequently, therapists might expect death anxiety to increase during those specific moments of treatment that are perceived as a threat to the therapeutic bond.

Mortality Salient Dyadic Encounters

Death anxiety increases most during threats to the close relationship and during MS situations (Greenberg et al., 1990). To serve as a reminder: MS situations comprise moments when death anxiety increases and the individual favors that which bolsters the psychological defense mechanism and rejects anything that weakens that mechanism. A similar phenomenon is likely to be discoverable in the clinical situation, wherein the close therapeutic relationship serves as the psychological defense mechanism. When the close therapeutic bond is threatened it leads to mortality salient dyadic encounters between the therapist and patient. An MS dyadic encounter comprises the same psychological dynamics of MS situations and signifies the moment when death anxiety has increased between therapist and patient. Following the TMT close relationship formula, the individual experiencing death anxiety (i.e., the patient, the therapist, or both simultaneously) will favor the close relational bond and reject, deny, diminish, or ignore anything that threatens the close therapeutic relationship. An MS dyadic encounter may be discoverable during the transition from an authentic mode to a fantasy bond enactment (transference) or vice versa (i.e., a fantasized mode transitioning to an authentic mode). While I suspect that the timings of MS dyadic encounters are largely unpredictable, that they occur too subtly to monitor, and they can happen at any point in the therapy process, it is most likely during terminations and endings when death anxiety can be expected to increase.

Death anxiety’s bombardment on the conscious mind may be induced by a number of MS dyadic encounters that are marked by the limitations of the close relationship. For instance, death anxiety may be expected during the endings of clinical sessions, throughout discussion of termination, during a forced termination, and ironically, as the patient’s health improves, thereby signaling temporal advancement and a successful treatment’s lead-in to termination (Vance, 2013). Illness, the geographical relocation of either person, or simply the recognition that there are only a few minutes left in the clinical hour, can also induce an MS dyadic encounter. Stephanie Brody (2009) draws on ontological concerns to describe such time limitations: “progress draws us to the end, the end of a relationship with the analyst, with the intimacy of the analytic world, with a painful awareness regarding its limits” (p. 94) and refers to termination as “an anachronistic stand-in term for death” (p. 94). Any moment the patient realizes that a deeply meaningful relationship must eventually end can similarly spark dread. Yalom (1980) says, “The termination work that occurs in the therapy of every patient is accompanied, if the therapist will only listen, by undercurrents of concern about death” (p. 57). The limitations of the relationship, the hour, the treatment, or even the abilities of patient and therapist to rectify misunderstandings, solve problems, or discover recovery and health press against existential limitations and therefore act as a potential avenue to the root MS dyadic encounter. The use of this new term, MS dyadic encounters, is meant to encourage the clinician to listen to moments of death’s threat on consciousness. While MS dyadic encounters likely occur on a frequent basis, it is perhaps an inability for clinicians to handle their own existential dread that death fears have not yet been discussed clinically.

MS Dyadic Encounter as Intervention

James Hillman (1965) says, “We never come fully to grips with life until we are willing to wrestle with death” (p. 15). There is a time, therefore, to explicitly address death fears with a patient who is ready to grip the realities of life. There are also times to allow MS dyadic encounters to pass and times it could be noted by the therapist for later conversation. I realize that it would not be prudent for a clinician to create an agenda to discuss death or to attempt to make death associations while undermining more pressing patient concerns. However, death anxiety is a patient concern that is largely being denied and one the therapist will frequently miss, often colluding with the patient’s denial instead of addressing blatant concerns about fear of death (Yalom, 1980).¹ It is partially due to the complex and abstract nature of death that we avoid it, but it is also due to a therapist’s own fear, which is predicated by a field that, under financial pressure and short-term approaches, further sidelines the issue of death. Lirian Razinsky (2012) asserts that though the task is nuanced and difficult, it must be attempted, “Whether death is available to us or not, the important thing is that we attempt to come closer to it, to bring it into our thoughts. To leave it outside our mental life has too high a price” (p. 29). Said positively, Rollo May (1981) states that “life is the opposite of death, and thoughts of death are necessary if we are to think significantly of life” (p. 108). Newer TMT studies (see, e.g., Das, Bushman, Bezemer, Kerkhof, & Cermeulen, 2009; Pyszczynski, Abdollahi, Greenberg, & Solomon, 2006) suggest that living without recognition of our death can lead to extremist views and, in extraordinary cases, hate toward people viewed within the out-group. Reactions to the 9/11 terrorist attacks, for instance, created death anxiety and lead to the extreme jump in George W. Bush’s approval rating (almost a 50% increase) when he promised justice (Pyszczynski, Solomon, & Greenberg, 2003). After the terrorist attacks created a mortality salient situation, the need to mitigate those fears increased among Americans, and Bush’s antidotal speeches bonded Americans against people Americans could hate and consider inferior, thereby boosting a sense of specialness and likely playing a role in Bush’s reelection (Cohen, Ogilvie, Solomon, Greenberg, & Pyszczynsk, 2005).

There is simply a high prize in the notion of death:

Death and life are interdependent: though the physicality of death destroys us, the idea of death saves us. Recognition of death contributes a sense of poignancy to life, provides a radical shift of life perspective, and can transport one from a mode of living characterized by diversions, tranquilization, and petty anxieties to a more authentic mode. (Yalom, 1980, p. 40)

Death seems to have the potential to light a fire under a person’s sense of purpose. Death ultimately gives ontological meaning to a person who would otherwise have no end and therefore have little motivation to get to living. To become romanticized by the notion of immortality or to speak of death as something that could happen, as opposed to something that absolutely will, dwindles the flame that paradoxically brings poignant and urgent meaning into existence. May (1981) says, “The paradox is that the very confrontation with the one breathes vitality into the other. Life is more alive, more zestful, when we are aware of death; and death has significance only because there is life” (p. 66). Death is a deadline, and the idea of death bears weight on living. May also credits creativity, honesty, and therapeutic strivings as the result of authentic death awareness. People having been diagnosed with a life-threatening disease such as cancer or those having deeply contemplated suicide at one point in the past will often speak of their changed perspective on life after having revisited their relationship to death. Stolorow (2011) posits that as a result of having death awareness thrust on them, a traumatized patient can gain a sense of possibility, freedom, and authenticity that did not exist at a prior time. In fact, Stolorow credits his own personal traumas with having provided “authentic resoluteness” and giving him the opportunity to now engage in the deeply meaningful work of writing extensively about emotional trauma.

To deny death in the clinical room may, in fact, deny the patient their creative drive to construct life. It may, in other words, create collusion with the notion of immortality, robbing a patient of the opportunity to make the most out of limited time. Explicit recognition of the MS dyadic encounter is an intervention that pulls back the veil of denial and fans the flame that burns under each life, thereby inviting immediacy of the moment, motivation to act, and freedom to live fully. Death anxiety is basic to the creation of close relationships, and so, denying its existence in the clinical room would be akin to denying sexual transference or, more fundamentally, the importance of the therapeutic relationship. Sharing personal death fears with patients (i.e., bringing recognition to the fact that the therapist is also not immune to death or the anxiety it creates) may also be an important aspect of a successful MS dyadic encounter. Such a disclosure of the therapist’s mortality is not only authentic, but it reminds the patient that the therapist is human and therefore subject to the same existential limitations. Limitations are necessary for understanding potentialities. A therapist’s disclosure also models the human capacity to face death along with its associated fears, thereby making a taboo subject a bit more normal.

Conclusion

Ernest Becker (1973) introduced a new way of understanding death, its impact on the psyche, and on relationships. Despite these efforts and subsequent research, the field of psychology continually marginalizes discussion of death and death anxiety as a dominant psychic factor. Since Becker (1973), theorists have attempted to bring such a core human phenomenon back into theoretical folds. Yalom (1980), Hoffman (1979, 1998), May (1981), Pyszczynski et al. (1999), Jerry Piven (2004), Langs (2004, 2008), Firestone and Catlett (2009), Stolorow (2011), Razinsky (2012), Shaver and Mikulincer (2012), and Schneider (2013) have all attempted to weave death anxiety into psychological theoretical systems. The depth psychologies still lack, however, robust case examples, instruction on how to speak about death, and how to use death to create poignancy, meaning-making, and the recognition of choice. Death is central—and such a fact should be reflected in a field that aims to attain scientific truths and a full sketch of life forces.

The MS dyadic encounter is an invitation to search for death anxiety and bring it to the fore of consciousness. The close relationship is bound by death anxiety, and death fears also emerge from it, so it seems fitting to bring death talk into the clinical realm, where it can be developed theoretically, applied in case conceptualization, and employed as an intervention. Death anxiety is fundamental to our existence and thus pleads to be given language in the field of psychology and in the lives that patient’s seek.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biography

Lee Michael Vance is a fifth-year doctoral student in clinical psychology (PsyD) at The Wright Institute in Berkeley, CA. For the 2013-2014 academic year, his APA Internship is at King’s County Hospital Center, Brooklyn, NY. He received his BA in psychology from Messiah College in Grantham, PA; his MA in theology from Fuller Theological Seminary in Pasadena, CA; and his MA in clinical psychology from the Wright Institute. His dissertation research is designed to assist the student-clinician in the navigation of forced terminations through the use of death anxiety constructs. His clinical and research interests include depth psychology, death anxiety, race and culture, and severe and persistent mental illness.

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