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Death, Dying, and Denial in the Aged

164

group indicated positive affect, whereas only 15 percent of the nursing home group showed it. Also,
the two groups showed a significant difference in negative affect (p < .0 I). Forty six percent of the
Hospitality House group achieved maximum scores of 3 to 4 on nega tive affect, while only 17 percent
of the nurs ing home group had such high scores. In fact, 31 percent of the nursing home group
had 0 scores on negative affect. Only 12 per cent of the Hospitality House group had 0 scores in this
category.

Discussion

A review of the literature reveals a number of papers concerning efforts to understand how the
elderly deal with feelings about death and dying (7-21).
We wanted to know if feelings about death and dying are a central issue for the aged, and, if so,
how they deal with them. Our literature search disclosed many divergent methods of investigation of
numerous varying aged populations so that no definitive con clusions could be drawn-except for, per
haps, the most significant conclusion of all. We learned that our question, as posed, was meaningless.
It assumed that the aged are a homogeneous group. Thus conflicting reports from various authors
seemed puzzling. With out this erroneous assumption, conflicting reports become understandable and
ex pected. Healthy, self-sufficient aged may view death one way, and the sick, helpless aged may
well view it differently.
The adaptive use of denial is well docu mented in the psychoanalytic literature. Classically, it is
defined as "an intrapsychic defense mechanism by means of which con sciously intolerable thoughts,
wishes, facts, and deeds are disowned by an unconscious denial of their existence. What is consciously
intolerable is unconsciously rejected by a protective mechanism of non-awareness" (22).
Anna Freud saw denial as a natural way for a young child to deal with unpleasant realities (23).
She saw its use by an adult as regressive, a resorting to an earlier, more primitive means of dealing
with life but at the price of compromising reality testing.
Jeffers and associates at Duke have made more recent observations about the use of denial in the
aged (18). They have longi-
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 DEATH, DYING. AND DENIAL IN THE AGED

tudinally studied over 200 aging volunteers. It is their impression that denial is an important
mechanism for dealing with anxiety in old age. They propose that denial "may be among the
most common adaptive tech niques employed in personality adjustment by persons beyond the
fifth decade of life." In terestingly, they offer as confirmation the fact that 90 percent of their
subjects replied "No" or "No, but ... " to the question, "Are you afraid to die?" Perhaps the
authors infer that a conscious answer of "No" represents psy chological denial.
Our studies question the belief that the aged must be using denial if they do not evince fear of
death. However, we do not question the proposition that some aged per sons make extensive use of
denial. The Duke group's discussion of why the elderly regress to denial fits very well with our
formulations as to who among the aged resort to this mechanism.
One must consider changes in body image and self-concept that occur with aging and chronic
disease, whether in the old or the young. Many workers have reported the use of denial by the
chronically ill (24-26). One of us (D.L.L.) has detected it in psychological evaluations of persons
suffering from chronic renal disease.
Perhaps old age per se does not result in changes in body image and self-concept. Havighurst
proposed the possibility in 1966 that healthy, intact, autonomous oldsters regardless of
chronological age-may not consciously recognize change in themselves (27). A recent pilot study
of ours lends sup port to this hypothesis (28).
It seems reasonable that the aged may turn to denial only if and when their physical con dition
has so grossly deteriorated that it compromises their autonomy. We propose that the gradual
changes accompanying nor mal aging are not experienced as threatening unless or until they
result in a lowered sense of autonomy. When the aged person becomes consciously aware of
physical and/or mental deterioration, increasing dependency, and debility, we suggest that this
causes him to face the dying process and that he then un consciously regresses psychologically
and utilizes denial as a means of defending against the unpleasant affects attendant upon the dying
process. We also suggest that dying a process-is distinct from death-a state-
A mer. J. Psychiat. 129:2, August 1972
KIMSEY, ROBERTS, AND LOGAN

and that the defensive use of denial is directed against the process of dying.
Lieberman (21) has suggested that the withdrawal of the dying aged may be an at tempt to cope
with inner disintegration rather than a defense against separation anxiety or a narcissistic
preoccupation.
From her work with dying patients Klibler Ross feels they all go through predictable psychological
stages in the course of dealing with dying (29). Significant to our study is her statement that denial is
the first psycho logical stage. She sees the old and the young coping in the same way, which we feel is
significant. She does not make age distinc tions.
We suggest that the normal aging indi vidual may never experience sufficiently abrupt or
significantly severe organic de terioration to produce the lowered self sufficiency that leads to
regressive adaptation. The fortunate old person who is able to maintain a position of involvement,
meaning, and usefulness within his society until his death may not require psychological regres sion
and the use of denial. If he and his society can enable him to psychologically maintain a sense of his
own autonomy and self-worth, he may age and die without fear of death and dying and without
denial.

Implications for Medical Education and Health Care Delivery

It is estimated that by 1985 there will be over 25 million people 65 years and older in the United
States (30). In order to avoid "warehousing" these aged, programs will have to be devised utilizing
medical, psychi atric, social, and economic criteria.
Our own studies of the extent to which medical schools in Texas teach geriatrics (31, 32) verify
other studies in the United States (33-36). These studies show that medical students do not receive
a compre hensive view of geriatrics; rather, the tendency of most schools is to divide the problems of
geriatrics along disciplinary lines of endeavor, resulting in the fragmentation of teaching with a
resultant loss of emphasis.
The concept that the aged fall into "well" and "sick and dependent" categories may eventuate in
new conceptualizations of teach ing and health care delivery systems based on
Amer. J. Psychiat. 129:2, August /972
 165

medical and psychological critera (28, 31, 32,

37, 38).

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Answers to Questions of the :\Ionth

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