The goal of child raring 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 counterwill 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's nosological system was based on the developmental vagaries of the will. He described three basic character types: creative, neurotic, and antisocial. The creative character has access to emotions and wills what he or she wants. The neurotic character has a will snarled with guilt and an inhibited emotional life. The antisocial character has a suppressed will and is dominated by impulse.

The Will and Psychotherapy. Rank felt that both Freud and Alfred Adler annihilated the will. Freud interpreted the will as sublimated sexual striving, and Adler viewed the will as a compensatory tendency to adjust for the child's sense of smallness and inferiority. Both men thus explained away the will by considering it as a derivative function. In contrast, Rank posited an a priori will and emphasized the central role of will not only in child development but also in therapy, which he felt was always carried out against the backdrop of the will.

Rank viewed therapist-patient interaction in much the same way as he did the parent-child experience. In therapy, he said, two wills clash. Either the one overthrows the other, or both struggle with and against one another for supremacy. The goal of therapy should be for the neurotic to learn to will, and above all, to learn to will without guilt. Will enters the therapeutic situation in the very first sessions. Rank observed, "The beginning of therapy is therefore nothing other than the opening of a great duel of wills in which the first easy victory over the apparently weak-willed patient is bitterly avenged many times. The patient engages in a will conflict with the therapist and wishes both to resist and to submit."

Freud, Rank felt, made a serious error in ignoring this will conflict. He said, "The battle for supremacy between analyst and patient is so clear that only the wish not to see it can explain its neglect by Freud." Rather than strengthening will, Rank felt that Freudian technique undermined it in two ways: through its basic procedure and through its management of resistance. First, Rank felt that the basic procedure in psychoanalysis, a procedure that requires a state of willlessness by both patient and therapist, acts to weaken will. He said, "The basic analytic rule of free association specifically states, eliminate entirely the little bit of will which your neurotic weakness has perhaps not yet undermined, and resign yourself to the guidance of the unconscious." This comment is prescient of criticisms levied at psychoanalysis decades later. For example, Sylvan Tomkins referred to psychoanalysis as a systematic training in indecision. And Alan Wheelis stated, "Knowledgeable moderns put their back to the couch and in so doing may occasionally fail to put their shoulders to the wheel."

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 counterwill and as such must not be eliminated but instead supported and transformed into creative will. As he said, the task of the therapist is to function in such a way that the will of the patient shall not be broken but strengthened. If the therapist tries to force the patient to do what is right, the patient will resist and therapy will fail. Certainly, within this statement lies the germ of the modern-day tactic of paradox in psychotherapy.

Rank therefore systematically reinforced all manifestations of the patient's will: 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 therapeutic strategies pertaining to will represent only one aspect of Rank's therapeutic approach. Later I shall discuss his views on experiencing, on the importance of the present and the future tenses, and on the nature of the therapeutic relationship.

Lesie Farber: Two Realms of the Will. In his effort to counter what he perceived in Freud and Adler as an undermining of will and responsibility, Rank may have overstated the role of willpower and willfulness. By and large, patients do not change in therapy as a result of an act of conscious will. In fact, what is so often perplexing to the therapist and maddening to the researcher is that change occurs at a subterranean level, far out of the ken of either the therapist or the patient. Is subterranean, nonvolitional change an act of will? It is precisely this question, this connection between willful acts and unconsciously based change, that has created so much difficulty for psychologists who have tried to fashion a succinct, workable definition of will.

Lesie Farber's contribution to a psychology of will offers a vital corrective to an exaggerated emphasis on conscious will. Farber suggests that efforts to define will have failed because there are two different realms of will, each so distinct from the other that only the most vapid definition can straddle them. Farber's first realm of the will, and it is here that he makes his most important contribution, is not experienced consciously during an act and must be inferred after an event. This realm may be said to be unconscious. Farber cites Whinen: "When I look back at the three or four choices in my life which have been decisive, I find that at the time I made them, I had very little sense of the seriousness of what I was doing, and only later did I discover what had seemed an unimportant brook was in fact a Rubicon." Thus, Farber suggests that the important choices that one makes in life, and I'm certain he would say in therapy, are not consciously experienced as choices. In fact, only after the fact is one able to deduce that one has actually made a choice. This realm of will may be thought of as a subterranean life current that has direction, but not discrete objects or goals. It provides propulsion to the individual but eludes immediate and direct scrutiny.

The second realm of will is the conscious component. It is experienced during the event. One can describe without much difficulty its presence, shape, and magnitude. This second realm of will presses toward some specific object. Unlike the first, which is pure propulsion and is utilitarian in character ("I do this to get that"), the goal of this realm of the will is known from the beginning. For example, weight loss, a change in interpersonal style, or graduation from college.

These two realms of will must be approached differently in therapy. The second, conscious realm of will is approached through exhortations and appeals to willpower, effort, and determination. The first realm is impervious to these enjoiners 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." Here, Farber provides an extraordinarily important insight to the therapist, an insight to which I shall return many times in this chapter. However, it is clear from some of the goings-on in the psychotherapy field, the "can't" bells ringing and the "winning through intimidation" genre of self-help books cascading off the presses, that Farber's warning has not been heeded and that many psychotherapists make the mistake of trying to make the will of the second, conscious realm do the work of the will of the first.

Rolo May: The Wish and the Will. Rolo May's excellent book, Love and Will, brims with rich clinical insights, among which is the incorporation of wish into the psychology of the will. May reminds us that wish is anterior to will; that there can be no meaningful action without a prior wish. Willing is not only power and resolve but potentiality that is intimately bound up with the future. Through the will, we project ourselves into the future, and the wish is the beginning of that process. The wish is an admission that we want the future to be such and such. It is a capacity to reach down deep into ourselves and preoccupy ourselves with a longing to change the future.

It is important to distinguish May's wish from the wish defined differently that plays an important role in the analytic model of mental functioning. Freud referred to wish throughout his metapsychology as the mental representation of a drive. Only a wish can set the mental apparatus into motion. Wish is the desire to relieve tension. As Freud stated repeatedly, the most complete statement of this position is to be found in the often-cited chapter 7 of The Interpretation of Dreams, 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 anaga 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.

Sartra criticized Freud's theory of repression on the ground that it omitted the self. "How can there be a lie without a liar?" Sartre asked, "or deception without a deceiver, or denial without a denier?" Freud's concept of the wish is open to the same criticism. How can there be a wish without a wisher?

May emphasizes that wishes differ from needs, forces, or tropisms. In one important aspect, wishes are imbued with meaning. An individual doesn't wish blindly. A man doesn't merely wish, for example, for sex with a woman. He finds one woman attractive, another repugnant. Wishing is selective and highly individualized. If a man indiscriminately desires sexual relationships with all women, then something is seriously wrong. This state occurs either as a result of unusual environmental press, as in the case of soldiers stationed for long periods in an isolated Arctic station, or else as a result of psychopathology. One gives up one's freedom and is then no longer the driver but the driven. It is precisely this state of wishing without a wisher that we term neurosis. That is what May meant when he said it is the symbolic meanings that have gone awry in neurosis, and not the id impulses.

Wish, which May defines as "the imaginative playing with the possibility of some act or state occurring," 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. As May wrote, "Wish gives the warmth, the content, the imagination, the child's play, the freshness and the richness to will. Will gives the self-direction, the maturity to wish. Without wish, will loses its lifeblood, its viability, and tends to expire in self-contradiction. If you have only will and no wish, you have the dried-up Victorian neopuritan man. If you have only wish and no will, you have the driven, unfree, infantile person who, as an adult remaining an infant, may become the robot man."

The Will and Clinical Practice. The will is not an esoteric concept of interest only to the unusual patient and therapist, but it enters in a number of ways into the course of therapy of every patient. Some patients seek therapy for problems of disordered will. Of course, since there is no place for will in the standard nosology, the problem is not referred to by that name. Instead, one may be considered obsessive-compulsive and forced by internal pressures to act against one's will. Or one may be indecisive, unable to wish, to want something for oneself, or to act. Or one may be caught in the throes of some particularly agonizing decision. Or one may be timid, shy, unassertive, or flooded with guilt when one attempts to will. As Rank suggested, an individual may have learned early in life that impulse expression is bad and generalized that verdict of badness to the entire realm of volition.

Even if there is no apparent willing disorder in the presenting clinical picture, it is inevitable that the issue of will will arise during psychotherapy. Will is inherent in the very act of change. At some point, the patient must come to terms with what he or she truly wishes. Must become committed to a certain course. Must take a stand. Must choose. Must say yay to something and nay to something else.

Will is also present in every therapist-patient relationship. Although Rank overstated the issue by characterizing therapy as a duel of two wills, he made a valuable contribution by calling attention to this important aspect in the therapeutic process. Some patients and therapists do indeed lock horns over issues of dominance, and in these instances Rank's observations are germane. Resistance or obstinency 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 of the major obstacles to the therapist's acceptance of a theory of will is the erroneous belief that will is synonymous with willpower. But as Farber's two-realm concept tells us, much more than conscious teeth-gritting resolution is involved in willing. In fact, as I shall discuss shortly, a full consideration of the meaning and roots of willing leads us into the area of the deepest unconscious concerns. But even unconscious willing does not occur without determination and commitment. Effortless change is not possible. The patient must transport himself or herself to therapy, must pay money, must bear the burden of responsibility, must experience the conflict and the anxiety that inevitably accompany the work of therapy. In short, the therapy vehicle has no slick, noiseless automatic transmission. Effort is required, and will is the trigger of effort.

The concept of will is so broad and so unwieldy that only generalized, trivial comments may be made about it as an entity. To discuss will in a clinically useful way, I must consider its component parts separately. Hannah Arent's philosophical treatise on the will provides a natural cleavage. She wrote, "There are two altogether different ways of understanding the faculty of the will: as a faculty of choice between objects or goals (the liberium arbitrum, which acts as arbiter between given ends and deliberates freely about means to reach them) and, on the other hand, as our faculty for beginning spontaneously a series in time. Kant or Augustine's 'Aptis est' man's capacity for beginning because he himself is a beginning." These two ways of understanding will—spontaneously beginning a series in time and deciding between given ends and choosing the means to reach them—have obvious and valuable clinical reference.

One initiates through wishing and then enacts through choice. The clinician's goal is change. Action. Responsible action begins with the wish. 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. What shall we call this process of transformation? The process between wish and action entails commitment. It entails putting myself on record to myself to endeavor to do it. The happiest term seems to me to be decision or choice, which is used by both clinicians and social scientists. I shall use decision and choice interchangeably. They are synonymous, but each emanates from a different tradition. Choice is the preferred philosophical term; decision, the preferred social psychological one. Used interchangeably, they reflect my effort to span these disciplines in this discussion. To decide means that action will follow. If no action occurs, then no true decision has been made. If wishing occurs without action, then there has been no genuine willing. If action occurs without wishing, then too there is no willing; there is only impulsive activity. Either of these phases of willing—wishing and deciding—can break down in a number of ways, each with a different clinical picture, each requiring a different therapeutic approach.

Wish. "What shall I do? What shall I do? What stops you from doing what you want to do?" "But I don't know what I want. If I knew, I wouldn't be here." How often does the therapist participate in some such sequence as this? How often do therapists work with patients who know what they should do, ought to do, or must do, but have no experience of what they want to do? To work with individuals with a profound incapacity to wish is a particularly frustrating experience, and few therapists have not shared May's inclination to shout, "Don't you ever want anything?"

The wish-blocked individual has enormous social difficulties. Others too wish to shout at such persons. They have no opinions, no inclinations, no desires of their own. They become parasitic on the wishes of others. And finally, others become bored, drained, or fatigued at having to supply wish and imagination for them.

Incapacity to wish is too strong a phrase. More often, the individual distrusts or suppresses his or her wishes. Many people, in an effort to appear strong, decide that it is better not to want. "Wanting makes one vulnerable or leaves one exposed. If I never wish, I'll never be weak." Others, demoralized, deaden themselves to internal experience. "If I never wish, I will never again be disappointed or rejected." Others submerge their wishes in the infantile hope that eternal caretakers will be able to read their wishes for them. There is something infinitely reassuring about having someone else meet one's unexpressed wishes. Still others so fear abandonment by caretakers that they repress all direct expression of personal desire. They do not permit themselves the right to wish, as though their wishing would irritate, threaten, or drive away others.

The Inability to Feel. The inability to wish or to experience one's wishes has not been widely and explicitly discussed in clinical literature. It is generally embedded in a global disorder: the inability to feel. The psychotherapist frequently encounters patients who seem unable to feel or to express their feelings in words. They are unable to differentiate between various affects and seem to experience joy, anger, sorrow, nervousness, and so on, all in the same manner. They cannot localize feelings within their body and have a particularly striking lack of fantasies referable to inner drives and affects. In 1967, Peter Sephanos suggested a term, alexithymia (from the Greek meaning "no words for feelings"), to describe this clinical picture, and a large body of literature has since accumulated about the alexithymic patient. The psychosomatic patient is particularly likely to be alexithymic.

Although many alexithymic individuals present with other clinical pictures, the expression of affect has always been considered an important part of psychotherapy. Freud, in 1895, in Studies on Hysteria, first postulated that hysteria was caused by the presence of some strong affect resulting, for example, from a traumatic incident in the individual. Unlike most strong emotional reactions, which are eliminated through the normal wearing-away process of AB reaction, this particular affect persists and is repressed into the unconscious. Once that occurs, the constancy principle is violated; that is, the need of the organism to maintain an optimal level of tension. The level of intercerebral excitation is increased, and the individual, to restore equilibrium, develops a symptom that symbolically provides an outlet for the tension. This psychiatric symptomatology is caused by strangulated affect, and psychiatric treatment should consist of releasing this imprisoned affect and allowing it to enter consciousness and to be discharged through catharsis. Though this was Freud's first formulation of the therapeutic mechanism, and though he rapidly realized that catharsis per se was an insufficient means of therapy, this formulation is so beautiful in its simplicity that it has persisted throughout the decades. Certainly, it is the popular view, incarnated in innumerable Hollywood films.

The contemporary view is that though catharsis does not in and of itself produce change, it plays a necessary role in the therapeutic process. Certainly, there is considerable research to support this view. For example, my colleagues and I studied a series of patients who had had highly successful psychotherapy outcomes. In an effort to delineate the effective therapeutic mechanisms, we developed a list of 60 items (see chapter 6) and asked the patients to rank them in the order of importance of each item to their personal change. Of the 60 items, the patients selected catharsis items as the second and the fourth most important mechanisms.

Recently, there has been an explosion of new therapies. For example, Gestalt therapy, intense feeling therapy, implosive therapy, bioenergetics, emotional flooding, psychodrama, primal stream therapy, which closely resemble one another in the importance placed on awareness and expression of feelings. Though each of these therapies advances its own rationale for this emphasis, they have, I believe, important views in common. They all hold that awareness and expression of feelings is helpful to the individual in two primary ways: by facilitating interpersonal relationships and by facilitating one's capacity to wish (Chapter 7b).

Feeling and Interpersonal Relationships. The role of affect expression in interpersonal relationships is self-evident. Significant problems arise in relationships for the alexithymic individual. Others never know how that person feels. He or she seems unspontaneous, wooden, heavy, lifeless, and boring. The other person feels burdened by having to generate all the affect in the relationship and begins to question whether he or she is really cared for by the blocked person. The movements of the blocked individual are so deliberate and unspontaneous that they seem forced and ungenuine. There's no play, no fun, only an awkward, ponderous self-consciousness. One who doesn't feel is not sought out by others but exists in a state of loneliness, cut off not only from one's own feelings but from those of others.

Feeling and Wishing. 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. One patient in a therapy group found himself unable to understand another patient who was upset because her therapist was leaving for a month's vacation. "Why get yourself in a turmoil if there's nothing you can do about it?" In other words, he placed feelings and wishes secondary to a utilitarian goal and said, in effect, "If nothing useful will come of it, why wish and why feel?" This type of individual acts and has an internal sense of guidance but does not wish. His or her wishes emanate from without, not from within. The exigencies of the environment and the dictates of rationality determine his or her internal state of wishing and feeling. To the observer, this individual may seem mechanical, predictable, and lifeless.

Another individual, and this one is especially obvious in a therapy group, tries to find out what he or she should feel and wish by attempting to find out what the other wants and then appeasing that other. These individuals are non-spontaneous. Their behavior is highly predictable and consequently they are invariably boring to others.

Wish is more than thought or aimless imagination. Wish contains an affect and a component of force. If affect is blocked, one cannot experience one's wishes, and the entire process of willing is stunted. No one has written a more arresting description of a man who could neither act nor wish because he could not reach his feelings than has Sartre in The Age of Reason. Quote: "He closed the paper and began to read the special correspondence dispatched on the front page. 50 dead and 300 wounded had already been counted. But that was not the total. There were certainly corpses under the debris. There were thousands of men in France who had not been able to read their paper that morning without feeling a clot of anger rise in their throat. Thousands of men who had clenched their fists and muttered 'swine.' Matthew clenched his fists and muttered 'swine,' and felt himself still more guilty. If at least he had been able to discover in himself a trifling emotion that was veritably, if modestly, alive, conscious of its limits. But no, he was empty. He was confronted by a vast anger, a desperate anger. He saw it and could almost have touched it, but it was inert. If it were to live and find expression and suffer, he must lend it his own body. It was other people's anger. 'Swine.' He clenched his fists. He strode along, but nothing came. The anger remained external to himself. Something was on the threshold of existence, a timorous dawn of anger at last, but it dwindled and collapsed. He was left in solitude, walking with the measured and decorous gait of a man in a funeral procession in Paris. He wiped his forehead with his handkerchief, and he thought, 'One can't force one's deeper feelings. Yonder was a terrible and tragic state of affairs that ought to arouse one's deepest emotions. It's no use. The moment will not come.'" End quote.

Feeling is prerequisite to wish but not identical with it. One can feel without wishing and consequently without willing. Some of the best-known wishless figures in modern literature, for example Measo in Albert Camus's The Stranger and Michel in Andre Gide's The Immoralist, were keen sensualists but were isolated from their own wishes and especially from wishes in the sphere of interpersonal relationships. Their actions were impulsively explosive and ultimately profoundly destructive to others and to themselves.

Affect Block and Psychotherapy. 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. The blockade is so apparent, even to the untrained eye, that it would be easy to conclude that if only it could be broken, if only the dam holding back the patient's affect could be dynamited away, then health and wholeness would come cascading through the breach. Consequently, many therapists, in search of a breakthrough, have used some of the new sophisticated Gestalt, psychodrama, bioenergetic, and encounter affect-generating techniques in working with the affect-blocked patient.

Does the breakthrough strategy work? Can the therapist blast a way through the affect-blocked patient's perimeter of defenses and allow the dammed-up emotion to escape? My colleagues and I attempted to test this in a research project where we studied 35 patients in the midst of long-term psychotherapy, many of whom were affect-blocked and stuck in therapy, and attempted to determine whether, as a result of an affect-arousing experience, the subsequent course of individual therapy would be significantly altered. We sent these patients to one of three different groups for a weekend experience. Two of these groups used powerful encounter and Gestalt affect-arousing techniques. The third, a meditation body-awareness group, served as an experimental control in that it provided a weekend with neither affect arousal nor interpersonal interaction. The results indicated that though during the group weekend, many patients had intense emotional breakthroughs, these were not sustained. There were no discernible effects on the subsequent course of individual therapy. 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 cycle therapy, 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.

If affect breakthrough is not an effective therapy model, neither is the opposite approach, the sterile, overly intellectualized, highly rational approach to therapy. Effective engagement, Franz Alexander termed it, the corrective emotional experience, is a necessary component of successful therapy. Though many early therapists, such as Sandor Ferenczi, Otto Rank, Wilhelm Reich, and Julius Moreno, recognized the need for effective engagement and introduced techniques to make the therapeutic encounter more real and affect-laden, Fritz Perls, more than any other, must be credited with the development of an approach designed to increase the individual's awareness of affect.

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 interpretive therapy, and he worked only in the present tense because he felt that neurotics live too much in the past. Perls wrote, "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." Pearls would often begin with awareness of sensory impressions and kinesthetic impressions. For example, if a patient complained of a headache, Perls might ask the patient to focus on the headache. Perls might ask the patient then to exaggerate the contractions and at each step to talk about what he or she was aware of. Gradually, the patient would be led from kinesesthetic sensation to affect. For example, a woman patient might then describe her face: "It's as if I were screwing up my face to cry." At this point, the therapist might encourage the affect by asking, "Would you like to cry?"

Perls began with awareness and gradually worked toward wish. As he said, "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 attempted to help patients feel things, to own these feelings, and then to become aware of wishes and desires. For example, if a patient intellectualized or addressed repeated questions to the therapist, Perls might urge him or her to verbalize the statement and the wish behind the question. For example: 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." At this point, the patient had greater access to his affect and also access to his wishes. The purpose of affect arousal is not sheer catharsis but to help patients rediscover their wishes.

One major problem of Gestalt therapy is that many therapists become so preoccupied with affect-arousing techniques that they lose sight of the deeper purpose of the technique. To some degree, this is a result of therapists modeling themselves after Perls, who is a great showman and enjoyed short, dramatic encounters with patients conducted before large audiences. But Perls, in his reflective moments, expressed dismay at the tendency of therapists to focus excessively on technique. As he said, "It took us a long time to debunk the whole Freudian crap, and now we are entering a new and more dangerous phase. We are entering the phase of the 'turn-ons'—turn on to instant cure, instant joy, instant sensory awareness. We are entering the phase of the quacks and the conmen who think if you get some breakthrough, you are cured. I must say, I am very concerned with what's going on right now. A technique is a gimmick. A gimmick should be used only in the extreme case. We've got enough people running around collecting gimmicks, more gimmicks, and abusing them. These techniques, these tools are quite useful in some seminar on sensory awareness or joy. But the sad fact is that this jazzing up more often becomes a dangerous substitute activity. Another phony therapy that prevents growth."

Other Therapeutic Approaches. Perls is not the only worker who grappled with the problem of affect block. Psychodrama, encounter groups, hypnotic therapy, and bioenergetics have all developed techniques designed to arouse affect and to increase the individual's awareness of wishes. In fact, there has been such a vast proliferation of approaches that it is no longer possible to trace their genealogy. All the techniques, however, rest on the assumption that at some deep level one knows one's wishes and feelings and that the therapist, through proper focusing, can increase the patient's conscious experience of such internal states.

Postural, gestural, or other subtle nonverbal cues may provide important information about underlying but dissociated feelings and wishes. Therapists must attend closely to such clues as clenched fists, the pounding of one's fist into one's palm, or the assumption of a closed, crossed-arms-and-legs position. Each of these is a manifestation of an underlying feeling or wish. In such instances, Perls attempted to facilitate the emergence of the repressed feeling by calling attention to the behavior and then requesting the patient to exaggerate it. For example, to hit the fist into the palm harder and faster. Indeed, some patients are so affect-isolated that physical or physiological data are their only contacts with their inner world. For example, "I must be sad if my eyes are teary," or "I must be embarrassed if I'm blushing."

The question, "What do you want?" often takes patients by surprise since they rarely ask it of themselves. Irving and Miriam Pollster provide an illustration. A college professor was feeling overburdened by having to cram each day with what seemed to be overwhelming requirements to write, read, teach, until his time felt like it was ready to burst at the seams. After a long recital of all the demands he experienced on his already overcommitted life, I asked him, "What do you want?" A pause and a gesture with his hands showing one hand fitting but very loosely and with space left over into another, and then, "I want some slop in my life." These recognitions are simple enough, but to many people, they are not readily accessible. Until these wants can be at least recognized, though focused action is unlikely.

If patients are severely schizoid and deeply isolated from their wishes, a focused inquiry on the immediate here-and-now interaction may be productive. For example, in a group session, a deeply troubled young man lamented in response to my question that he had no feelings and wishes and indicated that he could feel if only he knew what he should feel. Other members pursued the issue, asking him about how he felt about a number of topics such as loneliness, strong tranquilizers, some problems on the ward, all of which left the patient feeling more confused and discouraged. 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. Though he was frightened by all of the attention, he also felt pleased and grateful and wanted the group to continue to press him. He also felt like a hog for talking so much and feared that others would resent his taking away their time. Gradually, starting from this base of immediate affect, the patient gained confidence with his ability to have feelings and to identify them.

Another patient had for years distrusted and devalued the importance of her feelings. She considered feelings phony and contrived because whenever she was aware of a particular feeling, she could also generate an opposing feeling equal in magnitude. Endless hours of therapy had been wasted in blockbusting efforts to break down this defense. Progress only occurred by helping her to identify some feeling and wish of incontestable valence in the immediate here and now. She was in a therapy group on a hospital ward which was observed by the ward staff and then had the opportunity to observe the observers' open rehash of the meeting. When asked to describe her reaction to the rehash, she said that she had been annoyed by the fact that she was rarely discussed. When we investigated her annoyance, since it appeared without question to be deeply felt, it turned to pain—her hurt at being ignored—and then to fear, fear that the therapist had, in his mind, filed her, as she put it, "in the C chronic file." She was then urged to express what she wished the therapist had said or done. In this manner, she was gradually led to experience such non-phony wishes as her desire that he cradle and shelter her.

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 couldn't 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 the 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.

Impulsivity. A disorder of wishing doesn't necessarily lead to inhibition and paralysis. Some individuals avoid wishing by not discriminating among wishes, but act promptly and impulsively on all wishes. One who acts immediately on each impulse or whim avoids wishing as neatly as does one who stifles or represses wishes. Thus, one avoids having to choose among various wishes which, if experienced simultaneously, may be contradictory. Perint, as Rome points out, is an excellent example of a person who cannot discriminate among his wishes, attempts to fulfill all of them, and in so doing loses his true self—the self that wants one thing more deeply than another thing.

A wish always involves direction and time. To wish is to lunge into the future, and the individual must consider the future implications and the consequences of acting upon a wish. Nowhere is this necessity more evident than in the wish involving another person. Impulsive, perigish enactment of all interpersonal wishes results in violation or rape of the other rather than a true encounter. 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.

Another way to describe the basic disorder of wishing which underlies behavioral impulsivity is to consider two forms of ambivalence: sequential and simultaneous ambivalence. In sequential ambivalence, the individual experiences first one and then the other wish. When one is dominant, it is acted upon, and the individual does not have full access to the other. In simultaneous ambivalence, one is confronted by both wishes fully and directly. James Bugenl describes a patient who was tossed about in an agonized state of sequential ambivalence. At 42, Mabel had been married for 17 years to a man she loved deeply and with whom she had much that was meaningful and satisfying. Then, through a series of circumstances not important here, she found herself also very much in love with another man, a widower, and he returned her feeling. She had not lost her love for her husband, Greg, nor did she want only a simple fling with the other man, Hal. Thus, Mabel, when she was at home with Greg, would be very aware of how rich her life was with him, and would wonder that she could be tempted to overturn it with all the pain, guilt, and disruption of her own and his futures that would be involved. Then, when she was with Hal, or perhaps just away from Greg, she would be swept by anguish, as she knew how vital was her feeling for Hal and her yearning for the different life she would have were she to go to him.

The therapist's task is to help the impulsive patient transform sequential ambivalence into simultaneous ambivalence. The experiencing of conflicting wishes sequentially is a method of defending oneself from anxiety. When one fully experiences conflicting wishes simultaneously, one must face the responsibility of choosing one and relinquishing the other. Simultaneous ambivalence results in a state of extreme discomfort. And as Buggan notes, it is extremely important that the therapist avoid diluting the pain or the autonomy of the patient. The therapist is strongly tempted to advise, to sucker, to, as Haidiger puts it, "leap in ahead of the other." Yet if one is able to confront deeply and with full intensity all one's relevant wishes, then one will eventually fashion a creative, innovative solution, a solution that another could not have foreseen. In the preceding case, Mabel used her conflict to arrive at a truly creative insight. To quote Buggan, "She realized how all along she had subtly used her husband to define her own being, and how she had come near to doing the same thing with Hal." She began to realize her own identity as separate from either Hal or Greg. This did not mean that she would cease to love her husband, with whom she chose to remain, but it meant loving him in a different fashion. It meant loving him, not loving herself and him as a fused entity. It meant being able to face life alone without a loss of selfhood and without a devastating sense of loneliness.

Compulsivity. Compulsivity, a defense against responsibility awareness, also constitutes a disorder of wishing, one that appears more organized and less capricious than impulsivity. 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. Camus caught it perfectly when, to the protagonist of The Fall, he said, "Not taking what one doesn't desire is the hardest thing in the world." The compulsive individual is generally not aware of an inability to wish. He or she doesn't feel empty or rudderless. On the contrary, such an individual is active, often forceful, and at all times possessed with a sense of purpose. But there are often waves of doubt. Times when the individual realizes that though he or she has a purpose, it is not his or her own purpose; that though he or she has desires and goals, they are not his or her own desires and goals. The individual is so busy, so driven, that he feels he has neither the time nor the right to ask himself what he wishes to do. It is only when the defense cracks that the individual becomes aware of the suffocation of his or her real self. For example, the externally imposed goals may become irrelevant because of some environmental alteration such as loss of job or breakup of family, or they have been attained.

Money, Prestige, Power, Decision, Choice. Once an individual fully experiences wish, he or she is faced with decision or choice. Decision is the bridge between wishing and action. I use action not in an energetic but in a therapeutic sense. The slightest movement or the obliteration of some previous habitual action may constitute momentous therapeutic action. To decide means to commit oneself to a course of action. If no action ensues, I believe that there has been no true decision, but instead a flirting with decision, a type of failed resolve. Samuel Beckett's Waiting for Godot is a monument to aborted decision. The characters think, plan, procrastinate, and resolve, but they do not decide. The play ends with this sequence: Vladimir: "Shall we go?" Estragon: "Let's go." Stage directions: "No one moves."

Decision and the Therapeutic Contract. Therapy and a Specific Decision. The concept of decision enters into psychotherapy in many ways. Some patients seek therapy specifically because they are caught in the throes of a specific decision, often one related to relationship or career. Consequently, therapy will center about this decision.

If the therapy is brief, focused, and task-oriented, the therapist will enable the patient to make the decision. The therapist will consider with the latter the pros and cons of the decision and will try to help the patient sort out both conscious and subconscious implications of each choice.

If, on the other hand, therapy is more intensive and the goals are more extensive, the therapist uses the specific decision as a central trunk from which, as therapy proceeds, a diversity of themes will radiate. The therapist helps the patient understand the unconscious meaning of the decisional anxiety, reviews other past decisional crises, and though the treatment goal is not specifically to help the patient make a particular decision, hopes nonetheless to resolve the conflicted areas so that the patient may make that decision and related ones in an adaptive fashion.

Therapy and unconscious decision. Many therapists focus closely on decision even if the patient does not enter therapy for some particular crisis of decision. In an effort to augment the patient's sense of personal responsibility, these therapists emphasize that every act, including personal change, is preceded by a decision. Therapists who focus on decision in this manner often assume that decisions are involved in behavior not ordinarily associated with decision. Thus, the therapist focuses on the decision that the patient makes to fail, to procrastinate, to withdraw from others, to avoid closeness, or even to be passive, depressed, or anxious. Obviously, these decisions were never consciously made. The therapist assumes that since individuals are responsible for their behavior, each must have chosen to be as he or she is.

What kind of choosing is this? It is the choosing that Farber referred to as the first realm of will. Few major decisions are made with a full sense of deliberate conscious effort. William James, who thought deeply about how decisions are made, described five types of decision, only two of which, the first and the second, involve willful effort.

One, reasonable decision. We consider the arguments for and against a given course and settle on one alternative, a rational balancing of the books. We make this decision with a perfect sense of being free.

Two, willful decision, a willful and strenuous decision involving a sense of inward effort, a slow, dead heave of the will. This is a rare decision.

The great majority of human decisions are made without effort.

Three, drifting decision. In this type, there seems to be no paramount reason for either course of action. Either seems good, and we grow weary or frustrated at the decision. We make the decision by letting ourselves drift in a direction seemingly accidentally determined from without.

Four, impulsive decision. We feel unable to decide, and the determination seems as accidental as the third type. But it comes from within and not from without. We find ourselves acting automatically and often impulsively.

Five. Decision based on change of perspective. This decision often occurs suddenly and as a consequence of some important outer experience or inward change, for example, grief or fear, which results in an important change in perspective or a change in heart. Such were the decisions made by many of the cancer patients I described in chapter 5.

As James suggests, then, decision refers to a wide array of activities that have different subjective experiences, differing degrees of effort, rationality, consciousness, impulsivity, and sense of responsibility.

Therapy, decision, and character structure. Some therapists, for example, those of the transactional analysis (TA) school, use decision in an even more radically unconscious sense. They suggest that individuals make early, archaic decisions that shape their lives in critical ways. A typical formulation of psychopathological development by a TA therapist asserts the individual gets an injunction from his parent which is implanted by strokes (that is, reinforcements), makes a decision around that injunction, and then develops a script to support the injunction. End quote.

Thus, according to Eric Burn, the individual decides on a life script, an unconscious blueprint for one's life course, which encompasses personality variables and repetitive interpersonal interactions. Burn's life script is not very different from Adler's guiding fiction or Horn's idealized image system. Though it is more interpersonally based, it is loosely equivalent to the Freudian concept of character structure. According to Beta approach, the child makes a decision that determines his or her character structure and is thus responsible for it.

Yet problems arise when decision is used only in a conscious, willful sense. The definition of decision offered by TA reflects the confusion about the term. Quote, "The decision is the point in time when the youngster, applying all the adaptive resources of his ego, modifies his expectations and tries to align them with the realities of the home situation." End quote. Note that the definition begins, "The decision is the point in time," as though there were a specific moment of decision, as though between the original state and the changed state, there must have been some conscious decision.

The therapist who takes seriously the notion that the child made some concrete, momentous, archaic decision runs the danger of developing a concrete, simplistic approach to therapeutic change. Indeed, that is precisely what has happened. TA texts, for example, suggest that the therapist's task is to help the patient go back to the original decision, the first act experience, not unlike the original trauma of early Freudian theory, relive it, and make a redecision. The problem with this formulation is that the patient may be asked to make a current rational decision in order to neutralize an early decision of an entirely different type. This is what Farber warned against when he said, "It is important that one not try to force the will of the second conscious realm to do the work of the will of the first unconscious realm."

What is lost in this radical view of decision-making is the subtlety of the developmental process. An individual's character structure is not the result of a single momentous decision that can be traced and erased, but instead is constituted by a lifetime of innumerable choices made and alternatives relinquished. Although the child has, of course, no awareness of adult characterological options, nonetheless the child always has a modicum of ability to affirm or reject what is presented to him or to her, to submit or rebel, to identify positively or, as Eric Ericson has taught us, to form a negative identification with certain role models.

As I discussed in the last chapter, it is necessary to the treatment process that the patient accept responsibility for what he or she is, as well as for what he or she will become. Only then can the individual experience the power and the hope necessary for the process of change. But psychotherapeutic change will not consist of a single momentous, willful decision. Instead, it will be a gradual process of multiple decisions, each paving the way for the next.

Why are decisions difficult? Shall we go? Let's go. No one moves. What happens between the resolve and the committed decision to act? Why do so many patients find it so extraordinarily difficult to decide? Indeed, as I think of my current patients, almost everyone is wrestling with some decision. Some patients are concerned with a specific life decision: what to do about an important relationship, whether to stay married or to separate, whether to return to school, whether to attempt to have a child. Other patients say they know what they have to do—say, stop drinking or smoking, lose weight, try to meet people, or try to establish an intimate relationship—but cannot decide, that is, commit themselves to do it. Still others say they know what's wrong; for example, they're too arrogant, too workaholic, or too uncaring, but do not know how to decide to change and consequently do not commit themselves to work in therapy. There is something highly painful about these unmade decisions.

As I review my patients and attempt to analyze the meaning and the threat that decision has for them, I'm struck, first of all, by the diversity of response. Decisions are difficult for many reasons, some obvious, some unconscious, and some, as we shall see, that reach down to the deepest roots of being.

Alternatives exclude. The protagonist of John Gardner's novel *Grendel* made a pilgrimage to an old priest to learn about life's mysteries. The wise man said, "The ultimate evil is that time is perpetual perishing and being actual involves elimination." He summed up his meditations on life in two simple but terrible propositions. Four devastating words: Things fade. Alternatives exclude. I regard that priest's message as deeply inspired. Things fade is the underlying theme of the first section of this book. And alternatives exclude is one of the fundamental reasons that decisions are difficult. 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. Renunciation invariably accompanies decision. One must relinquish options, often options that will never come again."

Decisions are painful because they signify the limitation of possibilities. And the more one's possibilities are limited, the closer one is brought to death. Indeed, Heidegger defined death as the impossibility of farther possibility. The reality of limitation is a threat to one of our chief modes of coping with existential anxiety, the delusion of specialness—that though others may be subject to limitations, one is exempt, special, and beyond natural law. One may, of course, avoid awareness of renunciation by avoiding awareness of one's decisions.

Wheelis, in a metaphor where decision is a crossroads on a journey and renunciation is the road not taken, states the issue beautifully. Some persons can proceed untroubled by proceeding blindly, believing they have traveled the main highway and that all intersections have been byways. But to proceed with awareness and imagination is to be affected by the memory of crossroads which one will never encounter again. Some persons sit at the crossroads, taking neither path because they cannot take both, cherishing the illusion that if they sit there long enough, the two ways will resolve themselves into one and hence both be possible. A large part of maturity and courage is the ability to make such renunciations, and a large part of wisdom is the ability to find ways which will enable one to renounce as little as possible.

Sitting at the crossroads, taking neither path because they cannot take both, is a wonderfully apt image of one who is unable to relinquish 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. 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. At an unconscious level, they refuse to accept the existential implications of renunciation.

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 references, that one assigns an arbitrary meaning to the world, means to become aware of one's fundamental groundlessness. Decision plunges one, if one permits it, into such awareness. Decision, especially an irreversible decision, is a boundary situation in the same way that awareness of my death is a boundary situation. Both act as a catalyst to shift one from the everyday attitude to the ontological attitude, that is, to a mode of being in which one is mindful of being. Although, as we learned from Heidegger, such a catalyst and such a shift are ultimately for the good and prerequisites for authentic existence, they also call forth anxiety. If one is not prepared, one develops modes of repressing decision, just as one represses death. A major decision not only exposes one to the anxiety of groundlessness but also threatens one's defenses against death anxiety. By facing one with the limitation of possibilities, decision challenges one's myth of personal specialness. And decision, in so far as it forces one to accept personal responsibility and existential isolation, threatens one's belief in the existence of an ultimate rescuer.

A fundamental decision also confronts each of us with existential isolation. A decision is a lonely act, and it is our own act. No one else can decide for us. Many people, therefore, are highly distressed by decision and, as I shall discuss shortly, attempt to avoid it by coercing or persuading others to make the decision for them.

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 call of guilt. It arises, said Rank, first as counterwill. 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.

Masochistic characters who are encased in a symbiotic relationship with a parent have particular trouble with guilt and decision. Esther Meder suggests that each of these patients has a parent who in effect said, "You dare not be yourself. You have not the ability to be yourself. You need my presence to exist." During development, such individuals experience any free expression of choice as forbidden since it represents a violation to the parental mandate. In adulthood, major decisions elicit dysphoria stemming both from the fear of separateness and from the guilt at transgressing against the dominant other.

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. Bonnie, a 48-year-old woman whom I discussed briefly in chapter 4, illustrates some of these issues. For many years, Bonnie had suffered from Burger's disease, a disorder resulting in the occlusion of small blood vessels in the extremities. There is well-established medical evidence that nicotine is extremely toxic in Burger's disease. Patients who smoke accelerate the course of the disease and generally must face early amputation of one or more limbs. Bonnie had always smoked and could not, would not, stop. Various hypnotic and behavioral approaches had all failed, and she seemed unable, unwilling, to make the decision to stop smoking. She felt that in many ways her life had been ruined by her smoking habit. She had been married to a rather ruthless, authoritarian man who 10 years previously had left her because of her poor physical health. He was an avid outdoorsman and decided that he'd be far better off with a mate with whom he could share outdoor activities. That Bonnie had brought about her own disability through her "filthy habit," as he put it, and her weakness of will, sharply compounded the problem. Eventually, he gave Bonnie an ultimatum: choose smoking or marriage. When she continued to smoke, he left her.

When Bonnie and I considered the reasons that made it difficult for her to decide to stop smoking, one of the important themes that arose was her realization that if she stopped smoking now, then that would mean that she could have stopped smoking before. The implications of that insight were far-reaching indeed. Bonnie always considered herself as a victim: a victim of Burger's disease, of her habit, of a cruel, insensitive husband. But if, in fact, her fate had always been under her control, then she would have to face the fact that she must bear the entire responsibility for her disease, for the failure of her marriage, and for the wreckage, as she put it, of her adult life. To decide to change would entail accepting existential guilt, the guilt for the atrocity she had committed against herself.

In therapy, Bonnie had to be helped to understand the implication of deciding something for herself. That is, of not basing her decision upon the wishes of anyone else—her husband, her parents, or her therapist. She had to accept the guilt and the ensuing depression for having thwarted her own growth. She had to accept the crushing responsibility for her actions in the past by grasping her responsibility for the future. The best way, perhaps the only way, of dealing with guilt, guilt from violation either of another or of oneself, is through atonement. One cannot will backward. One can atone for the past only by altering the future.

Methods of avoiding decision. Clinical manifestations. Since decisions are extraordinarily difficult and painful for many individuals, it's not unexpected that one should develop methods of decision avoidance. The most obvious method of avoiding a decision is procrastination. And every therapist sees patients who pace tormentedly before the door of decision. 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 so much the better.

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 something else to make the decision.

Avoidance of renunciation. Trading down. If decision is difficult because one must relinquish one possibility at the same time as one chooses another, then the decision becomes happier if one arranges the situation so that one renounces less. For example, my patient Alice sought therapy because she could not decide to divorce her husband. He had made the decision to leave her, had moved out one year ago, but occasionally returned for sexual relations. Alice mourned him continually, and her fantasies brimmed with visions of winning him back. She schemed to find ways to meet him, and she humiliated herself by pleading with him to give their marriage another trial. 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. With the help of a few supportive counseling sessions, Alice finally handled her dilemma by becoming involved with another man. By using him as a support, she was able to let her husband go completely and in fact soon took the ultimate step of hauling him into court for refusing to pay child support. Alice was able to make the decision by stripping the deeper implications from it. She avoided the awareness of renunciation by altering the formula of the decision. No longer did she have to choose between a husband who was unavailable and toward whom she had good reason to feel much enmity and a state of loneliness. Instead, she could choose between this husband and a loving boyfriend. Not a difficult decision at all. In one sense, the brief support of therapy was helpful since it freed Alice from the agonizing throes of indecision. On the other hand, though, she missed an opportunity for growth by avoiding the deeper implications of her decision. For example, she might, had she been willing to plunge into these implications, have dealt with the fear of loneliness, her inability to face life in an autonomous fashion, and her ensuing proclivity to surrender herself to a dominant male. As it turned out, Alice learned little from the experience, and a few months later was in the same situation. The relationship with the boyfriend turned sour. She couldn't terminate it, and she again sought therapy in the throes of a decisional crisis.

Devaluation of the unchosen alternative. It is freedom we fear. And common sense, clinical experience, and psychological research all indicate that the sense and the discomfort of freedom increases when alternatives in a decision are perceived to be nearly equivalent. Comfortable decision-making strategy demands, therefore, that the chosen alternatives be regarded as attractive and the unchosen alternative as unattractive. One proceeds by magnifying, at an unconscious level, slight differences between two fairly equal options so that the decision between them is both obvious and painless. Thus, decisions may be made effortlessly, and the painful confrontation with freedom entirely avoided. For example, a schizoid, affect-stifled patient had for many years decided not to make an effort to change. Change, for reasons not germane to this discussion, was a terrifying prospect for him, and consequently he refused to commit himself to therapy and carved out a muted, isolated life for himself. Viewed objectively, his choice lay between a pervasive intra- and interpersonal isolation and a more spontaneous and expressive affective life. To continue in the decision not to change, the patient distorted the options available to him and devalued the unchosen alternative and overvalued the chosen one. He viewed affect suppression as dignity or decorum and spontaneity as an animalistic loss of control where he would run the risk of being overcome by rage and tears. Another patient of mine decided to stay in a highly unsatisfying marriage because the alternative, as she distorted and devalued it, was to join the singles horde, or, as she said, "the vast pathetic army of freaks, castoffs, and misfits."

Social psychological research confirms that the devaluation of the unchosen alternative is a common psychological phenomenon. After a subject makes a decision in which the chosen alternative does not have a clear edge over the unchosen one, he or she experiences postdecisional regret. To the degree that the alternative is attractive, the individual has an uncomfortable "what have I done?" feeling, which is in the literature often referred to as cognitive dissonance. That is, an individual's choice appears inconsistent, dissonant with his or her values. Cognitive dissonance theory holds that the tension of dissonance is highly unpleasant and that the individual engages, though not at a conscious level, in some activity to reduce that tension. Laboratory research indicates a number of ways that one uses to decrease the pain of renunciation. 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 non-chosen alternative. And conversely, one is closed to information that increases the attractiveness of the non-chosen alternative or decreases the attractiveness of the chosen one.

Delegating the decision to someone. Decision, as I have discussed, is also painful because it, if deeply considered, confronts each of us not only with freedom but with fundamental isolation, with the fact that each of us alone is responsible for our individual situations in life. 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 therapy, the patient strives mightily to coax or persuade the therapist to make decisions for him or her. And one of the therapist's chief tasks is to resist being manipulated into taking care of or taking over the patient. To manipulate the therapist, a patient may exaggerate helplessness or withhold evidence of strengths from him or her. Many patients caught in a decisional crisis scan the therapist's every syllable, gesture, or shift of posture as though each were the expression of an oracle. They rummage about in their post-session recollections of the therapist's words in search of clues to the latter's view of the proper decision. Regardless of their level of sophistication, patients secretly yearn for the therapist who will provide structure and guidance. The anger and the frustration that at some level occurs in every course of therapy stems from the patient's dawning recognition that the therapist will not relieve him or her of the burden of decision.

There are innumerable strategies by which one may find another to make the decision for one. Two acquaintances of mine recently divorced in such a manner that each believed the other had made the decision. The wife didn't request a divorce but did inform her husband that she was in love with another man. The husband predictably automatically concluded, in accordance with certain standards of his, that they must divorce, and so they did. Husband and wife each avoided decisional pain and postdecisional regret by concluding that the other had made the decision. The wife had only stated her affection for another man and had not asked for a divorce. The husband felt that his wife had, by her declaration, de facto made the decision.

One may avoid a decision by procrastinating until it is made for one by an outside agent or circumstance. Though such an individual may not apprehend that he or she is making a decision, for example, to fail a course, in fact, procrastination obscures the decision to fail by placing it in the hands of the instructor. Similarly, it might appear that an employer had made a decision to discharge an employee when in fact it was the employee who, by performing inadequately, covertly made the decision to leave the job. Another may not be able to decide to terminate a relationship and by acting cold, indifferent, or withdrawn, forces the other into making the decision.

In a vignette at the beginning of this section, a woman expressed the wish to catch her husband in bed with another woman and thus be able to leave him. Obviously, she wished to leave her husband but could not transform the wish into action. The pain of decision or the anticipation of postdecisional regret was too great. Therefore, she hoped that he, by breaking some definite rule of the relationship, would make the decision for her. She was, however, by no means limited to sheer waiting and hoping. She discovered many other ways of hastening the decision while still concealing from herself that it was she who was making it. For example, she subtly distanced herself from him and withheld sex while covertly implying that he could find it elsewhere.

Another patient, George, presented a similar problem. He would not take responsibility for an overt decision. He was particularly conflicted about a relationship to a woman. He enjoyed her sexually, yet disliked her in many other ways. He refused to make a decision about the relationship, either to say no and terminate it, or to say yes and commit himself to work on it. Consequently, he was forced to find a decision without making one. Unconsciously, he attempted to force her to make the decision. He stayed out of his apartment as much as possible so she couldn't phone him. Or he accidentally neglected to clean his car so that another woman's objects—cigarette butts, hairpins, etc.—were clearly in evidence. If, during this time, however, anyone had suggested to him that he was deciding to end the relationship, George would have vigorously denied it. His woman friend would not make the decision to end the relationship. Instead, she put pressure on him to move in with her. At that point, George searched for other individuals to make the decision for him. He canvassed all his friends for advice and repeatedly attempted to solicit his therapist's guidance in the matter. When the therapist finally succeeded in helping him sit still long enough to examine his behavior, George made an interesting comment. He said, "If someone else makes the decision, then I will not be committed to making the decision work." A substantial body of social psychological research indicates that an individual who participates in a decision, that is, the democratic process, takes responsibility for making that decision work. In contrast to the relatively apathetic or resisting posture one takes toward the decision another has forced upon one. George knew that it was in his best interests to end the relationship. It was better for his woman friend, too, that he end it, although for a long time he clung to the rationalization that he didn't want to hurt her, as though long, agonizing, covert rejection were painless. Yet, he could not bring himself to make the decision, and he slowly twisted in the wind because he couldn't find another to make his decision for him. Many patients act out in therapy in order to persuade the therapist to make their decisions for them.

Another patient, Ted, who was himself a psychotherapist, had for months struggled with strong dependency yearnings. Ted's therapist had in one session reflected on the difficulty of being one's own father and mother. This concept, stated in one form or another, must emerge in every existential therapeutic investigation of freedom. At the next session, Ted was extraordinarily distressed and announced that during the week he had lost control and become sexually involved with one of his patients and that he needed someone to blow the whistle on him. This situation seemed powerfully designed to force the therapist to take over decisions for Ted. After all, how could a responsible therapist sit passively and allow a patient to injure another patient and, in the process, to ruin his own professional career? The therapist, however, chose to examine all aspects of the acting out, and it was soon apparent that Ted was not wholly out of control but had made several decisions that indicated he had assumed some degree of responsibility. Rather than becoming involved with a psychotic or borderline patient, he had chosen a mature, well-integrated patient ready to terminate after 3 years of therapy. Furthermore, though he had violated the professional ethical code, he had, in fact, stopped far short of intercourse and had immediately brought the situation up for scrutiny in his personal therapy. Ted's interests were best served in the long run by the therapist's refusal to be manipulated into making Ted's decision (whistleblowing) and by the therapist's persistence in demonstrating to Ted that though it was frightening to make his own decisions, he was entirely capable of doing so.

Delegating the decision to something. An ancient mode of decision-making was to consult fate. Whether fate's answer was to be found in sheep entrails, tea leaves, the I Ching, meteorological changes, or any of a vast array of portents was of no matter. What was important was that by transferring decision to an outside agency, the individual was spared the existential pain inherent in decision. A modern version of total reliance on chance is to be found in Luke Reinhardt's novel, *The Dice Man*, in which the protagonist makes one fundamental decision: to leave all other decisions up to chance, the toss of the dice. Thereafter, he makes every major life decision by drawing up a list of options and allowing the dice to decide. True, some decisions have to be made in respect to which options are placed on the list, but these are minor and relatively uncommitting since each option has so many odds against it. The dice man's rationale for his behavior is that many aspects of his personality are permanently squelched by the majority rule of his other traits. By leaving the decision to the dice, he is permitting each part some opportunity to exist. Although the dice man is presented as an existential hero, an individual who embraces total freedom (that is, randomness and contingency), he may be also viewed as the opposite, one who has surrendered freedom and responsibility. Indeed, whenever the dice man is called upon to answer for some particularly outrageous act, he has one response: "The dice told me to do it."

Rules are another handy decision-making agency, and individuals have always sought the comfort of a comprehensive set of rules to relieve them from the pain of decision. The Orthodox Jews who follow the 513 Judaic laws are spared many decisions since so much of their behavior is prescribed for them, ranging from the daily rituals accompanying each of the day's events to the proper course of action when faced with major life crises. The rules of traditional societies often stifle initiation and limit ambition and choice. But they do offer blessed relief from such decisions as whom should I marry, should I divorce, what career shall I pursue, how shall I spend my free time, whom shall I befriend, and so forth.

Pugenl, in describing the treatment of a patient, an undergraduate dean of students, beautifully illustrates how rules allow one to avoid decision. As he tells it, "Dean Stoddard smiled understandingly, but with a trace of sadness at the girl, as she said, 'I certainly understand now why you did as you did, but you see, I really have no choice in the matter. If I made an exception for you now, then I'd have to make an exception for everyone else who had good reasons for breaking the rules. Pretty soon the rules would be meaningless, wouldn't they? So although I really am sorry about it, the situation is clear and it calls for you to be restricted to campus for the next month.'" The student looked appreciatively at the dean through her tears. "It helps to know that you understand, but but somehow it just doesn't seem fair under the circumstances. This will mean I'll lose my job, and I don't know whether Dad will be able to keep me in school or not." The dean was sympathetic but made it evident that she had no choice.

When the student was gone, Dean Stoddard sat back in her chair for a minute, herself swept by contradictory feelings. On the one hand, she felt a certain satisfaction that she had finally trained her feelings and her judgment to the point where she could stand firm when the regulations required it. For so many years she had found herself carried away by her sympathies, so that she almost never was able to combine understanding with consistent application of the rules. Ruthfully, Margaret's daughter reflected that it had been a real struggle to be able to handle a situation as she had just handled this one. Yet, and here the irony came in, somehow she wasn't content. Somehow she felt vaguely uneasy, even as she reassured herself that she had done the job well. Later in the day, on the couch in my office, she found herself ruminating. "I don't know what it is that keeps bothering me about that interview, but I feel restless whenever I think about it, and I keep thinking about it. It's like there's something I've overlooked, but I can't think what it might be." Margaret, as Buggan points out, had instead of administering the rules, become administered by the rules. She concluded that rules have meanings in themselves, that rules and consistency transcend consideration of human understanding and human needs. Margaret sensed that there was danger if choice was exercised. Her rationale of the danger was that "if I make an exception for you now, then I'd have to make an exception for everyone else who has good reasons for breaking the rules." But why should this be so? Why should consistency be elevated above all else? No, there were other more urgent reasons for Margaret's following the rules, though these reasons are not explicit in the clinical report. It is apparent that by avoiding decision, Margaret avoided the role of decision maker. She embraced and cherished the comforting illusion that there is some absolute external reference, that there is a prescribed right and wrong. And in so believing, Margaret avoided the existential isolation inherent in her real situation, that is, that she herself has fashioned her world and imbued it with structure and meaning.

Chapter 7. Decision: Clinical strategy and techniques. Decision plays a central role in every successful course of therapy. Even though a therapist may not explicitly focus on decision or even acknowledge it, even though a therapist may believe that change is brought about by exhortation or interpretation or by virtue of the therapeutic relationship, nonetheless, it is a decision that slips the machinery of change into gear. No change is possible without effort, and decision is the trigger of effort. Here I shall consider some therapeutic approaches to decision, both conscious and unconscious decision. Some patients come to therapy in the throes of some active decision-making. Some have periodic decision crises during the course of therapy. Others have long-term problems in being unable to make decisions. Even though the therapist does not formulate the patient's dynamics in terms of problems in decision-making, still the therapist's goal is, as I mentioned in the vignette at the beginning of part two, to bring the patient to the point where he or she can make a free choice.

Therapeutic approaches to decision, conscious levels. Beatrice, a patient in a therapy group, called me for an emergency session because of an acute decisional crisis. Three months previously, she had invited her Italian boyfriend to live with her. At that time, it appeared to be a short-term arrangement since he was slated to return to his own country in a month. However, his departure date had been postponed, and their relationship had rapidly deteriorated. He was drinking heavily, was verbally abusive to her, and had borrowed large sums of money, her car, and her apartment. Beatrice was overwhelmed with anxiety and in great despair about her inability to act. Finally, after weeks of struggling with the decision, she had asked him that morning to leave, but he refused to go, stating he had no money and no place to stay. Furthermore, since she had no lease on the apartment, he now had as much right to it as she. She considered calling the police but doubted that they could be effective because of the lack of a lease. Besides, she dreaded angering her boyfriend because he had a bad temper and was entirely capable of engaging in a prolonged vendetta against her. What should she do? He would leave in another four or 5 weeks. She had hoped to stick it out till then, but the situation had so deteriorated that she no longer felt that she could do so. If she asked him to leave, he might harm her physically or destroy her furniture or car. Furthermore, it was vitally important to her that she end the relationship in a way that would result in his continuing to care for her. What should she do? Beatrice felt paralyzed with apparently no possible course of effective action. During the emergency consultation, she appeared so distraught that I entertained the idea of hospitalizing her. I attempted directly to confront the decision panic and paralysis by asking repeatedly, "What are your alternatives?" Beatrice felt that there were none, but when I persisted, she listed a number of options. She could confront him much more openly, honestly, and forcibly than she had before. She could let him know precisely how devastating an experience this had been for her, and how determined she was not to spend another day with him in the apartment. She could insist that he leave, and then she could seek legal advice and police protection. She could enlist the help of some of her friends to help her confront him. She could move out of the apartment. She had neither lease nor particular attachment committing her to it. If she feared he would destroy her furniture, then she could call a moving company and have her furniture put into storage. Expensive, yes, but not as costly as the large sums she was giving him. She could easily stay with her sister, and so on and so on. By the end of this option-listing exercise, Beatrice no longer felt trapped; her sense of paralysis had diminished, and she was able to plan a course of action.

The follow-up of this session leads into areas that are not entirely germane to this discussion but that nonetheless illuminate the clinical problems surrounding decision-making sufficiently to warrant a digression. Beatrice felt better after the session. She reviewed all her options and chose to confront her tormentor. She braced herself and timidly told him that she could bear the situation no longer and asked him to leave. Although she had reported to me that she had spoken so to him previously, the message had apparently not gotten through since his response to this statement was immediate acquiescence. He packed up his belongings, found another place to stay, and agreed to leave the next day. That evening she agreed to have a last dinner with him, and in the course of conversation he remarked soulfully that it was a pity that two rational individuals who liked one another could not find some way to live together as good friends. And what did Beatrice reply? "I'd like that too," she said. And so they unpacked his bags, and he settled in again.

In the therapy group four days later, Beatrice began the meeting with a brief report of the incident. She described a brief argument, a crisis session with me, a resolve to ask her boyfriend to leave, a rapprochement, and an ensuing couple of days of a dramatically improved relationship. She did not mention extraordinary distress, the abuse she had suffered, the drinking, the financial exploitation, the threats. I was stunned by her account, and after Beatrice had finished, I told the group that I too had had an experience in the past week which I wish to share with them. A young woman in extraordinary anguish called me. I began, and in that vein proceeded to describe my version of our session. Indeed, the accounts were so different that it was several minutes before the group realized that Beatrice and I had been describing the same incident.

Why did Beatrice distort the information she relayed to the group? Unconsciously, she must have realized that if she provided the group, and for that matter herself, with an accurate portrayal of the relationship, the members would conclude that she should end the relationship. And indeed, every one of her friends had responded in that fashion. Among the more dispassionate responses were, "Kick the son of a bitch out. Are you crazy? Get rid of the jerk. Why do you put up with that?" At a deep level, Beatrice appreciated that she had made an irrational decision, one clearly not in her best interests. But she had decided, and she wished to avoid the anxiety of cognitive dissonance. As she valued the opinions of the group members, it was clearly in the interest of her personal comfort that she withhold the facts that would allow them to conclude that she had decided incorrectly.

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. In helping patients to communicate effectively, one of the first principles psychotherapists teach is that one owns one's feelings. It is equally important that one owns one's decisions. A decision made by another is no decision at all. One is not likely to commit oneself to it. And even if one does, no change in the process of decision-making has been affected. One will not generalize to the next decision.

The therapist must resist the patient's entreaties to make a decision. Neophyte therapists often succumb and fall into the trap of deciding for patients. Such a therapist later feels not only disappointed but curiously betrayed or angry when a patient fails to commit himself or herself to that decision. If the therapist takes over the patient's decision-making function, then the entire focus of therapy may be displaced from the crucial area of responsibility and decision to the area of obedience or defiance of authority. It is important to remember that deciding does not end either with a decision or with a failure to make one. The individual must redecide over and over. Failing to carry out a decision does not blow it forever and need not carry implications for the next decision, and much can be learned from such failure.

There are times also when a patient is not ready or able to make a decision. The alternatives are too equal, and the patient's anxiety and anticipation of regret are too high, and his or her awareness of the meaning of a decision (which I shall discuss shortly) is too limited. The therapist may afford the patient much relief by supporting the latter's decision not to decide at such a time. Many patients' decision-making abilities are paralyzed by "what ifs." "What if I quit this job and can't find another one? What if I leave my children alone and they get hurt? What if I consult another doctor and my pediatrician finds out about it?" 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. Two thousand years ago, Aristotle said, I believe, that the whole is greater than the sum of the parts. And folk wisdom has always reflected this insight, as in the Yiddish joke about the kreplach. A boy's mother is trying to rid the child of his extraordinarily powerful repugnance to kreplach, a meat-filled pastry. Painstakingly, she prepares the kreplach while he is in the kitchen. Patiently, she presents and discusses each of the ingredients. "See, you like flour and eggs and meat and so on." He agrees readily. "Well, then, that settles it, because that's all there is in kreplach." But at the word kreplach, the child once again promptly retches.

Therapeutic approaches to decision, unconscious levels. How can the therapist approach the unconscious aspects of decision-making? What Farber refers to as the first realm of will? The answer: indirectly. Much as they might wish to, therapists cannot create will or commitment, cannot flick the decision switch or inspirit a patient with resoluteness, but they can influence the factors that influence willing. No one has a congenital absence of will. Part of one's constitutional heritage, as Robert White and Karen Horney have ably argued, is a drive toward effect, 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 Horny put it, as an acorn develops into an oak. Thus, the therapist's task is not to create will, but to disencumber it. I shall describe several approaches to this task.

The therapist must first help the patient become aware of the inevitability and the omnipresence of decision. The therapist helps the patient frame or gain perspective upon a particular decision and then assists in laying bare the deeper implications, the meaning of that decision. Finally, through the leverage of insight, the therapist attempts to awaken the dormant will, the inevitability and the omnipresence of decision. One cannot not decide much as each of us would like it otherwise. Decisions are unavoidable. If it is true that one constitutes oneself, then it follows that decisions are the atoms of the being that one creates.

Acceptance of one's decisions is a step first taken in therapy during the work of assumption of responsibility. In later stages, the therapeutic work consists of sharpening and deepening that insight. The patient is helped not only to assume responsibility but to discover one by one each of his or her avoidance tactics. If one fully accepts the ubiquity of one's decisions, then one confronts one's existential situation in authentic fashion. Procrastination is a decision. As our failure and drinking and being seduced, exploited or trapped, one decides even to stay alive. Nietze 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 adrenalctomies 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.

Some therapists reinforce a patients awareness of the omnipresence of decisions by reminding him or her of the decisions that must be made about therapy. Thus, Kaiser, as we have seen, recommends a therapeutic format with no conditions whatsoever. And Greenwall persistently asks the patients to make decisions about the format of therapy. That is whether he or she wants to work on dreams, how many sessions to meet and so on. Therapists should help patients become fully aware of meta decisions that is decisions about decisions. For some individuals attempt to deny the importance of decisions by persuading themselves that they have decided not to decide. Such a decision is in actuality a decision not to decide actively. One cannot evade decision altogether but one may decide to decide passively by for example letting another decide for one.

I believe that the way one makes a decision is of the utmost importance. An active approach to decision is consonant with an active acceptance of one's own power and resources. Many of the patients I described earlier illustrated this principle. For example, Beatatrice, whose boyfriend would not leave her apartment, had little question about which decision was in her best interests. When I asked her to imagine how she would feel a month hence when he finally left the country, her response was fullbodied, blissful. The patient who prayed that she could catch her husband in bed with another woman also had little question about what she wanted. However, each woman boked at making an active decision to throw out the man in her life, and by arranging for another to make that decision, each had made another decision to decide passively. 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.

My patient Bill agonized for a year about ending a relationship with a woman, Jean. I had persistently taken the approach that the way he made the decision was extremely important, but he persistently denied that he was deciding. He said he could not decide about the relationship because his work was overwhelming and Jean was being very helpful to him in it. I reminded him that he chose to invite her to come to his office in the evenings to help him. Jean was wonderfully supportive when he was in a crisis. He said I suggested that not only did he have some choice about entering a crisis, for example, by needlessly missing a deadline at work and as a result having a humiliating confrontation with his boss. But he freely had chosen to tell Gene about his crisis and to solicit her help. Finally, Bill made a decision to terminate the relationship. But it was a decision he concealed from himself. The decision was to decide passively to persuade Jean to terminate the relationship. He chose a plan of subtle, gradual disengagement. He gave Jean so little affection that eventually she left him for another man. He had gone through this cycle on many previous occasions and each time he was left feeling rejected and worthless. Bill's primary problem was that he was flooded with self-contempt. An important function of therapy was to help him understand that the ignoble way he made decisions contributed to his self-contempt.

Framing a decision. In describing the difference between the two realms of will, conscious and unconscious, Farber says you can will going to bed but not going to sleep. The therapist may occasionally be able to influence the deeper levels of will by changing the frame of a decision by providing the patient with a different perspective on a decision. A personal incident is illustrative. Once many years ago, I had a severe siege of insomnia. The insomnia was linked to tension and was greatly exacerbated whenever I traveled to deliver a lecture. I was particularly apprehensive about an upcoming lecture trip to Cleveland, which I considered a bad sleeping city, because I had once spent an extraordinarily uncomfortable, sleepless night there. This apprehension, of course, initiates a vicious circle. Anxiety about not sleeping begets insomnia.

I have always taken advantage of episodes of personal distress to familiarize myself with various approaches to therapy. And on this occasion, I consulted a behavior therapist. In the four to five sessions I met with him, we worked with a systematic desensitization approach and with muscular relaxation tapes, neither of which was particularly helpful. However, as I was leaving his office after a session, the therapist made a casual remark that proved of enormous benefit. He said, "When you're packing your bag to go to Cleveland, don't forget to put in a revolver." "Why?" I asked him. "Well," he replied, "if you can't sleep, you can always shoot yourself." That comment clicked deep inside and even now years later I regard it as an inspired therapeutic maneuver. How did it work? It's difficult to explain precisely but it reframed the situation and put it into a meaningful existential perspective.

This is precisely the experience that I have observed in patients who have had some massive encounter with death. In chapter 2, I described a patient with advanced cancer who reported that her confrontation with death allowed her to trivialize the trivia in life or to stop doing those things she did not wish to do. Such patients as a result of an encounter with death have been able to remove the frame surrounding their everyday life and to experience the relative unimportance of everyday decisions from the perspective of their one and only life cycle. If all but a small segment of a large tapestry is covered from view, then the details of that small segment emerge and appropriate a new vividness. A vividness that pales when the rest of the tapestry is again uncovered. Similarly, the shift of perspective technique is a process of deframing and uncovering.

But how does the therapist deframe and unveil the tapestry of existence? Some therapists make an explicit appeal to reason. For example, I have observed how Victor Frankle, an existential therapist, attempted to treat a patient who was being smothered by a series of tormenting decisions. Frankle asked him to meditate upon his core being and then suggested that he simply draw a line around this core and become aware of the fact that these decisions involved concerns in outlying and in the long run petty areas of life. Such appeals to reason, however, are generally ineffective in generating a major shift of perspective. What is often required is some immediate confrontation with a boundary situation that propels the individual into an awareness of his or her existential situation. Accordingly, many of the techniques I have described in chapter 5 to help one to confront one's own mortality will often influence the decision process.

The meaning of decision. Every decision has a visible conscious component and a massive submerged unconscious component. A decision has its own dynamics and is a choice among several factors, some of which are beyond awareness. To help a patient caught in the throws of a particularly tormenting decision, the therapist must inquire about its many subterranean unconscious meanings. A decision with which Emma, a 66-year-old widow, struggled, is illustrative. Emma asked to be seen because of her anguish about whether to decide to sell her summer home, a luxurious estate about 150 mi away from her permanent residence. The house required frequent visits, constant attention to gardening, maintenance, police protection, and servants, as well as a substantial expense for upkeep. It seemed an unnecessary burden to a frail old woman in poor health.

There were, of course, financial factors to consider. Was the market at its peak, or would the estate continue to increase in value? Could she invest the money more profitably elsewhere? Emma ruminated continuously about these issues, but though they were important and complex, they seemed insufficient to account for her profound distress. Accordingly, I proceeded to explore the deeper meaning of her decision. Her husband had died a year ago, and she mourned him. Yet, they had spent many a good summer together at the house, and every room was rich still with his presence. Emma had changed the house very little. Every nook and corner contained her husband's personal effects, drawers and closets brimmed with his clothes. She clung to the house just as she clung to his memory. Thus, a decision to sell the house required a deeper decision for Emma, a decision to come to terms with her loss and with the fact that her husband would never return.

The house was so often visited by large numbers of friends that she referred to it as her hotel. Though she hated the long three-hour drive and resented the expenses of entertaining, she also was extremely lonely and felt grateful for the companionship. Emma had always felt that she had few internal provisions to offer friends, and since her husband's death, she had felt particularly depleted and superolous. Who would, she thought, visit me to see me? The house was her drawing card. Thus, a decision to sell the house meant testing the loyalty of her friends and risking loneliness and isolation. Her father had designed and built the house, and the land on which it stood had been in her family for generations. The great tragedy of Emma's life had been that she had no children. She had always envisioned the estate passing on through time to her children and to her children's children. But she was the last leaf. The line ended with her. A decision to sell the house, thus was a decision to acknowledge the failure of one of her major symbolic immortality projects.

Emma's decision then was no ordinary one. When the meaning of her decision was explored, it became clear that the implications were indeed staggering. She was deciding whether to punctuate the loss of her husband, to confront isolation and possible loneliness, and to accept her own finiteness. If I had been content to help her decide on the basis of convenience, poor health, or financial factors, I would have missed both the whole point of Emma's turmoil and the opportunity to help her in a fundamental way. I used the houseelling decision as a springboard to these deeper issues and helped Emma mourn both her husband, herself, and her unborn children. Once the deeper meanings of a decision are worked through, the decision itself generally glides easily into place, and after a dozen sessions, Emma effortlessly made the decision to sell the house.

Many therapists today inquire about the meaning of a decision when they explore the payoff of a decision. Greenwald, who bases an entire approach, decision therapy to psychotherapy around decisionm emphasizes the importance of investigating payoffs. In every decision, there are payoffs, some conscious, some unconscious. If the patient is unable to stick with a decision, the therapist must assume that the patient has made another decision which has its own corpus of payoffs. If the patient wishes to change but cannot decide to change, the therapist may focus not on the refusal to decide, but on the decision that was in fact made, the patients decision to stay the way he or she is. Staying sick is a decision and invariably has tangible or symbolic payoffs. For example, the patient may obtain a pension, the solicitude of friends, or the therapists continued ministrations. A decision will not stick unless one owns it and recognizes and discards the payoffs of opposing decisions. Thus of a patient who expresses the wish to kick a narcotic habit, Greenwald asks why and explores with him or her all the payoffs of drug taking such as anxiety relief, euphoria, or absolution from responsibility. One is more likely to own a decision if one discovers the limits to each of the opposing payoffs.

Two patients in a therapy group that I conducted wanted to have a sexual relationship, but decided not to because of my rules. I pointed out that I had made no rules and then asked the patients about the payoffs of their decision. When they had fully discussed their awareness, both that the group meant a great deal to them and that a sexual relationship would sabotage the group, the decision became their decision and much more firmly rooted than if I, therapist, had made it for them. Payoff is a new term but an old concept. Whether we speak of exploring meaning or payoff or secondary gratification, we are referring to the fact that every decision that one makes has benefits for that individual. If the decision seems to be self-destructive, we will invariably find that it makes sense in the patients experiential world and that in some highly personalized or symbolic mode, it is self-preservative. However, there will be many decisions whose full meaning the therapist will find difficult to comprehend because of their deep roots in the unconscious.

Insight and decision. The precise relationship between insight and the decision to change has always remained elusive. Although psychoanalytic texts generally equate insight and change, they employ a circular type of logic that guarantees the truth of the proposition that the reason the patient doesn't change is that he or she has not acquired enough insight. The issue is made even more problematic by the lack of a precise definition of insight. In its broadest clinical sense, insight refers to self-discovery, a sighting inwards. But clinicians differ widely in their conception of the type of self-discovery that instigates change. Is it insight into the way one behaves with other individuals, or insight into the current motivation behind one's behavior, or insight into childhood sources, often erroneously referred to as the genetic causes of behavior?

Freud always held that mutative insight was insight into the early sources of behavior and believed that successful therapy hinged on the excavation of the earliest layers of life's memories. Other therapists believe that effective insight is the discovery of currently active dynamics. For example, Emma, the widow faced with the decision to sell her summer home, improved by discovering the currently active dynamics without considering the genetic issue. Or how did you get to be that way? Is insight always necessary? Most assuredly not. Every clinician has worked with patients who have undergone substantial change in the absence of insight. Earlier, I discussed those who changed as a result of some radical shift in perspective. A shift that often one can explain only with a palid, I learned to count my blessings or I decided to live my life rather than postpone it. Comments that hardly qualify as insight.

Individuals go through therapy in a variety of ways. Some profit from insight, some from other mechanisms of change. Some may even obtain insight as a result of change rather than the other way around. May states, "I cannot perceive something until I can conceive it." 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. Though there is considerable discussion and controversy about the type of insight most likely to produce change, the literature is relatively silent about how insight affects change. Many of the traditional explanations, for example, making the unconscious conscious, undermining resistance, the working through of the past, the reintegration of dissociated material, a corrective emotional experience, all elaborate upon the problem, but still beg the question and fall short of providing a precise mechanism of the influence of insight.

The psychological construct of willing and particularly the concept of decision that process that stretches from wish into action provides the clinician with a model to explain how insight catalyzes change. The therapist's task is to disencumber will. Insight is one of the important tools that the therapist can use to accomplish that task. In the following section, I shall argue that insight affects change through one, facilitating the development of the therapist patient relationship and two, a series of maneuvers that help the therapist liberate the patients stifled will. These maneuvers are designed to enable patients to realize that only they can change the world they have created, that there is no danger in change, that to get what they really want, they must change, and that each individual has the power to change.

Facilitation of the patient therapist relationship. An accepting trusting patient therapist relationship is crucial to the process of change. As a result of the therapist's concern and unconditional regard, the patients self-love and self-regard gradually increase. Self-regard begets a belief that one has the right to wish and to act. The patients will is first exercised in the therapeutic arena where it is accepted and reinforced by the therapist. Once the patients belief in the destructiveness of his or her will is disisconfirmed in the therapeutic situation, he or she is gradually able to will effectively in other domains. How does insight catalyze the therapeutic relationship indirectly? Insight is an epipenomenon, a means to a means to an end. It is a fertilizer of the relationship. The search for understanding provides a context for the formation of the therapist patient relationship. It is the glue that binds patient and therapist together. It keeps them occupied in a mutually satisfying task. The patient is gratified by having his or her inner world scrutinized with such thoroughess. The therapist is charmed by the intellectual challenge. And all the while the real agent of change, the therapeutic relationship is silently germinating.

Leverage producing insights. In addition to its function in the development of the therapist patient relationship, insight may catalyze willing more directly. The therapist assists the patient in obtaining self-nowledge that applies leverage to the will. The following insights are four of the most common leverage producing statements made by the therapist to the will stifled patient.

Only I can change the world I have created. In the previous chapter, I described many techniques to help patients become aware of their responsibility for their life predicaments. Once a patient truly grasps the full implications of his or her responsibility, then the therapist must help that patient to understand that responsibility is continuous. One doesn't create one's situation in life once and for all. Rather, one is continuously creating oneself. Thus, responsibility for past creation implies responsibility for future change. Next, the therapist helps the patient take the short step toward realizing that just as one is solely responsible for being what one is, one is solely responsible for changing what one is. A patient who is to change must arrive at the insight, if I and only I have created my world, then only I can change it. Change is an active process. It will not occur unless we actively change. No one else can change us or change for us. This insight is at once simplistic and profound. Though the insight is easily stated and its mechanism fundamentally exhortative, nonetheless, its implications run very deep.

There is no danger in change. Many patients cannot make the crucial decision to change because of a powerful, often unconscious belief that some calamity would befall them if they were to change. The nature of the fantasized calamity varies from person to person. One fears being engulfed if he or she were to engage another. Another fears rejection or humiliation if he or she were to be more spontaneous or self-disclosing or catastrophic retribution as a result of self assertion or abandonment and isolation as a result of autonomous behavior. These fantasized calamities are encumbrances to the will and the therapist must search for methods to eliminate these incumbrances. The process of identifying and naming the fantasized calamity may in itself enable a patient to understand how far his or her fears are removed from reality. Another approach is to encourage the patient to perform by degrees in the therapy session various aspects of the behavior whose consequences the patient dreads. The fantasized calamity does not of course ensue and the dread is gradually extinguished. For example, a patient may avoid aggressive behavior out of a deep-seated fear of having a damned up reservoir of homicidal fury that requires constant vigilance lest it be unleashed and bring down on the patient retribution from others. The therapist helps such a patient express aggression in carefully calibrated doses in therapy. peak at being interrupted, irritation at the therapist's fallibility, anger at the therapist for charging him money, and so on. Gradually, the patient learns to dethize himself as an alien and homicidal being.

To get what I really want, I must change. What prevents individuals from making decisions that are clearly in their best interests? An obvious answer is that the patient who seems to be sabotaging his or her own mature needs and goals is satisfying another set of needs that are often unconscious and that are incompatible with the first. In other words, the patient has conflicting motivations that cannot be simultaneously satisfied. For example, the patient may consciously wish to establish mature heterosexual relationships, but unconsciously wish to be nurtured, to be cradled endlessly, to be sheltered from the terrifying freedom of adulthood, or to use another vocabulary, in the case of a man, to assuage castration anxiety by a maternal identification. Obviously, the patient cannot satisfy both sets of wishes. He cannot establish an adult heterosexual relationship with a woman if he is saying stovoce take care of me, protect me, nurse me, let me be a part of you. The therapist uses insight to attack this obstacle to the functioning of the will and helps the patient to become aware that he or she has conflicting needs and goals and that each decision including a decision not to decide satisfies some needs that is has some payoff. When the patient is fully aware of the nature of his or her conflicting needs, the therapist helps the former to realize that since all needs cannot be satisfied, the patient must choose among them and relinquish those that cannot be fulfilled except at enormous cost to his or her integrity and autonomy. Once the patient realizes what he or she really wants as an adult and that his or her behavior has been designed to fulfill opposing growth retarding needs, he or she gradually concludes that to get what I really want, I must change.

I have the power to change. Many individuals are aware that they do not will not make decisions that are in their best interests. Their internal experience is one of confusion spawned impotence. They experience themselves as victims rather than masters of their conduct. As long as this subjective state prevails, there is little possibility of willful constructive action on the part of a patient. The therapist attempts to counter the patients confusion and impotence with explanation and says in effect, "You behave in certain fashions because the because clause generally involves motivational factors that lie outside the patients awareness." How does this strategy help the patient change? 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. Human beings have always abhored uncertainty, and have sought through the ages to order the universe by providing explanations, primarily religious or scientific. The explanation of a phenomenon is the first step toward control of that phenomenon. 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. Furthermore, and this is very important, a course of action is available that augments their sense of mastery. If the volcano explodes because the god is displeased, then there must be methods of placating and eventually controlling the god.

Jerome Frank in a study of Americans reactions to an unfamiliar South Pacific disease shisttomiasis demonstrated that secondary anxiety stemming from uncertainty often creates more havoc than does the primary disease. Similarly with psychiatric patients, fear and anxiety that stem from uncertainty of the source, the meaning and the seriousness of psychiatric symptoms may so compound the total dysphoria that effective exploration becomes vastly more difficult. The therapist may effectively intervene by providing a patient with an explanation that allows that patient to view his or her dysphoria in some coherent and predictable schema. Through explanation, the therapist helps a patient to order previously unfamiliar phenomena and to experience them as being under his or her control. Thus, insight permits a patient to feel I am potent. I have the power to change. The implication of this sequence is that it is primarily the process that is the provision of insight rather than the precise content of the insight that is important. The function of the interpretation is to provide the patient with a sense of mastery. Accordingly, the value of an interpretation should be measured by this criterion. To the extent that it offers a sense of potency, insight is valid, correct or true. Such a definition of truth is completely relativistic and pragmatic. It argues that no explanatory system has hegemony or exclusive rights. That no system is the correct, the fundamental or the deeper and therefore better one.

In a study of encounter groups, my colleagues and I learned that positive outcome was highly correlated with insight. Those subjects who obtained insight and were able to organize their experience in some coherent pattern had a positive outcome. Furthermore, the successful group leaders were those who provided some type of cognitive framework for their members. The type of insight that the successful members had and the specific content of the ideological school from which the successful leaders sprang had little to do with the positive outcome. The important feature was not what they had learned, but that they had learned. Therapists may offer the patient any of a number of explanations to clarify the same issue. Each may be made from a different frame of reference. For example, Freudian, Yungian, Hornian, Salvenian, Adleran, and transactional analytic. And each may be true in that each provides an explanation that beggets a sense of potency. None, despite vehement claims to the contrary, has sole rights to the truth. After all, they are all based on imaginary as if structures. They all say you are behaving or feeling as if such and such a thing were true. The superego, the id, the ego, the archetypes, the idealized and the actual selves, the pride system, the selfsystem and the dissociated system, the masculine protest, parent, child and adult ego states. None of these really exists. They are all fictions, all psychological constructs created for semantic convenience, and they justify their existence only by virtue of their explanatory power.

The concept of the will provides a central organizing principle for these diverse explanatory systems. They all act by the same mechanism. They are effective to the degree that they afford a sense of personal mastery and thus in spirit the dormant will. Does this mean that psychotherapists abandon their attempts to make precise, thoughtful interpretations? Not at all. Only that they recognize the purpose and function of an interpretation. Some interpretations may be superior to others, not because they are deeper, but because they have more explanatory power, are more credible, provide more mastery, and therefore better catalyze the will. Interpretations to be truly effective must be tailored for the recipient. In general, they are more effective if they make sense. If they are logically consistent with sound supporting arguments, if they are bolstered by empirical observation, if they are consonant with the patients frame of reference, if they feel right, if they click with the internal experience of the patient, and if they can be applied to many analogous situations in the life of the patient. Global interpretations generally offer a novel explanation to the patient for some large pattern of behavior as opposed to a single trait or act. The novelty of the therapist's explanation stems from his unusual frame of reference which permits him to unify data about the patient in an original fashion. Indeed, often this data is material that has been overlooked by or is out of the awareness of the patient.

When I present this relativistic thesis to students, they respond with such questions as, "Do you mean that an astrological explanation is also valid in psychotherapy?" In spite of my own intellectual reservations, I have to respond affirmatively. If an astrological or a shamanistic or a magical explanation enhances one's sense of mastery and leads to inner personal change, then it is valid. Keeping in mind the proviso that it must be consonant with one's frame of reference. There is much evidence from cross-cultural psychiatric research to support my position. In most primitive cultures, only the magical or the religious explanation is acceptable and hence valid and effective. An interpretation, even the most elegant one, has no benefit if a patient doesn't hear it. The therapist should take pains to review some of the evidence with the patient and to present the explanation clearly. A therapist who cannot do so does not understand the explanation. It is not, as some claim, because the therapist is speaking directly to the patient's unconscious. A patient may not be able to accept an interpretation the first time a therapist makes it, but may hear the same interpretation many times until one day it seems to click. Why does it click that one day? The important thing for the therapist to recognize is that even though it appears that a decision to change may be made in an astonishingly short period of time, nevertheless, the groundwork for that change often takes many, many long months or even years.

Many therapists are impressed and puzzled by reports of individuals who report a dramatic sudden life transformation as a result of some brief therapeutic encounter or short participation in a personal growth workshop. It is extremely difficult to evaluate these reports. Richard Nisbet and Tim Wilson have demonstrated that individuals who make decisions are often inaccurate in their descriptions of the antecedance of that decision. From my interviews with those who have undergone dramatic breakthroughs, I have found that these life transformations are by no means sudden. The groundwork for change has been laid over preceding weeks, months, and years. By the time they have reached the point of seeking therapy or some other type of personal growth experience, many individuals have already at a deep level done the work and are on the brink of dramatic change. In these instances, therapy, that is the decision to seek therapy, is the manifestation, not the cause of change. Decisions to change generally require considerable time, and the therapist must exercise patience. Interpretations must be properly timed. The experienced therapist knows that an interpretation prematurely given will have little therapeutic impact.

An illustrative clinical example is provided by a patient in a therapy group who had been involved for several years in an exceedingly unsatisfying marriage. All attempts to improve the marriage had failed, and though she realized that it was destroying her, she clung to it because she was terrified of facing life alone. She perceived her husband not as a real person but as a figure who protected her from loneliness. Though the relationship was obviously unsatisfactory, she was so terrified of losing it that she refused to commit herself to a plan for change. Without any real relatedness and without any commitment for change, there was little possibility of the marriage working. It seemed clear to me that only if she could face separateness and autonomy could she have a chance at a genuine undistorted human encounter. Consequently, I ventured the opinion, "Only if you are willing to give up the marriage can you save it." That interpretation was deeply meaningful to her. She said that it struck her like a thunderbolt and subsequently it catalyzed considerable change. The fascinating aspect of this situation was that she had been in a therapy group after each meeting of which I had for many years written a summary to mail to the group members before the following session. See my book on group therapy for the rationale of this procedure. Thus, there was a written history of the therapy group, a chronicle that the patients had read after each meeting. This particular patient was an assiduous reader of the summaries and filed them so that she had an ongoing log of the group to which she referred from time to time. Shortly after I made this effective interpretation to her, I reviewed the summaries of the group over the past couple of years in conjunction with some writing I was doing and discovered to my astonishment that I had made the precise interpretation to her one year previously. Though the wording was identical and the interpretation had been underscored and heavily emphasized, she had not heard it previously because she was not ready to hear it.

The past versus the future in psychotherapy. It is a matter of no small significance that the word will has a double meaning. It suggests resolution and determination and it also denotes the future tense. I will do it not at this moment but in the future. As every therapist recognizes, psychotherapy is successful to the extent that it allows the patient to alter his or her future. Yet, it is not the future but the past tense that dominates psychotherapy literature. To a large extent, this domination by the past is a result of a confusion between explanation and originalology. Psychotherapists, especially those of a Freudian persuasion, often believe that in order to explain something, that is to provide insight, one must lay bear its origins or at the very least relate the present event to some past situation. In this frame of reference, the causes of individual behavior are to be found in antecedent circumstances of a person's life. Yet, as I suggested in the previous section, there are many modes of explanation or systems of causality that do not rely on the past. For example, the future, our present idea about the future, is no less than the past, a powerful determinant of behavior, and the concept of future determinism is fully defensible. The not yet influences our behavior in many formidable ways. Within one at both conscious and unconscious levels, there is a sense of purpose, an idealized self, a series of goals for which one strives, an awareness of destiny and of ultimate death. These constructs all stretch into the future, yet they powerfully influence inner experience and behavior.

Another mode of explanation applies a Galilean concept of causality which stresses the current field forces operating upon the individual. As we hurdle through space, our behavioral trajectories are influenced not only by the nature and the direction of the original push and the nature of the goal that beckons, but also by all the current field forces operating upon them. Thus, the therapist may explain a patient's behavior by examining the concentric rings of conscious and unconscious current motivations which envelop that individual. Consider, for example, one who has a strong inclination to attack others. Exploration of this behavior may reveal that the patients aggression is a reaction formation, concealing a layer of strong dependency wishes that are not expressed because of anticipation of rejection. This explanation need not include the question, how did the patient get that way? Still, the therapist's natural tendency is to focus on the past in psychotherapy. Most long-term intensive treatment devotes much energy to looking backward. Long developmental histories are gathered. Recollections about one's early relations with parents and siblings are explored at length. Early memories and infantile roots of dreams are painstakingly examined. Freud laid the foundations of this approach. He was a committed psychoarchchaeologist who to the end of his life believed that the excavation of the past was essential even tantamount to successful therapy. In fact, in one of his last papers, he makes an extended comparison between the work of the analyst and that of the professional archaeologist. He describes the therapist's task as construction of the past. As he put it, we all know that the person who is being analyzed has to be induced to remember something that has been experienced by him and repressed. The analyst has neither experienced nor repressed any of the material under consideration. His task cannot be to remember anything. What then is his task? His task is to make out what has been forgotten from the traces which it has left behind or more correctly to construct. His work of construction or if it is preferred of reconstruction resembles to a great extent an archaeologist's excavation of some dwelling place that has been destroyed and buried. The two practices are in fact identical except that the analyst works under better conditions and has more material at his command to assist him.

Freud goes on to argue that the therapist, like the archaeologist, must often reconstruct the available fragments as supplied by the patient and then offer this construction to the patient. In fact, Freud suggests that the word construction is a more appropriate label than interpretation for the therapist's activity. An analyst who is not successful in helping the patient to recollect the past should, Freud suggests, nonetheless give the patient a construction of the past as the analyst sees it. Freud believed that this construction would offer the same therapeutic benefit as would actual recollection of past material. As he said, 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. This latter remarkable statement is in agreement with the point I made earlier, namely that it is not the content but the process of interpretation or explanation that is important. Freud's emphasis on reconstruction of the past as an explanatory system is intimately related to his deterministic doctrine. All behavior and mental experience are the result of antecedent events. Events either environmental or instinctual in nature. The problem with such an explanatory system is that it contains within it the seeds of therapeutic despair. If we are determined by the past, whence comes the ability to change. It is evident from Freud's later works, especially analysis terminable and interminable that his uncompromising deterministic view of man led him to a position of therapeutic nihilism. Any system that explains behavior and mental experience on the basis of phenomena, for example, past or present environmental events or instinctual drives outside the domain of individual responsibility, leads to a treacherous position for the therapist. As rank puts it, the causality principle means the denial of the will principle since it makes the feeling, thinking, and acting of the individual dependent on forces outside of himself and thus frees him from responsibility and guilt. Of course, it is often useful to free oneself from guilt about past events and actions. The therapist who adheres to a deterministic doctrine is able to examine the past in such a way as to demonstrate to the patient that he or she was a victim of environmental events that given the circumstances he or she could not have acted differently. Thus, exploration of the past serves to absolve guilt, but leaves the therapist with the problem of how to deal with the past from one frame of reference to offer absolution and the future with another to invoke responsibility.

Gach and Telain studied transcripts of 20 therapists, 10 Freudian, and 10 existential analysts to determine how they dealt with this paradox. They found that as expected, the existential therapists made significantly more comments that underscored the patients choices, freedom, and responsibility. However, none of the 20 therapists ever spoke as if patients were currently victims of circumstances beyond their control. For a patient contemplating change, all therapists attempted to acknowledge and to underscore the alternatives available to that patient. Furthermore, when a patient spoke of his or her infancy or childhood, all therapists appeared to take a deterministic position that circumstances had been beyond the control of the patient as a child. It is apparent then that therapists learn to live with this inconsistent position. They may reduce the inconsistency by ailarating the deterministic doctrine to one of reciprocal determinism. They assume that in the past the coefficient of adversity was too great that given the patients youth and experience and the power of adult forces acting upon him, he or she could not have acted otherwise.

Most existential therapists tend to focus less on the past than do therapists of other persuasions and more on the future tense, on the decisions beckoning one, the goals stretching out before one. When existential therapists deal with guilt, it is not for the bad choices made, but for the refusal to make new ones. It is extraordinarily difficult to absolve guilt for the past in the presence of ongoing guilt-provoking behavior. One must learn first to forgive oneself for the present and the future. So long as one continues to operate toward the self in the present in the same way that one has acted in the past, then one cannot forgive oneself for the past. But even when working with the past, it is important that the individual does not assume disproportionate responsibility. One important concept is the categorical imperative for responsibility. What is true for one regarding responsibility is true for all. Many individuals assume excessive responsibility and guilt for others actions and feelings. Though the patient may truly have transgressed against another, there's also a realm of responsibility of the other who allowed him or herself to be hurt, scorned, or otherwise mistreated by the patient. Thus, the therapist must help the patient locate the boundaries of responsibility.

Not only is there serious question about the therapeutic efficacy of a causal explanatory system based on the past, but there is a serious methodological problem, namely that psychological reality is not identical with historical reality. As rank notes, Freud's natural science ideology led him to attempt to reconstruct the historical past from the patients recollection of it. But as he noted, the reconstruction of the past depends not on the facts but on the attitude or reaction of the individual to them. He continued, the problem of the past is a problem of memory and therefore a problem of consciousness. In other words, the past is reconstituted by the present. Even in a lengthy anomnesis, 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. Gooffman for this reason suggests the term apologia for this reconstruction of the past. As one through therapy changes one's present image of oneself, one may reconstitute or reintegrate one's past. For example, one may recall longforgotten positive experiences with parents. One may humanize them and rather than experiencing them soypistically as figures who existed by virtue of their service to one, one may begin to understand them as harried, well-intentioned individuals struggling with the same overwhelming facts of the human condition that anyone faces. This process is epitomized in a remark attributed to Mark Twain. He said, "When I was 17, I was convinced my father was a damn fool. When I was 21, I was astounded by how much the old man had learned in four years."

The hermeneutic approach to interpretation considers the relationship between understanding and background. It posits that grasping an understanding requires a certain background, but that this new understanding alters the perception of the background. Consequently, interpretation is an organic process in which background and understanding sequentially reconstitute one another. The same principle applies to the relationship between past and present. A human being's past, unlike the ruins of some ancient temple, is neither fixed nor finite. It is constituted by the present and in its everchanging symbolic iminence influences the present. If the past as a system of explanation is of limited value, what role does the past play in the process of psychotherapy? Earlier I alluded to the role of the search for genetic insight in the development of the therapeutic relationship. The intellectual venture which Freud likens to an archaeological dig provides a shared apparently meaningful activity in which patient and therapist engage. While the real agent of change, the therapeutic relationship unfolds. But the past facilitates relationship in another important manner. The explicit understanding of the early development of a particular interpersonal stance enhances the possibility of engagement. For example, a woman with a regal heir conveying ur and condescension may suddenly seem understandable, even winsome, when the therapist learns of her immigrant parents and her desperate struggle to transcend the degradation of her slum childhood. Knowing another's process of becoming is often an indispensable adjunct to knowing the person. What is important in this regard is the accent. The past is explored in order to facilitate and deepen the present relationship. This is precisely the reverse of Freud's formula where the present relationship serves as a means to deepen understanding of the past. Charles Ryf states this exceptionally clearly. He said it makes better sense to say that the analyst makes excursions into historical research in order to understand something which is interfering with his present communication with the patient. In the same way that a translator might turn to history to elucidate an obscure text than to say that he makes contact with the patient in order to gain access to biographical data.

Part three.

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Existential psychotherapy by Irvin D. Yalom 05

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