Transcription
Freud adam braided the field of stress disease linkage in 1901 in *The Psychopathology of Everyday Life*, where he suggested that accidental injuries are not accidental but instead are a manifestation of psychic conflict. He described the accident-prone individual who suffers an unusual amount of accidental injury.
Following Freud, two generations of analysts developed the field of psychosomatic medicine, in which a number of medical illnesses, for example, arthritis, ulcers, asthma, ulcerative colitis, were discovered to be powerfully influenced by a patient's psychological state. Modern biofeedback technology, meditation, a wide variety of autoregulatory mechanisms, has heralded a surge of renewed interest in the individual's control and responsibility for aspects of bodily function that are controlled by the autonomic nervous system, a division of the nervous system long referred to as the involuntary nervous system.
The concept of personal responsibility is now being applied in the treatment of such illnesses as cancer. Long thought to be far beyond the purview of individual control, cancer has always been viewed as the prototype of externally based disease. It strikes without warning, and the patient can do little to influence either its onset or its course. Recently, there have been highly publicized attempts to reverse this attitude toward cancer. Patients are being urged to examine their own roles in the disease.
O. Carl Simon, a radiation oncologist, has spearheaded this attempt by proposing a psychologically based therapy for cancer. His rationale is based on current disease theory, which suggests that the individual is constantly exposed to cancer cells and that one's body resists these cells unless resistance has been lowered by some factor, thus making one susceptible to cancer. There is considerable evidence that stress diminishes resistance to disease by affecting both the immunological system and the hormonal balance. If this evidence is further borne out, Simon reasons, then psychological forces may well be marshaled to influence the course of cancer.
Simon's treatment method consists of daily visual meditation, in which the patient first concentrates upon a visual metaphor of how he or she imagines the cancer to appear and then meditates upon some visual metaphor of the body defenses defeating that cancer. For example, one patient visualized the cancer as a mound of raw hamburger and the body's defenses, the white blood cells, as a band of wild dogs devouring the hamburger. Simon urges patients to examine their modes of dealing with stress. Of a patient whose disease spreads, the first question asked is, "What did you do that brought this upon yourself?"
To the best of my knowledge, there has been no trustworthy evidence that this approach increases survival time, and one must be skeptical of a system that promises so much but neglects to do the relatively simple research that would substantiate or disprove its claims. Nonetheless, the Simon approach teaches us something important about the role of responsibility in the management of severe illness. Because even those patients using visual meditation who are not helped physically are often helped psychologically by assuming a more active, responsible stance toward their disease.
This is of great importance because helplessness and profound demoralization are often major problems in the treatment of patients with cancer. Cancer, perhaps more than any other disease, fosters a sense of helplessness. Patients feel unable to exert any personal control over their condition. Patients with almost any other disease, such as heart disease or diabetes, have many ways in which they can participate in treatment. They can diet, follow medical regimens, rest, adhere to physical exercise schedules, and so on. But patients with cancer feel they can do nothing but wait. Wait until the next cancer cell pops up somewhere in the body.
This sense of helplessness is augmented, often by attitudes of doctors who frequently do not include patients in decision-making about the course of therapy. Many doctors are reluctant to share information with patients and often bypass them and consult with the family about important decisions that need to be made concerning future therapy. But if the Simon method is indeed unsubstantiated and does not increase survival time, then is it not based on a lie? And destined to cave in on itself? And what therapeutic methods are available to help those patients who cannot accept his premise and method?
I believe that the concept of responsibility assumption offers therapeutic leverage for any cancer patient, even those whose disease is far advanced. First, it must be noted that regardless of one's physical circumstances, that is, coefficient of adversity, one is always responsible for the attitude one assumes toward one's burden. In my work with patients with metastatic cancer, cancer that has spread to other parts of the body and is no longer amenable to surgical or medical cure, I have been singularly impressed with major differences between individuals in their attitude toward their illness. Some individuals give in to despair and die a premature psychological death and, as some research suggests, a premature physical death as well. Others, as I described in chapter 5, transcend their illness and use their impending death as a catalyst to improve their quality of life.
Responsibility for one's attitude does not necessarily mean responsibility for one's feelings, although Sartre would claim that to be the case, but for the stand that one takes toward one's feelings. A joke told by Victor Frankl illustrates this point. During World War I, a Jewish army doctor was sitting in a foxhole with his gentile friend, an aristocratic colonel, and heavy shooting began. Teasingly, the colonel said, "You're afraid, aren't you? That's just another proof that the Aryan race is superior to the Semitic one." "Sure, I'm afraid," was the doctor's answer. "But who is superior? If you, my dear colonel, were as afraid as I am, you would have run away long ago."
The therapist working with the cancer patient may offer a great deal by concentrating on the latter's hopelessness and helplessness. In our work with cancer patients in support groups, my colleagues and I developed several approaches geared to bolster a sense of power and control. For example, cancer patients often feel powerless and infantilized in relation to their physicians. My group focused sharply upon this issue and was effective in helping many patients assume responsibility for their relationship to their doctors. After patients described their relationships to their doctors, other members suggested other methods. Role-playing was done in which the patients practiced new methods of asserting themselves with physicians. Patients learned to request time from a physician to demand information if they wished it about their illness. Some learned to ask to see their medical charts or to view their X-rays. And some, when it seemed to make sense, assumed ultimate responsibility and refused further medication.
Many patients in the therapy group developed a sense of potency through social action. Many spoke out for the rights of cancer patients and campaigned for political issues affecting them, such as for tax credit for breast prosthesis. Finally, in ways already described, the group therapist helped patients regain a sense of potency by encouraging them to assume responsibility for the course of their own group. By increasing their awareness that they can shape the group to suit their needs, indeed that it is their responsibility to shape the group, the therapist can increase each individual's assumption of responsibility in other spheres of life.
Responsibility and Existential Guilt. In attempting to facilitate a patient's awareness of responsibility, the therapist soon discovers an uninvited presence in the therapeutic arena. That presence is guilt, the dark shadow of responsibility, which often trespasses into the process of existential psychotherapy. In existentially based therapy, guilt assumes a somewhat different meaning from its meaning in traditional therapy, where it refers to a feeling state related to a sense of wrongdoing, a pervasive, highly uncomfortable state, which has been described as anxiety plus a sense of badness. Freud comments that subjectively the sense of guilt and the sense of inferiority are difficult to distinguish.
A distinction may be made between neurotic guilt and real guilt. Or in Buber's terms, between guilt and guilt feelings. Neurotic guilt emanates from imagined transgressions or minor transgressions that are responded to in a disproportionately powerful manner against another individual, against ancient and modern taboos, or against parental or social tribunals. Real guilt flows from an actual transgression against another. Though the subjective dysphoric experience is similar, the meaning and the therapeutic management of these forms of guilt are very different. Neurotic guilt must be approached through a working through of the sense of badness, the unconscious aggressivity, and the wish for punishment, whereas real guilt must be met by actual or symbolically appropriate reparation.
An existential perspective in psychotherapy adds important dimensions to the concept of guilt. First, the full acceptance of responsibility for one's actions broadens the scope of guilt by diminishing escape hatches. No longer can the individual comfortably rely on such alibis as, "I didn't mean it. It was an accident. I couldn't help it. I followed an irresistible impulse." Thus, real guilt and its role in one's interpersonal dealings frequently enters into the existential therapeutic dialogue. But the existential concept of guilt adds something even more important than the broadening of the scope of accountability. Most simply put, one is guilty not only through transgressions against another or against some moral or social code, but one may be guilty of transgression against oneself.
Of all the existential philosophers, Kierkegaard and then Heidegger most fully developed this concept. It is important that Heidegger uses the same word to refer to both guilt and responsibility. After discussing traditional uses of the term guilty, he states, "Being guilty also has the signification of being responsible for, that is, being the cause or author or even the occasion for something. One is thus guilty to the same extent that one is responsible for oneself and one's world." Guilt is a fundamental part of Dasein, that is, human being. As Heidegger said, "Being guilty does not first result from an indebtedness. But on the contrary, indebtedness becomes possible only on the basis of a primordial being guilty." Heidegger then proceeds to develop the theme that in the idea of guilty lies the character of the "not." Dasein is always constituting and it constantly lags behind its possibilities. The guilt is thus intimately related to possibility or potentiality. When the call of conscience is heard, that is the call that brings one back to facing one's authentic mode of being, one is always guilty, and guilty to the extent that one has failed to fulfill authentic possibility.
This extraordinarily important concept has been developed more fully and far less obscurely by many others. Paul Tillich's contributions are particularly relevant to psychotherapy. In *The Courage to Be*, he discusses man's anxiety at the idea of non-being and distinguishes three sources of anxiety, three major modes by which non-being threatens being. Two of these, the threat to objective existence (death) and the threat to spiritual existence (meaninglessness), I examine elsewhere. The third is germane to this discussion. Non-being threatens being by threatening our moral self-affirmation, and we experience guilt and the anxiety of self-condemnation. Tillich's words are exceedingly clear. He said, "Man's being is not only given to him but also demanded of him. He is responsible for it. Literally, he is required to answer if he is asked what he has made of himself. He who asks him is his judge, namely he himself. The situation produces the anxiety which in relative terms is the anxiety of guilt. In absolute terms, the anxiety of self-rejection or condemnation. Man is asked to make of himself what he is supposed to become, to fulfill his destiny. In every act of moral self-affirmation, man contributes to the fulfillment of his destiny, to the actualization of what he potentially is."
Tillich's view that man is asked to make of himself what he is supposed to become to fulfill his destiny derives from Kierkegaard, who described a form of despair that emerged from not being willing to be oneself. Self-reflection, awareness of guilt, tempers the despair. Whereas not to know that one is in despair is a deeper form of despair. Yet the same point is made by the Hasidic rabbi Susya, who shortly before his death said, "When I get to heaven, they will not ask me why were you not Moses. Instead, they will ask why were you not Susya? Why did you not become what only you could become?"
Otto Rank was acutely aware of these issues and wrote that when we restrict ourselves from a too-intensive or too-quick living out or living up, we feel ourselves guilty on account of the unused life, the unlived life in us. Rollo May suggested that the concept of repression be understood from the perspective of one's relationship to one's own potential and that the concept of the unconscious be enlarged to include the individual's unrealized, repressed potential. He wrote, "We must ask the following questions, therefore, if we are to understand repression in a given person: What is this person's relation to his own potentialities? What goes on that he chooses or is forced to choose to block off from his awareness something that he knows and on another level knows that he knows? The unconscious then is not to be thought of as a reservoir of impulses, thoughts, and wishes that are culturally unacceptable. I define it rather as those potentialities for knowing and experiencing that the individual cannot or will not actualize."
Elsewhere, May describes guilt that is existential guilt as a positive, constructive emotion, a perception of the difference between what a thing is and what it ought to be. Therefore, existential guilt, as well as anxiety, is compatible with, even necessary for, mental health. As he put it, "When the person denies his potentialities, fails to fulfill them, his condition is guilt. It is an ancient idea that each human being has a unique set of potentialities that yearn to be realized. Aristotle's *telos* referred to the full realization of potentiality. The fourth cardinal sin, sloth or *acedia*, has been interpreted by many thinkers as the sin of failing to do with one's life all that one knows one can do. It is an extremely popular concept in modern psychology and appears in the writings of almost every modern humanistic or existential theorist or therapist. Although it has been given many names, that is, self-actualization, self-realization, self-development, development of potential, growth, autonomy, and so on, the underlying concept is simple. Each human being has an innate set of capacities and potentials and, furthermore, has a primordial knowledge of these potentials. One who fails to live as fully as one can experiences a deep, powerful feeling which I refer to here as existential guilt."
Karen Horney's mature work, for example, is based solidly on the concept that under favorable conditions, the human being will naturally develop his or her intrinsic potential, just as an acorn will develop into an oak tree. Horney's major work, *Neurosis and Human Growth*, is subtitled *The Struggle Toward Self-Realization*. Psychopathology, in her view, occurs when adverse circumstances inhibit a child from growing toward the realization of his or her own possibilities. The child then loses sight of its potential self and develops another self-image, an idealized self, toward which it directs its life energies. Though Horney does not use the term guilt, it is clear that she is well aware of the price paid by the individual for not fulfilling his or her own destiny. She speaks of the sense of alienation, of being split from what one really is, which results in one's overriding one's genuine feelings, wishes, and thoughts. One senses the existence of one's potential self, however, and at an unconscious level continuously compares it with one's actual self, that is, the self that actually lives in the world. The discrepancy between what one is and what one could be generates a flood of self-contempt with which the individual must cope throughout life.
Abraham Maslow, much influenced by Horney, was the first, I believe, to use the term self-actualization. He too believed that individuals naturally actualize themselves unless circumstances in their development are so adverse that they must strive for safety rather than for growth. That is, they must adopt a deficiency motivation rather than a growth motivation. He wrote, "If the essential, intrinsically given core of the person is denied or suppressed, he gets sick, sometimes in obvious ways, sometimes in subtle ways. This inner core is delicate and subtle and easily overcome by habit and cultural pressure. Even though denied, it persists underground forever pressing for actualization. Every falling away from our core, every crime against our nature, records itself in our unconscious and makes us despise ourselves."
But how is one to find one's potential? How does one recognize it when one meets it? How does one know when one has lost one's way? Heidegger, Tillich, Maslow, and May would all answer in unison: through guilt, through anxiety, through the call of conscience. There is general consensus among them that existential guilt is a positive, constructive force, a guide, calling oneself back to oneself. When patients told her that they did not know what they wanted, Horney often replied simply, "Have you ever thought of asking yourself?" In the center of one's being, one knows oneself. John Stewart Mill, in describing this multiplicity of selves, spoke of a fundamental, permanent self which he referred to as the enduring eye. No one has said it better than St. Augustine: "There is one within me who is more myself than myself."
A clinical vignette illustrates the role of existential guilt as a guide. A patient consulted me because of severe depression and feelings of worthlessness. She was 50 years old and for 32 years had been married to a highly disturbed, spiteful man. On many occasions in her life, she had considered entering therapy but had decided against it because she feared that self-examination would lead to the breakup of her marriage, and she couldn't bring herself to face isolation, pain, disgrace, economic hardship, and acknowledgment of failure. Finally, she became so incapacitated that she was forced to seek help. However, though she appeared physically in my office, she refused to commit herself to therapy, and we made little headway. There was a dramatic turning point one day as she was speaking of aging and her fear of death. I asked her to imagine herself close to death, to look back over her life and to describe her feelings. Without hesitation, she answered, "Regret? Regret for what?" I asked. "Regret for wasting my life? For never knowing what I could have been." Regret, her term for existential guilt, was the key to therapy. We used it as a constant guide from that time forward. Though months of hard work lay ahead for her, there was never a doubt about the outcome. She did examine herself, and she did break up her marriage, and she was able by the time therapy ended to experience her life with a sense of possibility rather than of regret.
The relationship between guilt, self-contempt, and self-fulfillment is clearly illustrated in the treatment of Bruce, the middle-aged patient I discussed in chapter 5. Since adolescence, Bruce had been preoccupied by sex and especially by breasts. He had been throughout his life self-contemptuous. Relief was what Bruce wanted from therapy: relief from anxiety, self-hatred, and the persistent sense of guilt that gnawed away at his insides. It is an understatement to say that Bruce did not experience himself as the author of his life. The concept that he had personal responsibility for his life situation was like a foreign language to him. He felt so driven, so perpetually panicked that, like Kafka, he felt fortunate to be able to sit in the corner and breathe.
For many long months of therapy, we examined his guilt and self-hatred. Why was he guilty? What transgressions had he committed? He confessed to banal, tired, petty crimes and obsessively paraded them back and forth hour after therapy hour. As a child, he had stolen loose change from his father. He had padded figures on insurance claims, cheated on his income tax, stolen his neighbor's morning newspaper, and, above all, screwed women. We investigated each at length, and each time determined that the self-punishment exceeded the crime. For example, when he discussed his promiscuity, he realized that he had injured no one. He treated his lady friends well, used no deceit, and was considerate of their feelings. He worked through each of his offenses on a rational level and realized that he was innocent and unfairly harsh on himself. Yet the guilt and self-hatred persisted undiminished.
The first glimmer of responsibility awareness occurred as he was discussing his fear of assertiveness. Though his professional position called for him to do so, he could not represent his company well in public discussions. It was especially difficult to disagree or to be publicly critical of another. Nothing terrified him more than a public debate. "What could happen in that situation?" I asked. "What is the ultimate calamity?" Bruce had no doubt about the answer: exposure. He feared his adversary would insistently read aloud a list of all the shameful sexual episodes in his life. He identified with the nightmare of James Joyce's Leopold Bloom in *Ulysses*, who, when placed on trial for his secret desires, is humiliated when evidence of his many peccadillos is paraded before the court. I wondered which he feared most: exposure of past or of current sexual adventures. He answered, "The present. I could handle the past affairs. I could say to myself, perhaps even aloud, 'That was then, the way I used to be. Now I've changed. I'm a different person.'"
Gradually, Bruce began to hear his own words, which were saying in effect, "My current behavior, what I am doing right now, is the source of my fear of assertiveness and is the source of my self-contempt and my guilt as well." Bruce eventually realized that he was immediately and entirely the source of his own self-hatred. If he wanted to feel better about himself or even to love himself, he had to stop doing things of which he was ashamed. But an even greater realization was to follow. After Bruce made a stand, which I described in chapter 5, and chose for the first time to forgo a sexual conquest, he gradually began to improve. In the following months, he underwent many changes, including the expected period of impotency. But gradually, his compulsivity gave way, and his sense of choicefulness increased. As his behavior changed, his self-image dramatically changed also, and he grew immensely in self-confidence and self-love.
Toward the end of therapy, Bruce gradually discovered two roots for his guilt. One stemmed from the way he had demeaned his encounters with other beings, which I shall have more to say about in chapter 8. The second source of guilt was the crime he committed against himself. For much of his life, his attentions and energies had been focused animalistically on sex, on breasts, genitals, copulation, seduction, and various ingenious, extravagant modifications of the sexual act. Bruce had, until his change in therapy, rarely given his mind free rein, rarely engaged in other thoughts, rarely read except to impress females, rarely listened to music except as a prelude to sex, rarely truly encountered another person. Bruce, who had a way with words, said that he had lived like an animal, constantly in heat, yanked to and fro by a tube of flesh dangling between his legs.
Suppose, he said one day, that we had the means to study closely the life of an insect species. Imagine that we find that the male insects are transfixed by two bumps on the thorax of the female and devote all their days on earth to finding ways of touching these bumps. What would we think? Why, what a peculiar way to spend one's life. Surely there must be more to life than the touching of bumps. Yet I was like that insect. Small wonder Bruce felt guilty. His guilt, as Tillich knew, came from his life denial and restriction, from his self-emulation and his refusal to become what he could become.
No one has depicted existential guilt more vividly and arrestingly than has Franz Kafka. The refusal to acknowledge and to confront one's existential guilt is a recurrent theme in Kafka's work. *The Trial* begins. "Someone must have maligned Josef K., for without having done anything wrong, he was arrested one fine morning." Josef K. is asked to confess, but declares, "I am completely guiltless." The entire novel is a depiction of Josef K.'s efforts to free himself from the court. He seeks help from every conceivable source, but to no avail, because he faces no ordinary official court of law. As the reader gradually realizes, Josef K. is confronted with an internal court, one residing in his private depths. Julius Hayman calls attention to the court's physical contamination with primitive, instinctual material. For example, the desks of the judges are littered with pornographic books. The court is located in a grimy attic of a slum dwelling.
When Josef K. enters a cathedral, he is addressed by a priest who attempts to help him by urging him to look within at his guilt. Josef K. replies that everything is a misunderstanding and then rationalizes, "And if it comes to that, how can any man be called guilty? We are all simply men here, one as much as the other." The priest appeals, "But that's how all guilty men talk," and once again counsels him to look within rather than to attempt to dissolve his guilt in collective guilt. When Josef K. describes his next step, "I'm going to get more help," the priest becomes angry. "You cast about too much for outside help." Finally, the priest shrieks from the pulpit, "Can't you see one pace before you?" Josef K. then hopes to obtain from the priest a method to circumvent the court, a mode of living completely outside the jurisdiction of the court, by which he means a mode of living outside of the jurisdiction of his own conscience. Is there a way? Josef K. asks, in effect, that one may never have to face existential guilt. The priest replies that the hope of escape is a delusion and tells him a parable in the writings that preface *The Law*, which describes that particular delusion.
This parable is the searing tale of the man and the doorkeeper. A man from the country begs for admittance to the law. A doorkeeper in front of one of the innumerable doors greets him and announces that he may not be admitted at the moment. When the man attempts to peer through the entrance, the doorkeeper warns him, "Try to get in without my permission, but note that I am powerful. From hall to hall, keepers stand at every door, one more powerful than the other, and the sight of the third man is already more than even I can stand." The supplicant decides that he had better wait until he gets permission to enter. He waits for days, for weeks, for years. He waits outside that door for his entire life. He ages. His vision dims. And as he lies dying, he poses one last question to the doorkeeper, a question he had never asked before: "Everyone strives to attain the law. How does it come about then that in all these years no one has come seeking admittance but me?" The doorkeeper bellows in the man's ear, for his hearing, too, is fading, "No one but you could gain admission through this door since this door was intended for you. I am now going to shut it."
Josef K. does not understand the parable and, indeed, until the very end when he dies like a dog, he continues to search for help from some external agency. Kafka himself, as he records in his diaries, did not at first understand the significance of the parable. Later, as Boyer points out, Kafka fully expressed the parable's significance in his notebooks: "Confession of guilt, unconditional confession of guilt, door springing open. It appears in the interior of the house of the world whose turbid reflection lay behind walls." Kafka's man from the country was guilty. Not only guilty of living an unlived life, of waiting for permission from another, of not seizing his life, of not going through the door intended for him alone, but he was guilty too of not accepting his guilt, of not using it as a guide to his interior, of not unconditionally confessing an act that would have resulted in the door springing open.
We are not told much about Josef K.'s life prior to the call of guilt, and therefore cannot with precision delineate the reasons for his existential guilt. However, Hayman, in a remarkably illuminating case report, provides a proxy Josef K., a patient, Mr. T., whose offenses against himself are readily apparent. Mr. T. consulted me because he could no longer swallow. For weeks he had limited himself to frequent small sips of liquids, and consequently had lost some 40 pounds. Before he became ill, his time was spent either in the plant, where his functions were interesting but well-defined, or in his home, where an intelligent but chronically neurotic, depressed, and alcoholic wife rendered impossible all social outings and all entertaining. Sexual intimacies had stopped years ago, allegedly by mutual consent, and the activities at home were restricted to reading, television viewing, impersonal conversation when the wife was not intoxicated, and an occasional visit by a distant relative. Though well-liked and an excellent conversationalist, he had no close friend, much as he wished for one, nor did he ever venture to develop some social activities in which his wife would not be included. Stuck in this rigid and restricted world, he cleverly parried any of the therapist's suggestions to the effect that he further this or that potential, pursue this or that option. Though Mr. T.'s symptomatology ameliorated, two years of therapy did nothing to alter his general lifestyle. Mr. T., like Josef K., did not listen to himself, and in his therapy studiously avoided a deep examination of his life. Yet he insisted on continuing therapy, and the therapist regarded his insistence as an indication of a dormant sense that a richer life might be available to him.
One day, Mr. T. brought in a dream, a dream that amazed him by its extreme clarity. Though he had not read Kafka, his dream has an uncanny resemblance to *The Trial*, which, like many of Kafka's works, had its origin in a dream. It is too long to repeat here in its entirety. But it begins, "I was arrested by the police and taken to the police station. They would not tell me what I was arrested for, but muttered something about a misdemeanor and asked me to plead guilty. When I refused, they threatened to charge me with a felony. 'Book me for anything you want,' I retorted. And so they did charge me with a felony. As a result of this, I was convicted and ended up in a prison farm since this was, according to one of the policemen, the place for nonviolent felonies. Initially, I had felt panicky for being asked to plead guilty. Then I felt angry and confused. I never found out what I was charged with, but the arresting officer had told me it was stupid to refuse to plead guilty since a misdemeanor conviction would get me only 6 months, while a felony conviction carried at least 5 years. I got 5 to 30 years."
Mr. T. and Josef K. are both summoned by existential guilt, and both choose to avoid the summons by interpreting guilt in the traditional manner. They both proclaim their innocence. After all, neither has committed a crime. There must have been some mistake, they reason, and each devotes himself to convincing the external authorities of the miscarriage of justice. But existential guilt is not the result of some criminal act that the individual has committed. Quite the contrary, existential guilt, by any of its many names (self-condemnation, regret, remorse, and so forth), issues from omission. Josef K. and Mr. T. are both guilty for what they have not done with their lives.
The experiences of Josef K. and Mr. T. have rich implications for the psychotherapist. Guilt is a dysphoric subjective state experienced as anxious badness. Yet there are different meanings of subjective guilt. The therapist must help the patient distinguish between real guilt, neurotic guilt, and existential guilt. Existential guilt is more than a dysphoric effect state, a symptom to be worked through and eliminated. The therapist should regard it as a call from within which, if heeded, can function as a guide to personal fulfillment. One who, like Josef K. or Mr. T., has existential guilt has transgressed against one's own destiny. The victim is one's own potential self. Redemption is achieved by plunging oneself into the true vocation of the human being, which, as Kierkegaard said, is a will to be oneself.
Chapter 7: Willing Responsibility, Willing and Action. A Japanese proverb states, "To know and not to act is not to know at all." Awareness of responsibility in itself is not synonymous with change. It is only the first step in the process of change. That was what I meant when in the last chapter I said that the patient who becomes aware of responsibility enters the vestibule of change. This chapter will consider the rest of the journey: the passage from awareness to action.
In order to change, one must first assume responsibility. One must commit oneself to some action. The word responsibility itself denotes that capability: response plus ability, that is, the ability to respond. Change is the business of psychotherapy, and therapeutic change must be expressed in action, not in knowing, intending, or dreaming. How obvious this seems! Yet the field of psychotherapy has traditionally obfuscated this self-evident fact. Early analysts were so convinced that self-knowledge was tantamount to change that they tended to see knowledge as the end point of therapy. If change did not occur, then it was assumed that the patient had not achieved sufficient insight.
In a well-known 1950 article in a leading psychiatric journal, Alan Wheelis thought it necessary to remind psychotherapists, "Therapy can bring about personality change only in so far as it leads a patient to adopt a new mode of behavior. A real change occurring in the absence of action is a practical and theoretical impossibility." From the standpoint of psychotherapy, what is action? Is thinking action? After all, thought can be demonstrated to consume energy. Wheelis argued that to extend the concept of action to include thought would rob action of its meaning. Thought in and of itself has no external consequences, although it may be an indispensable overture to action. One may, for example, plan, rehearse, or muster the resolve for action. Action extends one beyond oneself. It involves interaction with one's surrounding physical or interpersonal world. Action need not entail gross or even observable movement. A slight gesture or glance toward another may be action of momentous import. Action has two sides. Its obverse: the absence of action, for example, not acting in habitual fashion, not overreacting, not exploiting others, not being dishonest, may be a major action. Indeed, the therapist must court action. He or she may pretend to pursue other goals—insight, self-actualization, comfort—but in the final analysis, change, that is, action, is every therapist's secret quarry.
The problem is that nowhere in training does the therapist learn about the mechanics of action. Instead, the therapist is schooled in history taking, interpretation, and relationship, and takes the secular leap of faith that pursuance of these activities will ultimately generate change. But what if this faith is mistaken? The therapist then becomes bewildered and pushes for more insight, more self-scrutiny. Analysis and therapy stretch over three, four, and five years. Indeed, many courses of psychoanalysis consume seven and eight years, and a second analysis is so common it is no longer a mark of distinction. The therapist loses sight of how change is to come about but hopes merely that through a process of mutual fatigue, to use Wheelis's felicitous phrase, the patient's neurotic structure will crumble. But what if still no change occurs? The therapist loses patience and starts to gaze directly at volition and action instead of glancing surreptitiously at them as he or she has been trained to do.
In Wheelis's words, the therapist may find himself wishing that the patient were capable of more push, more determination, a greater willingness to make the best of it. Often this wish eventuates in remarks to the patient: "People must help themselves. Nothing worthwhile is achieved without effort. You have to try." Such interventions are seldom included in case reports, for it is assumed that they possess neither the dignity nor effectiveness of interpretation. Often an analyst feels uncomfortable about such appeals to volition as though he were using something he didn't believe in and as though this would have been unnecessary had only he analyzed more skillfully. "You have to try. People must help themselves." Wheelis says that this type of intervention is seldom included in case reports. Indeed, they are not. They are entirely off the record. Yet, they are commonplace. Every therapist thinks these thoughts and, in a vast variety of ways, conveys them to the patient. But when therapists say, "You have to try harder," or "One must make an effort," to whom are they speaking?
The problem that most therapists face is that there is no psychic agency in the analytic or behavioristic model of the mind to which such an appeal can be made. Freud's model of the mind, as I described in chapter 2, was based on Heleian principles, that is, it was an antivitalistic, deterministic model where the human being is activated and controlled by chemical-physical forces reducible to the force of attraction and repulsion. Freud was unrelenting on this issue. "Man," Freud said, "is lived by the unconscious. The deeply rooted belief in psychic freedom and choice is quite unscientific and must give ground before the claims of a determinism which governs mental life." Freud's man, as May said, is not driving anymore, but driven. Behavior is a vector, a resultant of the interplay of internal forces. But if that is true, if all a human being's mental and physical activity is determined, if there is no driver, then precisely who or what is it that can try harder or demonstrate resoluteness or courage?
The therapist who adopts a scientific deterministic position in clinical work soon encounters a serious problem. In a model of man subdivided into such interrelating but conflicting fractions as ego, superego, and id, where does the ultimate seat of responsibility lie? The issue was framed clearly by my supervisor, whom I quoted at the beginning of part two: "The goal of psychotherapy is to bring the patient to the point where he can make a free choice." But where is the choosing agency located in a deterministic model? No wonder that in our 50 sessions together, he never elaborated further upon the goal of psychotherapy. Freud never reconciled the contradiction between his deterministic model and his therapeutic endeavors. And in *The Ego and the Id*, written when he was 67, he noted that the therapist's task is to give the patient's ego freedom to choose one way or another. This often-quoted statement is supreme proof of the unacceptability of his deterministic model of man. Even though traditional analytic thought views human behavior as completely determined, even though it splits the human psyche into conflicting fractions (ego, superego, and id, or preconscious, unconscious, and conscious), still it seems necessary to include a core that is not determined. The latter-day ego analysts who proffer the concept of the autonomous ego continue to beg the question. It is as if a freely choosing homunculus were placed within one of the parts. But of course, this makes no sense at all, because, as May has noted, "How can a part be free without the whole being free?"
Some therapists have attempted to deal with this dilemma by stating that even though humans experience a subjective sense of freedom and choice, and the therapist attempts to augment this state, nonetheless, the state is an illusion, as determined as any other subjective state. This is precisely the argument made by such rationalists as Hobbes and Spinoza. Hobbes described man's sense of freedom as a "fantasm of consciousness." "If a wooden top lashed by the boys, sometimes spinning, sometimes hitting men on the shins, were sensible of its own motion, it would think that it proceeded from its own will." Similarly, Spinoza said that a self-conscious and sentient stone that was set into motion by some external, unknown force would believe itself to be completely free and would think that it continued in motion solely because of its own wish.
However, psychotherapists who believe that freedom is an illusory subjective state paint themselves into a corner. Since they state that successful psychotherapy results in the patient's feeling a greater sense of choice, they are in effect proclaiming that the purpose of therapy is to create or to restore an illusion. This view of the therapeutic process is, as May points out, entirely incompatible with one of psychotherapy's overarching values: the quest for truth and self-knowledge.
The analytic model of the psyche omits something vital, something that constitutes a major psychological construct and plays a central role in every course of psychotherapy. Before I christen this construct, let me review its characteristics and functions. It is the mental agency that transforms awareness and knowledge into action. It is the bridge between desire and act. Aristotle said it is the mental state that precedes action. Arendt said it is the "mental organ of the future," just as memory is the mental organ of the past. Kant said it is the "power of spontaneously beginning a series of successive things." It is the seat of volition, according to Farber, the "responsible mover within." Wheelis described it as the "decisive factor in translating equilibrium into a process of change." An act occurring between insight and action, which is experienced as effort or determination. It is responsibility assumption as opposed to responsibility awareness. It is that part of the psychic structure that has, as Arieti said, "the capacity to make and implement choices." It is a force composed of both power and desire, the trigger of effort, the mainspring of action.
To this psychological construct, we assign the label will, and to its function, willing. Frankly, I should much prefer some happier term, one simpler, less controversial, one not so encrusted with 2,000 years of theological and philosophical polemic. Will has the disadvantage of multiple, often conflicting definitions. For example, Schopenhauer, in his major work, *The World as Will and Representation*, regards will as the life force, "a nonrational force, a blind striving power whose operations are without purpose or design." Whereas Nietzsche, in *The Will to Power*, equates willing with power and command. He said, "To will is to command; inherent in will is the commanding thought."
One of the major sources of controversy stems from the fact that will is inextricably bound with freedom. For it makes little sense to speak of an unfree will unless we, like Hobbes and Spinoza, change the meaning of will so that it becomes an illusory subjective state rather than an actual seat of volition. Throughout history, free will has always managed to offend the prevailing worldview. Though the controversy regarding free will has continued without cessation, the opponents of the concept have changed over the centuries. The Greek philosophers had no term for free will; the very concept was incompatible with the prevailing belief in eternal recurrence, with the belief that, as Aristotle held, "coming into being necessarily implies the preexistence of something which is potentially but not actually." The Stoic fatalists, who believed that whatever is or will be was to be, rejected the idea of a freely willing agency in man. Christian theology could not reconcile the belief in divine providence, in an omniscient, omnipotent God, with the claims of free will. Later, free will clashed with scientific positivism, with Isaac Newton's and Pierre Laplace's belief in an explicable and predictable universe. Still later, the Hegelian idea of history as a necessary progress of the world spirit clashed with a free will ideology that by its very nature rejects necessity and holds that all that was or is done could as well not have been done. Lastly, free will is opposed by all deterministic systems, whether they be based on economic, behavioristic, or psychoanalytic principles.
The term will presents a problem to the psychotherapist. It was banished so long ago from the lexicon of therapy that when will is invoked now, the clinician has difficulty recognizing it, much as though it were an old, weathered acquaintance returning from exile. Perhaps, too, the clinician is not certain that he or she wishes to recognize it. Many years ago, will was replaced by motive, and therapists have learned to explain one's actions on the basis of one's motives. Thus, behavior such as paranoia is explained—that is, caused by the unconscious motivation of homosexual impulses. Genital exhibitionism is explained by unconscious castration anxiety. Yet to explain behavior on the basis of motivation is to absolve one of ultimate responsibility for one's actions. Motivation can influence, but cannot replace, will. Despite various motives, the individual still has the option of behaving or not behaving in a certain fashion.
Despite these many problems, no term other than will serves our purpose. The definitions of will that I cited earlier—trigger of effort, responsible mover, mainspring of action, seat of volition—are marvelously descriptive of the psychological construct appealed to by the psychotherapist. Many have noted the rich connotations of the word will. It conveys determination and commitment: "I will do it." As a verb, will connotes volition. As an auxiliary verb, it designates the future tense. A last will and testament is one's final effort to lunge into the future. Hannah Arendt's phrase, "the organ of the future," has particularly important implications for the therapist because the future tense is the proper tense of psychotherapeutic change. Memory, the organ of the past, is concerned with objects. The will is concerned with projects. And as I hope to demonstrate, effective psychotherapy must focus on patients' project relationships as well as on their object relationships.
The Clinician and the Will. If will is the responsible mover, and that is, I believe, a particularly useful definition of will, and if therapy requires movement and change, then it follows that the therapist, regardless of his or her frame of reference, must attempt to influence the will. To return for a moment to the previous chapter on responsibility: What happens once the clinician has succeeded in helping a patient become aware that each person bears primary responsibility for his or her unhappy life predicament? The most simple therapeutic approach available to the therapist is exhortative. For example, "You are responsible for what happens to you in your life. Your behavior is, as you yourself know, doing you in. It is not in your best interests. This is not what you want for yourself. Damn it. Change." The guileless expectation that an individual will change as a result of this approach stems directly from the moral philosophical belief that if one truly knows the good (that is, what is in the deepest sense in one's best interest), one will act accordingly. As Aquinas said, "Man, in so far as he acts willfully, acts according to some imagined good." Occasionally, very occasionally, this exhortative approach is effective. Individuals who undergo change as a result of short-term individual therapy or especially of a short-term experiential group experience, which generally focuses on awareness of responsibility, often change as
A result of this petition to conscious will. However, as I shall discuss, willpower constitutes only the first layer, and a thin layer at that, of willing. Few changes are made as a result of a deliberate, slow, dead heave of the will, as William James put it. Well-entrenched psychopathology simply will not yield to exhortation. More therapeutic power is needed.
Some therapists may attempt to increase therapeutic leverage by accenting the individual's sole responsibility. The therapist helps the patient realize that not only is the individual responsible for his situation, but that only he is responsible. The corollary of this realization is that the individual is also solely responsible for the transmutation of his or her world. In other words, no other can change one's world for one. One must actively change if one is to change.
This appeal to the will may generate some twitching or stirring in a patient, but generally is insufficient for sustained movement, and the therapist then embarks on the long, hard middle work of therapy. Though the particular tactics, strategy, formulated mechanisms, and goals depend upon the therapist's ideological school and upon personal style, I submit that the therapy is effective in so far as it influences the patient's will. The therapist may explicitly focus on interpretation and insight, interpersonal confrontation, development of a trusting and caring relationship, or analysis of maladaptive interpersonal behavior. But each of these may be viewed as a will-influencing venture.
I deliberately use the term "influence" rather than "create" or "generate." The therapist can neither create will nor inspirit or infuse the patient with will. What the therapist can do is to liberate will, to remove encumbrances from the bound, stifled will of the patient. But still, I am vague.
In my clinical work, I sometimes think of the will, that responsible mover within the patient, as a turbine encased and concealed by ponderous layers of metal. I know that the vital moving part is lodged deep in the inards of the machine. Puzzled, I circle it. I try to affect it from a distance by exertion, by poking, tapping, or incantation, by performing those rites that I have been led to believe will influence it. These rites require much patience and much blind faith, more, in fact, than many contemporary freethinking therapists are able to muster. What is required is a more expedient, rational approach to the will.
In the remainder of this chapter, I shall attempt to dismantle the turbine and systematically to examine Will in its naked form and separate the mutative steps in psychotherapy from the ritualistic, decorative ones. Because of Will's long banishment from the psychological psychotherapeutic literature, I shall first sketch the contours of a psychology of Will. I shall examine relevant clinical observations on will made by three outstanding psychotherapist theorists: Otto Rank, Leslie Farber, and Rollo May, and then, with their insights as a guide, discuss the clinical strategies and tactics of a will-influencing psychotherapy toward a clinical understanding of will.
Rank, Farber, May, Otto Rank, Will Therapy. A discussion of the will in clinical work must include the contributions of Otto Rank, for it was he who introduced the concept of the will into modern psychotherapy. Rank joined Freud in 1905 as one of his first students and was one of his close associates until 1929, when ideological differences created an unbridgeable chasm between the two men. A lay analyst and humanist with a deep and broad array of interests and knowledge, Rank's intellectual intensity, in conjunction with his protruding, fiery eyes, transfixed both students and patients. His position as editor of the leading psychoanalytic journal and as founder and director of the powerful Viennese psychoanalytic institute made him a highly influential figure in the early development of psychoanalysis.
But in the United States, destiny, abetted by wretched translations of his major works on psychotherapy, which now almost mercifully are out of print, has not dealt well with Rank. Although he has been an influential intellectual force at the Pennsylvania School of Social Work, he has had, until the recent voice of Ernest Becker, no one else to speak for him. Becker considers Rank as the brooding genius waiting in the wings. And indeed, I gasped at his prescience when reading his works, especially his books *Will Therapy* and *Truth and Reality*.
Rank's system of behavior and therapy was built around the concept of will and is far too rich and complex to allow in a short space more than a brief summary of clinically relevant issues. His departure from Freud resulted from his disagreement with the latter's psychic determinism. Despite Freud's belief that behavior is a vector of opposing drives and counterforces, a freely choosing homunculus has been, as I noted earlier, smuggled into the ego. Rank chose as his starting place that homunculus with executive function and labeled it will. He retained the concept of instinctual drives but placed them under the jurisdiction of the will. As he said, "I understand by will a positive guiding organization which utilizes creatively as well as inhibits and controls the instinctual drives."
Rank was concerned more with therapeutic outcome than with the construction of a model of the mind and was convinced that strict psychic determinism was incompatible with effective psychotherapy. A therapeutic procedure dedicated to uncovering influences upon the patient, both historical and unconscious, could only, Rank insisted, result in the patient's avoiding responsibility and becoming less able to act. As he said, "It is astonishing how much the patient knows and how relatively little is unconscious if one does not give the patient this convenient excuse for refusing responsibility."
Rank suggested that Freud's theory elevated the unconscious to a responsibility-dissolving function, the precise function played by a deity in previous systems. He wrote, "The unconscious, just as the original meaning of the word shows, is a purely negative concept which designates something momentarily not conscious, while Freud's theory has lifted it to the most powerful factor in psychic life. The basis for this, however, is not given in any psychological experience but in a moral necessity that is to find an acceptable substitute for the concept of God who frees the individual from responsibility."
The Development of the Will in the Development of the Individual. The will, Rank believed, arises in relation to instinctual impulses. The shaping of the will is influenced by the manner in which parents deal with impulse education. At first, the child's community is concerned primarily with restricting the child's impulse life in order to make the child fit for the community. The child responds to these parental restrictions with a counterforce, the anaga of the will, or as Rank put it, negative will. Gradually, the child begins to exert personal control over his or her impulses and decides, for example, on the basis of love for his or her parents, to curb these aggressive impulses. Thus, the will's function at first is inextricably tied up with impulse. Either it controls impulse, or it resists outside efforts to control impulse.
The child's emotional life too, Rank stated, develops in relation to the impulses. Emotions are different from impulses. We seek to discharge impulses, but we seek to prolong or dam up emotions. Rank referred here to pleasurable emotions but does not discuss dysphoric emotions. Hence, as he put it, "the emotional life corresponds, so to say, to an inhibited or dammed-up impulse life." Thus, Rank suggested that the emotional life is a mirror image of the impulse life, whereas the will is a separate executive entity equal in power to the impulse system. As he put it, "the will is an impulse positively actively placed in the service of the ego and not a blocked impulse as is the emotion." Later, Rank referred to the will as an ego impulse.
Rank was striving to wrench himself away from Freud but could not divest himself of Freudian drive theory. By continuing to use psychic compartmentalization, Rank created difficulties for himself. The will, a freely choosing agency, is described as an ego impulse, a term that creates as much confusion as clarity. Rank viewed the parent-child relationship, and indeed the entire assimilative process, and as we shall see, the therapeutic relation as well, as a struggle of wills and urged that parents pay exquisite sensitivity to this issue. Negative will should not be squashed but should be accepted in such a way that it is transformed into positive or creative will.
Rank subordinated other major issues of early life to the basic will struggle, saying, "The Oedipus complex has no other significance than that of a great, if not the first, will conflict between the growing individual and the counterwill of a thousand-year-old moral code represented in the parents." He continued, "Ironically, the child must subject himself to it, not in order that he should let his father live and not marry his mother, but that he should not believe in general that he can do what he wishes, that he should not trust himself to will."
Rank described three developmental stages of the will:
1. Counterwill: opposition to another's will.
2. Positive will: willing what one must.
3. Creative will: willing what one wants.
The goal of child rearing...