I have found that four givens are particularly relevant to psychotherapy: the inevitability of death for each of us and for those we love; the freedom to make our lives as we will; our ultimate aloneness; and, finally, the absence of any obvious meaning or sense to life.

Pain that is all too easily accessible. Many things—a simple group exercise, a few minutes of deep reflection, a work of art, a sermon, a personal crisis, a loss—remind us that our deepest wants can never be fulfilled: our wants for youth, for a halt to aging, for the return of vanished ones, for eternal love, protection, significance, for immortality itself. It is when these unattainable wants come to dominate our lives that we turn for help to family, to friends, to religion—sometimes to psychotherapists.

two particularly powerful and common methods of allaying fears about death, two beliefs, or delusions, that afford a sense of safety. One is the belief in personal specialness; the other, the belief in an ultimate rescuer.

Since patients tend to resist assuming responsibility, therapists must develop techniques to make patients aware of how they themselves create their own problems. A powerful technique, which I use in many of these cases, is the here-and-now focus. Since patients tend to re-create in the therapy setting the same interpersonal problems that bedevil them in their lives outside, I focus on what is going on at the moment between a patient and me rather than on the events of his or her past or current life.

When years of interpretation have failed to generate change, we may begin to make direct appeals to the will: “Effort, too, is needed. You have to try, you know. There’s a time for thinking and analyzing but there’s also a time for action.”

It is through willing, the mainspring of action, that our freedom is enacted. I see willing as having two stages: a person initiates through wishing and then enacts through deciding.

“Things fade: alternatives exclude.”

One’s efforts to escape isolation can sabotage one’s relationships with other people. Many a friendship or marriage has failed because, instead of relating to, and caring for, one another, one person uses another as a shield against isolation.

The person who has fallen in love, and entered a blissful state of merger, is not self-reflective because the questioning lonely I (and the attendant anxiety of isolation) dissolve into the we. Thus one sheds anxiety but loses oneself.

One of the great paradoxes of life is that self-awareness breeds anxiety. Fusion eradicates anxiety in a radical fashion—by eliminating self-awareness. The person who has fallen in love, and entered a blissful state of merger, is not self-reflective because the questioning lonely I (and the attendant anxiety of isolation) dissolve into the we. Thus one sheds anxiety but loses oneself.

In therapy, as in life, meaningfulness is a by-product of engagement and commitment, and that is where therapists must direct their efforts—not that engagement provides the rational answer to questions of meaning, but it causes these questions not to matter.

sufficiently objective to provide necessary rudimentary

I’ve seen too many patients badly damaged by therapists using them sexually. It’s always damaging to a patient.

Her love obsession—what else could one call it?—was powerful and tenacious, having dominated eight years of her life. Still, the roots of the obsession seemed extraordinarily friable. A little effort, a little ingenuity should suffice to yank the whole weed out. And then? Underneath obsession, what would I find? Would I discover the brutal facts of human experience that the enchantment concealed? Then I might really learn something about the function of love. Medical researchers discovered, in the early days of nineteenth-century medical research, that the best way to understand the purpose of an endocrine organ is to remove it and observe the subsequent physiological functioning of the laboratory animal. Though I was chilled by the inhumaneness of my metaphor, I wondered: Might not the same principle hold here?

I was becoming more convinced that my hunch about his behavior was correct: namely, that he had major psychosexual problems which he had acted out on Thelma (and probably other unfortunate patients).

For a love obsession drains life of its reality, obliterating new experience,

Indeed, most of my deeply held beliefs about therapy, and my areas of keenest psychological interest, have arisen from personal experience. Nietzsche claimed that a philosopher’s system of thought always arises from his autobiography, and I believe that to be true for all therapists—in fact, for anyone who thinks about thought.

the problem in therapy is always how to move from an ineffectual intellectual appreciation of a truth about oneself to some emotional experience of it. It is only when therapy enlists deep emotions that it becomes a powerful force for change.

If they are helpful to patients at all, ideological schools with their complex metaphysical edifices succeed because they assuage the therapist’s, not the patient’s, anxiety (and thus permit the therapist to face the anxiety of the therapeutic process). The more the therapist is able to tolerate the anxiety of not knowing, the less need there is for the therapist to embrace orthodoxy. The creative members of an orthodoxy, any orthodoxy, ultimately outgrow their disciplines.

The lonely I ecstatically dissolving into the we. How often I’ve heard that! It’s the common denominator of every form of bliss—romantic, sexual, political, religious, mystical. Everyone wants and welcomes this blissful merger.

“The final reward of the dead—to die no more.”

often the best way to prevent a calamitous reaction is to predict it.

“Which will you have: wise madness or foolish sanity?”

Cervantes asked, “Which will you have: wise madness or foolish sanity?”

“And that one of the most important principles of groups is that the group is a miniature world—whatever environment we create in the group reflects the way we have chosen to live? Remember that I said that each of us establishes in the group the same kind of social world we have in our real life?”

“All right, Carlos, let’s consider this ideal society you’re imagining and advocating—this society of legalized rape. Think now, for a few minutes, about your daughter.

In the past I hadn’t tampered with his denial. In general, it’s best not to undermine a defense unless it is creating more problems than solutions, and unless one has something better to offer in its stead.

Reincarnation is a case in point: though I personally consider it a form of death denial, the belief served Carlos (as it does much of the world’s population) very well;

the way one faces death is greatly determined by the model one’s parents set. The last gift a parent can give to children is to teach them, through example, how to face death with equanimity—and Carlos gave an extraordinary lesson in grace.

if one is to learn to live with the dead, one must first learn to live with the living. There seemed much work for Penny to do on her relationships with the living—especially with her sons and perhaps with her husband;

To lose a parent or a lifelong friend is often to lose the past: the person who died may be the only other living witness to golden events of long ago. But to lose a child is to lose the future: what is lost is no less than one’s life project—what one lives for, how one projects oneself into the future, how one may hope to transcend death (indeed, one’s child becomes one’s immortality project). Thus, in professional language, parental loss is “object loss” (the “object” being a figure who has played an instrumental role in the constitution of one’s inner world); whereas child loss is “project loss” (the loss of one’s central organizing life principle, providing not only the why but also the how of life).

The sentiment that one “should have done something more” reflects, it seems to me, an underlying wish to control the uncontrollable. After all, if one is guilty about not having done something that one should have done, then it follows that there is something that could have been done—a comforting thought that decoys us from our patent helplessness in the face of death.

Encased in an elaborate illusion of unlimited power and progress, each of us subscribes, at least until one’s midlife crisis, to the belief that existence consists of an eternal, upward spiral of achievement, dependent on will alone.

Of all possible boundary experiences, none—as in the story of Carlos (“If Rape Were Legal. . . “)—more potently confronts us with finiteness and contingency (and none is more able to effect immediate dramatic personal change) than the imminence of our own death.

Diving into deep water not uncommonly symbolizes the act of diving into the depths of one’s unconscious.

Sometimes, as in Penny’s family, the surviving children suffer because so much of the parents’ energy is bound up with the dead child, who is both memorialized and idealized. Some surviving children are filled with resentment toward their dead sibling for such claims upon the parents’ time and energy; often the resentment exists side by side with their own grief and their own understanding of the parents’ dilemma.

Wary though I am always of generalizations, in this instance male-female stereotypes often hold true. Many women, like Penny, need to move past the repetitive expression of their loss and to plunge back into engagement with the living, with projects, with all the things that may supply meaning for their own lives. Men usually must be taught to experience and share (rather than to suppress and evade) their sadness.

The fact that much of Penny’s therapeutic change was self-generated and self-directed contains an important lesson for therapists, a consoling thought a teacher shared with me early in my training: “Remember, you can’t do all the work. Be content to help a patient realize what must be done and then trust his or her own desire for growth and change.”

Another good example, I thought, of the pointlessness of the therapist rushing in with an interpretation, even a good one like this. Patients, like everyone else, profit most from a truth they, themselves, discover

“That dream makes me think of what you said before about your fear of losing weight, about having to stay heavy to avoid dying of cancer like your father. If the candle flame stays fat, you live.” “Maybe, but sounds farfetched.” Another good example, I thought, of the pointlessness of the therapist rushing in with an interpretation, even a good one like this. Patients, like everyone else, profit most from a truth they, themselves, discover.

the more unlived life, or unrealized potential, the greater one’s death anxiety.

There is a long tradition in psychotherapy going back to Carl Rogers and, before him, to Otto Rank, which understood that a preset termination date often increases the efficiency of therapy. Had Betty not known that her time in therapy was limited, she might, for example, have taken far longer to achieve the inner resolve she needed to begin her weight loss.

For as long as I can remember, I have taught my students that if something big in a relationship is not being talked about (by either patient or therapist), then nothing else of importance will be discussed either. Yet I had started therapy with intense negative feelings about Betty—feelings I had never discussed with her and that she had never recognized. Nevertheless, without doubt, we had discussed important issues. Without doubt, we had made progress in therapy. Had I disproven the catechism? Are there no “absolutes” in psychotherapy?

But we (some more than others) also have an irrational sense of specialness. It is one of our chief methods of denying death, and the part of our mind whose task it is to mollify death terror generates the irrational belief that we are invulnerable—that unpleasant things like aging and death may be the lot of others but not our lot, that we exist beyond law, beyond human and biological destiny.

I think my quarry is illusion. I war against magic. I believe that, though illusion often cheers and comforts, it ultimately and invariably weakens and constricts the spirit. But there is timing and judgment. Never take away anything if you have nothing better to offer. Beware of stripping a patient who can’t bear the chill of reality. And don’t exhaust yourself by jousting with religious magic: you’re no match for it. The thirst for religion is too strong, its roots too deep, its cultural reinforcement too powerful.

The love letters were an amulet, an instrument of death denial. They warded off aging and kept Dave’s passion frozen in time. To be truly loved, to be remembered, to be fused with another forever, is to be imperishable and to be sheltered from the aloneness at the heart of existence.

Years ago I conducted an experiment in which a patient and I each wrote our own view of each of our therapy hours. Later when we compared them, it was at times difficult to believe that we described the same hour. Even our views of what was helpful varied. My elegant interpretations? She never even heard them! Instead she remembered, and treasured, casual, personal, supportive comments I had made.

Almost immediately after her husband’s death, Dr. Z., despite his wife and five children, renewed his courtship and began to make sexual overtures to Marie. She rebuffed him angrily, but he was not deterred.

there is the barrier between image and language. Mind thinks in images but, to communicate with another, must transform image into thought and then thought into language. That march, from image to thought to language, is treacherous. Casualties occur: the rich, fleecy texture of image, its extraordinary plasticity and flexibility, its private nostalgic emotional hues—all are lost when image is crammed into language.

Listen to Flaubert’s lament, in Madame Bovary: Whereas the truth is that fullness of soul can sometimes over flow in utter vapidity of language, for none of us can ever express the exact measure of his needs or his thoughts or his sorrows; and human speech is like a cracked kettle on which we tap crude rhythms for bears to dance to, while we long to make music that will melt the stars.

We distort others by forcing them into our own preferred ideas and gestalts, a process Proust beautifully describes: We pack the physical outline of the creature we see with all the ideas we already formed about him, and in the complete picture of him which we compose in our minds, those ideas have certainly the principal place. In the end they come to fill out so completely the curve of his cheeks, to follow so exactly the line of his nose, they blend so harmoniously in the sound of his voice that these seem to be no more than a transparent envelope, so that each time we see the face or hear the voice it is our own ideas of him which we recognize and to which we listen.

“Each time we see the face . . . it is our own ideas of him which we recognize”—these words provide a key to understanding many miscarried relationships.

he was convinced he had entered into a spiritual linkage with another kindred soul. Whenever Dan discussed such experiences, I had to constrain my skepticism and rationalism: “Spiritual linkage, indeed! What we have here, Dan, is an autistic relationship. You don’t know this person. In a Proustian way, you’ve packed this creature full of the attributes you so desire. You’ve fallen in love with your own creation.”

Dan picked up these innuendos and, in his own defense, cited Nietzsche who said somewhere that when you first meet someone, you know all about him; on subsequent meetings, you blind yourself to your own wisdom. Nietzsche carries a lot of weight with me, and that citation gave me pause. Perhaps on a first meeting, guards are down; perhaps one has not yet determined what persona to don. Maybe first impressions are more accurate than second or third impressions. But that is a far distance from spiritually communing with the other. Besides, though Nietzsche was a seer in many domains, he was no guide to interpersonal relationships—has there ever lived a lonelier, more isolated man?

Occasionally the woman into whose eyes Dan was gazing experienced the same deep spiritual linkage, and they were drawn together into love—but a love that invariably passed quickly. Sometimes it simply waned painfully away; sometimes it turned into violent jealous accusations. Often Dan, his lover, or both, ended up depressed. Whatever the route the passing of love took, the final outcome was the same; neither got what they wanted from the other.

I am persuaded that, in these infatuating first meetings, Dan and the woman mistook what they each saw in the other. They each saw the reflection of their own beseeching, wounded gaze and mistook it for desire and fullness. They were each fledglings with broken wings who sought to fly by clasping another broken-winged bird. People who feel empty never heal by merging with another incomplete person. On the contrary, two broken-winged birds coupled into one make for clumsy flight. No amount of patience will help it fly; and, ultimately, each must be pried from the other, and wounds separately splinted.

Controversy has always existed among psychiatrists and psychologists about the validity of personality diagnosis. Some believe in the merits of the enterprise and devote their careers to ever greater nosological precision. Others, and among them I include myself, marvel that anyone can take diagnosis seriously, that it can ever be considered more than a simple cluster of symptoms and behavioral traits. Nonetheless, we find ourselves under ever-increasing pressure (from hospitals, insurance companies, governmental agencies) to sum up a person with a diagnostic phrase and a numerical category.

Details are wonderful. They are informative, they are calming, and they penetrate the anxiety of isolation: the patient feels that, once you have the details, you have entered into his life.

Since then the leitmotif in his life had been a ceaseless search for home, affection, and approval. Failure had always inflicted terrible wounds, which healed slowly and deeply intensified his feeling of insignificance and loneliness; success offered stupendous but evanescent exhilaration.

I also realized there are certain disadvantages in being too energetic. The overactive therapist often infantilizes the patient: he does not, in Martin Buber’s term, guide or help the other to “unfold” but instead imposes himself upon the other.

I left a message that he call me, but several hours passed with no word from him. I phoned again and left a message irresistible to patients: to call me because I had something very important to tell him.

I continued, “I’ve been thinking about you the last couple of days.” Now I was reaching deep into my repertory of engaging devices! A comment stating that the therapist has been thinking about the patient outside of their scheduled hour has never, in my experience, failed to galvanize the latter’s interest.

My old teacher, John Whitehorn, taught me that one can diagnose “psychosis” by the character of the therapeutic relationship: the patient, he suggested, should be considered “psychotic” if the therapist no longer has any sense that he and the patient are allies who are working together to improve the patient’s mental health.

“Why do we,” I mused, “pursue these unfavorable comparisons? It’s so self-punishing, so perverse—like grinding an aching tooth.”

My task as a therapist (not unlike that of a parent) is to make myself obsolete—to help a patient become his or her own mother and father.

Though charmed by her ingenuous compliment, I was made uncomfortable by both thoughts: the mysterious “somehow,” and the vision of me as a miracle worker. As long as Marge thought in those terms, she would not get better because the source of help was either outside of herself or beyond comprehension. My task as a therapist (not unlike that of a parent) is to make myself obsolete—to help a patient become his or her own mother and father. I didn’t want to make her better. I wanted to help her take the responsibility of making herself better, and I wanted the process of improvement to be as clear to her as possible.

“The main thing that turned me around—in fact, the moment the calm set in—was when you told me that your wife and I had similar problems at work. I feel I’m so icky, so creepy and your wife so holy that we couldn’t both be mentioned in the same breath. Confiding to me that she and I had some of the same problems proved you had some respect for me.”

“It also helped a lot when you kept asking me what had helped me in the past. You kept putting the responsibility onto me, making me take charge of the session. That was good. Usually I sulk in a depression for weeks, but you had me, within minutes, working to figure out what happened. “In fact, just asking the question, ‘What helped in the past?’ was helpful because it assured me that there was a way I could get better. Also, it helped that you didn’t get into your role of the wizard letting me guess about questions you know the answers to. I liked the way you admitted you didn’t know and then invited me to explore it together with you.”

I was certain that “Me,” the other Marge, was in love with me. Perhaps she loved me enough to change her behavior! Surely she must know that I would be repelled by wanton destructiveness. Now that’s a facet of psychotherapy we don’t learn about in training: have a romance with your patient’s worst enemy, and then, when you are sure the enemy loves you, use that love to neutralize her attacks upon your patient.

a therapist helps a patient not by sifting through the past but by being lovingly present with that person; by being trustworthy, interested; and by believing that their joint activity will ultimately be redemptive and healing.

The markers of one’s life stages are always significant, and few markers more so than retirement. How is it possible for retirement not to evoke deep feelings about the passage and passing of life, about the meaning and significance of one’s entire life project?

When investigating sexual problems it is always important to ask, Are there more than two people present during lovemaking? The presence of others—phantoms of parents, rivals, other lovers—vastly complicates the sexual act.

Marvin started to read the dream in such a mechanical manner that I stopped him and employed the old Fritz Perls device of asking him to begin again and to describe the dream in the present tense, as though he were experiencing it right now.

time. I suspected that Phyllis wanted to expiate

But he had overstepped himself. He ventured farther than his supply lines could reach, and now was assailed from all sides: the past was dusky and irretrievable; the future, blocked. It was too late: his house had been built, his final examination turned in. He had flung open the sluice gates of awareness, only to be inundated with death anxiety.

Sometimes death anxiety is dismissed as trivial in its universality. Who, after all, does not know and fear death? Yet it is one thing to know about death in general, to grit one’s teeth and stoke up a shudder or two; it is quite another to apprehend one’s own death and to experience it in the bones and sockets of one’s being.

Against this dread, he lacked even the most common defenses: childless, he could not be comforted by the illusion of immortal germ cells; he had no sustaining religious belief—neither of a consciousness-preserving afterlife nor of an omnipresent, protective personal deity; nor did he have the satisfaction of knowing that he had realized himself in life. (As a general rule, the less one’s sense of life fulfillment, the greater one’s death anxiety.)