Existential psychotherapy is a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence.

The majority of therapists realize, for example, that an apprehension of one’s finiteness can often catalyze a major inner shift of perspective, that it is the relationship that heals, that patients are tormented by choice, that a therapist must catalyze a patient’s “will” to act, and that the majority of patients are bedeviled by a lack of meaning in their lives.

Freud’s major contribution to the understanding of the human being is his dynamic model of mental functioning—a model that posits that there are forces in conflict within the individual, and that thought, emotion, and behavior, both adaptive and psychopathological, are the resultant of these conflicting forces. Furthermore—and this is important—these forces exist at varying levels of awareness; some, indeed, are entirely unconscious.

The psychodynamics of an individual thus include the various unconscious and conscious forces, motives, and fears that operate within him or her. The dynamic psychotherapies are therapies based upon this dynamic model of mental functioning.

The precise nature of the deepest internal conflicts is never easy to identify. The clinician working with a troubled patient is rarely able to examine primal conflicts in pristine form. Instead, the patient harbors an enormously complex set of concerns: the primary concerns are deeply buried, encrusted with layer upon layer of repression, denial, displacement, and symbolization.

the instincts collide with the demands of the environment and, later, with the demands of the internalized environment—the superego; the child is required to negotiate between the inner press for immediate gratification and the reality principle which demands delay of gratification. The instinctively driven individual is thus at war with a world that prevents satisfaction of innate aggressive and sexual appetites.

According to Freud, the child is governed by instinctual forces that are innate and, like a fern frond, gradually unfurl through the psychosexual developmental cycle.

FREUDIAN PSYCHODYNAMICS According to Freud, the child is governed by instinctual forces that are innate and, like a fern frond, gradually unfurl through the psychosexual developmental cycle. There are conflicts on several fronts: dual instincts (ego instincts versus libidinal instincts or, in the second theory, Eros versus Thanatos) oppose one another; the instincts collide with the demands of the environment and, later, with the demands of the internalized environment—the superego; the child is required to negotiate between the inner press for immediate gratification and the reality principle which demands delay of gratification. The instinctively driven individual is thus at war with a world that prevents satisfaction of innate aggressive and sexual appetites.

NEO-FREUDIAN (INTERPERSONAL) PSYCHODYNAMICS The neo-Freudians—especially Harry Stack Sullivan, Karen Horney, and Erich Fromm—present another view of the individual’s basic conflict. The child, rather than being instinct-powered and preprogrammed, is instead a being who, aside from innate neutral qualities like temperament and activity levels, is entirely shaped by cultural and interpersonal environment. The child’s basic need is for security—for interpersonal acceptance and approval—and the quality of interaction with security-providing significant adults determines his or her* character structure. The child, though not powered by instincts, nonetheless has great innate energy, curiosity, an innocence of the body, an inherent potential for growth, and a wish for exclusive possession of loved adults. These attributes are not always consonant with the demands of surrounding significant adults, and the core conflict is between these natural growth inclinations and the child’s need for security and approval. If a child is unfortunate enough to have parents so caught up in their own neurotic struggles that they can neither provide security nor encourage autonomous growth, then severe conflict ensues. In such a struggle, growth is always compromised for the sake of security.

“Freedom” in this sense, has a terrifying implication: it means that beneath us there is no ground—nothing, a void, an abyss. A key existential dynamic, then, is the clash between our confrontation with groundlessness and our wish for ground and structure.

The existential conflict is thus the tension between our awareness of our absolute isolation and our wish for contact, for protection, our wish to be part of a larger whole.

If we must die, if we constitute our own world, if each is ultimately alone in an indifferent universe, then what meaning does life have? Why do we live? How shall we live? If there is no preordained design for us, then each of us must construct our own meanings in life. Yet can a meaning of one’s own creation be sturdy enough to bear one’s life? This existential dynamic conflict stems from the dilemma of a meaning-seeking creature who is thrown into a universe that has no meaning.

DRIVE ANXIETY DEFENSE MECHANISM* is replaced by AWARENESS OF ULTIMATE CONCERN ANXIETY DEFENSE MECHANISM* Both formulas assume that anxiety is the fuel of psychopathology; that psychic operations, some conscious and some unconscious, evolve to deal with anxiety; that these psychic operations (defense mechanisms) constitute psychopathology; and that, though they provide safety, they invariably restrict growth and experience.

To Freud, exploration always meant excavation. With the deliberateness and patience of an archaeologist he scraped away at the many-layered psyche until he reached bedrock, a layer of fundamental conflicts that were the psychological residue of the earliest events in the life of the individual. Deepest conflict meant earliest conflict.

“At this moment, at the deepest levels of my being, what are the most fundamental sources of dread?” The individual’s earliest experiences, though undeniably important in life, do not provide the answer to this fundamental question.

noxious agents exist within the body at all times—just as stresses, inseparable from living, confront all individuals. Whether an individual develops clinical disease depends on the body’s resistance (that is, such factors as immunological system, nutrition, and fatigue) to the agent: when resistance is lowered, disease develops, even though the toxicity and the virility of the noxious agent are unchanged.

Thus, all human beings are in a quandary, but some are unable to cope with it: psychopathology depends not merely on the presence or the absence of stress but on the interaction between ubiquitous stress and the individual’s mechanisms of defense.

all human beings are in a quandary, but some are unable to cope with it: psychopathology depends not merely on the presence or the absence of stress but on the interaction between ubiquitous stress and the individual’s mechanisms of defense.

“Which would you have, wise madness or foolish sanity?”

Thomas Hardy’s comment, “if a way to the Better there be, it exacts a full look at the Worst,”

An existential therapeutic position, as I shall attempt to demonstrate in later chapters, rejects this dilemma. Wisdom does not lead to madness, nor denial to sanity: the confrontation with the givens of existence is painful but ultimately healing. Good therapeutic work is always coupled with reality testing and the search for personal enlightenment; the therapist who decides that certain aspects of reality and truth are to be eschewed is on treacherous ground.

The existential position cuts below this subject-object cleavage and regards the person not as a subject who can, under the proper circumstances, perceive external reality but as a consciousness who participates in the construction of reality.

I am reminded of the story of the man searching at night for a lost key, not in the dark alley where he dropped it but under a lamppost where the light was better.

Existence is inexorably free and, thus, uncertain. Cultural institutions and psychological constructs often obscure this state of affairs, but confrontation with one’s existential situation reminds one that paradigms are self-created, wafer-thin barriers against the pain of uncertainty. The mature therapist must, in the existential theoretical approach as in any other, be able to tolerate this fundamental uncertainty.

The fear of death plays a major role in our internal experience; it haunts as does nothing else; it rumbles continuously under the surface; it is a dark, unsettling presence at the rim of consciousness.

To cope with these fears, we erect defenses against death awareness, defenses that are based on denial, that shape character structure, and that, if maladaptive, result in clinical syndromes. In other words, psychopathology is the result of ineffective modes of death transcendence.

Death, the Stoics said, was the most important event in life. Learning to live well is to learn to die well; and conversely, learning to die well is to learn to live well.

Cicero said, “To philosophize is to prepare for death,”2 and Seneca: “No man enjoys the true taste of life but he who is willing and ready to quit it.”

Montaigne, in his penetrating essay on death, asked, “Why do you fear your last day? It contributes no more to your death than each of the others. The last step does not cause the fatigue, but reveals it.”

Although the physicality of death destroys man, the idea of death saves him.

Heidegger believed that there are two fundamental modes of existing in the world: (1) a state of forgetfulness of being or (2) a state of mindfulness of being.

In the other state, the state of mindfulness of being, one marvels not about the way things are but that they are.

“Limitation in the possibility of an enjoyment raises the value of the enjoyment.”

in the French playwright Jean Giraudoux’s Amphitryon 38, there is a conversation between the immortal gods. Jupiter tells Mercury what it is like to don earthly guise to make love to a mortal woman: She will use little expressions and that widens the abyss between us.… She will say, “When I was a child”—or “When I am old”—or “Never in all my life”—This stabs me, Mercury.… We miss something, Mercury—the poignance of the transient—the intimation of mortality—that sweet sadness of grasping at something you cannot hold?”

(Freud felt that anxiety was a reaction to helplessness; anxiety, he wrote, “is a signal which announces that there is danger” and the individual is “expecting a situation of helplessness to set in.”

How can we combat anxiety? By displacing it from nothing to something.

If we can transform a fear of nothing to a fear of something, we can mount some self-protective campaign—that is, we can either avoid the thing we fear, seek allies against it, develop magical rituals to placate it, or plan a systematic campaign to detoxify it.

To ward off death anxiety, the young child develops protective mechanisms which, as I shall discuss in the next chapter, are denial-based, pass through several stages, and eventually consist of a highly complex set of mental operations that repress naked death anxiety and bury it under layers of such defensive operations as displacement, sublimation, and conversion. Occasionally some jolting experience in life tears a rent in the curtain of defenses and permits raw death anxiety to erupt into consciousness. Rapidly, however, the unconscious ego repairs the tear and conceals once again the nature of the anxiety.

The cornerstone of dynamic psychology is precisely that strong anxiety does not remain conscious: it is repressed and “processed.” One of the major steps in the processing of the anxiety source is to separate or to isolate affect from object. Thus, one can think about death with only moderate discomfort, and one can experience displaced anxiety with few clues to its true source.

Other studies investigate deeper layers of consciousness and demonstrate that considerable death anxiety lies outside of awareness; that death anxiety increases as one moves from conscious to unconscious experience; that the fear of death stalks us in our dreams; that the aged fear death more if they are psychologically immature, or if they have few life activities in which to engage; and, lastly, that death anxiety, both conscious and unconscious, is related to neuroticism.

Perhaps, as I shall discuss later, it is not translation that the neurotic patient needs; he or she may not be out of contact with reality but instead, through failing to erect “normal” denial defenses, may be too close to the truth.

Denial does not spare the therapist, and in the treatment process the denial of the therapist and the denial of the patient enter into collusion. Many therapists, though they have had long years of personal analysis, have not explored and worked through their personal terror of death; they phobically avoid the area in their personal lives and selectively inattend to obvious death-linked material in their psychotherapy practice.

Freud suggested that, in his patients, memory of the trauma and the attendant emotions were repressed from conscious thought (the first use of the concept of repression and the unconscious) and thus were not subject to the normal processes of affect dissipation. The stifled affect persisted, however, with freshness and strength in the unconscious and found some conscious expression through conversion (hence, “conversion hysteria”) to physical symptoms.

The treatment implications are clear: one must enable the patient to remember the trauma and to give expression to the strangulated affect. Freud and Breuer used hypnosis, and later Freud used free association, to help patients recapture the original offending memory and express the affect verbally and behaviorally.

Freud’s speculations about affect build-up and dissipation, about the formation of symptoms, and about a system of therapy resting on these assumptions are of landmark importance and adumbrate much of the dynamic theory and therapy that followed him.

These latter cases, the footnotes, and Freud’s letters93 all bear evidence of the inexorable direction of Freud’s thinking about the source of anxiety: (1) he gradually shifted the time of the “real” trauma responsible for anxiety to a period earlier in life; and (2) he came to view the nature of the trauma as explicitly and exclusively sexual.

Two primary origins of anxiety survive Freud’s restless sifting: loss of mother (abandonment and separation) and loss of the phallus (castration anxiety).

Other major sources include superego or moral anxiety, the fear of one’s own self-destructive tendencies, and the fear of ego disintegration—of being overwhelmed by the dark, irrational night forces that reside within.

Always the archaeologist, always searching for more basic structures, Freud suggested that castration and separation had a common feature: loss—loss of love, loss of the ability to unite with mother.

Freud believed that anxiety is called forth by a situation that evokes an earlier, long-forgotten situation of terror and helplessness.

An important discovery: the unconscious, a residue of primitive wishes buried in the cellar of the mind because they were unfit for the sunlight, escaped briefly into consciousness and caused great anxiety which was ultimately bound by conversion symptomatology.

If, as Freud speculated, Fraulein Elisabeth thought, even for a fleeting moment, when her sister died, “Now her husband is free again, and I can be his wife,” then most certainly she also shuddered with the thought, “If my darling sister dies, then I, too, will die.”

“If you want to endure life, prepare yourself for death.”

Duality—the existence of two inexorably opposed basic drives—was the bedrock upon which Freud built his metapsychological system.

Freud is close to Nietzsche’s position, which considers conscious deliberation entirely superfluous to the production of behavior. Behavior, according to Nietzsche, is determined by unconscious mechanical forces: conscious consideration follows behavior rather than precedes it; one’s sense of governing one’s behavior is entirely illusion. One only imagines oneself to be choosing behavior in order to satisfy one’s will to power, one’s need to perceive oneself as an autonomous, deciding being.

his mother, who never doubted it, called him “my golden Siggy” and favored him above all her children. He wrote later: “A man who has been the indisputable favorite of his mother keeps for life the feeling of a conqueror, that confidence of success that often induces real success

Children’s coping strategies are invariably denial-based: it seems that we do not, perhaps cannot, grow up tolerating the straight facts about life and death.

When behavioral scientists choose to investigate the issue closely, they invariably discover that children are extraordinarily preoccupied with death.

Since death, one’s personal death, being and nonbeing, consciousness, finality, eternity, and the future are all abstract concepts, many developmental psychologists have concluded that young children have no accurate concept of death whatsoever.

When reality intrudes forcibly, the fledgling death-denial defenses falter, allowing anxiety to break through.

The fear of death, Klein states, is part of the infant’s earliest life experience. She accepts Freud’s 1923 theory that there is a universal unconscious drive toward death, but argues that, if the human being is to survive, then there must be a counterbalancing fear of loss of life.

Klein considers the fear of death as the original source of anxiety; sexual and superego anxiety are thus latecomers and derivative phenomena.

The danger arising from the inner working of the death instinct is the first cause of anxiety.… The fear of being devoured is an undisguised expression of the fear of total annihilation of the self.… The fear of death enters into castration fear and is not “analogous” to it.… Since reproduction is the essential way of counteracting death, the loss of the genital would mean the end of the creative power which preserves and continues life.

When the child realizes that eternal recurrence of vanished objects is not the order of the day, then the child searches for other strategies to protect himself or herself from the threat of nonbeing. The child becomes the master rather than the victim of “all gone.” The child pulls out the bathtub plug, flushes objects down the toilet, gleefully blows out matches, is delighted to assist mother by pressing the pedal of the garbage pail. Later the child disperses death, either symbolically in games of cowboys and Indians, or literally by extinguishing life in insects. Indeed, Karen Horney felt that the hostility and the destructiveness of a child are directly proportional to the extent to which that child feels his or her survival is endangered.

The known does not remain known. Matilda McIntire, Carol Angle, and Lorraine Struempler inquired of 598 children whether a dead pet knows that its owner misses it, and they found that seven-year-olds are far more inclined than are children of eleven and twelve to accept death’s finality and irreversibility

In personifying death, the child recapitulates cultural evolution: every primitive culture anthropomorphizes the blind forces of nature in an effort to experience greater control over its own destiny.

In other words, death is fearful because it re-evokes separation anxiety.

May argues, quite consistent on a deeper one: a child’s fears are “objectivated forms of underlying anxiety.”

Yet with the exception of Melanie Klein and D. W. Winnicott, who emphasize that primal anxiety is anxiety about annihilation, ego dissolution, or being devoured,66 the question, Why is the child fearful of these life-threatening situations? is rarely asked.

Empirical research demonstrates that the child is fearful when separated, but in no way demonstrates that separation anxiety is the primal anxiety from which death anxiety is derived

As I discussed in the previous chapter, one must distinguish between two meanings of “fundamental”: “basic” and “chronologically first.” Even were we to accept the argument that separation anxiety is chronologically the first anxiety, it would not follow that death anxiety “really” is fear of object loss.

The most fundamental (basic) anxiety issues from the threat of loss of self; and if one fears object loss, one does so because loss of that object is a threat (or symbolizes a threat) to one’s survival.

“One cannot look directly at either the sun or death.”

Rosenzweig and Bray presents data that indicates that among schizophrenic patients, when compared with a normal population, with a manic-depressive sample, and with a general paretic sample, there is a significantly greater incidence of a sibling dying before a patient’s sixth year.

The child suffers a deep loss and, furthermore, is extraordinarily beset with concern that his or her aggressive behavior or fantasies concerning the parent may have been instrumental in the latter’s death.

The role of loss and guilt is well known and has been competently discussed by others.

Maurer puts it well: “At some level below true cognition, the child with naive narcissism ‘knows’ that the loss of his parents is the loss of his tie to life.… Total terror for his life rather than jealous possessiveness of a lost love object is the etiology of the distress of separation anxiety.”

It is known, for example, from animal experimentation that the young, if separated from their mothers, will develop an experimental neurosis and respond far more adversely to stress than do those who remain with their mothers.

Josephine Hilgard and Martha Newman studied psychiatric patients who had lost a parent early in life, and reported an intriguing finding (which they termed the “anniversary reaction”): a significant correlation between a patient’s age at psychiatric hospitalization and his or her parent’s age at death.79 In other words, when a patient is hospitalized there is a greater-than-chance possibility that he or she will be the same age as his or her parent was when the latter died.

Furthermore, the patient’s oldest child is likely to be the same age as the patient was when the parent died. For example, a patient who was six years old when her mother died, is “at risk” psychiatrically when her oldest daughter is six years old.

However, if, as is often true in Western culture today, a parent experiences severe anxiety about the issue of death, then the child is given the message that there is much to fear.

In the Foré culture of New Guinea, for example, children participate in the ritual devouring of a dead relative.

The paradigm that I shall describe in this chapter rests, as do most paradigms of psychopathology, on the assumption that psychopathology is a graceless, inefficient mode of coping with anxiety.

An existential paradigm assumes that anxiety emanates from the individual’s confrontation with the ultimate concerns in existence.

Psychopathology (in every system) is, by definition, an ineffective defensive mode.

Kierkegaard knew that man limited and diminished himself in order to avoid perception of the “terror, perdition and annihilation that dwell next door to any man.”

Otto Rank described the neurotic as one “who refused the loan (life) in order to avoid the payment of the debt (death).”

Paul Tillich stated that “neurosis is the way of avoiding non-being by avoiding being.”

Ernest Becker made a similar point when he wrote: “The irony of man’s condition is that the deepest need is to be free of the anxiety of death and annihilation; but it is life itself which awakens it and so we must shrink from being fully alive.”

Naked death anxiety will not be easily apparent in the paradigm of psychopathology I shall describe. But that should not surprise us: primary anxiety in pristine form is rarely visible in any theoretical system.

The defensive structures exist for the very purpose of internal camouflage: the nature of the core dynamic conflict is concealed by repression and other dysphoria-reducing maneuvers. Eventually the core conflict is deeply buried and can be inferred—though never wholly known—only after laborious analysis of these maneuvers.

To take one example: an individual may guard himself from the death anxiety inherent in individuation by maintaining a symbiotic tie with mother. This defensive strategy may succeed temporarily, but as time passes, it will itself become a source of secondary anxiety; for example, the reluctance to separate from mother may interfere with attendance at school or the development of social skills; and these deficiencies are likely to beget social anxiety and self-contempt which, in turn, may give birth to new defenses which temper dysphoria but retard growth and accordingly generate additional layers of anxiety and defense.

The derivative, secondary forms of anxiety are nonetheless “real” anxiety. An individual may be brought down by social anxiety or by pervasive self-contempt; and, as we shall see in the next chapter, treatment efforts generally are directed toward derivative rather than toward primary anxiety.

Though Mike did not consciously fear death, his fear of therapy was an obvious displacement of death anxiety.

Sam’s efforts to help himself in his crisis were considerable but monothematic: he sought in a number of ways to reinforce his beliefs that some protective figure watched over and cared for him.

The human being either fuses or separates, embeds or emerges. He affirms his autonomy by “standing out from nature” (as Rank put it7), or seeks safety by merging with another force. Either he becomes his own father or he remains the eternal son. Surely this is what Fromm meant when he described man as either “longing for submission or lusting for power.”

Mike can be viewed from the vantage points of a continued rebellious conflict with his parents, of counterdependency, of neurotic perpetuation of the oedipal struggle, or of homosexual panic. Sam can be “grasped” from the vantage points of identification with Mother and unresolved grief, or of castration anxiety, or from a family dynamic one in which the clinician focuses attention on Sam’s interaction with his wife.

Both beliefs, in specialness and in an ultimate rescuer, can be highly adaptive. Each, however, may be overloaded and stretched thin, to a point where adaptation breaks down, anxiety leaks through, the individual resorts to extreme measures to protect himself or herself, and psychopathology appears in the form of either defense breakdown or defense runaway.

Perhaps these clinical illustrations begin to transmit something of the difference between knowing and truly knowing, between the everyday awareness of death we all possess and the full facing of “my death.” Accepting one’s personal death means facing a number of other unpalatable truths, each of which has its own force-field of anxiety: that one is finite; that one’s life really comes to an end; that the world will persist nonetheless; that one is one of many—no more, no less; that the universe does not acknowledge one’s specialness; that all our lives we have carried counterfeit vouchers; and, finally, certain stark immutable dimensions of existence are beyond one’s influence. In fact, what one wishes “has absolutely nothing to do with it.”

In an ironic way he was afraid of nothing precisely because he, like all of us, was afraid of nothingness. The Hemingway hero thus represents a runaway of the emergent, individualistic solution to the human situation.

Getting ahead of what? How? And (even worse) why? Those questions were, and are still, deeply disquieting.

What was brought home to me with unusual force was how I lull myself into a death-defeating delusion by continually projecting myself forward into the future.

“The chasm was life itself, the bridge that artificial life…” No one has said it more clearly. The defense, if successful, shields the individual from the knowledge of the chasm. The broken bridge, the failed defense, exposes one to a truth and a dread that an individual in midlife following decades of self-deception is ill equipped to confront.

When the dread is particularly strong, the aggressive drive is not contained by peaceful sublimation, and it accelerates. Arrogance and aggression are not uncommonly derived from this source.

Becker advances our understanding when he suggests that the terrible thing in surpassing one’s father is not castration but the frightening prospect of becoming one’s own father.25 To become one’s own father means to relinquish the comforting but magical parental buttress against the pain inherent in one’s awareness of personal finiteness.

Thus the individual who plunges into life is doomed to anxiety. Standing out from nature, being one’s own father or, as Spinoza put it, “one’s own god,” means utter isolation; it means standing alone without the myth of rescuer or deliverer and without the comfort of the human huddle.

Lena was overtly terrified of death and avoided any contact with death motifs, and she attempted to deal with her terror in a most ineffective and magical mode—a mode that I have seen many patients use: she attempted to elude death by refusing to live.

Most individuals remain unaware of the structure of their belief system until it fails to serve its purpose; or until, as Heidegger put it, there is a “breakdown in the machinery.”

Individuals differ in the tenacity with which they cling to denial, but eventually all denial crumbles in the face of overwhelming reality. Kübler-Ross, for example, reports that in her long experience she has seen only a handful of individuals maintain denial to the moment of death.

Restructuring a life ideology is beyond comprehension; and many patients, rather than question their basic belief system, conclude that they are too worthless or too bad to warrant the love and protection of the ultimate rescuer.

Their depression is abetted, furthermore, by the fact that, unconsciously, suffering and self-immolation function as a last desperate plea for love. Thus, they are bereft because they have lost love, and they remain bereft in order to regain it.

Her masturbatory fantasies consisted of her becoming very ill (either with a physical disease like tuberculosis, or a psychotic breakdown) and my feeding and cradling her.

“Being sick was the lie of my life,” said Karen. She sought pain to get succor. On more than one occasion during her childhood, she spent weeks in bed with a fictitious disease. During adolescence she became anorexic, only too glad to exchange physical starvation for the attention and solicitude it incited.

As a child, she had related to them through illness. “Being sick was the lie of my life,” said Karen. She sought pain to get succor. On more than one occasion during her childhood, she spent weeks in bed with a fictitious disease. During adolescence she became anorexic, only too glad to exchange physical starvation for the attention and solicitude it incited.

It was only then, when she had relinquished all hope of my continued, eternal presence, that she could work truly effectively in therapy

Like many neurotic patients, she did not really live in the present, but instead attempted to find the past (that is, the comforting bond with mother) in the future.

That was not to come until we turned to another question—the question crucial to the understanding of many tortured relationships between adults and their parents: Why was mother so important to Irene? Why was it her responsibility and task to ensure mother’s happiness? Why could she not separate herself from her mother?

The fear of life is the fear of having to face life as an isolated being, it is the fear of individuation, of “going forward,” of “standing out from nature.” Rank believed that the prototypical life fear was “birth,” the original trauma and the original separation. By “fear of death” Rank referred to the fear of extinction, of loss of individuality, of being dissolved again into the whole.

By “fear of life” Rank meant anxiety in the face of a “loss of connection with a greater whole.” The fear of life is the fear of having to face life as an isolated being, it is the fear of individuation, of “going forward,” of “standing out from nature.” Rank believed that the prototypical life fear was “birth,” the original trauma and the original separation. By “fear of death” Rank referred to the fear of extinction, of loss of individuality, of being dissolved again into the whole.

The attempt to assuage individuation anxiety through sexual merger is common. The successful man who devotes himself utterly to power, to getting ahead, standing out, and making a name for himself must at some point come face to face with the lonely unprotectedness inherent in individuation.

Sexual activity as a mode of assuaging death anxiety is often clinically observed.

The task of satisfying both needs—for separateness and autonomy and for protection and merger—and of facing the fear inherent in each, is a lifelong dialectic that govern one’s inner world.

The attempt to escape from death anxiety is at the core of the neurotic conflict.

As Rank put it: “When we protect ourselves… from a too intensive or too quick living out or living up, we feel ourselves guilty on account of the unused life, the unlived life in us.”42 Repression is thus a double-edged sword; it provides safety and relief from anxiety, while at the same time it generates life restriction and a form of guilt, henceforth referred to as “existential guilt.”

The therapist replied, “I gather that you’re realizing, perhaps, that it’s this way with human life, too—that, as with the leaves, human life ends in death.” She nodded, “Yes.” This realization marked the beginning of solid therapeutic progress.

First, the anxiety of facing death is infinitely greater in those who do not have the strengthening knowledge of personal wholeness and of whole participation in living. “A person,” Searles writes, “cannot bear to face the prospect of inevitable death until he has had the experience of fully living, and the schizophrenic has not yet fully lived.”

The child is helpless, too, in the face of the knowledge that this same person loves and hates him or her with great intensity. This helplessness requires continued maintenance of the fantasy, normal only in infancy, of personal omnipotence. Nothing would so completely destroy the sense of personal omnipotence than the acceptance of the inevitability of death, and the schizophrenic patient clings to his or her denial of death with a fierce desperation

it is the person who will not “live” who is most terrified of dying. “Why not,” Kazantzakis asked, “like a well-filled guest, leave the feast of life?”

Ordinarily what we do have and what we can do slips out of awareness, diverted by thoughts of what we lack or what we cannot do, or dwarfed by petty concerns and threats to our prestige or our pride systems.

“Contemplate death if you would learn how to live.”

Disidentification is an important part of Roberto Assagioli’s system of psychosynthesis. He tries to help an individual reach his “center of pure self-consciousness” by asking him to imagine shedding, in a systematic way, his body, emotions, desires, and finally intellect

Only when defenses against death anxiety are removed do we become fully aware of what they shielded us from.

Marital separation and divorce are prime examples of such events. These experiences are so painful that therapists often make the error of focusing attention entirely on pain alleviation and miss the rich opportunity that reveals itself for deeper therapeutic work.

Commitment carries with it the connotation of finality, and many individuals cannot settle into a permanent relationship because that would mean “this is it,” no more possibilities, no more glorious dreams of continued ascendancy.

It was precisely for the purpose of reminding one of life’s transiency that a human skull was a common furnishing in a medieval monk’s cell.

He who would teach men to die would teach them to live.

It is important to keep in mind that death anxiety, though it is ubiquitous and has pervasive ramifications, exists at the deepest levels of being, is heavily repressed, and is rarely experienced in its full sense.

Life cannot be lived nor can death be faced without anxiety. Anxiety is guide as well as enemy and can point the way to authentic existence

Recall that within a day or two I no longer experienced any explicit death anxiety but instead noted a specific phobia surrounding luncheon discussions. What happened was that I “handled” death anxiety by repression and displacement. I bound anxiety to a specific situation. Rather than being fearful of death or of nothingness, I became anxious about something. Anxiety is always ameliorated by becoming attached to a specific object or situation. Anxiety attempts to become fear. Fear is fear of some thing; it has a location in time and space; and, because it can be located, it can be tolerated and even “managed” (one may avoid the object or develop some systematic plan of conquering one’s fear); fear is a current sweeping over one’s surface—it does not threaten one’s foundation.

No doubt the repression, and subsequent invisibility, of death anxiety is the reason that many therapists neglect its role in their work. But surely the same state of affairs applies to other theoretical systems. The therapist always works with tracings of and defenses against primal anxiety.

As nature abhors a vacuum, we humans abhor uncertainty. One of the tasks of the therapist is to increase the patient’s sense of certainty and mastery. It is a matter of no small importance that one be able to explain and order the events in our lives into some coherent and predictable pattern. To name something, to locate its place in a causal sequence, is to begin to experience it as under our control.

Anxiety can be a useful guide, and there are times when the therapist and patient must openly court anxiety. Accordingly, when Bruce had increased his ability to tolerate anxiety, I suggested that he spend an evening entirely alone and record his thoughts and feelings.

Bruce was never alone, he was always in the midst of coitus (a frenetic effort to fuse with a woman), searching for a woman, or just having left a woman.

The role of magic is to allow one to transcend the laws of nature, to transcend the ordinary, to deny one’s creaturely identity—an identity that condemns one to biological death.

Though brief courses of therapy often entirely circumvent any explicit consideration of death anxiety, any long-term intensive therapy will be incomplete without working through awareness and fear of death. As long as a patient continues to attempt to ward off death through an infantile belief that the therapist will deliver him or her from it, then the patient will not leave the therapist.

The meaning of his symptoms in terms of castration anxiety, incestuous feminine identification, pregenital regression, oral incorporation, and so forth had been explored, but without therapeutic effect. Only when the analyst moved to a deeper level—the meaning of his symptoms in the context of death fear—did the clinical picture alter.

Finally, the therapist interpreted that through fusion with the analyst (father), he wanted to win protection against death. This interpretation brought out a wealth of material hitherto withheld. “Death is and always was around me.” He remembered having thought a lot about death as a child. “I have solved my fear of death through submission.… Being raped anally is protection against death.” He resented that this had not been pointed out to him earlier.

The therapist who treats a patient in midlife must remind himself or herself that much psychopathology emanates from death anxiety.

A person who reaches mid-life, either without having successfully established himself in marital and occupational life, or having established himself by means of manic activity and denial with consequent emotional impoverishment, is badly prepared for meeting the demands of middle age, and getting enjoyment out of his maturity.

The implicit message she delivered to her thirteen-year-old daughter was “Don’t grow up and leave me. I can’t bear to be alone. I need you to stay as young as you are and to remain with me. If you don’t grow up, I won’t grow older.” This message seriously affected her daughter, who displayed severe delinquent behavior.

Her mother faced her own death with unrelenting terror and provided Sylvia with a model that sensitized her even more to a fear of death. (Many patients report that their parents’ mode of facing death is extremely important in shaping their own attitudes toward death. There are, in this observation, some obvious implications for the treatment of the dying patient: one way to maintain meaning in life until the very end is to consider the model one sets for others.)

Denial confounds the process every step of the way. Fear of death exists at every level of awareness—from the most conscious, superficial, intellectualized levels to the realm of deepest unconsciousness.

A patient may be responsive to the therapist’s suggestion that the patient examine his or her feelings about his or her finiteness, but gradually the session becomes unproductive, the material runs dry, and the discourse moves into an intellectualized discussion. It is important at these times that the therapist not leap to the erroneous conclusion that he or she is drilling a dry well. The blocking, the lack of associations, the splitting off of affect are all manifestations of resistance and should be treated accordingly

The therapist must persevere. The therapist must continue to collect evidence, to work with dreams, to persist in his or her observations, to make the same points, albeit with different emphases, over and over again. Observations about the existence of death may seem so banal, so overly obvious that the therapist feels fatuous in persisting to make them. Yet simplicity and persistence are necessary to overcome denial.

The patient is not the only source of denial, of course. Frequently the denial of the therapist silently colludes with that of the patient. The therapist no less than the patient must confront death and be anxious in the face of it. Much preparation is required of the therapist who must in everyday work be aware of death.

If a therapist is to help patients confront and incorporate death into life, he or she must have personally worked through these issues. An interesting parallel is to be found in the initiation rites of healers in primitive cultures, many of which have a tradition requiring that a shaman pass through some ecstatic experience that entails suffering, death, and resurrection.

The patient dealing with unreconciled oedipal conflicts, for example, is hamstrung by phantasmal torments: some constellation of internal and external events that occurred long ago persists in the timeless unconscious and haunts the patient. The patient responds to current situations in distorted fashion: to the present as though it were the past. The therapist’s mandate is clear: to illuminate the present, to expose and scatter the demons of the past, to help the patient detoxify events that are intrinsically benign but irrationally experienced as noxious.

The therapeutic approach I describe here is dynamic and uncovering; it is not supportive or repressive. Existential therapy does increase the patient’s discomfort. It is not possible to plunge into the roots of one’s anxiety without, for a period of time, experiencing heightened anxiousness and depression.

Why some individuals are brought down by the conditions that all must face is a question I have already addressed: the individual, because of a series of unusual life experiences, is both unduly traumatized by death anxiety and fails to erect the “normal” defenses against existential anxiety.

I believe that one particularly useful equation for the clinician is: death anxiety is inversely proportional to life satisfaction.

Nietzsche, in his characteristic hyperbole, stated: “What has become perfect, all that is ripe—wants to die. All that is unripe wants to live. All that suffers wants to live, that it may become ripe and joyous and longing—longing for what is further, higher, brighter.”

Surely this insight gives the therapist a foothold! If he can help the patient experience an increased satisfaction in life, he can allay excessive anxiety.

Searles poses the same dilemma: “The patient cannot face death unless he is a whole person, yet he can become a truly whole person only by facing death.”

When, during our therapy hour, he described this incident, his reaction, and his thought, I, rather than comfort him, reminded him that something will happen to Mary, to the children, and to himself as well.

What Philip learned was that a life dedicated to the concealment of reality, to the denial of death, restricts experience and will ultimately cave in upon itself.

The therapist may help the patient deal with death terror in ways similar to the techniques that he uses to conquer any other form of dread. He exposes the patient over and over to the fear in attenuated doses. He helps the patient handle the dreaded object and to inspect it from all sides.

A basic principle of a behavioral approach to anxiety reduction is that the individual be exposed to the feared stimulus (in carefully calibrated amounts) in a psychological state and setting designed to retard the development of anxiety.

For the patient who will not accept such responsibility, who persists in blaming others—either other individuals or other forces—for his or her dysphoria, no real therapy is possible.

The heart of Kant’s revolution in philosophy was his position that it is human consciousness, the nature of the human being’s mental structures, that provides the external form of reality.

Freud realized, quite correctly, that such rigid suppression of natural inclinations was detrimental to the psyche; libidinal energy that could not be permitted to surface nakedly begat restrictive defenses and indirect means of expression.

When one man complained, bitterly and passively, that his wife would not have sexual intercourse with him, a therapist clarified the implicit choice with the remark, “You must like her that way; you’ve been married to her a long time.” A housewife complained, “I cannot manage my child, all he does is sit and watch TV all day.” The therapist explicated the implicit choice with: “And you’re too little and helpless to turn off the TV.”

In essence, then, what happened was that Doris had certain beliefs about men, certain expectancies about how they would behave toward her. These expectancies distorted her perception, and perceptual distortion resulted in her behaving in ways that elicited the very behavior she dreaded.

A therapist who has a sense of being heavily burdened by a patient, who is convinced that nothing useful will transpire in the hour unless he or she brings it to pass, has allowed that patient to shift the burden of responsibility from his or her own shoulders to those of the therapist. Therapists may deal with this process in a number of ways. Most therapists choose to reflect upon it. The therapist may comment that the patient seems to dump everything in his or her (the therapist’s) lap, or that he or she (the therapist) does not experience the patient as actively collaborating in therapy. Or the therapist may comment upon his or her sense of having to carry the entire load of therapy. Or the therapist may find that there is no more potent mode of galvanizing a sluggish patient into action than by simply asking, “Why do you come?”

The effective therapy group is one in which the members themselves are the primary agents of help.

The underlying principle is that if members assume responsibility for the functioning of the group, then they become aware that they have the ability (and the obligation) to assume responsibility in all spheres of life. The effective therapy group is one in which the members themselves are the primary agents of help.

It is important, therefore, that the group leader be aware that his or her task is to create a social system—a system in which the group and the members themselves are the agents of change.

If in response to the leader’s question about members’ evaluation of the meeting, a member comments that he or she was involved only for the first fifteen minutes but then tuned out for the next thirty minutes after Joe or Mary started talking, the leader may, in a variety of ways, question why that particular member let the meeting go on in a manner that was personally unrewarding. How could that person have rechanneled the meeting? The leader may poll the group and, finding that there was a general consensus that the meeting was unrewarding, ask, “All of you seem to have known this. Why did you not stop the meeting and redirect it? Why is it left to me to do what everyone here is capable of doing?”

Confinement in a psychiatric hospital has always been an autonomy-stripping experience: patients are deprived of power, of decision making, of freedom, of privacy, and of dignity.

It is not even important that the patient follow the suggestion; the most important message of the procedure may be precisely that the patient’s attention is called to the fact that he or she has never considered obvious options. Therapy may then proceed to consider the possibility of choice, the myth of choicelessness, and the feelings evoked by a confrontation with freedom.

As long as you fight a symptom, it will become worse. If you take responsibility for what you are doing to yourself, how you produce your symptoms, how you produce your illness, how you produce your existence—the very moment you get in touch with yourself—growth begins, integration begins.

Once Perls had identified the modes of responsibility avoidance, he then urged the patient to translate helplessness back into unwillingness.

Any anger that is not coming out, flowing freely, will turn into sadism, power drive, and other means of torture.

Viktor Frankl, for example, describes a technique of “paradoxical intention”17 in which a patient is asked deliberately to increase a symptom, be it an anxiety attack, compulsive gambling, fear of a heart attack, or binge eating. Don Jackson, Jay Haley, Milton Erickson, and Paul Watzlawick have all written on the same approach, which they label “symptom prescription.”

I observed Perls working with a patient who dreamed of driving his car, which began to sputter and finally died altogether. Under Perl’s instruction the patient played multiple parts: the driver, the car, the empty gas tank, the sluggish spark plugs, and so on. By this strategy Perls hoped that the patient could begin to reassemble into a whole the scattered bits of his personality (that is, to complete the individual gestalt). Responsibility assumption meant to Perls that the individual has to take responsibility for all his or her feelings, including unpleasant ones that are often projected upon others.

By reclaiming all previously disowned parts of oneself, the individual’s experience becomes richer: one is at home within oneself and within one’s world.

The therapist has three immediate tasks: to recognize how the patient tries to get support from others rather than to provide his own, to avoid getting sucked in and taking care of the patient and to know what to do with the patient’s manipulative behavior.

“I can’t cope, in this situation, and you can. I ‘need’ you to show me the way, so that I can go on with my life.” This is sometimes not much of a life at all, but rather an existence which includes a succession of propositions submitted by the patient to people who like to take over the management of others. The therapist is merely the latest try. Hopefully, “the buck stops here.”

So if you want to go crazy, commit suicide, improve, get “turned on,” or get an experience that will change your life, that’s up to you. I do my thing and you do your thing. Anybody who does not want to take responsibility for this, please do not attend this seminar. You came here out of your own free will. I don’t know how grown up you are, but the essence of a grown-up person is to be able to take responsibility for himself—his thoughts, feelings, and so on…

Kaiser believed that “anything that increases the patient’s feeling of responsibility for his own words must tend to cure him”; and as this illustration indicates, he refused even to accept the responsibility of instructing the patient how to operate in therapy.

Unfortunately these requirements are generally incompatible with the effort and the thoughtfulness that are needed if one is truly to examine and alter one’s life and world perspective. Thus a “leveling-down” occurs: we are subjected to exhortation, and best sellers, such as Your Erroneous Zones, tell us how to “put an end to procrastination”: Sit down and get started on something you’ve been postponing. Begin a letter or a book. Simply beginning will help you to eliminate anxiety about the whole project.… Give yourself a designated time slot (say Wednesday from 10:00 to 10:15 P.M.) which you will devote exclusively to the task you’ve been putting off.… Quit smoking. Now! Begin your diet… this moment! Give up booze… this second. Put this book down and do one push-up as your beginning exercise project. That’s how you tackle problems… with action now. Do it! Decide not to be tired until the moment before you get into bed. Don’t allow yourself to use fatigue or illness as an escape or to put off doing anything

Or “rid yourself of dependency”: Give yourself five-minute goals for how you’re going to deal with dominant people in your life. Try a one-shot “No, I don’t want to,” and test the reaction of your reaction in the other person.… Stop taking orders!

This tendency, of course, makes research very difficult: the common design of recruiting volunteers for a personal growth procedure (such as an encounter group) and contrasting their outcomes with those of a similar number of nonvolunteer control subjects, is highly flawed. In fact, a growth group or workshop composed of dedicated individuals who have committed themselves to the experience, who are desirous of personal growth, and who have high expectational sets (created in part by an effective pre-group “hype”), will always be deemed successful by the great majority of participants. To deny benefit would create significant cognitive dissonance. The post-group “high,” the glowing testimonials, are ubiquitous. Only a particularly inept leader could fail under these circumstances.

Research on placebo reactors, on subject expectational sets, and on the psychological attitudes of volunteers strongly indicates that the outcome to the individual is heavily influenced by factors that exist before the workshop. This tendency, of course, makes research very difficult: the common design of recruiting volunteers for a personal growth procedure (such as an encounter group) and contrasting their outcomes with those of a similar number of nonvolunteer control subjects, is highly flawed. In fact, a growth group or workshop composed of dedicated individuals who have committed themselves to the experience, who are desirous of personal growth, and who have high expectational sets (created in part by an effective pre-group “hype”), will always be deemed successful by the great majority of participants. To deny benefit would create significant cognitive dissonance. The post-group “high,” the glowing testimonials, are ubiquitous. Only a particularly inept leader could fail under these circumstances.

Many have demonstrated that depressed individuals have an external locus of control and, as a result of the breakdown of a perceived correction between behavior and outcome, develop a deep sense of helplessness and hopelessness

A major theory of depression is the “learned-helplessness” model formulated by Martin Seligman which postulates that the various components of depression (affective, cognitive, and behavioral) are consequences of one’s learning early in life that outcomes (that is, rewards and punishments) are out of one’s control.

The learned-helplessness model of depression is rooted in the experimental laboratory and is based on observations that experimental animals exposed to unavoidable stress become less adaptive at avoiding subsequent escapable stress. For example, dogs given inescapable shock were subsequently poorer at escaping from avoidable shock than were dogs given prior escapable shock or no shock at all.

These results demonstrate, then, that if individuals are “taught” in the laboratory that their behavior cannot extricate them from situations, then subsequent coping behavior is impaired. Furthermore, David Klein and Martin Seligman found that depressed individuals (who did not receive pretreatment of inescapable noise) performed in a comparable manner with those nondepressed subjects who did receive inescapable noise.68 William Miller and Seligman found comparable findings with problem-solving experiments.69 In other experiments it has been found that depressed subjects (unlike nondepressed subjects) have low expectancies for future successes on laboratory tasks, and that these expectancies are not influenced by reinforcement.

There is some evidence that the antecedents of internality and externality lie in early family environment: a consistent, warm, attentive, and responsive milieu is a precursor of the development of an internal locus of control, while an inconsistent, unpredictable, and relatively uncongenial milieu (much more frequently found in lower socioeconomic classes) begets a sense of personal helplessness and an external locus of control.73 Ordinal position, too, makes a difference: first-borns are more likely to be internals (possibly because they are more often placed in positions of responsibility for household affairs and for their own conduct and are often put in charge of younger siblings as well).

One item 5—”Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others”—was especially highly valued. Of the sixty items, it was ranked fifth most important by the patients.

The more active and forceful the therapist (even if ostensibly in the service of helping the patient assume responsibility), the more is the patient infantilized.

Eventually she arrived at the realization that, though she bore no responsibility for her deformity, she bore complete responsibility for her attitude toward it and for her decision to adhere to a belief system that resulted in severe self-deprecation.

Responsibility for one’s attitude does not necessarily mean responsibility for one’s feelings (although Sartre would claim that to be the case) but for the stand that one takes toward one’s feelings.

For example, cancer patients often feel powerless and infantilized in relation to their physicians. My group focused sharply upon this issue and was effective in helping many patients assume responsibility for their relationship to their doctors. After patients described their relationships to their doctors, other members suggested other methods; role playing was done in which the patients practiced new methods of asserting themselves with physicians. Patients learned to request time from a physician, to demand information (if they wished it) about their illness; some learned to ask to see their medical charts or to view their X-rays; and some, when it seemed to make sense, assumed ultimate responsibility and refused further medication.

Many patients in the therapy group developed a sense of potency through social action.

Finally, in ways already described, the group therapist helped patients regain a sense of potency by encouraging them to assume responsibility for the course of their own group. By increasing their awareness that they can shape the group to suit their needs—indeed, that it is their responsibility to shape the group—the therapist can increase each individual’s assumption of responsibility in other spheres of life.

(Freud comments that, subjectively, “the sense of guilt and the sense of inferiority are difficult to distinguish.”)

In existentially based therapy “guilt” assumes a somewhat different meaning from its meaning in traditional therapy, where it refers to a feeling state related to a sense of wrongdoing—a pervasive, highly uncomfortable state which has been described as anxiety plus a sense of badness.

Neurotic guilt emanates from imagined transgressions (or minor transgressions that are responded to in a disproportionately powerful manner) against another individual, against ancient and modern taboos, or against parental or social tribunals. “Real” guilt flows from an actual transgression against another.

Though the subjective dysphoric experience is similar, the meaning and the therapeutic management of these forms of guilt are very different: neurotic guilt must be approached through a working through of the sense of badness, the unconscious aggressivity, and the wish for punishment; whereas “real” guilt must be met by actual, or symbolically appropriate, reparation.

But the existential concept of guilt adds something even more important than the broadening of the scope of “accountability.” Most simply put: one is guilty not only through transgressions against another or against some moral or social code, but one may be guilty of transgression against oneself.

Dasein is always constituting, and it “constantly lags behind its possibilities.”105 Guilt is thus intimately related to possibility or potentiality. When the “call of conscience” is heard (that is, the call that brings one back to facing one’s “authentic” mode of being), one is always “guilty”—and guilty to the extent that one has failed to fulfill authentic possibility

Tillich’s view that man is “asked to make of himself what he is supposed to become, to fulfill his destiny” derives from Kierkegaard who described a form of despair that emerged from not being willing to be oneself.

The same point is made by the Hasidic rabbi, Susya, who shortly before his death said, “When I get to heaven they will not ask me, ‘Why were you not Moses?’ Instead they will ask ‘Why were you not Susya? Why did you not become what only you could become?”

Otto Rank was acutely aware of these issues and wrote that when we restrict ourselves from a too intensive or too quick living out, or living up, we feel ourselves guilty on account of the unused life, the unlived life in us.

Rollo May suggested that the concept of repression be understood from the perspective of one’s relationship to one’s own potential, and that the concept of the unconscious be enlarged to include the individual’s unrealized repressed potential: We must ask the following questions, therefore, if we are to understand repression in a given person: What is this person’s relation to his own potentialities? What goes on that he chooses or is forced to choose, to block off from his awareness something that he knows and on another level knows that he knows?… The unconscious, then, is not to be thought of as a reservoir of impulses, thoughts, and wishes that are culturally unacceptable. I define it rather as those potentialities for knowing and experiencing that the individual cannot or will not actualize.

“When the person denies his potentialities, fails to fulfill them, his condition is guilt.”

Aristotle’s “entelechy” referred to the full realization of potentiality. The fourth cardinal sin, sloth, or accidie has been interpreted by many thinkers as “the sin of failing to do with one’s life all that one knows one can do.”

Horney’s major work, Neurosis and Human Growth, is subtitled The Struggle toward Self-Realization. Psychopathology, in her view, occurs when adverse circumstances inhibit a child from growing toward the realization of his or her own possibilities.

One senses the existence of one’s potential self, however, and, at an unconscious level, continuously compares it with one’s “actual” self (that is, the self that actually lives in the world). The discrepancy between what one is and what one could be generates a flood of self-contempt with which the individual must cope throughout life.

If the essential [intrinsically given] core of the person is denied or suppressed, he gets sick, sometimes in obvious ways sometimes in subtle ways.… This inner core is delicate and subtle and easily overcome by habit and cultural pressure.… Even though denied, it persists underground, forever pressing for actualization.… Every falling away [from our core], every crime against our nature records itself in our unconscious and makes us despise ourselves.

No one has said it better than Saint Augustine: “There is one within me who is more myself than my self.”

Existential guilt is more than a dysphoric affect state, a symptom to be worked through and eliminated; the therapist should regard it as a call from within which, if heeded, can function as a guide to personal fulfillment. One who, like Joseph K. or Mr. T, has existential guilt, has transgressed against one’s own destiny. The victim is one’s own potential self. Redemption is achieved by plunging oneself into the “true” vocation of the human being, which, as Kierkegaard said, “is to will to be oneself

In order to change, one must first assume responsibility: one must commit oneself to some action.

Early analysts were so convinced that self-knowledge was tantamount to change that they tended to see knowledge as the end point of therapy. If change did not occur, then it was assumed that the patient had not achieved sufficient insight.

Hobbes described man’s sense of freedom as a phantasm of consciousness. “If a wooden top, lashed by the boys… sometimes spinning, sometimes hitting men on the shins were sensible of its own motion [it] would think it proceeded from its own will.”9 Similarly, Spinoza said that a self-conscious and sentient stone that was set into motion by some external (unknown) force “would believe itself to be completely free and would think that it continued in motion solely because of its own wish.”

However, psychotherapists who believe that freedom is an illusionary subjective state paint themselves into a corner: since they state that successful psychotherapy results in the patient’s feeling a greater sense of choice, they are in effect proclaiming that the purpose of therapy is to create (or to restore) an illusion. This view of the therapeutic process is, as May points out, entirely incompatible with one of psychotherapy’s overarching values: the quest for truth and self-knowledge.

(“Man, insofar as he acts willfully, acts according to some imagined good.” [Aquinas

“It is astonishing how much the patient knows and how relatively little is unconscious if one does not give the patient this convenient excuse for refusing responsibility.”28 Rank suggested that Freud’s theory elevated the unconscious to a responsibility-dissolving function, the precise function played by a deity in previous systems:

The unconscious, just as the original meaning of the word shows, is a purely negative concept, which designates something momentarily not conscious, while Freud’s theory has lifted it to the most powerful factor in psychic life. The basis for this, however, is not given in any psychological experience but in a moral necessity, that is, to find an acceptable substitute for the concept of God, who frees the individual from responsibility

Gradually the child begins to exert personal control over his or her impulses and decides, for example, on the basis of love for his or her parents to curb those aggressive impulses. Thus, the will’s function at first is inextricably tied up with impulse: either it controls impulse, or it resists outside efforts to control impulse.

The child’s emotional life, too, Rank stated, develops in relation to the impulses. Emotions are different from impulses: we seek to discharge impulses, but we seek to prolong or dam up emotions.

Rank viewed the parent-child relationship and, indeed, the entire assimilative process—and, as we shall see, the therapeutic relation as well—as a struggle of wills and urged that parents pay exquisite sensitivity to this issue. Negative will should not be squelched but should be accepted in such a way that it is transformed into positive or “creative” will.

The goal of child rearing (and of therapy) is to transform the first two stages into creative will. The major “error” of child rearing, Rank suggested, is the squelching of impulse life and of early will (“counter” or “negative” will). If parents teach the child that all free impulse expression is undesirable and all counter will is bad, the child suffers two consequences: suppression of his or her entire emotional life, and stunted, guilt-laden will. The child then grows into an adult who suppresses his or her emotions and regards the very act of willing as evil and forbidden. These consequences are of the utmost importance for the therapist who frequently sees patients who are unable to feel and unable, because of guilt, to will.

Rank viewed therapist-patient interaction in much the same way as he did the parent-child experience. In therapy “two wills clash, either the one overthrows the other or both struggle with and against one another for supremacy.”35 The goal of therapy should be for the neurotic to learn to will and, above all, to learn to will without guilt.

Sylvan Tomkins referred to psychoanalysis as a “systematic training in indecision,”

During the course of therapy the patient opposes what he perceives to be the will of the therapist. Freud labeled this opposition “resistance,” considered it an obstacle, and suggested various techniques (patience, guidance, interpretation) to overcome it. To Rank, this view of resistance was a serious error: he believed that the patient’s protest was a valid and important manifestation of counter will and, as such, must not be eliminated but instead supported and transformed into creative will.

“The task of the therapist is to function in such a way that the will of the patient shall not be broken but strengthened.”

Rank, therefore, systematically reinforced all manifestations of the patient’s will: if the patient resisted or the patient suggested termination, Rank was careful to point out that he considered these stands as progress. He stated: “The neurotic cannot will without guilt. That situation can be changed not by himself but only in relation to a therapist who accepts the patient’s will, who justifies it, submits to it, and makes it good.”

One situation where the patient’s and the therapist’s wills are certain to clash is the termination of therapy. Some patients choose to terminate precipitately; while others refuse to terminate and, if necessary, cling to their symptoms to resist the therapist’s efforts to bring therapy to a conclusion. Rank felt that this clash of wills contained so much therapeutic potential that it was unfortunate that it had to be carried out at the end of therapy—and, indeed, often outside of therapy altogether.

Would it not be more sensible to transfer this will conflict to the center of the therapeutic arena—indeed, even to the beginning of therapy? Rank attempted to do just that by the special device of setting, at the beginning of therapy, a precise “time limit.” His “end-setting” thus projected the final phase of therapy forward to the onset of treatment.

These two realms of will must be approached differently in therapy. The second (conscious) realm of will is approached through exhortations and appeals to will power, effort, and determination. The first realm is impervious to these enjoinders and must be approached obliquely. A serious problem occurs when one applies exhortative second-realm techniques to first-realm activities. Farber offers some examples: I can will knowledge, but not wisdom; going to bed, but not sleeping; eating, but not hunger; meekness, but not humility; scrupulosity, but not virtue; self-assertion or bravado, but not courage; lust, but not love; commiseration, but not sympathy; congratulations, but not admiration; religiosity, but not faith; reading, but not understanding

When a disequilibrium occurs (for example, when the infant experiences hunger), the organism experiences a “wish” to be fed and acts in such a way (for example, cries or signals discomfort in some manner) to restore equilibrium. Gradually, as hunger is repetitively followed by feeding, the infant acquires a visual representation (an image or a “hallucination”) of being fed. Later, under the pressure of the reality principle, the child learns to delay gratification by evoking the visual representation of the feeding experience. This process of wishing and internal, temporary gratification of the wish, Freud argued, is the anlage of all thinking. A wish can exist on various levels of consciousness. An unconscious wish is the mental representation of an id impulse. Conscious wishes are generally compromise formations—that is, unconscious wishes tempered and molded by the superego and by unconscious parts of the ego. To Freud, then, wish is an unfree force akin to a tropism.

The most complete statement of this position is to be found in the often-cited chapter 7 of The Interpretation of Dreams,52 where Freud stated clearly his view that man operates on the constancy principle: that is, man attempts to maintain the level of cortical excitation at a constant level. When a disequilibrium occurs (for example, when the infant experiences hunger), the organism experiences a “wish” to be fed and acts in such a way (for example, cries or signals discomfort in some manner) to restore equilibrium. Gradually, as hunger is repetitively followed by feeding, the infant acquires a visual representation (an image or a “hallucination”) of being fed. Later, under the pressure of the reality principle, the child learns to delay gratification by evoking the visual representation of the feeding experience. This process of wishing and internal, temporary gratification of the wish, Freud argued, is the anlage of all thinking. A wish can exist on various levels of consciousness. An unconscious wish is the mental representation of an id impulse. Conscious wishes are generally compromise formations—that is, unconscious wishes tempered and molded by the superego and by unconscious parts of the ego. To Freud, then, wish is an unfree force akin to a tropism.

Wish, which May defines as “the imaginative playing with the possibility of some act or state occurring,”55 is the first step of the process of willing. Only after wishing occurs can the individual pull the “trigger of effort” and initiate the remainder of the act of willing, commitment and choice, which culminates in action.

If you have only “will” and no “wish,” you have the dried-up, Victorian, neopuritan man.

Resistance or obstinacy on the part of the patient is not always an impediment to therapy, nor is it necessarily to be analyzed away. Instead, as Rank suggests, it is a stand that the patient is taking; and, by accepting and reinforcing that stand, the therapist may facilitate the patient’s ability to will guiltlessly.

One can only act for oneself if one has access to one’s desires. If one lacks that access and cannot wish, one cannot project into the future, and responsible volition dies stillborn. Once wish materializes, the process of willing is launched and is transformed finally into action.

One’s capacity to wish is automatically facilitated if one is helped to feel. Wishing requires feeling. If one’s wishes are based on something other than feelings—for example, on rational deliberation or moral imperatives—then they are no longer wishes but “shoulds” or “oughts,” and one is blocked from communicating with one’s real self.

Psychotherapy with the affect-blocked (that is, feeling-blocked) patient is slow and grinding. Above all, the therapist must persevere. Time after time he will have to inquire, “What do you feel?” “What do you want?” Time after time he will need to explore the source and the nature of the block and of the stifled feelings behind it.

Thus, while it is important to generate affect in therapy, there is no evidence that rapid intensive affect arousal per se is therapeutic. Much as we would like it otherwise, psychotherapy is “cyclotherapy”71—a long, lumbering process in which the same issues are repeatedly worked through in the therapy environment and are tested and retested in the patient’s life environment.

Fritz Perls: “Lose Your Head and Come to Your Senses.” Perls focused doggedly on awareness. His therapy is an “experiential therapy rather than a verbal or interpretative therapy,”73 and he worked only in the present tense, because he felt that neurotics live too much in the past:

Gestalt therapy is a “here and now” therapy in which we ask the patient during the session to turn all his attention to what he is doing in the present, during the course of the session—right here and now… to become aware of his gestures, of his breathing, of his emotions and of his facial gestures as much as his pressing thoughts.

Perls began with awareness and gradually worked toward “wish.” I am convinced that the awareness technique alone can produce valuable therapeutic results. If the therapist were limited in his work only to asking three questions, he would eventually achieve success with all but the most seriously disturbed of his patients. These three questions are “What are you doing?” “What do you feel?” “What do you want?”

Perls might urge him or her to verbalize the statement and the wish behind the question. Patient: What do you mean by support? Therapist: Could you turn that into a statement? Patient: I would like to know what you mean by support. Therapist: That’s still a question. Could you turn it into a statement? Patient: I would like to tear hell out of you on this question if I had the opportunity

The purpose of affect arousal is not sheer catharsis but to help patients rediscover their wishes.

We finally became more helpful to him when we focused the inquiry onto immediate process: “How do you feel about being questioned about your feelings?” At this level he was able to experience a number of genuine feelings and wishes.

Freud pointed out long ago that fantasies are wishes; and the investigation of fantasy—either spontaneous or guided fantasy—is often a productive technique in the uncovering and the assimilation of wishes.

For example, one patient could not decide whether to continue seeing his girlfriend or to break off the relationship. His response to such questions as “What do you want to do?” or “Do you care for her?” was invariably a bewildered and frustrated “I don’t know.” The therapist asked him to fantasize receiving a phone call from her in which she suggested that they end their relationship. The patient visualized this clearly, sighed with relief, and became aware of feeling liberated after the phone call. From this fantasy it was only a short step to realize his true wish about the relationship and to begin working on those factors that inhibited the recognition and the enactment of his wish.

What is required is internal discrimination among wishes and assigning priorities to each. If two wishes are mutually exclusive, then one must be relinquished. If, for example, a meaningful, loving relationship is a wish, then a host of conflicting interpersonal wishes—such as conquest, power, seduction, or subjugation—must be denied. If a writer’s primary wish is to communicate, he must relinquish other, interfering wishes (such as the wish to appear clever). Impulsive and indiscriminate enactment of all wishes is a symptom of disordered will: it suggests an inability or a reluctance to project oneself into the future.

The therapist’s task is to help the impulsive patient transform sequential ambivalence into simultaneous ambivalence

The compulsive individual acts in accordance with inner demands that are not experienced as wishes. Something “ego-alien” directs such an individual. He is propelled to act, often against his wishes, and, if he does not act, feels acutely uncomfortable. Though he wishes not to act in a particular way, he finds it extraordinarily difficult not to follow the dictates of the compulsion.

For every yes there must be a no. To decide one thing always means to relinquish something else. As one therapist commented to an indecisive patient, “Decisions are very expensive, they cost you everything else.”

Heidegger defined death as “the impossibility of farther possibility.”

Ancient philosophical metaphors depict the same dilemma: Aristotle’s example of the hungry dog unable to choose between two equally attractive portions of food, or the celebrated problem of Buridan’s ass, a poor beast starving between two equally sweet smelling bundles of hay.95 In each instance the creature would have died if it had refused to relinquish options; the salvation of each lay in trusting desire and grasping what lay within reach.

The metaphor has clinical relevance to those patients who suffer paralysis of willing not only because they cannot say yes but because they cannot say no.

Decisions as a Boundary Experience. To be fully aware of one’s existential situation means that one becomes aware of self-creation. To be aware of the fact that one constitutes oneself, that there are no absolute external referents, that one assigns an arbitrary meaning to the world, means to become aware of one’s fundamental groundlessness

By facing one with the limitation of possibilities, decision challenges one’s myth of personal specialness. And decision, insofar as it forces one to accept personal responsibility and existential isolation, threatens one’s belief in the existence of an ultimate rescuer.

Decision and Guilt. Some individuals find decisions difficult because of guilt which, as Rank emphasized, is entirely capable of paralyzing the willing process. Will is born in a caul of guilt; it arises, said Rank, first as counter will. The child’s impulses are opposed by the adult world, and the child’s will first arises to oppose that opposition. If the child is unfortunate enough to have parents who attempt to squelch all impulsive expression, then the child’s will becomes heavily laden with guilt and experiences all decisions as evil and forbidden. Such an individual cannot decide because one feels one does not have the right to decide.

Existential guilt goes beyond the traditional guilt whereby the individual regrets a real or fantasized transgression against another. In chapter 6 I defined existential guilt as arising from one’s transgressions against oneself; it emanates from regret, from an awareness of the unlived life, of the untapped possibilities within one. Existential guilt, too, may be a powerful decision-blocking factor, in that a major decision to change causes the individual to reflect upon wastage, upon how he has sacrificed so much of his one and only life.

Responsibility is a two-edged sword: if one accepts responsibility for one’s life situation and makes the decision to change, the implication is that one alone is responsible for the past wreckage of one’s life and could have changed long ago.

One cannot will backward. One can atone for the past only by altering the future.

But there are many, more subtle methods of dealing with the intrinsic pain of decision—methods that permit one to decide while concealing from oneself that one is deciding. After all, it is the process, not the content, of decision that is painful; and if one can decide without knowing one is doing so, then tant mieux. I answered the question Why are decisions difficult? by stressing the renunciation, the anxiety, and the guilt that accompany decision. To soften the awareness and pain of decision, one must erect defenses against these threats: one can avoid the sense of renunciation by distorting the alternatives and/or can avoid existential anxiety and guilt by arranging for someone or some thing else to make the decision.

Reason told her that the marriage never had or never would work and that she was far better off alone. But she continued to give him all the power in the relationship and refused to consider that she, too, had a decision to make in the matter. Her decision, as she viewed it, consisted of a choice between a comfortable, dependent relationship with her husband and a fearful isolation.

Comfortable decision-making strategy demands therefore that the chosen alternatives be regarded as attractive, and the unchosen alternative as unattractive.

A common method that has obvious clinical relevance is information distortion: one is open to information that either upgrades the chosen alternative or downgrades the nonchosen alternative; and, conversely, one is closed to information that increases the attractiveness of the nonchosen alternative or decreases the attractiveness of the chosen one.

One can have one’s decision and avoid the pain of isolation if one can locate and persuade another to make that decision for one. Erich Fromm has repeatedly emphasized that human beings have always had a highly ambivalent attitude toward freedom. Though they fight fiercely for freedom, they leap at the opportunity to surrender it to a totalitarian regime that promises to remove the burden of freedom and decision from them. The charismatic leader—one who makes every decision crisply and confidently—has no difficulty recruiting subjects.

In my emergency session with her I had alleviated Beatrice’s panic by helping her consider the available options. That technique is generally effective in the face of decision panic; but it is important for the therapist to keep in mind that it is the patient—not the therapist—who must generate and choose among those options.

A logical, systematic analysis of the possibilities is sometimes useful. The therapist may, for example, ask the patient to consider the whole scenario of each “what if” in turn: to fantasize its happening, with possible ramifications, and then to experience and analyze his or her emergent feelings. Though these conscious approaches have some usefulness, they have severe limitations because so much of a decision dilemma exists at a subterranean level and is impervious to a rational approach.

Part of one’s constitutional heritage, as Robert White102 and Karen Horney103 have ably argued, is a drive toward effectance, toward mastering one’s environment, toward becoming what one is capable of becoming. Will is blocked by obstacles in the path of the child’s development; later these obstacles are internalized, and the individual is unable to act even though no objective factors are blocking him or her. The therapist’s task is to help remove those obstacles. Once that is done, the individual will naturally develop—just, as Horney put it, as an acorn develops into an oak.

Thus, the therapist’s task is not to create will but to disencumber it.

Nietszche said that only after one has fully considered suicide does one take one’s life seriously. Many cancer patients with whom I have worked have had adrenalectomies (part of the treatment program of metastatic breast carcinoma) and must take cortisone replacement therapy every day. Many take their daily tablets as automatically as they brush their teeth, but others are very much aware of making a decision every day to remain alive. My impression is that awareness of this decision enriches life and encourages one to commit oneself to the task of living as fully as possible.

If one is to love oneself, one must behave in ways that one can admire.

Each, however, paid a price for the decision about how to decide. Both patients had severely impaired self-esteem, and the way by which they avoided decisions contributed to that self-contempt. If one is to love oneself, one must behave in ways that one can admire.

May states, “I cannot perceive something until I can conceive it.”109 One is often unable to perceive truths about oneself only after taking some stand toward change. Once having made a decision, once having put oneself on record to oneself, then one has constituted one’s world differently and is able to seize truths that one had previously hidden from oneself.

These fantasied calamities are encumbrances to the will, and the therapist must search for methods to eliminate these encumbrances. The process of identifying and naming the fantasied calamity may in itself enable a patient to understand how far his or her fears are removed from reality.

Explanation is a potent enemy of the powerlessness that emanates from ignorance. Explanation, identifying, and labeling are all part of the natural sequence of the development of mastery—or of a sense of mastery which, in turn, begets effective behavior.

If, for example, natives live in terror of the unpredictable eruptions of a nearby volcano, their first step toward mastery of their situation is explanation. They may, for example, explain the volcano’s eruption as the behavior of a displeased volcano god. Although their external circumstances may be entirely the same, their phenomenological world is altered by explanation.

Quite often we do not succeed in bringing the patient to recollect what has been repressed. Instead of that, if the analysis is carried out correctly, we produce in him an assured conviction of the truth of the construction which achieves the same therapeutic results as a recaptured memory.

Even in a lengthy anamnesis, one recalls only a minute fraction of one’s past experience and may selectively recall and synthesize the past so as to achieve consistency with one’s present view of oneself.

Mark Twain: “When I was seventeen I was convinced my father was a damn fool. When I was twenty-one I was astounded by how much the old man had learned in four years.”

The single most frequently chosen item by far was “discovering and accepting previously unknown or unacceptable parts of myself.”

In a research project that I described in chapter 6, successful patients were asked to rank-order sixty factors in therapy according to degree of helpfulness.5 The single most frequently chosen item by far was “discovering and accepting previously unknown or unacceptable parts of myself.”

Existential isolation refers to an unbridgeable gulf between oneself and any other being.

I am awake in my room. Suddenly I begin to notice that everything is changing. The window frame seems stretched and then wavy, the bookcases squashed, the doorknob disappears, and a hole appears in the door which gets larger and larger. Everything loses its shape and begins to melt. There’s nothing there any more and I begin to scream.

Thomas Wolfe was forever haunted by his unusually acute awareness of existential isolation. In the autobiographical Look Homeward, Angel the protagonist muses on isolation even while an infant in the crib: Unfathomable loneliness and sadness crept through him: he saw his life down the solemn vista of a forest aisle, and he knew he would always be the sad one: caged in that little round of skull, imprisoned in that beating and most secret heart, his life must always walk down lonely passages. Lost. He understood that men were forever strangers to one another, that no one ever comes really to know anyone, that imprisoned in the dark womb of our mother, we come to life without having seen her face, that we are given to her arms a stranger, and that, caught in that insoluble prison of being, we escape it never, no matter what arms may clasp us, what mouth may kiss us, what heart may warm us. Never, never, never, never, never.

No one can take the other’s death away from him.”

I believe that if we are able to acknowledge our isolated situations in existence and to confront them with resoluteness, we will be able to turn lovingly toward others. If, on the other hand, we are overcome with dread before the abyss of loneliness, we will not reach out toward others but instead will flail at them in order not to drown in the sea of existence.

one relates to another with less than one’s whole being, if one holds something back by, for example, relating through greed or anticipation of some return, or if one remains in the objective attitude, a spectator, and wonders about the impression one’s actions will make on the other, then one has transferred an I-Thou encounter into an I-It one.

If one relates to another with less than one’s whole being, if one holds something back by, for example, relating through greed or anticipation of some return, or if one remains in the objective attitude, a spectator, and wonders about the impression one’s actions will make on the other, then one has transferred an I-Thou encounter into an I-It one.

If one is to relate truly to another, one must truly listen to the other: relinquish stereotypes and anticipations of the other, and allow oneself to be shaped by the other’s response. Buber’s distinction between “genuine” and “pseudo” listening obviously has important implications for the therapeutic relationship. To relate to another in a need-less fashion, one must lose or transcend oneself.

existential isolation. He would protest at my positing

One of Maslow’s fundamental propositions was that an individual’s basic motivation is oriented toward either “deficit” or “growth.” Psychoneurosis, he thought, is a deficiency disease resulting from a lack of fulfillment, beginning early in life, of certain basic psychological “needs”—that is, safety, belongingness, identification, love, respect, prestige.39 Individuals who have these needs satisfied are growth-oriented: they are able to realize their own innate potential for maturity and self-actualization. Growth-oriented individuals, in contrast to those with a deficiency orientation, are far more self-sufficient and far less dependent upon their environment for reinforcement or gratification. In other words, the determinants that govern them are not social or environmental but inner:

Fromm’s starting point is that the human being’s most fundamental concern is existential isolation, that the awareness of separateness is “the source of all anxiety,”44 and that our major psychological task, throughout the ages, has been the overcoming of separateness

Fromm discusses several historical attempts at solution: creative activity (the union of artist with material and product), orgiastic states (religious, sexual, drug-induced), and conformity with customs and beliefs of the group. All of these attempts fall short:

The unity in productive (creative) work is not interpersonal; the unity achieved in orgiastic fusion is transitory; the unity achieved by conformity is only pseudo-unity. Hence they are only partial answers to the problem of existence. The full answer lies in the achievement of interpersonal union, of fusion with another person, in love.

What Fromm meant by “the full answer” is not clear, but I assume it to be “the most satisfactory” answer. Love does not take away our separateness—that is a given of existence and can be faced but never erased. Love is our best mode of coping with the pain of separateness.

Symbiotic love, consisting of an active (sadism)

Not all forms of love answer equally well the anguish of separateness. Fromm differentiated “symbiotic union”—a form of fallen love—from “mature” love. Symbiotic love, consisting of an active (sadism) and a passive (masochism) form, is a state of fusion where neither party is whole or free (I shall discuss this among the forms of maladaptive love in the following section). Mature love is “union under the condition of preserving one’s integrity, one’s individuality.… In love the paradox occurs that two beings become one and yet remain two.”

Fromm traces the individual development of love from early childhood when one experiences being loved for what one is or, perhaps more accurately, because one is. Later, between eight and ten, a new factor enters the child’s life: awareness that one produces love by one’s own activity. As the individual overcomes egocentricity, the needs of the other become as important as his or her own; and gradually the individual transforms the concept of love from “being loved” into “loving.”

Fromm equates “being loved” with a state of dependency in which by remaining small, helpless, or “good,” one is rewarded by being loved; whereas “loving” is an effective potent state. “Infantile love follows the principle ‘I love because I am loved.’ Mature love follows the principle: ‘I am loved because I love.’ Immature love says, ‘I love you because I need you.’ Mature love says, ‘I need you because I love you.’”

Patients complain of loneliness, of being unloved and unlovable, but the productive work is always to be done in the opposite realm: their inability to love.

To love means to be actively concerned for the life and the growth of another.

Another patient who, on several occasions, had mutilated herself stated that she had done so because of her despair about a highly unsatisfying relationship with a man. Yet she could not leave him because of her terror of being alone. When I asked her what terrified her about loneliness, she said with stark, direct, psychotic insight, “I don’t exist when I’m alone.”

The solution fails also because one misidentifies the problem: one considers it to be that one is unloved, whereas in actuality it is that one is unable to love. As we have seen, loving is more difficult than being loved and requires greater awareness and acceptance of one’s existential situation.

Others combat isolation by escaping from the present, solitary moment: they comfort themselves with blissful memories of the past (even though at the time their experiences may have been far from blissful), or they project themselves into the future by enjoying the imagined spoils of as yet unrealized projects.

isolation through fusion and the concept of escaping the terror of death through belief and immersion of oneself

safety-in-fusion,

The difference between the masochist and the sadist is between fuser and fusee. One seeks security by being swallowed by another; the other, by swallowing someone else. In both cases existential isolation is assuaged—either through losing one’s separateness and isolation or through enlarging oneself by the incorporation of others. That is why masochism and sadism often oscillate within an individual: they are different solutions to the same problem.

Sex may be used in the service of repression of death anxiety. On several occasions I have worked with patients with metastatic cancer who seemed obsessed with sexual concerns. I have met with married couples, one of whom had terminal cancer, who spoke of little else except their sexual maladjustment. At times, in the heat of the discussion, during the recriminations and countercharges, I forgot entirely that one of these individuals was facing imminent death.

Ellen Greenspan described research demonstrating that women with severe breast cancer, in comparison with an age-matched healthy cohort, had a higher incidence of illicit sexual fantasies.

We try to escape the pain of existential isolation in a variety of ways: we soften ego boundaries and attempt to fuse with another; we attempt to incorporate another; we take something from the other that makes us feel larger, more powerful, or cherished. The common interpersonal theme in these attempts and in a number of others, which I shall now discuss, is that the individual is not with the other person. Instead, the individual uses the other person as equipment to serve a function, and a mutually enriching relationship never occurs;

He explained that the relationship would never evolve into a long-term one because Jamelia did not quite match up to what he had been looking for in a woman. The main reason was that her social skills were not highly enough developed: she was not sufficiently articulate; she was too inhibited and too socially introverted. He knew that he did not speak well and wanted very much to marry a woman with greater verbal dexterity: since he learned well by imitating, he had hoped to improve as a result of contact with such a woman. He also expected a woman to provide him with a less restricted social life. Furthermore, he worried that if the two of them spent too much time alone and became very loving, then he would give all his caring to her and would never have any to give to others.

Barry viewed love as an exhaustible commodity: the more he offered to one person, the less he would have for others. But, as Fromm has taught us, this marketing approach to love makes no sense: engaging others always leaves one richer not poorer.

If one holds back part of oneself in order to observe the relationship or the impact one has upon the other, then, to that extent, one has failed to relate.

Each of an individual’s relationships reflects the others: it is rare, I believe, for one to be able to relate in bad faith to some individuals and in an authentic, caring way to a select few.

A full caring relationship is a relationship to another, not to any extraneous figure from the past or the present. Transference, parataxic distortions, ulterior motives and goals—all must be swept away before an authentic relation with another can prevail.

One of the therapist’s first tasks is to help the patient identify and apprehend what he or she does with others. The characteristics of a need-free relationship provide the therapist with an ideal or a horizon against which the patient’s interpersonal pathology is starkly silhouetted. Does, for example, the patient relate exclusively to those who can provide something for him? Is his love focused on receiving rather than giving? Does he attempt to know, in the fullest sense, the other person? How much of himself is held back? Does he genuinely listen to the other person? Does he use the other to relate to yet another—that is, how many people are in the room? Does he care about the growth of the other?

Eve also was able to learn how her behavior made others feel. (This feature is one of the real strengths of the group therapy approach:

Toward the end of this meeting Anna was asked to describe what her experience had been like over the past hour. (Effective use of the here-and-now in therapy always entails two processes: sheer experiencing and the subsequent examination of that experience.)

Clark Moustakas, in his essay on loneliness, made the same point: The individual in being lonely, if let be, will realize himself in loneliness and create a bond or sense of fundamental relatedness with others. Loneliness rather than separating the individual or causing a break or division of self, expands the individual’s wholeness, perceptiveness, sensitivity and humanity

In The Art of Loving, Fromm wrote that “the ability to be alone is the condition for the ability to love,”

Linda Sherby describes a patient whose symptoms were frenzied activity and an unsatisfying, dependent posture toward would-be relationships.11 In an effort to break through an impasse, the therapist suggested to the patient that she spend twenty-four hours alone in a motel cut off from all distractions (people, television, books, and so on), except for writing a diary of her thoughts and feelings. The major outcome, and it was of considerable import for this patient, was that she learned she could tolerate isolation without panic.

I remember two maxims of psychotherapy that I learned in the very beginning of my training. I discussed the first—“the goal of psychotherapy is to bring the patient to the point where he can make a free choice”—in the section on freedom. The second—“it is the relationship that heals”—is the single most important lesson the psychotherapist must learn. There is no more self-evident truth in psychotherapy; every therapist observes over and over in clinical work that the encounter itself is healing for the patient in a way that transcends the therapist’s theoretical orientation.

If any single fact has been established by psychotherapy research, it is that a positive relationship between patient and therapist is positively related to therapy outcome.

Several years ago I established a contract (for reasons not germane to this discussion) with a patient which stipulated that we both would write impressionistic summaries after each individual therapy hour, deliver them sealed to my secretary, and every few months read each other’s notes. (Later we published these notes in the book Every Day Gets a Little Closer: A Twice-Told Therapy24) What impressed me very much was the discrepancy between my perceptions of an hour and those of the patient.

It seems clear that in some as yet undefined fashion the therapist-patient personal relationship is crucial to the process of change, and also that the therapist often underestimates the importance of this factor and overestimates that of his cognitive contributions.

The use of the relationship to illuminate the past is the traditional transference approach to the patient-therapist relationship, where the patient “transfers” feelings and attitudes from important figures, especially parental ones, onto the person of the therapist. The patient dresses the therapist, who serves as a mannikin, with feelings that have been stripped from others. The relationship with the therapist is a shadow play, reflecting the vicissitudes of a drama that transpired long ago. The analytic therapeutic goal of recapturing and illuminating events in early life is well served in this approach.

The therapist may represent different things to different patients, but to most patients he or she embodies images of authority—teacher, boss, parent, judge, supervisor, and so forth. By helping the patient improve his or her relationships to such individuals, the therapist performs a real service.

Many circumstances exist that may result in estrangement between parent and child, teacher and student, worshiper and deity. But the mature therapist will care despite rebelliousness, narcissism, depression, hostility, and mendacity. In fact, one might say that the therapist cares because of these traits, since they reflect how much the individual needs to be cared for.

Fromm, Maslow, and Buber all stressed that true caring for another means to care about the other’s growth and to bring something to life in the other.

What is required is a major shift in perspective: rather than strive to order the interview “material” into an intellectually coherent framework, the therapist must strive toward authentic engagement.

The major task of the maturing therapist is to learn to tolerate uncertainty. What is required is a major shift in perspective: rather than strive to order the interview “material” into an intellectually coherent framework, the therapist must strive toward authentic engagement.

I listen to a woman patient. She rambles on and on. She seems unattractive in every sense of the word—physically, intellectually, emotionally. She is irritating. She has many off-putting gestures. She is not talking to me; she is talking in front of me. Yet how can she talk to me if I am not here? My thoughts wander. My head groans. What time is it? How much longer to go? I suddenly rebuke myself. I give my mind a shake. Whenever I think of how much time remains in the hour, I know I am failing my patient. I try then to touch her with my thoughts. I try to understand why I avoid her. What is her world like at this moment? How is she experiencing the hour? How is she experiencing me? I ask her these very questions. I tell her that I have felt distant from her for the last several minutes. Has she felt the same way? We talk about that together and try to figure out why we lost contact with one another. Suddenly we are very close. She is no longer unattractive. I have much compassion for her person, for what she is, for what she might yet be. The clock races; the hour ends too soon.

C. G. Jung, for example, felt that meaninglessness inhibited fullness of life and was “therefore equivalent to illness.”8 He wrote: “Absence of meaning in life plays a crucial role in the etiology of neurosis. A neurosis must be understood, ultimately, as a suffering of a soul which has not discovered its meaning.… About a third of my cases are not suffering from any clinically definable neurosis but from the senselessness and aimlessness of their lives.”

Psychotherapy is a child of the Enlightenment. At bottom it always embraces the goal of unflinching self-exploration.

God, in Aristotelian terms, is “thought thinking itself”; and one approaches the deity through perfection of one’s rational faculties.

Jung’s idea that the human being completes the work of creation and “puts the stamp of perfection upon it,” is a conclusion arrived at by others. Earlier Hegel wrote “without the world God is not god.… God is God only insofar as he knows himself and his self-knowledge is his consciousness of himself in man and man’s knowledge of god.”21 Or the poet Rilke in this century: What will you do, God, if I die? I am your jug, what if I shatter? I am your drink, what if I spoil? I am your robe and your profession Losing me, you lose your meaning.

A provocative comment by Thomas Mann echoes this thought: “With the generation of life from the inorganic, it was man who was ultimately intended. With him a great experiment is initiated, the failure of which would be the failure of creation itself.… Whether that be so or not, it would be well for man to behave as if it were so.”

To create something new, something that rings with novelty or beauty and harmony is a powerful antidote to a sense of meaninglessness. The creation justifies itself, it defies the question What for?, it is “its own excuse for being.” It is right that it be created, and it is right that one devotes oneself to its creation.

Irving Taylor suggests that creative artists who have worked with the greatest personal handicaps and the greatest social constraints (only think of Galileo, Nietzsche, Dostoevsky, Freud, Keats, the Brontë sisters, Van Gogh, Kafka, Virginia Woolf) may have had faculties of self-reflection so highly developed that they had a keener vision than most of us of the human existential situation and the universe’s cosmic indifference.51 Consequently, they suffered more keenly from a crisis of meaninglessness and, with a ferocity born of desperation, plunged into creative efforts.

I am reminded of an old psychology text where I once saw two pictures, juxtaposed. One showed children playing with one another in all the freshness and spontaneity of childhood exuberance and innocence; the other, a crowd of New York subway travelers with vacant stares and mottled gray faces dangling lifelessly from the subway straps and poles. Under the two pictures was the simple caption: “What happened?”

Self-Transcendence. The last two types of meaning (hedonism and self-actualization) differ from the previous ones (altruism, dedication to a cause, and creativity) in one important aspect. Hedonism and self-actualization are concerned with self, whereas the others reflect some basic craving to transcend one’s self-interest and to strive toward something or someone outside or “above” oneself.

Buber writes: “Depart from evil and do good. You have done wrong? Then counteract it by doing good.”

Frankl begins by taking issue with Freud’s basic laws of motivation, the homeostasis principle, which posited that the human organism attempts unceasingly to maintain an inner equilibrium. The pleasure principle acts to maintain homeostasis and has as its fundamental goal the removal of tension. The pleasure principle operates in naked, unashamed form early in life; later, as the individual matures, the workings of the pleasure principle become more obscure when the reality principle requires delay or sublimation of gratification.

Frankl is less clear about the meaning derived from experience, but in general he refers to what one derives from beauty, from truth, and especially from love. Engagement in deep experience constitutes meaning: “If someone tapped your shoulder while listening to your favorite music, and asked you if life were meaningful, would you not,” asks Frankl, “answer Yes? The same answer would be given by the nature lover on a mountain top, the religious person at a memorable service, the intellectual at an inspiring lecture, the artist in front of a masterpiece.”

Survival in extreme circumstances depends upon one’s being able to find a meaning in one’s suffering.

Moreover, their work was intrinsically worthwhile. Who, after all, can challenge the task of growing food with the question What for? Growing food is an endeavor that is simply right beyond questioning.

Freud once stated, “The moment a man questions the meaning of life, he is sick.… By asking this question one is merely admitting to a store of unsatisfied libido to which something else must have happened, a kind of fermentation leading to sadness and depression.”

He posits a psychological horror vacui: when there is a distinct (existential) vacuum, symptoms will rush in to fill it.

Modern man’s dilemma, Frankl states, is that one is not told by instinct what one must do, or any longer by tradition what one should do. Nor does one know what one wants to do. Two common behavioral reactions to this crisis of values are conformity (doing what others do) and submission to totalitarianism (doing what others wish).

Nihilism is characterized by an active, pervasive proclivity to discredit activities purported by others to have meaning. The nihilist’s energy and behavior flow from despair; he or she seeks the angry pleasure involved in destruction to quote Maddi: He will be quick to point out that love is not altruistic but selfish, how philanthropy is a way of expiating guilt, that children are vicious rather than innocent, how leaders are vain and power-mad rather than inspired by a grand vision, and how work is not productive but rather a thin veneer of civilization hiding the monster in us all.

Nihilism is so common, Maddi suggests, that it is not even recognized as a problem; in fact, it often masquerades as a highly enlightened, sophisticated approach to life.

He cites the novelist and film maker Alain Robbe-Grillet, whose film, Last Year at Marienbad, contains seemingly meaningful threads but each defies the attempts of the moviegoer to discover its meaning. The film, Maddi suggests, was intended to frustrate any search for meaning in order to demonstrate the futility of believing in the meaningfulness of anything.

The event that propelled Harvey into a crisis of meaning was that he had successfully and precociously achieved his life goal (always a danger in a nontranscendent life-meaning schema). Other events that may precipitate such a crisis include a confrontation with death or some urgent (boundary) experience that confronts the individual with his or her existential situation and illuminates the insubstantial nature of many systems of meaning.

Some major upheaval that suddenly uproots the ritual and tradition of the social order may also throw certain values (for example, the social customs of “society”) into sharp relief: one not only stops being rewarded extrinsically for adherence to ritual but, even more important, one becomes aware of the absolute relativity of the values one once considered as absolutes.

One study compared PIL scores of physically ill patients and reported an interesting finding: patients who were critically ill had higher PIL scores than had patients with a minor ailment or nonpatients.114 The authors speculated that these results indicate the approach of death catalyzed the critically ill patients to come to terms with their lives, to “work through” their doubts, and to come to some inner peace.

One must, as Erik Erikson suggested, solve the task of establishing self-worth and personal identity before being able to develop a satisfying sense of life meaning.

Throughout his writing Frankl asserts: “Meaning is something to be found rather than given. Man cannot invent it but must discover it.”2 Frankl’s position is basically religious and rests on the assumption that there is a God who has ordained a meaning for each of us to discover and fulfill. Even though we cannot comprehend the meaning in its entirety, Frankl insists we must accept on faith that there is a coherent pattern to life and a purpose to man’s suffering. Just as the experimental animal cannot comprehend the reason for its pain, so too is it with human beings who cannot discover their meaning because it lies in a dimension beyond their comprehension

Once a sense of meaning is developed, it gives birth to values—which, in turn, act synergistically to augment one’s sense of meaning.

Thus, one meaning of meaning is that it is an anxiety emollient: it comes into being to relieve the anxiety that comes from facing a life and a world without an ordained, comforting structure. There is yet another vital reason why we need meaning. Once a sense of meaning is developed, it gives birth to values—which, in turn, act synergistically to augment one’s sense of meaning.

What are values and why do we need them? Tolstoy in his crisis of meaning not only asked Why questions (“Why do I live?”) but also How questions, (“How shall I live? By what shall I live?”)—all of which expressed a need for values—some set of guidelines or principles to tell him how to live.

if one’s meaning schema stresses service to others, then one is easily able to develop guidelines, or values, that permit one to say “this behavior is right or this behavior is wrong.”

I have stressed in earlier chapters that one creates oneself by a series of ongoing decisions. But one cannot make each and every decision de novo throughout one’s life; certain superordinate decisions must be made that provide an organizing principle for subsequent decisions. If that were not the case, much of life would be consumed by the turmoil of decision making

A shared belief system not only tells individuals what they ought to do but what others probably will do as well.

the wish to leave something behind of one’s self to matter, to make a difference, Becker would argue, is an expression of an effort to transcend death.

Meaning, used in the sense of one’s life having made a difference, of one’s having mattered, of one’s having left part of oneself for posterity, seems derivative of the wish not to perish. When Tolstoy lamented that there was no meaning in his life that would not be destroyed by the inevitable death awaiting him, he was stating not that death destroyed meaning but that he failed to find a meaning that would destroy death.

Not only does death anxiety often masquerade as meaninglessness, but the anxiety stemming from awareness of freedom and isolation is also frequently confused with the anxiety of meaninglessness.

Envisioning existence as part of some grand design that exists “out there” and in which one is assigned some role is a way of denying one’s freedom and one’s responsibility for the design and structure of one’s own life and a way of avoiding the anxiety of groundlessness

Fear of absolute loneliness also propels one into a search for identification with something or someone. To be part of a larger group or to dedicate oneself to some movement or cause are effective ways of denying isolation.

The question of meaning in life is not only confounded by issues belonging to the ultimate concerns of death, freedom, and isolation, but it is also extraordinarily difficult to comprehend it free of the biases inherent in a particular culture.

No human can always achieve, always create. No human being can be continuously successful in his endeavors. But to go in the right direction, not to have achieved, but achieving, not arriving at the inn but walking toward the inn, not resting on the laurels, but moving towards the laurels, putting one’s talents to the most constructive, productive and creative use—this is perhaps the main sense of life and the only possible answer to the existential neurosis which cripples human efforts and maims human minds.

Is striving, creating, achieving, or progressing part of existence, part of the deepest layers of human motivation? The answer is, most assuredly, no. There were other eras in our own culture where goal-directed striving was by no means accepted as a commonly sanctioned mode of finding meaning in life.

The Western world has, thus, insidiously adopted a world view that there is a “point,” an outcome of all one’s endeavors. One strives for a goal. One’s efforts must have some end point, just as a sermon has a moral and a story, a satisfying conclusion.

The Eastern world never assumes that there is a “point” to life, or that it is a problem to be solved; instead, life is a mystery to be lived.

The Indian sage Bhaqway Shree Rajneesh says, “Existence has no goal. It is pure journey. The journey in life is so beautiful, who bothers for the destination?”

Life just happens to be, and we just happen to be thrown into it. Life requires no reason.

The experience of meaningless may be a “stand-in” for anxiety associated with death, groundlessness, and isolation; and the therapist is well advised to analyze and approach these concerns along the lines discussed in previous chapters of this book.

For any patient who is excessively self-absorbed, Frankl feels that a long search within for causes of the anxiety generally compounds the problem and is ultimately counterproductive by making the patient even more self-absorbed. For such a patient he recommends that a therapist take the position (and convey this position to the patient) that, because of irreversible factors (the patient’s family history, genetically transmitted anxiety, genetic imbalance of the autonomic system, and so forth), the patient is destined to experience a high baseline amount of anxiety, for which there is relatively little one can do except take medication or engage in exercise or some similar ameliorative activity. The therapist must then direct attention toward work on the patient’s attitude toward his or her situation and toward the detection of meanings available for the patient.

Frankl’s point stands nonetheless: it is often vitally important to shift the patient’s gaze from himself or herself onto others. The therapist must find a way to help the patient develop curiosity and concern for others. The therapy group is especially well suited for this endeavor. Self-absorbed, narcissistic proclivities are readily apparent, and inevitably the pattern of “taking without giving” becomes a key issue in the group.

Crumbaugh makes the assumption that if one is to find some coherent pattern in complex life situations, one must be able to perceive details and events in a comprehensive manner and then to recombine this data into some new gestalt.

Nagel suggests that a true appreciation of the nebula’s-eye view, coupled with the knowledge that it is our strength to be able to assume that view, should permit us to return to our absurd life “laced with irony” instead of with despair.

For example, though Schopenhaurer concluded that nothing matters, “nothing is worth our striving,” many things mattered to him. It mattered to him to convince others that things did not matter; it mattered to him to oppose a Hegelian system of thought, to continue writing actively until the end of his life, to philosophize rather than to commit suicide. Even to the man who wrote the suicide note about the brick-carrying morons, things mattered: it mattered that he try to comprehend the human condition and to communicate his conclusions to others. If he had sought my help before his suicide, I should have tried to communicate to this “mattering” life-searching part of him.

Meaninglessness is an experiential state; and though it is so consuming that it appears to render meaningless everything in the past and the future as well as in the present, it can do that only when we view our lives from the galactic perspective. “Meaning” is what something needs to matter only when in that perspective. At other times things matter because they matter. Things matter to us all the time. It matters to me that I communicate these ideas as clearly as possible. At other times other things matter—relationships, tennis, reading, chess, talking. Must the fact that these activities don’t matter from the nebula’s-eye view, that they don’t hang together as some unified whole, take away their mattering? When things matter, they don’t need meaning to matter!

David Hume, in a famous passage in the Treatise, points the way. As a result of musing while in the galactic perspective, he was beset by clouds of doubt (“philosophical melancholy”): Most fortunately it happens, that since reason is incapable of dispelling these clouds, nature herself suffices to that purpose, and cures me of this philosophical melancholy by some avocation, and lively impression of my senses, which obliterate all these chimeras. I dine, I play a game of backgammon, I converse, and am merry with my friends; and when after three or four hours’ amusement, I would return to these speculations, they appear so cold, and strain’d, and ridiculous, that I cannot find in my heart to enter into them any farther.38 Hume’s antidote to the meaninglessness inherent in the cosmic perspective is engagement; and engagement is Sartre’s and Camus’s solution as well; a leap into commitment and action.

Tolstoy chose that solution, too, when he said, “It is possible to live only as long as life intoxicates us.”

And engagement is the therapist’s most effective approach to meaninglessness.

Engagement is the therapeutic answer to meaninglessness regardless of the latter’s source. Wholehearted engagement in any of the infinite array of life’s activities not only disarms the galactic view but enhances the possibility of one’s completing the patterning of the events of one’s life in some coherent fashion.

The therapist’s goal, then, is engagement. The task is not to create engagement nor to inspirit the patient with engagement—these the therapist cannot do. But it is not necessary: the desire to engage life is always there within the patient, and the therapist’s clinical activities should be directed toward removal of obstacles in the patient’s way. What, for example, prevents the patient from loving another individual? Why is there so little satisfaction from relationships with others? What are the parataxic distortions that systematically poison his or her relationships? Why is there so little work satisfaction? What blocks the patient from finding work that is commensurate with his or her talents or finding pleasurable aspects of current work? Why has the patient neglected his or her creative or religious or self-transcendent strivings?