Eur J Ageing (2011) 8:169–175 DOI 10.1007/s10433-011-0195-3
ORIGINAL INVESTIGATION
Gratitude lessens death anxiety Rosanna W. L. Lau • Sheung-Tak Cheng
Published online: 4 August 2011 Ó Springer-Verlag 2011
Abstract This study investigated whether a brief gratitude induction could reduce death anxiety. 83 Chinese older adults (mean age = 62.7, SD = 7.13) were randomly assigned into one of three conditions: gratitude, hassle, and neutral, in which they wrote different types of life events before responding to measures of death anxiety and affect. Participants in the gratitude induction reported lower death anxiety than the hassle and the neutral condition, whereas no difference was observed for the latter two conditions. There was no experimental effect on positive affect, and a significant effect on negative affect but which did not favor the gratitude condition. By reexamining life events with a thankful attitude, people may become less fearful of death due to a sense that life has been well-lived. Because gratitude can be induced using a very brief procedure, there are broad applications in clinical and health-care settings for the relief of death anxiety. Keywords Gratitude Death anxiety Positive affect Negative affect Chinese older adults
Introduction Death anxiety is a negative psychological reaction to the prospect of mortality (Templer et al. 2006). It is related to human beings’ inability to accept mortality and is a common phenomenon. To some people, it can be an immense
Responsible editor: D.J.H. Deeg. R. W. L. Lau S.-T. Cheng (&) Department of Psychological Studies, Hong Kong Institute of Education, 10 Lo Ping Road, Tai Po, NT, Hong Kong e-mail: [email protected]
terror of non-being and underlies many forms of anxiety and phobia such as the fear of what comes after death and suffering when dying. It is also related to the fear of disappearing from the world without really fulfilling their lives (Firestone 2009). It has been theorized that the fear of mortality, or a shortened lifespan, is the reason why people often deny major physical illness when it happens to them (Yalom 1980; Becker 1973). Clinical experiences suggest that denial is commonly employed to cope with this terror so that people often believe that their likelihood of mortality is lower than that of others (Yalom 1980). U.S. epidemiological surveys suggest that death anxiety affects 10–15% of the population (Agras et al. 1969; Noyes et al. 2000). Research suggests that physical illnesses, institutionalization, and the loss of loved ones are associated with thoughts of personal vulnerability and mortality (Fortner and Neimeyer 1999; Sanders 1980–1981). These events are more common in older adults and have the potential of triggering heightened death anxiety in them. Studies have found death anxiety to be associated with psychological distress, anxiety, and depression (Gilliland and Templer 1985–1986; Thorson and Powell 2000) in both subclinical and clinical ranges. (For a review of the relationship between death anxiety and a range of anxiety disorders, see Furer and Walker 2008.) In terms of public health implications, death anxiety is associated with resistance to engage in health behaviors, to seek health information, and to receive medical treatment (Knight and Elfenbein 1996). Furthermore, death anxiety prevents effective end-of-life preparations; a population survey of adults aged in the mid-50s showed that avoidance of thoughts about death predicted a lack of end-of-life planning 10 years later, after controlling for previous informal planning, health status, religious affiliation, and demographic factors (Carr and Khodyakovi 2007). Death anxiety
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has also been found to be associated with a lower inclination to donate posthumous organs and a higher expectation of medical neglect (Wu and Tang 2009). Thus, death anxiety can be a rather serious issue with a wide range of consequences, including making health-care decisions, adherence to treatment regime, preventive health behaviors, and even psychological disorders. Additionally, health-care professionals working with terminally ill patients are themselves at risk for death anxiety due to the nature of their job, which is associated with perceived occupational stress and interferes with their readiness to care for dying patients (Bene´ and Foxall 1991; Carr and Merriman 1995). Thus, death anxiety poses a significant health-care issue in aging societies. Despite its potential significance, little research has been done on the methods to tackle death anxiety. People in late adulthood are likely to engage in life review and find meanings, purpose, and order in their lives so as to attain the stage of intergrity (Erikson 1997). Empirical research shows that ego integrity and the feeling of a life well-lived, as indicated by life satisfaction and a sense of purpose, are associated with lower death anxiety (see metaanalysis by Fortner and Neimeyer 1999). Thus, some scholars have proposed that death anxiety is a function of the perceived inability to fulfill major life goals, or a sense of regret (Tomer and Eliason 1996). Life regrets are feelings that one is unable to fulfill certain major life goals, which may be due to past errors of omission or commission or the perception that future life circumstances make realizing important goals unlikely. Regrets lead to the wish to undo past mistakes and realign actions with goals (Giloviqh and Medvec 1995), but death is a state that rules out the possibility of undoing altogether. Therefore regrets exacerbate the fear of personal mortality (Tomer and Eliason 1996). Death anxiety can be a transient state, as when it is temporarily triggered by a health-threatening event, or a chronic phenomenon. For instance, Furer and Walker (2008) described a patient who, despite without imminent health threats, was so preoccupied with the possibility of dying in the future that she could not write a will, celebrate birthdays, or look at family photo albums, all reminding her of aging and mortality. Her fear of death significantly affected her life enjoyment and even her family members, which went on for a long time. Despite such a potentially debilitating condition, there are currently no effective ways to reduce death anxiety. Experimental studies are lacking, and the few studies that have been done found little support for behavioral approaches (e.g., systematic desensitization and relaxation; Rasmussen et al. 1998; Testa 1981; White et al. 1983–1984) or life review therapy (Vaughan and Kinnier 1996). Other approaches, such as regret therapy (Tomer and Eliason 1996) or spiritual counseling (Eliason 2000), have not been subject to experimental investigation.
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In light of such negative findings, new ways to tackle death anxiety are needed. This study examined the effectiveness of a new gratitude-induction approach in an experiment. Gratitude is the feeling of thankfulness and appreciation to benefits received that is unexpected or felt to be undeserved. Gratitude can be felt toward a person, or toward an impersonal (nature) or non-human object (e.g., God; Emmons and Shelton 2002). Gratitude is one of the most common feelings in everyday life in very old adults, along with happiness and contentment (Chipperfield et al. 2003). The relative frequency with which gratitude is felt may account for the fact that very old adults are able to maintain low death anxiety (Gesser et al. 1988; Russac et al. 2007) despite social losses, physical decline, and nearness to death. Our work is guided by the potential of a gratitude orientation to changing people’s perceptions of their lives, and hence a sense of meaning and order (Emmons and Mishra 2011). Other scholars (e.g., Janoff-Bulman 1992; Thompson and Janigian 1988) have suggested that searching for meaning is important for coping with negative or traumatic events, and a sense of meaning and order can be enhanced by changing people’s perceptions of events in life. For instance, Emmons and McCullough (2003) asked college students to write five grateful events, hassles, or events that had an impact on their lives on a weekly basis over 10 weeks. Results showed that participants who did the gratitude reports had more life satisfaction and positive affect, and fewer headaches after the intervention. Thus, gratitude is a potential candidate for intervention that has death anxiety as the outcome. By reviewing their own lives in a new, positive light, individuals are expected to reduce their sense of unfulfilled wishes and regrets, thus promoting a sense of ego integrity and acceptance of death. Gratitude may thus be considered a counter-emotion to regret as well. This approach is also similar to life review but selectively focuses on grateful events, not all kinds of important events, and for this reason, it might be treated as a specific form of positive reminiscence. Relatedly, it is important to note that older adults’ reminiscence is heavily loaded by happy rather than sad or traumatic memories, especially those about the second and third decades of life (i.e., the reminiscence bump; Berntsen and Rubin 2002), and that the positive memories are predictive of morale (Havighurst and Glasser 1972; Westerhoff et al. 2010). Thus a gratitude-based, positive reminiscence approach is likely to be highly adaptive. A gratitude approach is also not toned in spiritual terms (as the objects of gratitude do not have to be of a spiritual nature) and hence is more acceptable to those who are not spiritually oriented. (Although culture was not our primary consideration when formulating the study, we note that the Chinese
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culture is a rather secular one. For instance, a survey showed that 77% of Mainland Chinese self-identified as ‘not at all’ or ‘slightly’ religious—the highest among 18 nations worldwide (Saxena 2006).) We examined the effectiveness of a brief gratitude induction procedure in reducing death anxiety. A brief procedure has the advantage of being applicable in a variety of situations and settings. In this study, older adults were exposed to brief manipulations that directed them to focus on grateful events, hassles, or other important events (control) in life. We then examined whether such manipulations led to changes in death anxiety. We contrasted gratitude with hassles because attending to hassles suppresses feelings of gratitude (Emmons and McCullough 2003). If gratitude is an antidote to death anxiety, then asking people to attend to hassles should lead to higher death anxiety than those who attend to thankful or nonhassle events. We expected the gratitude group to report the lowest death anxiety, the hassle group to report the highest death anxiety, and the neutral group to be somewhere in between. To further examine whether the effect of gratitude was specific to death anxiety, we included measures of general positive (PA) and negative affect (NA). We hypothesized that whereas gratitude would have an effect on death anxiety, it did not do so because of arousing an overall sense of ‘‘feeling good’’ (i.e., no effect on PA and NA).
Method Participants A convenience sample of 83 Chinese adults aged 55–85 (M = 62.7, SD = 7.13; 60.0% women) provided informed consent to participate. A sample size of 27 per group was targeted to achieve a power of 0.80 for a moderate effect size in one-way analysis of variance (ANOVA) designs with three levels (Cohen 1988). The majority (84.3%) of the participants were married. About one-third (37.3%) had primary or no formal education, 54.2% had secondary education, and 8.4% had tertiary education. They were recruited from social centers or clubs for older persons and through personal contacts. Because of the nature of the study, only persons with sufficient literacy were targeted, who were referred by staff of the participating agencies. Thus, the older adults in this study did not represent the general profile of older adults in Hong Kong, most of whom had received little or no education (Census and Statistics Department 2007). In fact, because educational attainment is higher among the young-olds, we had targeted a younger age group, many of whom may not normally be considered ‘‘old.’’ Despite a wide range, there is
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generally little variation in death anxiety within this age range (Russac et al. 2007; see also ‘‘Results’’ section for a lack of correlation between age and death anxiety in this sample); thus it was a relatively homogeneous sample in terms of levels of death anxiety. Measures Death anxiety Because the original 15-item Death Anxiety Scale has been shown to have low internal reliability in Chinese older adults (Wu et al. 2002), we used the extended version of the scale, which has 51 items (Templer et al. 2006). Moreover, because the scale is rated on a yes/no basis and hence is unlikely to be responsive to change, we adopted McMordie and Kumar’s (1984) modification so that the items were rated on a 7-point scale of 1 (very strongly disagree) to 7 (very strongly agree). The alpha coefficient was 0.96 in this sample. Positive and negative affect The Chinese Affect Scale (Cheng 2004), with six items each measuring PA (excited, joyful, happy, content, relaxed, comfortable) and NA (irritable, frightened, bitter, sad, disappointed, depressed), was used. Initially, 10 items each for PA and NA were selected from list of over 120 Chinese adjectives of affect on the basis of frequency of occurrence in the daily lives of Hong Kong Chinese adults (Hamid and Cheng 1996). The present 6-item versions which correlated at r * 0.95 with the 10-item versions in older adults were subsequently used in a large number of studies as brief measures of emotional well-being in this population (e.g., Cheng 2004; Cheng and Chan 2006; Cheng et al. 2010). Participants rated how they felt ‘‘at the moment’’ on a scale of 1 (not at all) to 5 (very much). In this sample, the alpha coefficients were 0.91 and 0.84 for the PA and the NA subscale, respectively. Procedure Participants were randomly assigned into three conditions: gratitude (n = 29), hassle (n = 25), and neutral (n = 29). Participants in groups of 10–15 were invited to a laboratory in which they wrote up to five events in a 15–20 min period. Modeled after Emmons and McCullough (2003), participants in the gratitude condition were asked to recall gratitude-inducing events for which they feel ‘‘grateful, thankful, or appreciative,’’ in which they recognize and respond with grateful emotion to the outcomes that one obtain and have a feeling of thankful appreciation for favors received. Those in the hassle condition recalled
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events that were annoying, and those in the neutral condition wrote about important events in life. Subsequently, they responded to measures of death anxiety and affect. Ethics approval was obtained from the Ethics Subcommittee of the Research Committee of the City University of Hong Kong.
pleasant, 13% unpleasant, and 57% neutral. These figures showed that our manipulation was more successful than those in previous studies (e.g., Study 1 in Emmons and McCullough (2003) reported a distribution of 30, 30, and 40% for these events, respectively). Thus, the neutral group in our study recalled primarily events of significance but not clearly pleasant or unpleasant.
Results
Experimental effects on death anxiety and affect
Manipulation check
Preliminary analysis showed that the three groups did not differ by age (F(2, 81) = 1.07, p = 0.35), gender (v2(2) = 1.26, p = 0.53), and educational level (F(2, 81) = 1.11, p = 0.34). Moreover, age (rs = -0.08, -0.05, and 0.11 with death anxiety, PA, and NA, respectively, all ps C 0.33), gender (t(82) = 1.27, 1.28, -1.83 for death anxiety, PA, and NA, respectively, all ps C 0.09), and education (rs = -0.08, -0.11, and 0.07 with death anxiety, PA, and NA, respectively, all ps C 0.35) were all unrelated to any of the dependent variables. Hence age, gender, and education were not included in further analysis. One-way ANOVAs were conducted separately for death anxiety, PA, and NA as dependent variables, with experimental condition (three levels) as the between-subjects factor. For death anxiety, results of ANOVA revealed a large main effect for experimental condition (F(2, 81) = 7.45, p = 0.001, gp2 = 0.16). Post hoc comparisons with Bonferroni correction showed that the gratitude group (M = 2.83, SE = 0.20) reported significantly lower death anxiety than the hassle (M = 3.95, SE = 0.22, d = 1.10) and the neutral group (M = 3.49, SE = 0.20, d = 0.64), whereas the latter two groups did not differ from each other. There was no experimental effect on PA (F(2, 81) = 2.73, p = 0.07). However, the effect on NA was significant (F(2, 81) = 4.83, p = 0.01, gp2 = 0.11). Post hoc comparisons with Bonferroni correction showed that the hassle group (M = 2.02, SE = 0.13) reported significantly more NA than both the gratitude (M = 1.51, SE = 0.12, d = 0.77) and the neutral (M = 1.56, SE = 0.12, d = 0.63) groups, but the latter two groups did not differ from each other.
As a manipulation check, we examined the degree to which the experimental manipulation guided the participants to focus on different events in life. Each event was coded by the first author as representing either gratitude (expressing a sense of thankfulness, appreciation, or indebtedness; e.g., ‘‘I am glad I have good sons and daughters’’), hassle (distressful, irritating, or frustrating events that require coping resources; e.g., ‘‘physical illness’’), pleasant but not gratitude (any positive event without the expression of gratitude; e.g., ‘‘traveled to other countries’’), unpleasant but not hassle (any negative event without a clear demand on coping; e.g., ‘‘disappointment about government responses to economy’’), and neutral (events without a clear positive or negative tone; e.g., ‘‘knowing more about the world after being a volunteer in social centers’’). (Note that the above examples were translated from Chinese literally but their connotations need to be understood within the context of the subtlety of Chinese expression and the Hong Kong culture, which are beyond the scope of this paper.) An independent rater blind to the group assignment rated 20% of the events selected randomly, and the kappa coefficient was found to be 0.99. Thus, there was very high agreement in event categorization among raters, and event categorization was not affected by knowledge of group assignment. The distribution of the events across experimental conditions is shown in Table 1. As one can see, the manipulations were extremely successful, with all events in the gratitude and the hassle condition being in the intended category. Events in the neutral condition were 30%
Table 1 Average number of events recalled by participants in different experimental conditions Event type
Experimental condition
F(2, 80)
Gratitude
Hassle
Neutral
Gratitude
4.83 (0.53)
0.00 (0.00)
0.00 (0.00)
3858.46
Hassle
0.00 (0.00)
4.60 (0.81)
0.00 (0.00)
924.16
Pleasant (non-gratitude)
0.00 (0.00)
0.00 (0.00)
1.52 (1.70)
23.08
Unpleasant (non-hassle) Neutral
0.00 (0.00) 0.00 (0.00)
0.00 (0.00) 0.00 (0.00)
0.55 (0.74) 2.90 (1.65)
16.29 88.84
Note: All F values were significant at 0.001 level
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Fig. 1 (a) Death anxiety, (b) positive affect, and (c) negative affect by experimental condition, controlling for gender. Error bars denote 95% confidence intervals
Effects of the experimental manipulation are graphically displayed in Fig. 1.
Discussion To our knowledge, this was the first study that examined whether a brief gratitude induction can alter death anxiety as well as affect. Results supported our contention that older adults’ death anxiety could be reduced by orienting their attention toward grateful events in life. The main effects on death anxiety for the experimental manipulation were driven by the beneficial effects of gratitude, but not by the potentially deleterious effects of writing about hassles, as there was no significant difference between the hassle and the neutral group in their reported death anxiety. As expected, there was no experimental effect on PA and the effect on NA, though significant, was not theoretically and clinically meaningful, as will be explained below. Gratitude may be felt because what happened to oneself was truly desirable and undeserved, and/or because things were initially bad, but turn out to be not so bad. Thus, a gratitude intervention may help older adults to see how things end up in positive ways, despite how they began. It should enhance a sense of order and positive meanings in life, a condition that is conducive to achieving ego integrity (Erikson 1997). Compared with current therapeutic models, including regret therapy, life review therapy, and so on, which directly confronts death anxiety in patients, a gratitude intervention focuses on and thereby accentuates the positive. In a sense, it is an indirect way to reduce death anxiety, and has an advantage over direct approaches which may sometimes have the opposite effect. For example, a meta-analysis of the effect of death education on death anxiety showed that after education, people’s death anxiety actually increased significantly, presumably because they were sensitized to issues of death by the programs (Maglio and Robinson 1994). Similarly, regrets
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may not be easily resolved; even if they can be, the process of resolution can be long and painful, and thus cognitively and emotionally demanding for older persons. On the contrary, by diverting the individual’s attention from past regrets, a gratitude intervention has the potential of facilitating relaxation and enjoyment of the present, and avoids potential pitfalls in treatment. There was no significant effect on PA, and the effect on NA was unimpressive. Whereas NA was higher in the hassle group, it was not lower in the gratitude group when compared to the neutral group. Our findings mimicked those in the literature, which generally found that gratitude manipulation did not yield better indices of emotional wellbeing, whether concurrently or prospectively, as compared to control conditions (Emmons and McCullough 2003; Froh et al. 2008). Our brief gratitude induction procedure may not be sufficient to bring about an overall change in positive and negative emotions. On the whole, the results suggest that gratitude is able to reduce death anxiety without changing the overall emotional state of the person. Further research may be needed to see whether repeated exposures to gratitude manipulations would lead to significant changes in emotional well-being in the longer term. Several limitations of the present study need to be mentioned. First, the sample was recruited on a convenience basis and, in order to complete the writing task, was more educated than the older cohort in Hong Kong. Further research is needed on older adults who are representative of the general older Chinese population in Hong Kong. Second, this was not a clinical sample and further research should be conducted to examine how well a gratitude intervention works in patients with clinically elevated death anxiety. Third, our data were based on a brief induction procedure. Future studies using a more long-term induction, such as the diary method, would provide more definitive conclusions regarding the beneficial effects of gratitude. Fourth, because belief in the afterlife is a buffer against death anxiety (Wink and Scott 2005) and a more popular belief in Western than in Asian societies (e.g., 80% of the U.S. population, but somewhat less in European countries, believe in afterlife; Hood et al. 2009), it is unclear whether the effect of gratitude might be attenuated (because belief in afterlife reduces the effect of regret on fear of mortality) in Western societies. Cross-cultural research should be conducted to investigate how findings might vary by differences in spiritual beliefs. Finally, no studies to date, including ours, have provided data on the long-term effects of interventions on death anxiety. Future studies should attempt to collect long-term follow-up data. Although the long-term effects of gratitude interventions are not yet known, it is noteworthy that even the temporary relief of death anxiety may be pivotal in facilitating the making of important health-care or end-of-life decisions at crucial
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times. Because gratitude can be induced using a very brief procedure, there are broad potential applications in clinical and health-care settings for the relief of death anxiety.
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ORIGINAL INVESTIGATION
Gratitude lessens death anxiety Rosanna W. L. Lau • Sheung-Tak Cheng
Published online: 4 August 2011 Ó Springer-Verlag 2011
Abstract This study investigated whether a brief gratitude induction could reduce death anxiety. 83 Chinese older adults (mean age = 62.7, SD = 7.13) were randomly assigned into one of three conditions: gratitude, hassle, and neutral, in which they wrote different types of life events before responding to measures of death anxiety and affect. Participants in the gratitude induction reported lower death anxiety than the hassle and the neutral condition, whereas no difference was observed for the latter two conditions. There was no experimental effect on positive affect, and a significant effect on negative affect but which did not favor the gratitude condition. By reexamining life events with a thankful attitude, people may become less fearful of death due to a sense that life has been well-lived. Because gratitude can be induced using a very brief procedure, there are broad applications in clinical and health-care settings for the relief of death anxiety. Keywords Gratitude Death anxiety Positive affect Negative affect Chinese older adults
Introduction Death anxiety is a negative psychological reaction to the prospect of mortality (Templer et al. 2006). It is related to human beings’ inability to accept mortality and is a common phenomenon. To some people, it can be an immense
Responsible editor: D.J.H. Deeg. R. W. L. Lau S.-T. Cheng (&) Department of Psychological Studies, Hong Kong Institute of Education, 10 Lo Ping Road, Tai Po, NT, Hong Kong e-mail: [email protected]
terror of non-being and underlies many forms of anxiety and phobia such as the fear of what comes after death and suffering when dying. It is also related to the fear of disappearing from the world without really fulfilling their lives (Firestone 2009). It has been theorized that the fear of mortality, or a shortened lifespan, is the reason why people often deny major physical illness when it happens to them (Yalom 1980; Becker 1973). Clinical experiences suggest that denial is commonly employed to cope with this terror so that people often believe that their likelihood of mortality is lower than that of others (Yalom 1980). U.S. epidemiological surveys suggest that death anxiety affects 10–15% of the population (Agras et al. 1969; Noyes et al. 2000). Research suggests that physical illnesses, institutionalization, and the loss of loved ones are associated with thoughts of personal vulnerability and mortality (Fortner and Neimeyer 1999; Sanders 1980–1981). These events are more common in older adults and have the potential of triggering heightened death anxiety in them. Studies have found death anxiety to be associated with psychological distress, anxiety, and depression (Gilliland and Templer 1985–1986; Thorson and Powell 2000) in both subclinical and clinical ranges. (For a review of the relationship between death anxiety and a range of anxiety disorders, see Furer and Walker 2008.) In terms of public health implications, death anxiety is associated with resistance to engage in health behaviors, to seek health information, and to receive medical treatment (Knight and Elfenbein 1996). Furthermore, death anxiety prevents effective end-of-life preparations; a population survey of adults aged in the mid-50s showed that avoidance of thoughts about death predicted a lack of end-of-life planning 10 years later, after controlling for previous informal planning, health status, religious affiliation, and demographic factors (Carr and Khodyakovi 2007). Death anxiety
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has also been found to be associated with a lower inclination to donate posthumous organs and a higher expectation of medical neglect (Wu and Tang 2009). Thus, death anxiety can be a rather serious issue with a wide range of consequences, including making health-care decisions, adherence to treatment regime, preventive health behaviors, and even psychological disorders. Additionally, health-care professionals working with terminally ill patients are themselves at risk for death anxiety due to the nature of their job, which is associated with perceived occupational stress and interferes with their readiness to care for dying patients (Bene´ and Foxall 1991; Carr and Merriman 1995). Thus, death anxiety poses a significant health-care issue in aging societies. Despite its potential significance, little research has been done on the methods to tackle death anxiety. People in late adulthood are likely to engage in life review and find meanings, purpose, and order in their lives so as to attain the stage of intergrity (Erikson 1997). Empirical research shows that ego integrity and the feeling of a life well-lived, as indicated by life satisfaction and a sense of purpose, are associated with lower death anxiety (see metaanalysis by Fortner and Neimeyer 1999). Thus, some scholars have proposed that death anxiety is a function of the perceived inability to fulfill major life goals, or a sense of regret (Tomer and Eliason 1996). Life regrets are feelings that one is unable to fulfill certain major life goals, which may be due to past errors of omission or commission or the perception that future life circumstances make realizing important goals unlikely. Regrets lead to the wish to undo past mistakes and realign actions with goals (Giloviqh and Medvec 1995), but death is a state that rules out the possibility of undoing altogether. Therefore regrets exacerbate the fear of personal mortality (Tomer and Eliason 1996). Death anxiety can be a transient state, as when it is temporarily triggered by a health-threatening event, or a chronic phenomenon. For instance, Furer and Walker (2008) described a patient who, despite without imminent health threats, was so preoccupied with the possibility of dying in the future that she could not write a will, celebrate birthdays, or look at family photo albums, all reminding her of aging and mortality. Her fear of death significantly affected her life enjoyment and even her family members, which went on for a long time. Despite such a potentially debilitating condition, there are currently no effective ways to reduce death anxiety. Experimental studies are lacking, and the few studies that have been done found little support for behavioral approaches (e.g., systematic desensitization and relaxation; Rasmussen et al. 1998; Testa 1981; White et al. 1983–1984) or life review therapy (Vaughan and Kinnier 1996). Other approaches, such as regret therapy (Tomer and Eliason 1996) or spiritual counseling (Eliason 2000), have not been subject to experimental investigation.
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In light of such negative findings, new ways to tackle death anxiety are needed. This study examined the effectiveness of a new gratitude-induction approach in an experiment. Gratitude is the feeling of thankfulness and appreciation to benefits received that is unexpected or felt to be undeserved. Gratitude can be felt toward a person, or toward an impersonal (nature) or non-human object (e.g., God; Emmons and Shelton 2002). Gratitude is one of the most common feelings in everyday life in very old adults, along with happiness and contentment (Chipperfield et al. 2003). The relative frequency with which gratitude is felt may account for the fact that very old adults are able to maintain low death anxiety (Gesser et al. 1988; Russac et al. 2007) despite social losses, physical decline, and nearness to death. Our work is guided by the potential of a gratitude orientation to changing people’s perceptions of their lives, and hence a sense of meaning and order (Emmons and Mishra 2011). Other scholars (e.g., Janoff-Bulman 1992; Thompson and Janigian 1988) have suggested that searching for meaning is important for coping with negative or traumatic events, and a sense of meaning and order can be enhanced by changing people’s perceptions of events in life. For instance, Emmons and McCullough (2003) asked college students to write five grateful events, hassles, or events that had an impact on their lives on a weekly basis over 10 weeks. Results showed that participants who did the gratitude reports had more life satisfaction and positive affect, and fewer headaches after the intervention. Thus, gratitude is a potential candidate for intervention that has death anxiety as the outcome. By reviewing their own lives in a new, positive light, individuals are expected to reduce their sense of unfulfilled wishes and regrets, thus promoting a sense of ego integrity and acceptance of death. Gratitude may thus be considered a counter-emotion to regret as well. This approach is also similar to life review but selectively focuses on grateful events, not all kinds of important events, and for this reason, it might be treated as a specific form of positive reminiscence. Relatedly, it is important to note that older adults’ reminiscence is heavily loaded by happy rather than sad or traumatic memories, especially those about the second and third decades of life (i.e., the reminiscence bump; Berntsen and Rubin 2002), and that the positive memories are predictive of morale (Havighurst and Glasser 1972; Westerhoff et al. 2010). Thus a gratitude-based, positive reminiscence approach is likely to be highly adaptive. A gratitude approach is also not toned in spiritual terms (as the objects of gratitude do not have to be of a spiritual nature) and hence is more acceptable to those who are not spiritually oriented. (Although culture was not our primary consideration when formulating the study, we note that the Chinese
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culture is a rather secular one. For instance, a survey showed that 77% of Mainland Chinese self-identified as ‘not at all’ or ‘slightly’ religious—the highest among 18 nations worldwide (Saxena 2006).) We examined the effectiveness of a brief gratitude induction procedure in reducing death anxiety. A brief procedure has the advantage of being applicable in a variety of situations and settings. In this study, older adults were exposed to brief manipulations that directed them to focus on grateful events, hassles, or other important events (control) in life. We then examined whether such manipulations led to changes in death anxiety. We contrasted gratitude with hassles because attending to hassles suppresses feelings of gratitude (Emmons and McCullough 2003). If gratitude is an antidote to death anxiety, then asking people to attend to hassles should lead to higher death anxiety than those who attend to thankful or nonhassle events. We expected the gratitude group to report the lowest death anxiety, the hassle group to report the highest death anxiety, and the neutral group to be somewhere in between. To further examine whether the effect of gratitude was specific to death anxiety, we included measures of general positive (PA) and negative affect (NA). We hypothesized that whereas gratitude would have an effect on death anxiety, it did not do so because of arousing an overall sense of ‘‘feeling good’’ (i.e., no effect on PA and NA).
Method Participants A convenience sample of 83 Chinese adults aged 55–85 (M = 62.7, SD = 7.13; 60.0% women) provided informed consent to participate. A sample size of 27 per group was targeted to achieve a power of 0.80 for a moderate effect size in one-way analysis of variance (ANOVA) designs with three levels (Cohen 1988). The majority (84.3%) of the participants were married. About one-third (37.3%) had primary or no formal education, 54.2% had secondary education, and 8.4% had tertiary education. They were recruited from social centers or clubs for older persons and through personal contacts. Because of the nature of the study, only persons with sufficient literacy were targeted, who were referred by staff of the participating agencies. Thus, the older adults in this study did not represent the general profile of older adults in Hong Kong, most of whom had received little or no education (Census and Statistics Department 2007). In fact, because educational attainment is higher among the young-olds, we had targeted a younger age group, many of whom may not normally be considered ‘‘old.’’ Despite a wide range, there is
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generally little variation in death anxiety within this age range (Russac et al. 2007; see also ‘‘Results’’ section for a lack of correlation between age and death anxiety in this sample); thus it was a relatively homogeneous sample in terms of levels of death anxiety. Measures Death anxiety Because the original 15-item Death Anxiety Scale has been shown to have low internal reliability in Chinese older adults (Wu et al. 2002), we used the extended version of the scale, which has 51 items (Templer et al. 2006). Moreover, because the scale is rated on a yes/no basis and hence is unlikely to be responsive to change, we adopted McMordie and Kumar’s (1984) modification so that the items were rated on a 7-point scale of 1 (very strongly disagree) to 7 (very strongly agree). The alpha coefficient was 0.96 in this sample. Positive and negative affect The Chinese Affect Scale (Cheng 2004), with six items each measuring PA (excited, joyful, happy, content, relaxed, comfortable) and NA (irritable, frightened, bitter, sad, disappointed, depressed), was used. Initially, 10 items each for PA and NA were selected from list of over 120 Chinese adjectives of affect on the basis of frequency of occurrence in the daily lives of Hong Kong Chinese adults (Hamid and Cheng 1996). The present 6-item versions which correlated at r * 0.95 with the 10-item versions in older adults were subsequently used in a large number of studies as brief measures of emotional well-being in this population (e.g., Cheng 2004; Cheng and Chan 2006; Cheng et al. 2010). Participants rated how they felt ‘‘at the moment’’ on a scale of 1 (not at all) to 5 (very much). In this sample, the alpha coefficients were 0.91 and 0.84 for the PA and the NA subscale, respectively. Procedure Participants were randomly assigned into three conditions: gratitude (n = 29), hassle (n = 25), and neutral (n = 29). Participants in groups of 10–15 were invited to a laboratory in which they wrote up to five events in a 15–20 min period. Modeled after Emmons and McCullough (2003), participants in the gratitude condition were asked to recall gratitude-inducing events for which they feel ‘‘grateful, thankful, or appreciative,’’ in which they recognize and respond with grateful emotion to the outcomes that one obtain and have a feeling of thankful appreciation for favors received. Those in the hassle condition recalled
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events that were annoying, and those in the neutral condition wrote about important events in life. Subsequently, they responded to measures of death anxiety and affect. Ethics approval was obtained from the Ethics Subcommittee of the Research Committee of the City University of Hong Kong.
pleasant, 13% unpleasant, and 57% neutral. These figures showed that our manipulation was more successful than those in previous studies (e.g., Study 1 in Emmons and McCullough (2003) reported a distribution of 30, 30, and 40% for these events, respectively). Thus, the neutral group in our study recalled primarily events of significance but not clearly pleasant or unpleasant.
Results
Experimental effects on death anxiety and affect
Manipulation check
Preliminary analysis showed that the three groups did not differ by age (F(2, 81) = 1.07, p = 0.35), gender (v2(2) = 1.26, p = 0.53), and educational level (F(2, 81) = 1.11, p = 0.34). Moreover, age (rs = -0.08, -0.05, and 0.11 with death anxiety, PA, and NA, respectively, all ps C 0.33), gender (t(82) = 1.27, 1.28, -1.83 for death anxiety, PA, and NA, respectively, all ps C 0.09), and education (rs = -0.08, -0.11, and 0.07 with death anxiety, PA, and NA, respectively, all ps C 0.35) were all unrelated to any of the dependent variables. Hence age, gender, and education were not included in further analysis. One-way ANOVAs were conducted separately for death anxiety, PA, and NA as dependent variables, with experimental condition (three levels) as the between-subjects factor. For death anxiety, results of ANOVA revealed a large main effect for experimental condition (F(2, 81) = 7.45, p = 0.001, gp2 = 0.16). Post hoc comparisons with Bonferroni correction showed that the gratitude group (M = 2.83, SE = 0.20) reported significantly lower death anxiety than the hassle (M = 3.95, SE = 0.22, d = 1.10) and the neutral group (M = 3.49, SE = 0.20, d = 0.64), whereas the latter two groups did not differ from each other. There was no experimental effect on PA (F(2, 81) = 2.73, p = 0.07). However, the effect on NA was significant (F(2, 81) = 4.83, p = 0.01, gp2 = 0.11). Post hoc comparisons with Bonferroni correction showed that the hassle group (M = 2.02, SE = 0.13) reported significantly more NA than both the gratitude (M = 1.51, SE = 0.12, d = 0.77) and the neutral (M = 1.56, SE = 0.12, d = 0.63) groups, but the latter two groups did not differ from each other.
As a manipulation check, we examined the degree to which the experimental manipulation guided the participants to focus on different events in life. Each event was coded by the first author as representing either gratitude (expressing a sense of thankfulness, appreciation, or indebtedness; e.g., ‘‘I am glad I have good sons and daughters’’), hassle (distressful, irritating, or frustrating events that require coping resources; e.g., ‘‘physical illness’’), pleasant but not gratitude (any positive event without the expression of gratitude; e.g., ‘‘traveled to other countries’’), unpleasant but not hassle (any negative event without a clear demand on coping; e.g., ‘‘disappointment about government responses to economy’’), and neutral (events without a clear positive or negative tone; e.g., ‘‘knowing more about the world after being a volunteer in social centers’’). (Note that the above examples were translated from Chinese literally but their connotations need to be understood within the context of the subtlety of Chinese expression and the Hong Kong culture, which are beyond the scope of this paper.) An independent rater blind to the group assignment rated 20% of the events selected randomly, and the kappa coefficient was found to be 0.99. Thus, there was very high agreement in event categorization among raters, and event categorization was not affected by knowledge of group assignment. The distribution of the events across experimental conditions is shown in Table 1. As one can see, the manipulations were extremely successful, with all events in the gratitude and the hassle condition being in the intended category. Events in the neutral condition were 30%
Table 1 Average number of events recalled by participants in different experimental conditions Event type
Experimental condition
F(2, 80)
Gratitude
Hassle
Neutral
Gratitude
4.83 (0.53)
0.00 (0.00)
0.00 (0.00)
3858.46
Hassle
0.00 (0.00)
4.60 (0.81)
0.00 (0.00)
924.16
Pleasant (non-gratitude)
0.00 (0.00)
0.00 (0.00)
1.52 (1.70)
23.08
Unpleasant (non-hassle) Neutral
0.00 (0.00) 0.00 (0.00)
0.00 (0.00) 0.00 (0.00)
0.55 (0.74) 2.90 (1.65)
16.29 88.84
Note: All F values were significant at 0.001 level
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Fig. 1 (a) Death anxiety, (b) positive affect, and (c) negative affect by experimental condition, controlling for gender. Error bars denote 95% confidence intervals
Effects of the experimental manipulation are graphically displayed in Fig. 1.
Discussion To our knowledge, this was the first study that examined whether a brief gratitude induction can alter death anxiety as well as affect. Results supported our contention that older adults’ death anxiety could be reduced by orienting their attention toward grateful events in life. The main effects on death anxiety for the experimental manipulation were driven by the beneficial effects of gratitude, but not by the potentially deleterious effects of writing about hassles, as there was no significant difference between the hassle and the neutral group in their reported death anxiety. As expected, there was no experimental effect on PA and the effect on NA, though significant, was not theoretically and clinically meaningful, as will be explained below. Gratitude may be felt because what happened to oneself was truly desirable and undeserved, and/or because things were initially bad, but turn out to be not so bad. Thus, a gratitude intervention may help older adults to see how things end up in positive ways, despite how they began. It should enhance a sense of order and positive meanings in life, a condition that is conducive to achieving ego integrity (Erikson 1997). Compared with current therapeutic models, including regret therapy, life review therapy, and so on, which directly confronts death anxiety in patients, a gratitude intervention focuses on and thereby accentuates the positive. In a sense, it is an indirect way to reduce death anxiety, and has an advantage over direct approaches which may sometimes have the opposite effect. For example, a meta-analysis of the effect of death education on death anxiety showed that after education, people’s death anxiety actually increased significantly, presumably because they were sensitized to issues of death by the programs (Maglio and Robinson 1994). Similarly, regrets
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may not be easily resolved; even if they can be, the process of resolution can be long and painful, and thus cognitively and emotionally demanding for older persons. On the contrary, by diverting the individual’s attention from past regrets, a gratitude intervention has the potential of facilitating relaxation and enjoyment of the present, and avoids potential pitfalls in treatment. There was no significant effect on PA, and the effect on NA was unimpressive. Whereas NA was higher in the hassle group, it was not lower in the gratitude group when compared to the neutral group. Our findings mimicked those in the literature, which generally found that gratitude manipulation did not yield better indices of emotional wellbeing, whether concurrently or prospectively, as compared to control conditions (Emmons and McCullough 2003; Froh et al. 2008). Our brief gratitude induction procedure may not be sufficient to bring about an overall change in positive and negative emotions. On the whole, the results suggest that gratitude is able to reduce death anxiety without changing the overall emotional state of the person. Further research may be needed to see whether repeated exposures to gratitude manipulations would lead to significant changes in emotional well-being in the longer term. Several limitations of the present study need to be mentioned. First, the sample was recruited on a convenience basis and, in order to complete the writing task, was more educated than the older cohort in Hong Kong. Further research is needed on older adults who are representative of the general older Chinese population in Hong Kong. Second, this was not a clinical sample and further research should be conducted to examine how well a gratitude intervention works in patients with clinically elevated death anxiety. Third, our data were based on a brief induction procedure. Future studies using a more long-term induction, such as the diary method, would provide more definitive conclusions regarding the beneficial effects of gratitude. Fourth, because belief in the afterlife is a buffer against death anxiety (Wink and Scott 2005) and a more popular belief in Western than in Asian societies (e.g., 80% of the U.S. population, but somewhat less in European countries, believe in afterlife; Hood et al. 2009), it is unclear whether the effect of gratitude might be attenuated (because belief in afterlife reduces the effect of regret on fear of mortality) in Western societies. Cross-cultural research should be conducted to investigate how findings might vary by differences in spiritual beliefs. Finally, no studies to date, including ours, have provided data on the long-term effects of interventions on death anxiety. Future studies should attempt to collect long-term follow-up data. Although the long-term effects of gratitude interventions are not yet known, it is noteworthy that even the temporary relief of death anxiety may be pivotal in facilitating the making of important health-care or end-of-life decisions at crucial
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times. Because gratitude can be induced using a very brief procedure, there are broad potential applications in clinical and health-care settings for the relief of death anxiety.
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