Dying and the Near-Death Dying and the Near-Death ExperienceExperience

Dusana RybarovaDusana RybarovaChapter 3Chapter 3

2007 Psyc 4562007 Psyc 456

PTSD revisitedPTSD revisited Most clinicians agree that victims of PTSD should face the original Most clinicians agree that victims of PTSD should face the original

trauma to be able to cope with the debilitating effects of the disordertrauma to be able to cope with the debilitating effects of the disorder Exposure TherapyExposure Therapy Helps PTSD Victims Overcome Trauma's Helps PTSD Victims Overcome Trauma's

Debilitating EffectsDebilitating Effects– In the 1980’s, Dr. Terence M. Keane and his colleagues found that In the 1980’s, Dr. Terence M. Keane and his colleagues found that

exposure therapy was effective in treating the PTSD symptoms of exposure therapy was effective in treating the PTSD symptoms of Vietnam War veterans. Exposure therapy, previously known as imaginal Vietnam War veterans. Exposure therapy, previously known as imaginal flooding therapy, involves carefully exposing the patient to prolonged and flooding therapy, involves carefully exposing the patient to prolonged and repeated imagined images of the trauma until the images no longer cause repeated imagined images of the trauma until the images no longer cause severe anxiety. In Keane’s randomized clinical trial involving 24 Vietnam severe anxiety. In Keane’s randomized clinical trial involving 24 Vietnam veterans, Keane found that exposure therapy was effective in reducing veterans, Keane found that exposure therapy was effective in reducing many of the veteran’s PTSD symptoms, including nightmares, flashbacks, many of the veteran’s PTSD symptoms, including nightmares, flashbacks, memory and concentration problems, and irritability.memory and concentration problems, and irritability. http://www.psychologymatters.org/keane.htmlhttp://www.psychologymatters.org/keane.html

For more on efficacy of psychological treatments for PTSD checkFor more on efficacy of psychological treatments for PTSD check– http://www.nimh.nih.gov/publicat/reliving.cfmhttp://www.nimh.nih.gov/publicat/reliving.cfm– http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.htmlhttp://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_treatmentforptsd.html

Kubler-Ross’ Stage Model of DyingKubler-Ross’ Stage Model of Dying

Pioneered research with the dying in 1960sPioneered research with the dying in 1960s– Difficulty in access to dying patients hindered by Difficulty in access to dying patients hindered by

physiciansphysicians– Patients were usually surprised, amazed, and grateful; Patients were usually surprised, amazed, and grateful;

relieved to share their last concerns and expressing relieved to share their last concerns and expressing their feelingstheir feelings

– Interviewed 400 dying persons over a 10 year periodInterviewed 400 dying persons over a 10 year period Her work resulted in a bookHer work resulted in a book

– On Death and DyingOn Death and Dying (1969) usual stages of dying (1969) usual stages of dying

Stages of dying according to Stages of dying according to Kubler-RossKubler-Ross

Shock/DenialShock/Denial– Numbness, shock, withdrawal and cognitive denialNumbness, shock, withdrawal and cognitive denial– Can take from few seconds to few months Can take from few seconds to few months – 1% of terminally ill people stay in that stage1% of terminally ill people stay in that stage

AngerAnger– Envy and resentment of those whose lives will continueEnvy and resentment of those whose lives will continue– Anger can be expressed towards everyone they Anger can be expressed towards everyone they

encounter in various forms such as complaintsencounter in various forms such as complaints– Important to see the dying person as a unique human Important to see the dying person as a unique human

being engaged in the process of grieving rather than being engaged in the process of grieving rather than somebody who is threatening or just a ‘patient’somebody who is threatening or just a ‘patient’

Stages of dying according to Stages of dying according to Kubler-RossKubler-Ross

BargainingBargaining– Making promises (usually towards spiritual figures) in Making promises (usually towards spiritual figures) in

exchange to more time to liveexchange to more time to live– It is natural and healthy way to cope with the reality of It is natural and healthy way to cope with the reality of

approaching deathapproaching death DepressionDepression

– Acute depression, the dying regrets past failures and Acute depression, the dying regrets past failures and mistakes that can not be correctedmistakes that can not be corrected

– Grief about the lost timeGrief about the lost time– Recognition of approaching deathRecognition of approaching death

Stages of dying according to Stages of dying according to Kubler-RossKubler-Ross

AcceptanceAcceptance– Without anger or depressionWithout anger or depression– ‘‘it’s my time now, and it’s all right’ without defeat or it’s my time now, and it’s all right’ without defeat or

disappointmentdisappointment– In our culture the dying person is often drowsy, In our culture the dying person is often drowsy,

withdrawn, drugged, and asleep much of the timewithdrawn, drugged, and asleep much of the time– Often does not like to engage in conversationOften does not like to engage in conversation– But, it is important to show that others care through But, it is important to show that others care through

physical presencephysical presence– The dying often realizes our connectedness to all The dying often realizes our connectedness to all

living/dying beings living/dying beings

Stages of dying according to Kubler-Stages of dying according to Kubler-Ross – Advantages and CriticismRoss – Advantages and Criticism

Positive aspectsPositive aspects– Focus on humane treatment of the dying and their needsFocus on humane treatment of the dying and their needs– Encourages the caregivers to view the world through the Encourages the caregivers to view the world through the

eyes of the dyingeyes of the dying– Learning from the dying about ourselves, our values and Learning from the dying about ourselves, our values and

our own search for valuesour own search for values CritiqueCritique

– Lack of empirical support in scientific literatureLack of empirical support in scientific literature– Restrictive nature of the stagesRestrictive nature of the stages– Problem with the way it was applied by healthcare Problem with the way it was applied by healthcare

professionals – annoyance if the dying people do not professionals – annoyance if the dying people do not move neatly through the expected stagesmove neatly through the expected stages

Pattison’s Phase ModelPattison’s Phase Model

Based on his book Based on his book The Experience of DyingThe Experience of Dying (1977)(1977)

Lists three phases of dying to assist clinical Lists three phases of dying to assist clinical practice – not meant to be viewed as practice – not meant to be viewed as inevitable inevitable – The acute phaseThe acute phase– The chronic living/dying phaseThe chronic living/dying phase– Terminal phaseTerminal phase

Pattison’s Phase ModelPattison’s Phase Model

The Acute PhaseThe Acute Phase– Corresponds to Kubler-Ross’ denial, anger, and Corresponds to Kubler-Ross’ denial, anger, and

bargaining stagesbargaining stages– Rising anxiety can result in frozen fear – the Rising anxiety can result in frozen fear – the

person can not functionperson can not function– For caregiversFor caregivers

Emphasizing reality issues connected to dyingEmphasizing reality issues connected to dying Providing emotional support throughout the processProviding emotional support throughout the process

Pattison’s Phase ModelPattison’s Phase Model The Chronic Living/Dying PhaseThe Chronic Living/Dying Phase

– Confrontation of fears surrounding dying and deathConfrontation of fears surrounding dying and death1.1. Fear of abandonmentFear of abandonment

- ranked as number one fear of the dying- ranked as number one fear of the dying - dying without loved ones- dying without loved ones - may include fear of loneliness, fear of social death, - may include fear of loneliness, fear of social death,

fear of loss of family and friendsfear of loss of family and friends2. Fear of loss of self control2. Fear of loss of self control

- sense of dependency on others- sense of dependency on others- feeling ugly and unacceptable- feeling ugly and unacceptable- important to keep sense of power and authority over - important to keep sense of power and authority over day-to-day livesday-to-day lives

Pattison’s Phase ModelPattison’s Phase Model

3. Fear of suffering and pain3. Fear of suffering and pain- 50% of dying patients in American hospitals report - 50% of dying patients in American hospitals report moderate to sever pain during their final daysmoderate to sever pain during their final days- helps to reframe attitudes to view the pain as part of - helps to reframe attitudes to view the pain as part of the disease process not punishment or abandonmentthe disease process not punishment or abandonment

4. Fear of loss of personal identity4. Fear of loss of personal identity- loss of loved ones, body functions, consciousness, - loss of loved ones, body functions, consciousness, and control over life as a threat to the selfand control over life as a threat to the self

- important to keep in touch and maintain contact with - important to keep in touch and maintain contact with work and community whenever possiblework and community whenever possible

Pattison’s Phase ModelPattison’s Phase Model5. Fear of the Unknown5. Fear of the Unknown- questions about afterlife – spiritual crisis - questions about afterlife – spiritual crisis in some casesin some cases- what will happen to his/her family- what will happen to his/her family6. Fear regression into Self6. Fear regression into Self- facing the experience of entering ‘… into a - facing the experience of entering ‘… into a primordial sense of being where there is no primordial sense of being where there is no awareness of time or space or boundaries awareness of time or space or boundaries between self and others..’ (Pattison, 1977:55)between self and others..’ (Pattison, 1977:55)-dying person may fight against the regression -dying person may fight against the regression resulting in so-called death-agoniesresulting in so-called death-agonies

Pattison’s Phase ModelPattison’s Phase Model Terminal phaseTerminal phase

– Realizing that death is not going to go awayRealizing that death is not going to go away– Social deathSocial death

Physical separation from loved ones and communityPhysical separation from loved ones and community– Psychological deathPsychological death

Regress deep into self by way of various states of Regress deep into self by way of various states of consciousness (sleep, dream, coma)consciousness (sleep, dream, coma)

– Biological deathBiological death Vegetative stage – no intentional (purposeful) activityVegetative stage – no intentional (purposeful) activity

– Physiological deathPhysiological death Vital organs stop operatingVital organs stop operating

Humanistic psychologists such as Maslow were first Humanistic psychologists such as Maslow were first to acknowledge higher needs - need for love, self-to acknowledge higher needs - need for love, self-

fulfillment, aesthetic and spiritual needsfulfillment, aesthetic and spiritual needshttp://chiron.valdosta.edu/whuitt/col/regsys/maslow.htmlhttp://chiron.valdosta.edu/whuitt/col/regsys/maslow.html

Corr’s Task-based Coping ModelCorr’s Task-based Coping Model

Charles Corr (1992) – coping model of Charles Corr (1992) – coping model of active participation in living our dyingactive participation in living our dying– Physical needsPhysical needs

Communicating needs such as pain control, nutrition, Communicating needs such as pain control, nutrition, hydration, sleep pattern to family and medical staffhydration, sleep pattern to family and medical staff

– Psychological needsPsychological needs Needs of psychological security, autonomy, richness Needs of psychological security, autonomy, richness As identified by caregivers As identified by caregivers healthy deathhealthy death was was

associated with approaching death with seriousness associated with approaching death with seriousness as well as humor, reviewing past, exploring afterlife, as well as humor, reviewing past, exploring afterlife, discussing practicalities of dying with others etc.discussing practicalities of dying with others etc.

Corr’s Task-based Coping ModelCorr’s Task-based Coping Model– Social needsSocial needs

Sustaining and enhancing relationships that we valueSustaining and enhancing relationships that we value Finishing unfinished businessFinishing unfinished business Deciding who to spend the terminal phase of life withDeciding who to spend the terminal phase of life with

– Spiritual needsSpiritual needs Seeking source of spiritual nurturance and meaningSeeking source of spiritual nurturance and meaning Three principal spiritual tasks for the dyingThree principal spiritual tasks for the dying

– The need to find meaning in or the ultimate significance of The need to find meaning in or the ultimate significance of lifelife

– The need to die an appropriate death (appropriate with The need to die an appropriate death (appropriate with respect to our values, and spiritual beliefs)respect to our values, and spiritual beliefs)

– The need to transcend death (reassurance of immortality or The need to transcend death (reassurance of immortality or continuity of future generations)continuity of future generations)

Final momentsFinal momentsSleep/Death analogiesSleep/Death analogies

Regression into self (Pattison, 1977)Regression into self (Pattison, 1977)– The state of consciousness we experience just before The state of consciousness we experience just before

we fall to sleep each night, or just before we are awakewe fall to sleep each night, or just before we are awake Hypnagogic state of consciousnessHypnagogic state of consciousness – altered state – altered state

of consciousness between wakefulness and sleepof consciousness between wakefulness and sleep Greeks talk about similarities between death Greeks talk about similarities between death

(thanatos) and sleep (hypnos)(thanatos) and sleep (hypnos) Sogyal Rinpoche (1992:344)Sogyal Rinpoche (1992:344)

‘‘The senses and grosser layers of consciousness The senses and grosser layers of consciousness dissolve… Next, there is a dimension of consciousness dissolve… Next, there is a dimension of consciousness which is so subtle we are normally completely unaware which is so subtle we are normally completely unaware of its very existence…’of its very existence…’

Near-death ExperiencesNear-death Experiences Near-death experience (NDEs)Near-death experience (NDEs)

– Individuals at the edge of permanent death are revivedIndividuals at the edge of permanent death are revived Raymond Moody (1975) pioneered work on NDERaymond Moody (1975) pioneered work on NDE Survivors describe death as unpleasant at first, but Survivors describe death as unpleasant at first, but

upon ‘letting go’ they report experiences of great upon ‘letting go’ they report experiences of great joyjoy– Travel through darkness, then trough a tunnel filled with Travel through darkness, then trough a tunnel filled with

bright light; bright light; – afterwards the mind emerges into the bright light, often afterwards the mind emerges into the bright light, often

accompanied by beings of light; accompanied by beings of light; – reports of ‘life reviews’reports of ‘life reviews’

Research shows that NDEs occur in other cultures Research shows that NDEs occur in other cultures as well as well http://www.nderf.org/http://www.nderf.org/

Dimensions of the Near-Death Dimensions of the Near-Death ExperienceExperience

Hyperalertness dimensionHyperalertness dimension– Higher levels of attentionHigher levels of attention– Thoughts and images become sharper and Thoughts and images become sharper and

speeded upspeeded up– Visions become highly intenseVisions become highly intense

Depersonalization dimensionDepersonalization dimension– Experience of lacking personal identityExperience of lacking personal identity– Sense of detachment Sense of detachment – Loss of ability to keep track of timeLoss of ability to keep track of time

Dimensions of the Near-Death Dimensions of the Near-Death ExperienceExperience

Out-of-body dimensionOut-of-body dimension– Awareness of what is happening to the body with Awareness of what is happening to the body with

accompanying feeling of being separate from itaccompanying feeling of being separate from it– Floating above the body while others are trying to revive Floating above the body while others are trying to revive

itit– Viewing body as watching a movie, detachmentViewing body as watching a movie, detachment– NDE survivors reporting information they could not have NDE survivors reporting information they could not have

found out about through guesswork or prior knowledgefound out about through guesswork or prior knowledge Mystical dimensionMystical dimension

– Transcendence, leaving earthly dimensionTranscendence, leaving earthly dimension– Encounters with mystical beings or invisible spiritsEncounters with mystical beings or invisible spirits– Harmony, revelation, unity, joyHarmony, revelation, unity, joy

The Death-as-Door ThesisThe Death-as-Door Thesis The spiritual viewThe spiritual view Awakening of latent spiritual energy such as holy Awakening of latent spiritual energy such as holy

spirit, vital winds, chi, tumo or kundalini which can spirit, vital winds, chi, tumo or kundalini which can lead to the experience of enlightenment or lead to the experience of enlightenment or illuminationillumination

Across spiritual traditionsAcross spiritual traditions– Death leading to resurrection and everlasting lifeDeath leading to resurrection and everlasting life– Hindi – reincarnationHindi – reincarnation– Tibetan Buddhist – door into bardo (state in between, in Tibetan Buddhist – door into bardo (state in between, in

this case between death and future rebirth)this case between death and future rebirth)

The Death-as-Wall ThesisThe Death-as-Wall Thesis

The scientific viewThe scientific view NDE as strong reactions of the nervous-NDE as strong reactions of the nervous-

system enabling us to adapt to dangerous system enabling us to adapt to dangerous circumstancescircumstances– Not everyone experiences NDEs or ‘dies’ Not everyone experiences NDEs or ‘dies’

blissful, accepting deathblissful, accepting death– The NDE can occur in situations not related to The NDE can occur in situations not related to

deathdeath– We hear reports of NDE only from the survivors We hear reports of NDE only from the survivors

The near-death event as a major life The near-death event as a major life transitiontransition

Impact of NDE on the survivors:Impact of NDE on the survivors:– Reduction in death anxietyReduction in death anxiety– Focus on here and now rather than preoccupation with Focus on here and now rather than preoccupation with

deathdeath– Sense of relative invulnerabilitySense of relative invulnerability– Strong belief in continued existenceStrong belief in continued existence– Significant shift towards spiritualitySignificant shift towards spirituality– Changes in values, priorities towards love and caring of Changes in values, priorities towards love and caring of

othersothers– New interests in caring aspects of human relationshipsNew interests in caring aspects of human relationships