Existential psychotherapy by Irvin D. Yalom 01

Existential psychotherapy, written by Irvin D. Yalom, narrated by Douglas James. Copyright 1980 by Irvin D. Yalom. This edition is published by arrangement with Basic Books, an imprint of Perseus Books LLC, a subsidiary of Hatchet Book Group, Inc. New York, New York, USA. All rights reserved. Produced in the year 2024 by Echo Point Books and Media LLC, which holds the copyright there, too.

Chapter 1. Introduction.

Once several years ago, some friends and I enrolled in a cooking class taught by an Armenian matriarch and her aged servant. Since they spoke no English, and we knew no Armenian, communication was not easy. She taught by demonstration. We watched and diligently tried to quantify her recipes as she prepared an array of marvelous eggplant and lamb dishes. But our recipes were imperfect, and try as hard as we could, we couldn't duplicate her dishes. What was it, I wondered, that gave her cooking that special touch?

The answer eluded me until one day, when I was keeping a particularly keen watch on the kitchen proceedings, I saw our teacher, with great dignity and deliberation, prepare a dish. She handed it to her servant, who wordlessly carried it into the kitchen to the oven, and without breaking stride, threw in handful after handful of assorted spices and condiments. I am convinced that those surreptitious throw-ins made all the difference.

That cooking class often comes to mind when I think about psychotherapy, especially when I think about the critical ingredients of successful therapy. Formal texts, journal articles, and lectures portray therapy as precise and systematic with carefully delineated stages, strategic technical interventions, the methodical development and resolution of transference, analysis of object relations, and a careful rational program of insight-offering interpretations. Yet, I believe deeply that when no one is looking, the therapist throws in the real thing.

But what are these throw-ins? These elusive, off-the-record extras. They exist outside of formal theory. They are not written about. They are not explicitly taught. Therapists are often unaware of them. Yet, every therapist knows that he or she cannot explain why many patients improve. The critical ingredients are hard to describe, even harder to define. Indeed, is it possible to define and teach such qualities as compassion, presence, caring, extending oneself, touching the patient at a profound level, or that most elusive one of all, wisdom?

One of the first recorded cases of modern psychotherapy is highly illustrative of how therapists selectively inattend to these extras. Later descriptions of therapy are less useful in this regard because psychiatry became so doctrinaire about the proper conduct of therapy that off-the-record maneuvers were omitted from case reports. In 1892, Sigmund Freud successfully treated Fräulein Elizabeth von R., a young woman who was suffering from psychogenic difficulties in walking. Freud explained his therapeutic success solely by his technique of abreaction of repressing certain noxious wishes and thoughts. However, in studying Freud's notes, one is struck by the vast number of his other therapeutic activities.

For example, he sent Elizabeth to visit her sister's grave and to pay a call upon a young man whom she found attractive. He demonstrated a friendly interest in her present circumstances by interacting with the family on the patient's behalf. He interviewed the patient's mother and begged her to provide open channels of communication with the patient and to permit the patient to unburden her mind periodically. Having learned from the mother that Elizabeth had no possibility of marrying her dead sister's husband, he conveyed that information to his patient. He helped untangle the family financial tangle.

At other times, Freud urged Elizabeth to face with calmness the fact that the future for everyone is inevitably uncertain. He repeatedly consoled her by assuring her that she was not responsible for unwanted feelings and pointed out that her degree of guilt and remorse for these feelings was powerful evidence of her high moral character. Finally, after the termination of therapy, Freud, hearing that Elizabeth was going to a private dance, procured an invitation so he could watch her whirl past in a lively dance. One cannot help but wonder what really helped Fräulein von R. Freud's extras, I have no doubt, constituted powerful interventions. To exclude them from theory is to court error.

It is my purpose in this book to propose and elucidate an approach to psychotherapy. A theoretical structure and a series of techniques emerging from that structure which will provide a framework for many of the extras of therapy. The label for this approach, existential psychotherapy, defies succinct definition, for the underpinnings of the existential orientation are not empirical but are deeply intuitive. I shall begin by offering a formal definition and then, throughout the rest of this book, I shall elucidate that definition.

Existential psychotherapy is a dynamic approach to therapy which focuses on concerns that are rooted in the individual's existence. It is my belief that the vast majority of experienced therapists, regardless of their adherence to some other ideological school, employ many of the existential insights I shall describe. The majority of therapists realize, for example, that an apprehension of one's finitude can often catalyze a major inner shift of perspective; that it is the relationship that heals; that patients are tormented by choice; that a therapist must catalyze a patient's will to act; and that the majority of patients are bedeviled by a lack of meaning in their lives.

But the existential approach is more than a subtle accent or an implicit perspective that therapists unwittingly employ. Over the past several years, when lecturing to psychotherapists on a variety of topics, I have asked who among you consider yourselves to be existentially oriented. A sizable proportion of the audience, generally over 50%, respond affirmatively. But when these therapists are asked what is the existential approach, they find it difficult to answer. The language used by therapists to describe any therapeutic approach has never been celebrated for its crispness or simple clarity. But of all the therapy vocabularies, none rivals the existential in vagueness and confusion. Therapists associate the existential approach with such intrinsically imprecise and apparently unrelated terms as authenticity, encounter, responsibility, choice, humanistic, self-actualization, centering, Sartrean, and Heideggerian. And many mental health professionals have long considered it a muddled, soft, irrational, and romantic orientation which, rather than being an approach, offers a license for improvisation for undisciplined, woolly therapists to do their thing. I hope to demonstrate that such conclusions are unwarranted; that the existential approach is a valuable, effective psychotherapeutic paradigm as rational, as coherent, and as systematic as any other.

Existential therapy: A dynamic psychotherapy.

Existential psychotherapy is a form of dynamic psychotherapy. Dynamic is a term frequently used in the mental health field, as in psychodynamics. And if one is to understand one of the basic features of the existential approach, it is necessary to be clear about the meaning of dynamic therapy. Dynamic has both lay and technical meanings. In the lay sense, dynamic, deriving from the Greek *dynamis* to have strength or power, evokes energy and movement: a dynamic football player or politician, dynamo, dynamite. But this is not its technical sense. For if it were, what therapist would own to being non-dynamic, that is, slow, sluggish, stagnant, inert? No, the term has a specific technical use that involves the concept of force.

Freud's major contribution to the understanding of the human being is his dynamic model of mental functioning. A model that posits that there are forces in conflict within the individual and that thought, emotion, and behavior, both adaptive and psychopathological, are the resultant of these conflicting forces. Furthermore, and this is important, these forces exist at varying levels of awareness. Some indeed are entirely unconscious. The psychodynamics of an individual thus include the various unconscious and conscious forces, motives, and fears that operate within him or her. The dynamic psychotherapies are therapies based upon this dynamic model of mental functioning. So far so good.

Existential therapy, as I shall describe it, fits comfortably in the category of the dynamic therapies. But what if we ask which forces, and fears, and motives are in conflict? What is the content of this internal conscious and unconscious struggle? It is at this juncture that dynamic existential therapy parts company from the other dynamic therapies. Existential therapy is based on a radically different view of the specific forces, motives, and fears that interact in the individual. The precise nature of the deepest internal conflicts is never easy to identify. The clinician working with a troubled patient is rarely able to examine primal conflicts in pristine form. Instead, the patient harbors an enormously complex set of concerns. The primary concerns are deeply buried, encrusted with layer upon layer of repression, denial, displacement, and symbolization. The clinical investigator must contend with a clinical picture of many threads so matted together that disentanglement is difficult. To identify the primary conflicts, one must use many avenues of access: deep reflection, dreams, nightmares, flashes of profound experience and insight, psychotic utterances, and the study of children.

I shall, in time, explore these avenues, but for now, a stylized schematic presentation may be helpful. A brief review of three contrasting views of the individual's prototypic intrapsychic conflict: Freudian, neo-Freudian, and existential, illustrates by counterpoint the existential view of psychodynamics.

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

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

Existential psychodynamics. The existential position emphasizes a different kind of basic conflict: neither a conflict with suppressed instinctual strivings, nor one with internalized significant adults, but instead a conflict that flows from the individual's confrontation with the givens of existence. And I mean by givens of existence, certain ultimate concerns, certain intrinsic properties that are a part, and an inescapable part, of the human being's existence in the world. How does one discover the nature of these givens? In one sense, the task is not difficult. The method is deep personal reflection. The conditions are simple: solitude, silence, time, and freedom from the everyday distractions with which each of us fills his or her experiential world. If we can brush away or bracket the everyday world, if we reflect deeply upon our situation in the world, upon our existence, our boundaries, our possibilities, if we arrive at the ground that underlies all other ground, we invariably confront the givens of existence, the deep structures, which I shall henceforth refer to as ultimate concerns.

This process of reflection is often catalyzed by certain urgent experiences. These boundary or border situations, as they are often referred to, include such experiences as a confrontation with one's own death, some major irreversible decision, or the collapse of some fundamental meaning-providing schema. This book deals with four ultimate concerns: death, freedom, isolation, and meaninglessness. The individual's confrontation with each of these facts of life constitutes the content of the existential dynamic conflict.

Death. The most obvious, the most easily apprehended ultimate concern is death. We exist now, but one day we shall cease to be. Death will come, and there is no escape from it. It is a terrible truth, and we respond to it with mortal terror. Everything, in Spinoza's words, endeavors to persist in its own being, and a core existential conflict is the tension between the awareness of the inevitability of death and the wish to continue to be.

Freedom. Another ultimate concern, a far less accessible one, is freedom. Ordinarily, we think of freedom as an unequivocally positive concept. Throughout recorded history, has not the human being yearned and striven for freedom? Yet, freedom viewed from the perspective of ultimate ground is riveted to dread. In its existential sense, freedom refers to the absence of external structure. Contrary to everyday experience, the human being does not enter and leave a well-structured universe that has an inherent design. Rather, the individual is entirely responsible for, that is, the author of, his or her own world, life design, choices, and actions. Freedom in this sense has a terrifying implication. It means that beneath us there is no ground, nothing, a void, an abyss. A key existential dynamic then is the clash between our confrontation with groundlessness and our wish for ground and structure.

Existential isolation. A third ultimate concern is isolation. Not interpersonal isolation with its attendant loneliness, or intrapersonal isolation, isolation from parts of oneself, but a fundamental isolation. An isolation both from creatures and from world which cuts beneath other isolations. No matter how close each of us becomes to another, there remains a final, unbridgeable gap. Each of us enters existence alone and must depart from it alone. The existential conflict is thus the tension between our awareness of our absolute isolation and our wish for contact, for protection, our wish to be part of a larger whole.

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

Existential psychodynamics: General characteristics.

Existential psychodynamics refers thus to these four givens, these ultimate concerns, and to the conscious and unconscious fears and motives spawned by each. The dynamic existential approach retains the basic dynamic structure outlined by Freud but radically alters the content. The old formula is: drive leads to anxiety leads to defense mechanism. Here, anxiety is a signal of danger. That is, if instinctual drives are permitted free reign, the organism is endangered since the ego will be overwhelmed and retaliatory punishment (castration, abandonment) is inevitable, and the defense mechanisms restrict direct drive gratification but afford indirect expression (that is, in displaced, sublimated, or symbolic form). That's the old formula. The dynamic existential approach replaces that formula with: awareness of ultimate concern leads to anxiety leads to defense mechanism. Here, the anxiety springs from fear of death, groundlessness, isolation, and meaninglessness. And the defense mechanisms are of two types: one, conventional mechanisms of defense, which have been described thoroughly by Freud, Anna Freud, and Sullivan, and which defend the individual generally against anxiety regardless of its source; and two, specific defenses, to be discussed shortly, which arise to serve the specific function of coping with each of the primary existential fears.

Both formulas assume that anxiety is the fuel of psychopathology. That psychic operations, some conscious and some unconscious, evolve to deal with anxiety. That these psychic operations, defense mechanisms, constitute psychopathology, and that though they provide safety, they invariably restrict growth and experience. A major difference between these two dynamic approaches is that Freud's sequence begins with drive, whereas an existential framework begins with awareness and fear. As Otto Rank knew, the therapist has far more leverage if he or she views the individual primarily as a fearful, suffering being rather than as an instinctually driven one.

These four ultimate concerns—death, freedom, isolation, and meaninglessness—constitute the corpus of existential psychodynamics. They play an extraordinarily important role at every level of individual psychic organization and have enormous relevance to clinical work. They also provide a central organizing principle. The four sections of this book will focus on each ultimate concern in turn and explore the philosophical, psychopathological, and therapeutic implications of each.

Existential psychodynamics: The question of depth.

Another major difference between existential dynamics and Freudian and neo-Freudian dynamics involves the definition of depth. To Freud, exploration always meant excavation. With the deliberateness and patience of an archaeologist, he scraped away at the many-layered psyche until he reached bedrock, a layer of fundamental conflicts that were the psychological residue of the earliest events in the life of the individual. Deepest conflict meant earliest conflict. Freud's psychodynamics are thus developmentally based, and fundamental or primary are to be grasped chronologically. Each is synonymous with first. Accordingly, the fundamental sources of anxiety, for example, are considered to be the earliest psychosexual calamities: separation and castration.

Existential dynamics are not wedded to a developmental model. There is no compelling reason to assume that fundamental (that is, important or basic) and first (that is, chronologically first) are identical concepts. To explore deeply from an existential perspective does not mean that one explores the past. Rather, it means that one brushes away everyday concerns and thinks deeply about one's existential situation. It means to think outside of time. To think about the relationship between one's feet and the ground beneath one, between one's consciousness and the space around one. It means to think not about the way one came to be the way one is, but that one is. The past, that is, one's memory of the past, is important in so far as it is part of one's current existence and has contributed to one's current mode of facing one's ultimate concerns. But it is, as I shall discuss later, not the most rewarding area for therapeutic exploration. The future becoming present is the primary tense of existential therapy.

This distinction does not mean that one cannot explore existential factors in a developmental framework. In fact, chapter 3 explores in depth the development of the child's concept of death. But it does mean that developmental issues are not germane when an individual asks, "At this moment, at the deepest levels of my being, what are the most fundamental sources of dread?" The individual's earliest experiences, though undeniably important in life, do not provide the answer to this fundamental question. In fact, the residue of earliest life creates a biological static that serves to obscure the answer. The answer to the inquiry is transpersonal. It is an answer that cuts beneath any individual's personal life history. It is an answer that applies to every person. It belongs to the human being's situation in the world.

This distinction between the developmental dynamic-analytic model and the immediate, ahistorical existential one has more than theoretical interest. As I shall discuss in later chapters, it has profound implications for the technique of the therapist.

The existential orientation: Strange but oddly familiar.

A great deal of my material on the ultimate concerns will appear strange, yet in an odd way familiar, to the clinician. The material will appear strange because the existential approach cuts across common categories and clusters clinical observations in a novel manner. Furthermore, much of the vocabulary is different. Even if I avoid the jargon of the professional philosopher and use common-sense terms to describe existential concepts, the clinician will find the language psychologically alien. Where is the psychotherapy lexicon that contains such terms as choice, responsibility, freedom, existential isolation, mortality, purpose in life, willing? The medical library computers snickered at me when I requested literature searches in these areas.

Yet the clinician will find in them much that is familiar. I believe that the experienced clinician often operates implicitly within an existential framework. In his bones, he appreciates a patient's concerns and responds accordingly. That response is what I meant earlier by the crucial throw-ins. A major task of this book is to shift the therapist's focus to attend carefully to these vital concerns and to the therapeutic transactions that occur on the periphery of formal therapy and to place them where they belong: in the center of the therapeutic arena.

Another familiar note is that the major existential concerns have been recognized and discussed since the beginning of written thought, and that their primacy has been recognized by an unbroken stream of philosophers, theologians, and poets. That fact may offend our sense of pride in modernism, our sense of an eternal spiral of progress. But from another perspective, we may feel reassured to travel a well-worn path trailing back into time, hewed by the wisest and the most thoughtful of individuals.

These existential sources of dread are familiar too in that they are the experience of the therapist as everyman. They are by no means the exclusive province of the psychologically troubled individual. Repeatedly I shall stress that they are part of the human condition. How then, one may ask, can a theory of psychopathology rest on factors that are experienced by every individual? The answer, of course, is that each person experiences the stress of the human condition in highly individualized fashion. In this regard, the existential model does not differ significantly from every major competing theory. Every individual passes through certain developmental stages, each with its own attendant anxiety. Everyone passes through the Oedipal conflict, the disturbing emergence of aggressive and sexual feelings, castration anxiety (for males, at least), the pain of individuation and separation, and many other severe developmental challenges. The only model of psychopathology that does not rest on universally experienced factors is one based on acute trauma. However, traumatic neuroses are rare. The overwhelming majority of patients suffer from stress that, to differing degrees, is part of every person's experience. In fact, only the universality of human suffering can account for the common observation that patients are ubiquitous.

André Malraux, to cite one such observation, once asked a parish priest who had been taking confession for 50 years what he had learned about mankind. The priest replied, "First of all, people are much more unhappy than one thinks. And then, the fundamental fact is that there is no such thing as a grown-up person." Often it is only external circumstances that result in one person and not another being labeled a patient: for example, financial resources, availability of psychotherapists, personal and cultural attitudes toward therapy, or choice of profession. The majority of psychotherapists become themselves bonafide patients.

The universality of stress is one of the major reasons that scholars encounter such difficulty when attempting to define and describe normality. The difference between normality and pathology is quantitative and not qualitative. The contemporary model that seems most consistent with the evidence is analogous to a model in physical medicine that suggests that infectious disease is not simply a result of a bacterial or a viral agent invading an undefended body. Rather, disease is a result of a disequilibrium between the noxious agent and host resistance. In other words, noxious agents exist within the body at all times, just as stresses inseparable from living confront all individuals. Whether an individual develops clinical disease depends on the body's resistance (that is, such factors as immunological system, nutrition, and fatigue) to the agent. When resistance is lowered, disease develops, even though the toxicity and the virility of the noxious agent are unchanged. Thus, all human beings are in a quandary, but some are unable to cope with it. Psychopathology depends not merely on the presence or the absence of stress, but on the interaction between ubiquitous stress and the individual's mechanisms of defense.

The claim that the ultimate existential concerns never arise in therapy is entirely a function of a therapist's selective inattention. A listener tuned into the proper channel finds explicit and abundant material. A therapist may choose, however, not to attend to the existential ultimate concerns precisely because they are universal experiences and therefore nothing constructive can come from exploring them. Indeed, I have often noted in clinical work that when existential concerns are broached, the therapist and the patient are intensely energized for a short while, but soon the discussion becomes dull, and the patient and therapist seem to say tacitly, "Well, that's life, isn't it? Let's move on to something neurotic, something we can do something about."

Other therapists veer away from dealing with existential concerns not only because these concerns are universal but because they are too terrible to face. After all, neurotic patients and therapists too have enough to worry about without adding such cheery items as death and meaninglessness. Such therapists believe that existential issues are best ignored since there are only two ways to deal with the brutal existential facts of life: anxious truth or denial, and either is unpalatable. Cervantes voiced this problem when his immortal Don Quixote said, "Which would you have: wise madness or foolish sanity?" An existential therapeutic position, as I shall attempt to demonstrate in later chapters, rejects this dilemma. Wisdom does not lead to madness, nor denial to sanity. The confrontation with the givens of existence is painful but ultimately healing. Good therapeutic work is always coupled with reality testing and the search for personal enlightenment. The therapist who decides that certain aspects of reality and truth are to be eschewed is on treacherous ground. Thomas Hardy's comment, "If a way to the better there be, it exacts a full look at the worst," is a good frame for the therapeutic approach.

I shall describe the field of existential psychotherapy. Existential psychotherapy is rather much a homeless waif. It doesn't really belong anywhere. It has no homestead, no formal school, no institution. It is not welcomed into the better academic neighborhoods. It has no formal society, no robust journal. A few sickly offspring were carried away in their infancy. No stable family, no *pater familias*. It does, however, have a genealogy: a few scattered cousins and friends of the family, some in the old country, some in America.

Existential philosophy, the ancestral home.

Existentialism is not easily definable. So begins the discussion of existential philosophy in *Philosophy's Major Contemporary Encyclopedia*. Most other reference works begin in similar fashion and underscore the fact that two philosophers, both labeled existential, may disagree on every cardinal point aside from their shared aversion to being so labeled. Most philosophical texts resolve the problem of definition by listing a number of themes relating to existence, for example, being, choice, freedom, death, isolation, absurdity, and by proclaiming that an existential philosopher is one whose work is dedicated to exploring them. This is, of course, the strategy I use to identify the field of existential psychotherapy.

There is an existential tradition in philosophy and a formal existential school of philosophy. Obviously, the existential tradition is ageless. What great thinker has not at some point in both work and life turned his or her attention to life and death issues? The formal school of existential philosophy, however, has a clearly demarcated beginning. Some trace it to a Sunday afternoon in 1834 when a young Kierkegaard sat in a café smoking a cigar and mused upon the fact that he was on his way to becoming an old man without having made a contribution to the world. He thought about his many successful friends, benefactors of the age who know how to benefit mankind by making life easier and easier: some by railways, others by omnibuses and steamboats, others by telegraph, others by easily apprehended compendiums and short recitals of everything worth knowing. And finally, the true benefactors of the age who by virtue of thought make spiritual existence systematically easier and easier. His cigar burned out. The young Kierkegaard lit another and continued musing. Suddenly there flashed in his mind this thought: "You must do something. But inasmuch as with your limited capacities it will be impossible to make anything easier than it has become, you must, with the same humanitarian enthusiasm as the others, undertake to make something harder."

Kierkegaard reasoned that when all combined to make everything easier, then there is a danger that easiness will be excessive. Perhaps someone is needed to make things difficult again. It occurred to him that he had discovered his destiny. He has to go in search of difficulties like a new Socrates. And which difficulties? They were not hard to find. He only had to consider his own situation in existence, his own dread, his choices, his possibilities, and limitations. Kierkegaard devoted the remainder of his short life to exploring his existential situation and during the 1840s published several important existential treatises. His work remained untranslated for many years and exerted little influence until after the First World War, when it found fertile soil and was taken up by Martin Heidegger and Karl Jaspers.

The relation of existential therapy to the existential school of philosophy is much like that of clinical pharmacotherapy to biochemical bench research. I shall frequently draw upon philosophical works to explicate, corroborate, or illustrate some of the clinical issues, but it is not my intention, nor within my range of scholarship, to discuss in a comprehensive fashion the works of any philosopher or the major tenets of existential philosophy. This is a book for clinicians, and I mean it to be clinically useful. My excursions into philosophy will be brief and pragmatic. I shall limit myself to those domains that offer leverage in clinical work. I can't blame the professional philosopher who may liken me to the Viking raider who grabbed gemstones while leaving behind their intricate and precious settings.

As the education of the great majority of psychotherapists includes little or no emphasis on philosophy, I shall not assume any philosophical background in my readers or listeners. When I do draw upon philosophical texts, I shall attempt to do so in a straightforward, jargon-free fashion. Not an easy task, incidentally, since professional existential philosophers surpass even psychoanalytic theoreticians in the use of turbid, convoluted language. The single most important philosophical text in the field, Heidegger's *Being and Time*, stands alone as the undisputed champion of linguistic obfuscation. I have never understood the reason for the impenetrable, deep-sounding language. The basic existential concepts themselves are not complex. They don't need to be uncoded and meticulously analyzed as much as they need to be uncovered. Every person, at some point in life, enters a brown study and has some traffic with existential ultimate concerns. What is required is not formal explication. The task of the philosopher, and of the therapist as well, is to de-repress, to reacquaint the individual with something he or she has known all along. This is precisely the reason that many of the leading existential thinkers (for example, Jean-Paul Sartre, Albert Camus, Miguel de Unamuno, and Martin Buber) prefer literary exposition rather than formal philosophical argument. Above all, the philosopher and the therapist must encourage the individual to look within and to attend to his or her existential situation.

The existential analysts: Old country cousins.

A number of European psychiatrists took issue with many of the basic tenets of Freud's psychoanalytic approach. They objected to Freud's model of psychic functioning, to his efforts to understand the human being by way of an energy conservation schema borrowed from the physical sciences, and suggested that such an approach resulted in an inadequate view of the human being. If one applies one schema to explain all individuals, they argued, one misses the unique experience of the particular person. They objected to Freud's reductionism (that is, tracing all human behavior to a few basic drives), to his materialism (that is, explaining the higher in terms of the lower), and to his determinism (that is, the belief that all mental functioning is caused by identifiable factors already in existence).

The various existential analysts agreed on one fundamental procedural point: the analyst must approach the patient phenomenologically. That is, he or she must enter the patient's experiential world and listen to the phenomena of that world without the presuppositions that distort understanding. As Ludwig Binswanger, one of the best known of the existential analysts, said, "There is not one space and time only, but as many spaces and times as there are subjects."

Aside from their reaction against Freud's mechanistic, deterministic model of the mind and their assumption of a phenomenological approach in therapy, the existential analysts have little in common and have never been regarded as a cohesive ideological school. These thinkers, who include Ludwig Binswanger, Medard Boss, Eugene Minkowski, V. E. Frankl, Roland [__] G. Caruso, F. T. Bentdike, G. Bal, and Victor Frankl, were almost entirely unknown to the American psychotherapeutic community until Rollo May's highly influential 1958 book *Existence*, and especially his introductory essay, introduced their work into this country. However, today, more than 20 years after May's book, it is striking that these figures exert little influence upon American psychotherapeutic practice. They mean little more than the unknown faces and faded daguerreotypes in the family photo album. In part, this neglect has resulted from a language barrier. Aside from some of the writings of Binswanger, Boss, and Frankl, these philosophers have been seldom translated. For the most part, however, it is due to the obtrusive nature of their writing. They are steeped in a continental philosophical, world-view, far out of synchrony with the American pragmatic tradition in therapy. Thus, the continental existential analysts remain scattered and, for the most part, lost cousins of the existential therapy approach I intend to describe. I do not draw heavily from them here, with the single exception of Victor Frankl, an eminently pragmatic thinker whose work has been widely translated.

Humanistic psychologists: Flashy American cousins.

The European existential analytic trend arose both from a desire to apply philosophical concepts to a clinical study of the person and as a reaction to Freud's model of man. In the United States, an analogous movement began to rumble in the late 1950s. It surfaced and coalesced in the 1960s, and it rode madly off in all directions at once. In the 1970s, academic psychology had by the 1950s been long dominated by two major ideological schools. The first and by far the longest dominant was a scientific, positivistic behaviorism. The second was Freudian psychoanalysis. A minor voice, first heard in the late 1930s and 1940s, belonged to abnormal and social psychologists who coexisted uncomfortably in the experimental psychology bastions. Gradually, those personality theorists (for example, Gordon Allport, Henry Murray, and Gardner Murphy, and later George Kelly, Abraham Maslow, Carl Rogers, and Rollo May) grew uncomfortable with the limitations of both the behavioristic and the analytic schools. They felt that both of these ideological approaches to the person excluded some of the most important qualities that make the human being human: for example, choice, values, love, creativity, self-awareness, human potential.

In 1950, they formally established a new ideological school, which they labeled humanistic psychology. Humanistic psychology, sometimes referred to as the third force in psychology (after behaviorism and Freudian analytic psychology), became a robust organization with growing membership rolls and an annual convention attended by thousands of mental health professionals. In 1961, the American Association of Humanistic Psychology founded the *Journal of Humanistic Psychology*, which has included on its editorial board such well-known figures as Carl Rogers, Rollo May, Lewis Mumford, Kurt Goldstein, Charlotte Bühler, Abraham Maslow, Aldous Huxley, and James Bugental.

The fledgling organization made some early attempts to define itself. In 1962, it formally stated: "Humanistic psychology is primarily concerned with those human capacities and potentialities that have little or no systematic place either in positivist or behaviorist theory or in classical psychoanalytic theory. For example, love, creativity, self, growth, organism, basic need, gratification, self-actualization, higher values, being, becoming, spontaneity, play, humor, affection, naturalness, warmth, ego, transcendence, objectivity, autonomy, responsibility, meaning, fair play, transcendental experience, psychological health, and related concepts." In 1963, the association's president, James Bugental, suggested five basic postulates:

1. Man as man supersedes the sum of his parts. That is, man cannot be understood from a scientific study of part functions.

2. Man has his being in a human context. That is, man cannot be understood by part functions which ignore interpersonal experience.

3. Man is aware and cannot be understood by a psychology which fails to recognize man's continuous, many-layered self-awareness.

4. Man has choice. Man is not a bystander to his existence. He creates his own experience.

5. Man is intentional. Man points to the future. He has purpose, values, and meaning.

Much in these early manifestos—anti-determinism, the emphasis on freedom, choice, purpose, values, responsibility, the dedication to appreciating the unique experiential world of each individual—is of great importance in the existential frame of reference I present in this book. But by no means is the American field of humanistic psychology synonymous with the continental existential tradition. There is a fundamental difference in accent. The existential tradition in Europe has always emphasized human limitations and the tragic dimensions of existence. Perhaps it has done so because Europeans have had a greater familiarity with geographic and ethnic confinement, with war, death, and uncertain existence. The United States and the humanistic psychology it spawned bathed in a zeitgeist of expansiveness, optimism, limitless horizons, and pragmatism. Accordingly, the imported form of existential thought has been systematically altered. Each of the basic tenets has a distinct New World accent. The European focus is on limits, on facing and taking into oneself the anxiety of uncertainty and non-being. The humanistic psychologists, on the other hand, speak less of limits and contingency than of development, of potential; less of acceptance than of awareness; less of anxiety than of peak experiences and oceanic oneness; less of life meaning than of self-realization; less of apartness and basic isolation than of I-thou and encounter.

In the 1960s, the counterculture with its attendant social phenomena such as the free speech movement, the flower children, the drug culture, the human potentialists, the sexual revolution engulfed the humanistic psychological movement. Soon the association conventions developed aspects of a carnival. The big tent of humanist psychology was, if nothing else, generous, and soon included a bewildering number of schools, barely able to converse with one another, even in an existential *espéranto*: Gestalt therapy, transpersonal therapy, encounter groups, holistic medicine, psychosynthesis, Sufi, and many, many others pranced into the arena. The new trends have value orientations that bear significant implications for psychotherapy. There is an emphasis on hedonism ("If it feels good, do it"), on anti-intellectualism (which considers any cognitive approach as mind-f***ing), on individual fulfillment ("doing your own thing"), peak experiences, and on self-actualization (a belief in human perfectability is common to most humanistic psychologists, with the major exception of Rollo May, who is more deeply grounded in the existential philosophical tradition). These proliferating trends, especially the anti-intellectual ones, soon effected a divorce between humanistic psychology and the academic community. Humanistic psychologists in established academic positions felt uneasy about the company they were keeping and gradually disaffiliated themselves. Fritz Perls himself, far from an advocate of discipline, expressed great concern about the "turner honors," the "anything goes," the "instant sensory awareness" approach. I, and eventually the three figures who supplied humanistic psychology with its initial intellectual leadership—May, Rogers, and Maslow—grew deeply ambivalent about these irrational trends and gradually decreased their active sponsorship.

Existential psychotherapy thus has a hazy relationship with humanistic psychology. They share many basic tenets; however, and many humanistic psychologists have an existential orientation. Among them, Maslow, Perls, Bugental, Bühler, and especially Rollo May will be cited frequently in this text.

Humanistic psychoanalysts: Friends of the family.

There remains a group of relatives whom I shall refer to as humanistic psychoanalysts, and who split off early from the genealogical branches I have described. Though they never considered themselves a clan, they closely parallel one another in their work. The major voices in this group—Otto Rank, Karen Horney, Erich Fromm, and Helmuth Kaiser—were all trained in the European Freudian psychoanalytic tradition but immigrated to America, and all, with the exception of Rank, made their major contributions while immersed in the American intellectual community. Each objected to Freud's instinct-powered model of human behavior, and each suggested important correctives. Though the work of each was far-ranging, each for a period of time turned his or her attention to some aspect of existential therapy. Rank, whose contributions have been brilliantly augmented by latter-day interpreter Ernest Becker, emphasized the importance of the will and of death anxiety. Horney, the crucial role of the future as an influencer of behavior (the individual is motivated by purpose, ideals, and goals rather than shaped and determined by past events). Fromm has masterfully eliminated the role and fear of freedom in behavior, while Kaiser has dealt with responsibility and isolation.

In addition to these major branches of philosophers, humanistic psychologists, and humanistically oriented psychoanalysts, the genealogical tree of existential therapy contains another important segment constituted by the great writers who no less fully than their professional brethren explored and explicated existential issues. Thus, the voices of Dostoevsky, Tolstoy, Kafka, Sartre, Camus, and many other distinguished teachers will be heard frequently throughout this book. Great literature survives, as Freud pointed out in his discussion of *Oedipus Rex*, because something in the reader leaps out to embrace its truth. The truth of fictional characters moves us because it's our own truth. Furthermore, great works of literature teach us about ourselves because they are scorchingly honest, as honest as any clinical data. The great novelist, however his or her personality may be split among many characters, is ultimately highly self-revelatory. Thornton Wilder once wrote, "If Queen Elizabeth or Frederick the Great or Ernest Hemingway were to read their biographies, they would exclaim, 'Ah, my secret is still safe.' But if Natasha Rostova were to read *War and Peace*, she would cry out as she covered her face with her hands, 'How did he know? How did he know?'"

Existential therapy and the academic community.

Earlier I likened existential therapy to a homeless waif who was not permitted into the better academic neighborhoods. The lack of academic support from academic psychiatry and psychology has significant implications for the field of existential therapy since academically dominated institutions control all the vital supply routes that influence the development of the clinical disciplines, the training of clinicians and academicians, research funding, tenure, and journal publication. It is worth taking a moment to consider why the existential approach is so quarantined by the academic establishment. The answer centers primarily on the issue of the basis of knowledge. That is, how do we know what we know? Academic psychiatry and psychology, grounded in a positivist tradition, value empirical research as the method of validating knowledge. Consider the typical career of the academician. And I speak not only from observation but from my own 20-year academic career. The young lecturer or assistant professor is hired because he or she displays aptitude and motivation for empirical research, and later is rewarded and promoted for carefully and methodically performed research. The crucial tenure decision is made on the basis of the amount of empirical research published in refereed scientific journals. Other factors, such as teaching skills or non-empirical books, book chapters, and essays, are given decidedly secondary consideration.

It is extraordinarily difficult for a scholar to carve out an academic career based on an empirical investigation of existential issues. The basic tenets of existential therapy are such that empirical research methods are often inapplicable or inappropriate. For example, the empirical research method requires that the investigator study a complex organism by breaking it down into its component parts, each simple enough to permit empirical investigation. Yet, this fundamental principle negates a basic existential principle. A story told by Viktor Frankl is illustrative. Two neighbors were involved in a bitter dispute. One claimed that the other's cat had eaten his butter and accordingly demanded compensation. Unable to resolve the problem, the two, carrying the accused cat, sought out the village wise man for a judgment. The wise man asked the accuser, "How much butter did the cat eat?" "10 lb," was the response. The wise man placed the cat on the scale. Lo and behold, it weighed exactly 10 lb. "Marvellous!" he proclaimed. "Here we have the butter. But where is the cat?" Where is the cat? All the parts taken together do not reconstruct the creature. A fundamental humanistic credo is that man is greater than the sum of his parts. No matter how carefully one understands the composite parts of the mind (for example, the conscious and the unconscious, the superego, the ego, and the id), one still does not grasp the central, vital agency, the person whose unconscious or superego or id or ego it is. Furthermore, the empirical approach never helps one to learn the meaning of this psychic structure to the person who possesses it. Meaning can never be obtained from a study of component parts because meaning is never caused; it is created by a person who is supraordinate to all his parts.

But there is in the existential approach a problem for empirical research even more fundamental than the one of "where is the cat?" Rollo May alluded to it when he defined existentialism as "the endeavor to understand man by cutting below the cleavage between subject and object which has bedeviled Western thought and science since shortly after the Renaissance." The cleavage between subject and object. Let's take a closer look at that. The existential position challenges the traditional Cartesian view of a world full of objects and of subjects who perceive those objects. Obviously, this is the basic premise of the scientific method. There are objects with a finite set of properties that can be understood through objective investigation. The existential position cuts below this subject-object cleavage and regards the person not as a subject who can, under the proper circumstances, perceive external reality but as a consciousness who participates in the construction of reality. To emphasize this point, Heidegger always spoke of the human being as *Dasein* (pronounced "dah-zain"). *Da* there refers to the fact that the person is there (is a constituted object, an empirical ego) but at the same time constitutes the world (that is, is a transcendental ego). *Dasein* is at once the meaning-giver and the known. Each *Dasein*, therefore, constitutes its own world. To study all beings with some standard instrument as though they inhabited the same objective world is to introduce monumental error into one's observations.

It is important to keep in mind, however, that the limitations of empirical psychotherapy research are not confined to an existential orientation in therapy. It is only that they are more explicit in the existential approach. In so far as therapy is a deeply personal human experience, the empirical study of psychotherapy of any ideological school will contain errors and be of limited value. It is common knowledge that psychotherapy research has had, in its 30-year history, little impact upon the practice of therapy. In fact, as Carl Rogers, the founding father of empirical psychotherapy research, sadly noted, "not even psychotherapy researchers take their research findings seriously enough to alter their approach to psychotherapy."

It is also common knowledge that the great majority of clinicians stop doing empirical research once they finish their dissertation or earn tenure. If empirical research is a valid truth-seeking, truth-finding endeavor, why do psychologists and psychiatrists, once they have fulfilled academic requirements, put away their tables of random numbers for good?

I believe that as the clinician gains maturity, he or she gradually begins to appreciate that there are staggering problems inherent in an empirical study of psychotherapy. A personal experience may be illustrative. Several years ago, two colleagues and I conducted a large research project on the process and the outcome of encounter groups. We published the results in a book, *Encounter Groups: First Facts*, which has been at once hailed as a benchmark for precision in clinical work and attacked furiously by many humanistic psychologists. In fact, an issue of the aforementioned *Journal of Humanistic Psychology* was devoted to a vigorous attack on this work. My two colleagues wrote robust and effective replies to the critiques, but I declined to do so. For one thing, I was entirely occupied in writing my present book. At a deeper level, I had doubts about the meaning of our research, not for the reasons under public attack, but for something else. I could not believe that the true experience of the participants was adequately described by our highly technical computerized statistical approach.

One finding in the methodological center of the work particularly troubled me. We had used an enormous battery of psychological instruments to assess how much each encounter group participant had changed. Outcome measures were taken from four different perspectives: one from the participant himself, two from the group leader, three from the participant's co-members, four from the participant's social network. The correlation between these four perspectives of change was zero. In other words, there was zero order agreement between the various sources of information about who had changed and how much they had changed. Now, of course, there are statistical ways to handle this finding, but the fact remains that outcome evaluation is highly relative and depends heavily on the source of information. Nor is this a problem confined to this project. It plagues every psychotherapy outcome study. The more methods used to assess outcome, the less certain is the researcher of his results.

How do researchers deal with this problem? One method is to increase reliability by asking fewer questions and to rely upon a single source of data. Another common method is to steer clear of soft or subjective criteria and measure only objective criteria such as amount of alcohol consumed, the number of times one spouse interrupts the other in some given period of time, the number of bites of food taken, galvanic skin response, or the size of penile tumescence while looking at slides of naked youths. But woe to the researcher who tries to measure the important factors such as ability to love or care for another, zest in life, purposefulness, generosity, exuberance, autonomy, spontaneity, humor, courage, or engagement in life. Again and again, one encounters a basic fact of life in psychotherapy research: the precision of the result is directly proportional to the triviality of the variables studied. A strange type of science.

What is the alternative? The proper method of understanding the inner world of another individual is the phenomenological one: to go directly to the phenomena themselves. To encounter the other without standardized instruments and presuppositions. So far as possible, one must bracket one's own world perspective and enter the experiential world of the other. Such an approach to knowing another person is eminently feasible in psychotherapy. Every good therapist tries to relate to the patient in this manner. That is what is meant by empathy, presence, genuine listening, non-judgmental acceptance, or an attitude of disciplined naivety, to use May's felicitous phrase. Existential therapists have always urged that the therapist attempt to understand the private world of the patient rather than to focus on the way the patient has deviated from the norms. But this phenomenological approach, which by definition is non-empirical, raises staggering and as yet unsolved problems for the researcher who struggles to achieve high scientific standards in his or her work.

In spite of these reservations, my professional training has compelled me to consider the extent research for each of the four basic existential concerns: death, freedom, isolation, and meaninglessness. And of course, careful research can shed light on several important areas of inquiry. For example, research can tell us how frequently patients are explicitly concerned with existential issues or how frequently therapists perceive these concerns. For the many existential topics that have never been explicitly studied by researchers, I have examined research in tangential areas which may possibly bear upon the issue. For example, chapter 6 discusses locus of control research because it's relevant to the areas of responsibility and willing. Other topics do not, for reasons discussed, permit empirical research. Researchers have accordingly selected some partial problems that are more available for study. For example, as we shall see, there exist many death anxiety scales which study the phenomenon of dread, but in such a superficial and norm-based manner as to offer little illumination. I'm reminded of the story of the man searching at night for a lost key, not in the dark alley where he dropped it, but under a lamppost where the light was better. I cite this partial problem research with appropriate caveats. There are still other domains where knowledge must remain intuitive. Certain truths of existence are so clear and sure that logical argument or empirical research corroboration seems highly gratuitous. Carl Lashley, the neuro-psychologist, is said to have once commented, "If you teach an Airedale to play the violin, you don't need a string quartet to prove it."

I have attempted to write this book in a style sufficiently lucid and free of jargon that it will be intelligible to the lay reader. However, the primary audience for whom I intend it is the student and the practicing psychotherapist. It is important to note that even though I assume for my reader no formal philosophical education, I do assume some clinical background. I don't mean this to be a first or a complete psychotherapy text, but expect the reader or listener to be familiar with conventional clinical explanatory systems. Hence, when I describe clinical phenomena from an existential frame of reference, I don't always offer alternate modes of explanation for them. My task, as I view it, is to describe a coherent psychotherapy approach based on existential concerns, which gives an explicit place to the procedures that the majority of therapists employ implicitly. I do not pretend to describe the theory of psychopathology and psychotherapy. Instead, I present a paradigm, a psychological construct that offers the clinician a system of explanation, a system that permits him or her to make sense out of a large array of clinical data and to formulate a systematic strategy of psychotherapy. It is a paradigm that has considerable explanatory power. It is parsimonious, that is, it rests on relatively few basic assumptions, and it is accessible, that is, the assumptions rest on experiences that may be intuitively perceived by every introspective individual. Furthermore, it is a humanistically based paradigm, consonant with the deeply human nature of the therapeutic enterprise. But it is a paradigm, not *the* paradigm. Useful for some patients, not for all patients; employable by some therapists, not by all therapists. The existential orientation is one clinical approach among other approaches. It repatterns clinical data, but like other paradigms, has no exclusive hegemony and is not capable of explaining all behavior. The human being has too much complexity and possibility to permit that it do so. Existence is inexorably free and thus uncertain. Cultural institutions and psychological constructs often obscure this state of affairs. But confrontation with one's existential situation reminds one that paradigms are self-created, wafer-thin barriers against the pain of uncertainty. The mature therapist must, in the existential theoretical approach as in any other, be able to tolerate this fundamental uncertainty.

Part One: Death. In the next four chapters, I shall explore the role played by the concept of death in psychopathology and psychotherapy. The basic postulates I describe are simple: One, the fear of death plays a major role in our internal experience. It haunts as does nothing else. It rumbles continuously under the surface. It is a dark, unsettling presence at the rim of consciousness. Two, the child at an early age is pervasively preoccupied with death, and his or her major developmental task is to deal with terrifying fears of obliteration. Three, to cope with these fears, we erect defenses against death awareness. Defenses that are based on denial, that shape character structure, and that, if maladaptive, result in clinical syndromes. In other words, psychopathology is the result of ineffective modes of death transcendence. Four, lastly, a robust and effective approach to psychotherapy may be constructed on the foundation of death awareness.

Chapter 2 will provide an overview of the role of the concept of death in psychotherapy. We'll present relevant clinical and research evidence, and then we'll explore why traditional analytic thought has painstakingly omitted death from both psychotherapy theory and technique. Chapter 3 will discuss the development of the concept of death in children and will focus on the defense mechanisms that emerge to protect the individual from death anxiety. Chapter 4 will present a paradigm of psychopathology based on these death-denying defenses. And chapter 5 will describe both the theory and the practical implementation of an approach to therapy based on death awareness.

Chapter 2: Life, Death, and Anxiety. "Don't scratch where it doesn't itch," the great Adolf Meyer counseled a generation of student psychiatrists. Is that adage not an excellent argument against investigating patients' attitudes toward death? Don't patients have quite enough fear and quite enough dread without the therapist reminding them of the grimmest of life's horrors? Why focus on bitter and immutable reality? If the goal of therapy is to instill hope, why invoke hope-defeating death? The aim of therapy is to help the individual learn how to live. Why not leave death for the dying?

These arguments demand a response, and I shall address them in this chapter by arguing that death *itches* all the time, that our attitudes toward death influence the way we live and grow, and the way we falter and fall ill. I shall examine two basic propositions, each of which has major implications for the practice of psychotherapy. One, life and death are interdependent. They exist simultaneously, not consecutively. Death burrs continuously beneath the membrane of life and exerts a vast influence upon experience and conduct. Two, death is a primordial source of anxiety, and as such is the primary fuel of psychopathology.

Life-Death Interdependence. A venerable line of thought, stretching back to the beginning of written thought, emphasizes the interdigitation of life and death. It is one of life's most self-evident truths that everything fades, that we fear the fading, and that we must live nonetheless in the face of the fading, in the face of the fear. Death, the Stoic said, was the most important event in life. Learning to live well is to learn to die well. And conversely, learning to die well is to learn to live well. Cicero said, "To philosophize is to prepare for death." And Seneca, "No man enjoys the true taste of life but he who is willing and ready to quit it." St. Augustine expressed the same idea: "It is only in the face of death that man's self is born." It is not possible to leave death to the dying. The biological life-death boundary is relatively precise. But psychologically, life and death merge into one another. Death is a fact of life. A moment's reflection tells us that death is not simply the last moment of life. The Roman poet Marcus Manilius said, "Even in birth we die. The end is there from the start." Montaigne, in his penetrating essay on death, asked, "Why do you fear your last day? It contributes no more to your death than each of the others. The last step does not cause the fatigue, but reveals it." It would be a simple matter, and a most seductive one, to continue citing important quotations about death. Virtually every great thinker, generally early in life or toward its end, has thought deeply and written about death. And many have concluded that death is inextricably a part of life, and that lifelong consideration of death enriches rather than impoverishes life.

"Although the physicality of death destroys man, the idea of death saves him." This last thought is so important that it bears repeating: "Although the physicality of death destroys man, the idea of death saves him." But what precisely does this statement mean? How does the idea of death save man, and save him from what? A brief look at a core concept of existential philosophy may provide clarification. Martin Heidegger, in 1926, explored the question how the idea of death may save man and arrived at the important insight that the awareness of our personal death acts as a spur to shift us from one mode of existence to a higher one. Heidegger believed that there are two fundamental modes of existing in the world: one, a state of forgetfulness of being, or two, a state of mindfulness of being. When one lives in a state of forgetfulness of being, one lives in the world of things and immerses oneself in the everyday diversions of life; one is leveled down, absorbed in idle chatter, lost in the "they." One surrenders oneself to the everyday world, to a concern about the way things are. In the other state, the state of mindfulness of being, one marvels not about the way things are, but *that* they are. To exist in this mode means to be continually aware of being. In this mode, which is often referred to as the ontological mode (from the Greek *ontos*, meaning existence), one remains mindful of being—not only mindful of the fragility of being, but mindful too, as I shall discuss in chapter 6, of one's responsibility for one's own being. Since it is only in this ontological mode that one is in touch with one's self-creation, it is only here that one can grasp the power to change oneself.

Ordinarily, one lives in the first state. Forgetfulness of being is the everyday mode of existence. Heidegger refers to it as inauthentic—a mode in which one is unaware of one's authorship of one's life and world, in which one flees, falls, and is tranquilized, in which one avoids choices by being carried along by the "nobody." When, however, one enters the second mode of being, mindfulness of being, one exists authentically—hence the frequent modern use of the term authenticity in psychology. In this state, one becomes fully self-aware, aware of oneself as a transcendental constituting ego as well as an empirical constituted ego. One embraces one's possibilities and limits. One faces absolute freedom and nothingness and is anxious in the face of them.

Now, what does death have to do with all this? Heidegger realized that one doesn't move from a state of forgetfulness of being to a more enlightened, anxious mindfulness of being by simple contemplation, by bearing down, by gritting one's teeth. There are certain unalterable, irrefutable conditions, certain urgent experiences that jolt one, that tug one from the first, everyday state of existence to the state of mindfulness of being. Of these urgent experiences, Jaspers later referred to them as border, or boundary, or limit situations. Death is the nonpareil. Death is the condition that makes it possible for us to live life in an authentic fashion.

This point of view, that death makes a positive contribution to life, is not one easily accepted. Generally, we view death as such an unmitigated evil that we dismiss any contrary view as an implausible joke. "We can manage quite well without the plague. Thank you." But suspend judgment for a moment and imagine life without any thought of death. Life loses something of its intensity. Life shrinks when death is denied. Freud, who for reasons I shall discuss shortly, spoke little of death, believed that the transience of life augments our joy in it. He said, "Limitation in the possibility of an enjoyment raises the value of the enjoyment." Freud, writing during the First World War, said that the lure of war was that it brought death into life. Once again, as he put it, "Life has indeed become interesting again. It has recovered its full content." When death is excluded, when one loses sight of the stakes involved, life becomes impoverished. It is turned into something, Freud wrote, "as shallow and empty as, let us say, an American flirtation, in which it is understood from the first that nothing is to happen, as contrasted with a continental love affair, in which both partners must constantly bear its serious consequences in mind."

Many have speculated that the absence of the fact of death, as well as the idea of death, would result in the same blunting of one's sensibilities to life. For example, in the French playwright Jean Giraudoux's *The Trojan War Will Not Take Place*, there is a conversation between the immortal gods. Jupiter tells Mercury what it is like to don earthly guise to make love to a mortal woman. "She will use little expressions, and that widens the abyss between us. She will say, 'When I was a child,' or 'When I am old,' or 'Never in all my life.' This stabs me, Mercury. We miss something, Mercury. The poignancy of the transient, the intimation of mortality, that sweet sadness of grasping at something you cannot hold." Similarly, Montaigne imagines a conversation in which Chiron, half god, half mortal, refuses immortality when his father, Saturn, the god of time and duration, describes the implications of the choice. "Imagine honestly how much less bearable and more painful to man would be an everlasting life than the life I have given him. If you did not have death, you would curse me incessantly for having deprived you of it. I have deliberately mixed it with a little bitterness to keep you seeing the convenience of it, from embracing it too greedily and intemperately, to lodge you in the moderate state that I ask of you, of neither fleeing life nor fleeing back from death. I have tempered both of them between sweetness and bitterness."

I do not wish to participate in a necrilic cult or to advocate a life-denying morbidity. But it must not be forgotten that our basic dilemma is that each of us is both angel and beast of the field. We are the mortal creatures who, because we are self-aware, know that we are mortal. A denial of death at any level is a denial of one's basic nature and begets an increasingly pervasive restriction of awareness and experience. The integration of the idea of death saves us rather than sentences us to existences of terror or bleak pessimism. It acts as a catalyst to plunge us into more authentic life modes and it enhances our pleasure in the living of life.

As corroboration, we have the testimony of individuals who have had a personal confrontation with death.

Confrontation with Death, Personal Change. Some of our greatest literary works have portrayed the positive effects on an individual of a close encounter with death. Tolstoy's *War and Peace* provides an excellent illustration of how death may instigate a radical personal change. Pierre, the protagonist, feels deadened by the meaningless, empty life of the Russian aristocracy. A lost soul, he stumbles through the first 900 pages of the novel, searching for some purpose in life. The pivotal point of the book occurs when Pierre is captured by Napoleon's troops and sentenced to death by firing squad. Sixth in line, he watches the execution of the five men in front of him and prepares to die, only at the last moment to be unexpectedly reprieved. The experience transforms Pierre, who then spends the remaining 300 pages of the novel living his life zestfully and purposefully. He is able to give himself fully in his relationships to others, to be keenly aware of his natural surroundings, to discover a task in life that has meaning for him, and to dedicate himself to it.

Tolstoy's story *The Death of Ivan Ilyich* contains a similar message. Ivan Ilyich, a mean-spirited bureaucrat, develops a fatal illness (probably abdominal cancer) and suffers extraordinary pain. His anguish continues relentlessly until shortly before his death, Ivan Ilyich comes upon a stunning truth: he is dying badly because he has lived badly. In the few days remaining to him, Ivan Ilyich undergoes a dramatic transformation that is difficult to describe in any other terms than personal growth. If Ivan Ilyich were a patient, any psychotherapist would beam with pride at the changes in him. He relates more empathically to others. His chronic bitterness, arrogance, and self-aggrandizement disappear. In short, in the last few days of his life, he achieves a far higher level of integration than he has ever reached previously.

This phenomenon occurs with great frequency in the world of the clinician. For example, interviews with six of the ten would-be suicides who leaped off the Golden Gate Bridge and survived indicate that as a result of their leap into death, these six had changed their views of life. One reported, "My will to live has taken over. There is a benevolent God in heaven who permeates all things in the universe." Another, "We are all members of the Godhead, that great God humanity." Another, "I have a strong life drive now. My whole life is reborn. I have broken out of old pathways. I can now sense other people's existence." Another, "I feel I love God now and wish to do something for others." Another, "I was refilled with a new hope and purpose in being alive. It's beyond most people's comprehension. I appreciate the miracle of life, like watching a bird fly. Everything is more meaningful when you come close to losing it. I experienced a feeling of unity with all things and a oneness with all people. After my psychic rebirth, I also feel for everyone's pain. Everything was clear and bright."

Other clinical examples abound. Abraham Schmidt describes in detail a chronically depressed patient who made a serious suicide attempt and survived by sheer chance, and points out what Schmidt described as the total discontinuity between the two halves of her life before and after her suicide attempt. Schmidt speaks of his professional contact with her not as therapy but as a monitoring of her drastic life change. To describe her, her friends use the word "vibrant," meaning "tinkling with life and enthusiasm." The therapist states that following her suicide attempt, she was "in touch with herself, her life, and her husband. Her life is now lived to the fullest and is filling many other lives." Within a year after the suicide and the transition, she became pregnant with the first of several children who were born in quick succession. She had long been barren.

Russell Noyes studied 200 individuals who had near-death experiences (automobile accidents, drownings, mountain climbing, falls, and so forth) and reported that a substantial number, 23%, described, even years later, that as a result of their experience, they possessed "a strong sense of the shortness of life and the preciousness of it, a greater sense of zest in life, a heightening of perception and emotional responsivity to immediate surroundings, an ability to live in the moment and to savor each moment as it passes. A greater awareness of life, awareness of life and living things, and the urge to enjoy it now before it is too late." Many described a reassessment of priorities, of becoming more compassionate and more human-oriented than they had been before. Abdul Hussein and Seymour Tossman, physicians on a prison's death row, describe in a clinical case report three men condemned to death who received last-minute reprieves. All three, according to the authors, evinced a deep alteration in personality style and a remarkable change in attitude which persisted through the follow-up of several months.

Cancer, Confrontation with Death. The Chinese pictogram for crisis is a combination of two symbols: danger and opportunity. Over my many years of work with terminally ill cancer patients, I have been struck by how many of them use their crisis and their danger as an opportunity for change. They report startling shifts, inner changes that can be characterized in no other way than personal growth: a rearrangement of life's priorities, a trivializing of the trivial, a sense of liberation, being able to choose not to do those things that they do not wish to do. An enhanced sense of living in the immediate present rather than postponing life until retirement or some other point in the future. A vivid appreciation of the elemental facts of life: the changing seasons, the wind, falling leaves, the last Christmas, and so forth. Deeper communication with loved ones than before the crisis. Fewer interpersonal fears, less concern about rejection, greater willingness to take risks than before the crisis.

Senator Richard Newberger, shortly before his death from cancer, described these changes: "A change came over me which I believe is irreversible. Questions of prestige, of political success, of financial status became all at once unimportant. In those first hours when I realized I had cancer, I never thought of my seat in the Senate, of my bank account, or of the destiny of the free world. My wife and I have not had a quarrel since my illness was diagnosed. I used to scold her about squeezing the toothpaste from the top instead of the bottom, about not catering sufficiently to my fussy appetite, about making up guest lists without consulting me, about spending too much on clothes. Now I'm either unaware of such matters, or they seem irrelevant. In their stead has come a new appreciation for things I once took for granted: eating lunch with a friend, scratching Muffet's ears and listening for his purr, the company of my wife, reading a book or magazine in the quiet cone of my bed lamp at night, raiding the refrigerator for a glass of orange juice or slice of coffee cake. For the first time, I think I actually am savoring life. I realize finally that I am not immortal. I shudder when I remember all the occasions that I spoiled for myself, even when I was in the best of health, by false pride, synthetic values, and fancied slights."

How commonly do positive personal changes follow a confrontation with death? The cancer patients I studied were a self-selected sample consisting of psychologically minded women with cancer who had elected to seek a support group for cancer patients. To examine the general prevalence of this phenomenon, my colleagues and I designed a research project to study patients in a purely medical setting. We constructed a questionnaire to measure some of these personal changes and administered it to 70 consecutive patients who consulted medical oncologists for treatment of metastatic breast cancer, cancer that had spread elsewhere in the body and for which there is no surgical or medical cure. The patients in the study were all outpatients. Few had incapacitating physical pain or disability. They all knew their diagnosis and knew too that though they might live for months or even years, they would ultimately die of their disease.

One part of the questionnaire consisted of 17 personal growth statements, each of which patients were asked to score on a five-point scale, ranging from hardly ever to always, for two time periods: before the onset of cancer and now. The 17 statements were:

1. I communicate openly with my husband.

2. I appreciate the beauty of nature.

3. I have a sense of personal freedom.

4. I try to communicate openly with my children.

5. It is important to me to be liked by everyone.

6. I obtain much pleasure from life.

7. I communicate honestly and frankly.

8. I do only things I really want to do.

9. I live in the present rather than in the past or future.

10. I have moments of deep serenity.

11. I stand up for my own personal rights.

12. I have a sense of psychological well-being.

13. I communicate openly with my friends.

14. I feel I have something of value to teach others about life.

15. I am able to choose what I want to do.

16. My life has meaning and purpose.

17. Religious or spiritual beliefs have much significance for me.

When we examined the results, we learned that the majority of patients had rated no changes between before and now. However, of those patients who did report differences between before and now, the differences were almost invariably in the direction of greater growth since the onset of cancer. More patients reported positive than negative changes on 14 of the 17 items. Some of the items showed significant differences. For example, on item 14, "I feel I have something of value to teach others about life," 18 patients reported a positive shift; three, a negative one. Item 11, "I stand up for my own personal rights," 12 positive, three negative. Item 2, "I appreciate the beauty of nature," 11 positive, two negative. Who would suspect that terminal cancer might increase one's moments of deep serenity? Item 10. Yet 18 patients reported such an increase in contrast to eight who reported a negative shift.

Another part of the questionnaire examined changes in the intensity of common fears. 29 fears were selected from a standard fear checklist, and patients were asked to rate severity before cancer and now. The listed fears are:

1. Dead people.

2. Angry people.

3. Parting from friends.

4. Enclosed places.

5. Feeling rejected by others.

6. Feeling disapproved of.

7. Being ignored.

8. Darkness.

9. People with deformities.

10. Making mistakes.

11. Looking foolish.

12. Losing control.

13. Being in charge or responsible for decisions.

14. Becoming mentally ill.

15. Taking written tests.

16. Being touched by others.

17. Feeling different from others.

18. Being alone.

19. Being in a strange place.

20. Speaking in public.

21. Bad dreams.

22. Failure.

23. Entering a room where other people are already seated.

24. Looking down from high buildings.

25. Strangers.

26. Feeling angry.

27. People in authority.

28. A lull in conversation.

29. Crawling insects.

The results of this questionnaire indicated the same trend in the personal growth items, though not of the same magnitude. On nine items, patients reported greater fear since the onset of cancer. On one item, there was an equal shift. The same number of patients reported less fear now as reported more fear now. And on 19 of the 29 items, more patients reported less fear now than before they had cancer.

Though no other systematic studies of this phenomenon appear in the literature, most therapists can supply anecdotal clinical material to illustrate it. Many therapists have worked with patients who, in the midst of therapy, had some confrontation with death, which resulted in a rapid change in life perspective and a realignment of life's priorities. Schmidt had a patient whom kidney failure had brought extremely close to death. After a long period of time on renal dialysis, the patient had a successful kidney transplant and re-entered life with a sense of both physical and psychological rebirth. She describes her experience: "Actually, the only way I can describe myself is that I think of myself as having lived two lives. I even call them the first and the second Kathy. The first Kathy died during dialysis. She could not make it long in the face of death. A second Kathy had to be born. This is the Kathy that was born in the midst of death. The first Kathy was a frivolous kid. She lived only one minute at a time. She quibbled about cold food in the cafeteria, about the boredom of surgical nursing lectures, about the unfairness of her parents. Her goal in life was to have fun on the weekends. The future was far away and of little concern. She lived for trivia only. But the second Kathy, that's me now. I'm infatuated with life. Look at the beauty in the sky. It's gorgeously blue. I go into a flower garden, and every flower takes on such fabulous colors that I'm dazzled by their beauty. One thing I do know: had I remained my first Kathy, I would have played away my whole life, and I would never have known what the real joy of living was all about. I had to face death eyeball to eyeball before I could live. I had to die in order to live."

An unusual confrontation with death afforded a turning point in the life of Arthur, an alcoholic patient. The patient had had a progressive downhill course. He had been drinking heavily for several years and had had no periods of sobriety sufficiently long to permit effective psychotherapeutic contact. He entered a therapy group, and one day came to the session so intoxicated that he passed out. The group, with Arthur unconscious on the couch, continued their meeting, discussed what to do with Arthur, and finally carried him bodily from the session to the hospital. Fortunately, the session was videotaped, and later, when Arthur watched the videotape, he had a profound confrontation with death. Everyone had been telling him for years he was drinking himself to death. But until he saw the videotape, he never truly allowed that possibility to register. The videotape of himself stretched out on the couch with the group surrounding his body and talking about him bore an uncanny resemblance to the funeral of his twin brother who had died of alcoholism a year previously. He visualized himself at his own wake, stretched out on a slab and surrounded by friends talking about him. Arthur was deeply shaken by the vision, embarked on the longest period of sobriety he had had in adult life, and for the first time committed himself to therapeutic work, which was ultimately of considerable benefit to him.

My interest in existential therapy was to a large extent kindled by witnessing several years ago the impact of death upon one of my patients. Jane was a 25-year-old perpetual college student who sought therapy because she was depressed, had severe functional gastric distress, and experienced a pervasive sense of helplessness and purposelessness. In her initial session, she presented her problems in a diffuse manner and lamented repetitively, "I don't know what's going on." I didn't understand what she meant by this statement, and since it was embedded in a lengthy litany of self-derogation, soon forgot it.

I introduced Jane into a therapy group, and in the group she again had a strong sense of not knowing what was going on. She didn't understand what was happening to her, why the other members were so uninterested in her, why she developed a conversion paralysis, why she developed masochistic relationships with the other members, why she became so infatuated with the therapist. To a great extent, life was a mystery, something out there happening to her, something raining upon her. In the therapy group, Jane was timid and boring. Her every statement was predictable. Before speaking, she scanned the sea of faces in the group for clues about what others wanted and then shaped her statements to please as many people as possible. Anything to avoid offense, to avoid driving others away. What happened, of course, was that she drove people away, not from anger, but from boredom. It was clear that Jane was in chronic retreat from life.

Everyone in the group tried to find the real Jane within the cocoon of compliance she had spun about herself. They tried to encourage Jane. They urged her to socialize, to study, to write the last paper she needed for graduation, to buy clothes, to pay her bills, to groom herself, to comb her hair, to prepare her resume, to apply for jobs. This exhortation, like most exhortation in therapy, was not successful. So the group tried another tack. They urged Jane to consider the lure and the blessing of failure. What was the payoff? Why was failure so rewarding? That line of inquiry was more productive, and we learned that the payoff was considerable. Failing kept Jane young, kept her protected, kept her from having to make choices. Idealizing and worshiping the therapist served the same purpose. Help was out there. Her task in therapy, as she viewed it, was to enable herself to the point where the therapist could not in all good conscience withhold his royal touch.

The critical event in therapy occurred when Jane developed a large, ominous auxiliary lymph node. The group met on Tuesday evenings, and it had happened that she had a biopsy done on a Tuesday morning and had to wait 24 hours before learning whether the growth was malignant. She came to the meeting that evening in terror. She had never previously contemplated her own death, and the meeting was a powerful one for her, as the group helped her face and express her fears. Her paramount experience was a terrifying loneliness, a loneliness that she had always perceived on the edge of consciousness and had always dreaded. In that meeting, Jane realized on a deep level that no matter what she did, no matter how she inflated herself, she would ultimately face death alone. No one could intercede for her. No one could die her death for her. The following day, she learned that the lymph node was benign, but nonetheless, the psychological effects of the experience were profound. Many things began to fall together for Jane. She began to make decisions in a way that she had never done before, and she took over the helm of her life. At one meeting, she commented, "I think I know what's going on." I had long since forgotten her initial complaint, but now I remembered and finally understood it. It had been important for her not to know what was going on. More than anything else, she had been trying to avoid the loneliness and the death that accompany adulthood. In a magical way, she had tried to defeat death by staying young, by avoiding choice and responsibility, by choosing to believe the myth that there would always be someone who would choose for her, would accompany her, would be there for her. Growing up, choosing, separating oneself from others also means facing loneliness and death.

To summarize, the concept of death plays a crucial role in psychotherapy because it plays a crucial role in the life experience of each of us. Death and life are interdependent. Though the physicality of death destroys us, the idea of death saves us. Recognition of death contributes a sense of poignancy to life, provides a radical shift of life perspective, and can transport one from a mode of living characterized by diversions, tranquilization, and petty anxieties to a more authentic mode. There are, in the examples of individuals undergoing significant personal change after confrontation with death, obvious and important implications for psychotherapy. What is needed are techniques to allow psychotherapists to mine this therapeutic potential with all patients rather than be dependent upon fortuitous circumstances or the advent of a terminal illness. I shall consider these issues fully in chapter 5.

Death and Anxiety. Anxiety plays such a central and obvious role in psychotherapy that there is little need to belabor the point. The unique position of anxiety is apparent from traditional psychiatric nosology, in which the major psychiatric syndromes are called reactions: psychotic reactions, neurotic reactions, psychophysiological reactions. We consider these conditions reactions to anxiety; they are efforts, albeit maladaptive ones, to cope with anxiety. Psychopathology is a vector, the resultant of anxiety and the individual's anxiety-combating defenses, both neurotic and characterological. Therapists generally begin work with a patient by focusing on manifest anxiety, anxiety equivalence, or the defenses that the individual sets up in an attempt to protect himself or herself from anxiety. Though therapeutic work extends in many directions, therapists continue to use anxiety as a beacon or compass point. They work toward anxiety, uncover its fundamental sources, and attempt, as their final goal, to uproot and dismantle these sources.

Death Anxiety: An Influential Determinant of Human Experience and Behavior. The terror of death is ubiquitous and of such magnitude that a considerable portion of one's life energy is consumed in the denial of death. Death transcendence is a major motif in human experience. From the most deeply personal internal phenomena—our defenses, our motivations, our dreams and nightmares—to the most public macro-societal structures—our monuments, theologies, ideologies, slumber cemeteries, and bombings, our stretch into space—indeed, our entire way of life, our failing time, our addiction to diversions, our unfaltering belief in the myth of progress, our drive to get ahead, our yearning for lasting fame. The basic human group, the molecules of social life, were, as Freud speculated, formed out of the fear of death. The first humans huddled together out of a fear of separateness and a fear of what lurked in the dark. We perpetuate the group in order to perpetuate ourselves, and history taking of the group is a symbolic quest for mediated immortality. Indeed, as Hegel postulated, history itself is what man does with death.

Robert J. Lifton has described several modes by which man attempts to achieve symbolic immortality. Consider their pervasive cultural implications:

1. The biological mode: living on through one's progeny, through an endless chain of biological attachments.

2. The theological mode: living on in a different, higher plane of existence.

3. The creative mode: living on through one's works, through the enduring impact of one's personal creation or impact on others. Lifton suggests that the therapist draws personal sustenance from this fountain. By helping his patient, he initiates an endless chain as the patient's children and associates pass on his spore.

4. The theme of eternal nature: one survives through rejoining the swirling life forces of nature.

5. The experiential transcendent mode: through losing oneself in a state so intense that time and death disappear and one lives in the continuous present.

These social ramifications of the fear of death and the quest for immortality are so widespread that they extend far beyond the range of this book. Among those who have written of these issues, Norman Brown, Ernest Becker, and Robert J. Lifton, in particular, have brilliantly demonstrated how the fear of death has permeated the fabric of our social structure. Here I am concerned with the effects of death anxiety on the internal dynamics of the individual. I shall argue that the fear of death is a primal source of anxiety. Although this position is simple and consonant with everyday intuition, its ramifications for theory and clinical practice are, as we shall see, extensive.

Death Anxiety: Definition. First, let me examine the meaning of death anxiety. I shall use several terms interchangeably: death anxiety, fear of death, mortal terror, fear of finitude. Philosophers speak of the awareness of the fragility of being (Jasper), of dread of nonbeing (Kierkegaard), of the impossibility of further possibility (Heidegger), or of ontological anxiety (Tillich). Many of these phrases imply a difference in emphasis, for individuals may experience the fear of death in very different ways. Can we be more precise? What exactly is it that we fear about death? Researchers investigating this issue have suggested that the fear is a composite of a number of smaller, discrete fears. For example, James Digory and Dorene Rothman asked a large sample (n=563) drawn from the general population to rank order several consequences of death. In order of descending frequency, these were the common fears about death:

1. My death would cause grief to my relatives and friends.

2. All my plans and projects would come to an end.

3. The process of dying might be painful.

4. I could no longer have any experiences.

5. I would no longer be able to care for my dependents.

6. I am afraid of what might happen to me if there is a life after death.

7. I am afraid of what might happen to my body after death.

Of these fears, several seem tangential to personal death. Fears about pain obviously lie on this side of death. Fears about an afterlife beg the question by changing death into a non-terminal event. Fears about others are obviously not fears about oneself. The fear of personal extinction seems to be at the vortex of concern: "My plans and projects would come to an end," and "I could no longer have any experiences." Jacques Choron, in a review of major philosophic views about death, arrives at a similar analysis. He distinguishes three types of death fear: one, what comes after death; two, the event of dying; and three, ceasing to be. Of these, the first two are, as Robert Castenbaum points out, fears related to death. It is the third, ceasing to be, obliteration, extinction, annihilation, that seems more centrally the fear of death. And it is this fear to which I refer in these chapters.

Kierkegaard was the first to make a clear distinction between fear and anxiety (dread). He contrasted fear that is "fear of something" with dread that is "a fear of no thing"—not, as H. Riley noted, "a nothing with which the individual has nothing to do." One dreads or is anxious about losing oneself and becoming nothingness. This anxiety can't be located. As Rollo May says, "it attacks us from all sides at once." A fear that can neither be understood nor located cannot be confronted and becomes more terrible still. It begets a feeling of helplessness which invariably generates further anxiety. Freud felt that anxiety was a reaction to helplessness. Anxiety, he wrote, "is a signal which announces that there is danger and the individual is expecting a situation of helplessness to set in." How can we combat anxiety? By displacing it from nothing to something. This is what Kierkegaard meant by the nothing which is the object of dread becomes, as it were, more and more a something. It is what Rollo May means by "anxiety seeks to become fear." If we can transform a fear of nothing to a fear of something, we can mount some self-protective campaign. That is, we can either avoid the thing we fear, seek allies against it, develop magical rituals to placate it, or plan a systematic campaign to detoxify it.

Death Anxiety: Clinical Manifestations. The fact that anxiety seeks to become fear confounds the clinician's attempt to identify the primal source of anxiety. Primal death anxiety is rarely encountered in its original form in clinical work. Like nascent oxygen, it is rapidly transformed to another state. To ward off death anxiety, the young child develops protective mechanisms which, as I shall discuss in the next chapter, are denial-based, pass through several stages, and eventually consist of a highly complex set of mental operations that repress naked death anxiety and bury it under layers of such defensive operations as displacement, sublimation, and conversion. Occasionally, some jolting experience in life tears a rent in the curtain of defenses and permits raw death anxiety to erupt into consciousness. Rapidly, however, the unconscious ego repairs the tear and conceals once again the nature of the anxiety. I can provide an illustration from my personal experience. While I was engaged in writing this book, I was involved in a head-on automobile collision. Driving along a peaceful suburban street, I suddenly saw looming before me a car out of control and heading directly at me. Though the crash was of sufficient force to demolish both automobiles, and though the other driver suffered severe lacerations, I was fortunate and suffered no significant physical injury. I caught a plane two hours later and was able to deliver a lecture in another city that evening. Yet, without question, I was severely shaken. I felt dazed, was tremulous, and couldn't

eat or sleep. The next evening, I was unwise enough to see a frightening movie, Carrie, which thoroughly terrified me, and I left before its end. I returned home a couple of days later with no obvious psychological squelli aside from occasional insomnia and anxiety dreams. Yet a strange problem arose.

At the time I was spending a year as a fellow at the center for advanced study in the behavioral sciences in Palo Alto, California. I enjoyed my colleagues and especially looked forward to the daily leisurely lunchon discussions of scholarly issues. Immediately after the accident, I developed intense anxiety around these lunches. Would I have anything of significance to say? How would my colleagues regard me? Would I make a fool of myself? After a few days, the anxiety was so extreme that I began to search for excuses to lunch elsewhere by myself.

I also began, however, to analyze my predicament. And one fact was abundantly clear. The lunchon anxiety appeared for the first time following the automobile accident. Furthermore, explicit anxiety about the accident, about so nearly losing my life had within a day or two entirely vanished. It was clear that anxiety had succeeded in becoming fear. Considerable death anxiety had erupted immediately following the accident, and I had handled it primarily by displacement, by splitting it from its true source, and riveting it to a convenient, specific situation. My fundamental death anxiety thus had only a brief efflloresence before being secularized to such lesser concerns as self-esteem, fear of interpersonal rejection, or humiliation. Although I had handled or processed my anxiety, I had not eradicated it, and traces were evident for months afterward.

Even though I had worked through my lunch phobia, a series of other fears emerged, fears of driving a car, of bicycling. Months later, when I went skiing, I found myself so cautious, so frightened of some mishap, that my skiing pleasure and ability were severely compromised. Still, these spheres could be located in space and time and could be managed in some systematic way. Annoying as they were, they were not fundamental. They did not threaten my being.

In addition to these specific fears, I noted one other change. The world seemed precarious. It had lost for me its horniness. Danger seemed everywhere. The nature of reality had shifted as I experienced what Haidiger called uncanniness unheimish the experience of not being at home in the world which he considered and to which I can attest a typical consequence of death awareness.

One further property of death anxiety that has often created confusion in mental health literature is that the fear of death can be experienced at many different levels. One may, as I have discussed, worry about the act of dying, fear of pain of dying, regret unfinished projects, mourn the end of personal experience, or consider death as rationally and dispassionately as the Epicurans who concluded simply that death holds no terror because where I am, death is not. Where death is, I am not. Therefore, death is nothing to me. Lucriccious. Yet keep in mind that these responses are adult conscious reflections on the phenomenon of death. By no means are they identical to the primitive dread of death that resides in the unconscious. A dread that is part of the fabric of being that is formed early in life at a time before the development of precise conceptual formulation. A dread that is chilling, uncanny, and incoit. a dread that exists prior to and outside of language and image.

The clinician rarely encounters death anxiety in its stark form. This anxiety is handled by conventional defenses, for example, repression, displacement, rationalization, and by some defenses specific only to it. See chapter 4. Of course, this situation should not overly trouble us. It prevails for every theory of anxiety. Primary anxiety is always transformed into something less toxic for the individual. That is the function of the entire system of psychological defenses. It is rare to use a Freudian frame of reference for a clinician to observe undisguised castration anxiety. Instead, one sees some transformation of anxiety. For example, a male patient may be phobic of women or fearful of competing with males in certain social situations or inclined to obtain sexual gratification in some mode other than heterosexual intercourse. A clinician who has developed the existential set, however, will recognize the processed death anxiety and be astonished at the frequency and the diversity of its appearance.

Let me give some clinical examples. I recently saw two patients who sought therapy not because of existential anxiety but to solve commonplace painful relationship problems. Joyce was a 30-year-old university professor who was in the midst of a painful divorce. She had first dated Jack when she was 15 and married him at 21. The marriage had obviously not gone well for several years and they had separated 3 years previously. Although Joyce had formed a satisfying relationship with another man, she was unable to proceed with a divorce. In fact, her chief complaint when entering therapy was her uncontrollable weeping whenever she talked to Jack. An analysis of her weeping uncovered several important factors. First, it was of the utmost importance that Jack continued to love her. Even though she no longer loved him or wanted him, she wanted very much that he think of her often and love her as he had never loved any other woman. Why? I asked. Everyone wishes to be remembered, she replied. It's a way of putting myself into posterity. She reminded me that the Jewish catish ritual is built around the assumption that as long as one is remembered by one's children, one continues to exist. When Jack forgot her, she died a little. Alan Sharp in a green tree in Gettis describes a small Mexican cemetery that is divided into two parts. The dead whose graves are still adorned with flowers placed there by the living and the truly dead whose grave sites are no longer maintained. They are remembered by no living soul. In a sense, then when a very old person dies, many others die also. The dead person takes them along. All of those recently dead who are remembered by no one else become at that moment truly dead.

Another source of Joyce's tears was her feeling that she and Jack had shared many lovely and important experiences. Without their union, these events, she felt, would perish. The fading of the past is a vivid reminder of the relentless rush of time. As the past disappears, so does the coil of the future shorten. Joyce's husband helped her to freeze time, the future as well as the past. Though she wasn't conscious of it, it was clear that Joyce was frightened of using up the future. She had a habit, for example, of never quite completing a task. If she were doing housework, she always left one corner of the house unclean. She dreaded being finished. She never started a book without another one on her night table awaiting its turn. One is reminded of P, whose major literary corpus was devoted to escaping the devouring jaws of time by recapturing the past. Still, another reason why Joyce wept was her fear of failure. Life had until recently been an uninterrupted stairway of success. To fail in her marriage meant that she would be, as she often put it, just like everyone else. Though she had considerable talent, her expectations were grandiose. She anticipated achieving international prominence, perhaps winning a Nobel Prize for a research program upon which she was embarking. If that success did not occur within 5 years, she planned to turn her energies to fiction and write the you can't go home again of the 1970s. Although she had never written any fiction, yet she had reasoned for her sense of specialness. Thus far she had not failed to accomplish every one of her goals. The failure of her marriage was the first interruption of her ascent, the first challenge to her solopscistic assumptive world. The failure of the marriage threatened her sense of specialness, which as I will discuss in chapter 4, is one of the most common and potent deathdenying defenses. Joyce's commonplace problem then had roots stretching back to primal death anxiety. To me, an existentially oriented therapist, these clinical phenomena, the wish to be loved and remembered eternally, the wish to freeze time, the belief in personal invulnerability, the wish to merge with another, all served the same function for Joyce, to assuage death anxiety. As she analyzed each one and came to understand the common source of these phenomena, Joyce's clinical picture improved remarkably. Most strikingly, as she gave up her neurotic needs for Jack and stopped using him for all the deathdeying functions he served, she was able to turn toward him for the first time in a truly loving fashion and reestablish the marriage on an entirely different basis. But that's another issue which I shall address in chapter 8.

Then there was Beth, a 30-year-old single woman who sought therapy because of her inability to form a gratifying relationship with a man. She had on many occasions previously chosen poorly, as she put it, and had broken off the relationship because she lost interest in the man. While in therapy, she repeated the cycle. She fell in love with a man, entered a tormented state of indecision, and finally was unable to make a commitment to him. As we analyzed her dilemma, it became apparent that she felt pressured to form an enduring relationship. She was tired of loneliness, tired of living the single life, and desperately eager to have children. The pressure was intensified by her concerns about growing older and passing the childbearing age. When, however, her lover tried to discuss marriage, she panicked, and the more he pressed, the more anxious she grew. Beth likened marriage to being pinned to the wall. She would be fixed forever, the way forldahhide fixes a biological specimen. It was important to keep growing, to become something else, something other than what she was. And she feared her lover was too complacent, too satisfied with himself and his life. Gradually, Beth became aware of the importance of this motif in her life. She had never lived in the present. Even when eating or serving a meal, she had stayed one course ahead. When eating a main course, her thoughts were dwelling on dessert. She had often thought with horror about settling down, which she equated with settling in. "Is this all there is to life?" she frequently asked herself when she thought of marriage or any other form of commitment. As Beth in therapy delved into these areas, her compulsion to be always ahead of herself, her fear of aging, of death and stagnation, she grew more anxious than ever before. One evening, following a session in which we had probed particularly deeply, she experienced extraordinary terror. While walking her dog, she had the uncanny feeling that she was being pursued by some unearly being. She looked behind herself on all sides and finally broke into a run and scured home. Later a rainstorm broke out and she lay awake all night with an irrational terror that the roof would be torn off or that her house would be washed away.

As I will discuss in chapter 5, an augmentation of anxiety often occurs when fear of something, in Beth's case, a fear of marriage or of making the wrong choice, is understood for what it truly is, a fear of no thing. For Beth, both the press toward marriage and the fear of marriage were in part surface reverberations of a deeper struggle to contain death anxiety.

Many clinicians have described the presence and the transformation of death anxiety across the entire spectrum of clinical psychopathology. Chapter 4 deals with this in depth and I need only highlight it here. R. Skoo reports that over 70% of patients with a severe obsessional neurosis had at the onset of illness a security disturbing death experience. As the syndrome develops, patients are increasingly concerned about controlling their world and preventing the unexpected or accidental. Patients shun disorder or uncleanliness and develop rituals to ward off evil and danger. Irwin Strauss notes that the obsessional patients disgust at decay, illness, germs, and dirt was intimately related to fear of personal annihilation. W. Schwitter observes that these obsessive defenses were not entirely effective in absorbing death anxiety. In a study of over a 100 obsessional phobic patients, he notes that a third feared constriction and darkness and that a somewhat larger proportion had explicit death anxiety. Herbert Lazarus and John Cen in an extensive study of the hyperventilation syndrome, an extremely common condition between 5 and 10% of all patients consulting physicians suffer from this complaint, emphasized the underlying dynamic of death anxiety which is transformed into a series of other phobias. An inability to bind death anxiety sufficiently results in the hyperventilation panic. DB Freriedman describes an obsessional patient whose death anxiety took the form of an obsessive thought that he would be forgotten by everyone. Linked to this was his preoccupation that he was always missing the exciting things in the world about him. As he put it, something really new happens only when I'm not around. Before my time or after my time, before I was born or after I'm dead. Death anxiety is only thinly disguised in the hypochondriacal patient who is continually concerned about the safety and well-being of his or her body. Hypochondrial illness in a patient often begins after a severe illness suffered by that patient or by someone close to him or her. Early in the course of the affliction, V. Cra observes there is a directly experienced fear of death which is later diffused among many body organs. Several clinical investigations have reported the central role of death anxiety in depersonalization syndromes. Martin Roth for example found that death or severe illness was the precipitating event in over 50% of patients reporting a depersonalization syndrome. These neurotic syndromes share one important common feature. Though they inconvenience and restrict a patient, they all succeed in protecting him or her from overt and terrifying death anxiety.

Death anxiety. Empirical research. Over the past three decades, there has been a continuous but feeble stream of empirical social science research on death. Virtually every research article in death begins with a clarion call to research and either a lament or an indignant protest about the lack of careful investigation. After reviewing the literature, I can't help but echo a similar complaint. Certainly, the contrast between the speculative or impressionistic writings on death and the methodical research into it is striking. For example, a bibliography on death up to 1972 listed over 2600 books and articles. Yet fewer than 2% report empirical research, and only a handful bear direct relevance to existential theory and therapy. The research, even remotely relevant to my present discussion, attempts to investigate the following issues. The incidence of death anxiety. Correlative studies of the degree of death anxiety and a number of variables demographic age, sex, marital status, occupation, religion, education and so forth, personality factors, MMPI dimensions, general anxiety or depression levels and life experiences, early loss, institutionalization, and the relation of death anxiety to psychopathology or to other psychological experience, especially fantasy. ies dreams and nightmares. So far so good. However, as Robert Castenbomb and Ruth Eisenberg point out in their thoughtful review, the studies, with few exceptions, are either severely limited in scope or severely flawed methodologically. Many studies investigate death in an imprecise fashion. For example, they failed to distinguish between one's fear of one's own death, one's fear of the death of another, or one's fear of the effects of one's death on others. An even more serious problem, however, is that most studies have measured conscious attitudes toward death or conscious manifest anxiety. To compound the problem still further, the studies use instruments that with a couple of exceptions are hastily constructed, home brerew scales whose reliability or validity has not been established.

One occupational study is of interest. Medical students were studied using a conscious death anxiety scale and the authoritarian scale, California personality inventory F scale. A negative relationship was found between death anxiety and authoritarianism. That is, the more authoritarianism, the less death anxiety and vice versa. Moreover, medical students who chose to enter psychiatry had more death anxiety and were less authoritarian than those who entered surgery. Perhaps surgeons are better defended against death anxiety and psychiatrists more aware of death anxiety. Perhaps too, fledgling psychiatrists have more absolute death anxiety and enter the mental health field in search of personal relief. Several projects report that devoutly religious individuals have less death anxiety. Students who have lost a parent have higher death anxiety. Most studies show few differences related to age, although there is a positive relationship between death concerns and nearness to death. A study of the most common fears of 1,000 college co-eds indicates that death related fears are extremely important in this population group. Several projects have demonstrated, but not attempted to explain that females have higher conscious death anxiety than males. A consideration of conscious death anxiety, though of some interest, is of limited relevance to an understanding of personality structure and psychopathology. The cornerstone of dynamic psychology is precisely that strong anxiety does not remain conscious. It is repressed and processed. One of the major steps in the processing of the anxiety source is to separate or to isolate effect from object. Thus, one can think about death with only moderate discomfort, and one can experience displaced anxiety with few clues to its true source. A few studies to be discussed shortly have been sensitive to the difference between conscious and unconscious death anxiety and have attempted to examine death fear at unconscious levels. They have used such instruments as the TAT, the thematic app perception test, the roarshock, dream analysis, word association tests, sentence completion tests and statistic projection and the galvanic skin response, death anxiety and psychopathology, conscious death anxiety.

A few scattered reports attempt to correlate conscious death anxiety and psychopathology. There is a positive correlation in student volunteers between death anxiety and neuroticism. Isaac neuroticism scale. Prisoners incarcerated for a minor offense. No further details of offense given when compared with normal controls have significantly more death anxiety, death preoccupation and more fear of funerals in medical diseases and are more often aware of suppressing thoughts about death. Conscious death anxiety correlates positively with the MMPI depression scale in aged psychiatric patients. In fact, the correlation was so strong that the investigators suggested that heightened death anxiety be considered part of the depressive syndrome in the aged. The same study revealed no correlation between death anxiety and somatic symptomatology on the Cornell medical index. Possibly somatization emerges in response to and acts as a sump for death anxiety. Though studies indicate a lack of overt death anxiety in the normal aged population, those aged who are psychologically immature or psychiatrically disturbed show evidence of high death anxiety. Adolescents tend to show higher death anxiety than other age groups. And once again we find that the individuals who give evidence of psychopathology in this study defined as delinquent acts of significant magnitude to warrant incarceration express more death anxiety than do the controls. A study of normal and institutionalized subnormal adolescent girls demonstrated that the institutionalized population was more overtly fearful about death. Similarly, another researcher found that poorly achieving high school girls had considerably greater fear of death. Often so pervasive that it can be communicated only indirectly.

Chapter 2b unconscious death anxiety. But these studies of conscious death attitudes and anxiety are of little help in understanding the role of death anxiety in psychonamics. Several researchers have accordingly attempted to study unconscious concerns about death. Fifel and his associates have defined three levels of concern. One, conscious measured by scoring the response to the question, "Are you afraid of your own death? Two, fantasy measured by coding the positivity or negativity of responses to the directive, what ideas or pictures come to your mind when you think about your death?" Three, below level awareness measured by mean reaction time to death words on a word association test and a color word interference test. The investigators found that death concerns varied greatly at each of these levels. On a conscious level, the great majority, over 70% of individuals, denied a fear of death. On the fantasy level, 27% denied death fear. 62% answered ambivalently and 11% gave considerable evidence of death anxiety. At a level below awareness, most of the subjects gave evidence of considerable aversion to death. The major difference among normals, neurotics, and psychotics was that psychotic individuals evinced more overall death anxiety than the others. On the more conscious levels, the older subjects and the more religious subjects perceived death in a fairly positive vein, but succumbed to anxiety at the gut level. Though these studies use crude instrumentation, nonetheless, they do point out the necessity of studying death concerns at different levels of awareness.

In an interesting experiment, WW Meisner demonstrated the existence of significant unconscious anxiety. He tested the galvanic skin response gsr of normal subjects who were presented with a series of 50 items. 30 neutral terms and 20 death symbols. For example, black, a candle burning out, a journey, a sleeping person, the silent one, crossing a bridge. The death symbols evoked a significantly greater gsr response than did the control words. Close magny tested unconscious death anxiety in another way. Death relevant scenes, pictures of funerals, decayed and mutilated corpses and so forth were projected to kistocopically in progressively longer exposures. Magny measured the time required by a subject to identify the scene and demonstrated that theology students planning to enter parish priesthood required significantly less time to identify the scene and thus presumably had significantly less unconscious death anxiety than did students planning research or teaching careers where they would be less intimately engaged in ministering to others. Several studies using interview data or TAT data indicate that individuals with higher levels of neuroticism have greater death anxiety. Studies of unconscious death anxiety in the aged using the TAT and sentence completion tests indicate that elderly individuals who are assigned separate living quarters similar to a familiar setting have significantly less death anxiety than those individuals in traditional institutions for the aged. Furthermore, the aged have less unconscious death anxiety if they are involved in many life activities. Death anxiety on the tat in the aged is positively correlated with MMPI neurotic indicators. Hypochondriases, dependency, impulsivity, and depression. A study of unconscious death anxiety, a sentence completion projective technique, in a population of middle-aged to aged adults, demonstrated that the younger adults had more death anxiety than their elderly cohorts. If fear of death is a primary source of anxiety, then it should be found in dreams where unconscious themes often appear in relatively undisguised form. A large normative study of dreams indicated that overt death anxiety was found in 29% of dreams. An extensive study of nightmares revealed that the most common anxiety theme in the dreams of adults was either dying or being murdered. The other common themes were also death linked. Some family member or other individual dying or the dreamer's life being threatened by an accident or by someone chasing him or her. Does the amount of conscious death anxiety correlate with the number of death nightmares? The studies show conflicting results depending upon the specific death anxiety scale used. However, a subject who has suffered, especially when under the age of 10, the death of close friends and relatives is more likely to have death nightmares. One study reports an intriguing finding. There is a curve linear relationship between conscious death anxiety and death themes in dreams. In other words, those individuals who have very high or very low conscious death anxiety tend to dream of death. Possibly high conscious anxiety reflects such high unconscious anxiety that it cannot be contained and spills over into failed dreams, nightmares and into consciousness. Very low conscious death anxiety, less than one would expect in the average individual, may reflect strong unconscious death anxiety, which in the waking state is contained by denial and repression, but which in the sleeping state overwhelms the dream sensor.

In summary, the research literature on death anxiety offers some limited help in increasing our understanding of the role of death fear in psychopathology and psychotherapy. Most of the research consists of correlational studies of conscious death anxiety on crudely constructed scales and a host of demographic and psychometric variables. These studies demonstrate some positive correlation between high death anxiety and depression, early loss, lack of religious belief, and occupational choice. Other studies investigate deeper layers of consciousness and demonstrate that considerable death anxiety lies outside of awareness, that death anxiety increases as one moves from conscious to unconscious experience, that the fear of death stalks us in our dreams. that the aged fear death more if they are psychologically immature or if they have few life activities in which to engage. And lastly, that death anxiety, both conscious and unconscious, is related to neuroticism.

The inattention to death in psychotherapy theory and practice. All of the foregoing perspectives on death, cultural tradition, clinical experience, and empirical research bear strong implications for psychotherapy. The incorporation of death into life enriches life. It enables individuals to extricate themselves from smothering trivialities, to live more purposefully and more authentically. The full awareness of death may promote radical personal change. Yet death is a primary source of anxiety. It permeates inner experience and we defend against it by a number of personal dynamisms. Furthermore, as I shall discuss in chapter 4, death anxiety dealt with maladaptively results in the vast variety of signs, symptoms, and character traits we refer to as psychopathology. Yet despite these compelling reasons, the dialogue of psychotherapy rarely includes the concept of death. Death is overlooked and overlooked glaringly in almost all aspects of the mental health field, theory, basic and clinical research, clinical reports, and all forms of clinical practice. The only exception lies in the area in which death cannot be ignored. The care of a dying patient. The sporadic articles dealing with death that do appear in the psychotherapy literature are generally in second or third line journals and are anecdotal in form. They are curiosities that are peripheral to the mainstream of theory and practice.

Clinical case reports. The omission of the fear of death in clinical case reports, to take one example, is so blatant that one is tempted to conclude that nothing less than a conspiracy of silence is at work. There are three major strategies for dealing with death in clinical case reports. First, the authors selectively inattend to the issue and report no material whatsoever pertaining to death. Second, authors may present copious clinical data related to death, but ignore the material completely in their dynamic formulation of the case. This is the situation, for example, in Freud's case histories, and I shall shortly provide evidence of it. Third, authors may present death related clinical material, but in a formulation of the case, translate death into a concept compatible with a particular ideological school. In a widely cited article, the attitudes of psychonurotics toward death, published in a leading journal, two eminent clinicians, Walter Bramberg and Paul Schilder, present several case histories in which death plays a prominent role. For example, one female patient developed acute anxiety after the death of a woman friend for whom she had had some erotic longings. Although the patient stated explicitly that her personal fear of death was kindled by watching her friend die, the authors conclude that her anxiety reaction was against the unconscious homosexual attachment with which she struggled. Her own death meant the reunion with the homosexual beloved who had departed. To die means a reunion with the denied love object. Another patient whose father was an undertaker described her severe anxiety. I have always feared death. I was afraid I would wake up while they were embombing me. I have these queer feelings of imminent death. My father was an undertaker. I never thought of death while I was with corpses, but now I feel I want to run. I think of it steadily. I feel as though I was fighting it off. The authors conclude that the anxiety about death is the expression of a repressed wish to be passive and to be handled by the father undertaker. In their view, the patients anxiety is the product of her self-defense against these dangerous wishes and of her desire for self-punishment because of her incestuous wish. The other case histories in the same article provide further examples of translations of death into what the authors consider to be more fundamental fears. Quote, "Death means for this boy final sat masochistic gratification in a homosexual reunion with the father." Or death means for him separation from the mother and an end to expression of his unconscious libidinal desires. quote. Obviously, one cannot but wonder why there is such a press for translation. If a patients life is curtailed by a fear, let us say, of open spaces, dogs, radioactive fallout, or if one is consumed by obsessive ruminations about cleanliness, or whether doors are locked, then it seems to make sense to translate these superficial concerns into more fundamental meanings. But The thing speaks for itself. A fear of death may be a fear of death and not translatable into a deeper fear. Perhaps, as I shall discuss later, it is not translation that the neurotic patient needs. He or she may not be out of contact with reality, but instead through failing to erect normal denial defenses, may be too close to the truth.

Clinical research. Inattention to the concept of death has far-reaching implications for clinical research as well. To take one example, consider the field of mourning and bereiement. Although many researchers have studied in painstaking detail the adjustment of the survivors, they have consistently failed to take into consideration that the survivor has not only suffered an object loss, but has encountered the loss of himself or herself as well. Beneath the grief for the loss of another lies the message, "If your mother, father, child, friend, spouse dies, then you will die, too." Shortly after, a patient of mine lost his father, he had the hallucination of a voice from above booming down to him the words, "You're next." In a heavily cited study of the first year of bereavement of widows, the researcher records statements from the subjects like, "I feel like I'm walking on the edge of a black pit." Or comments to the fact that they now view the world as an insecure and potentially harmful place, or that life seems pointless and without purpose, or that they are angry, but without a focus for that anger. I believe that each of these reactions would, if explored in depth, lead an investigator to important conclusions about the role of loss as an experience that has the potential to facilitate the survivor's encounter with his or her personal death. However, the researcher in this study and in each of the other extensive studies in briefment I have read worked from a different frame of reference and accordingly failed to till some rich soil. This failure is another sorry example of the impoverishment that ensues when behavioral science ignores intuitively evident truths. 4,000 years ago in one of the first pieces of written literature, the Babylonian epic Gilgamesh, the protagonist knew well that the death of his friend Enkidu betokened his own death. Now what sleep is this that has taken hold of thee? Thou hast become dark and castst not hear me. When I die, shall I not be like unto Enkidu? Sorrow enters my heart and I am afraid of death.

The clinical practitioner. Some therapists state that death concerns are simply not voiced by their patients. I believe, however, that the real issue is that the therapist is not prepared to hear them. A therapist who is receptive, who inquires deeply into a patients concerns, will encounter death continuously in his or her everyday work. Patients, given the slightest encouragement, will bring in an extraordinary amount of material related to a concern about death. They discuss the deaths of parents or friends. They worry about growing old. Their dreams are haunted by death. They go to class reunions and are shocked by how much everyone else has aged. They notice with an ache the ascendancy of their children. They occasionally take note with a start that they enjoy old people's sedentary pleasures. They are aware of many small deaths. Scenile plaques, liver spots in their skin, gray hairs, stiff joints, stooped posture, deepening wrinkles. Retirement approaches. Children leave home. They become grandparents. Their children take care of them. the life cycle envelops them. Other patients may speak of annihilation fears, the common horrifying fantasy of some murderous aggressors forcing entry into the home, or fearful reactions to television or cinematic violence. The termination work that occurs in the therapy of every patient is accompanied, if the therapist will only listen, by undercurrents of concern about death. My personal clinical experience is highly corroborative of the ubiquity of death concerns. Throughout the writing of this book, I have encountered considerable amounts of heretofor invisible clinical material. Undoubtedly to some extent I have cued patients to provide me with certain evidence. But it is my belief that in the main it was always there. I was simply not properly tuned in. Earlier in this chapter, for example, I presented two patients, Joyce and Beth, who had commonplace clinical problems involving the establishment and the termination of interpersonal relationships. On deeper inquiry, both women evinced much concern about existential issues, which I would never have been able to recognize had I not had the appropriate psychological set. Another example of tuning in is offered by a psychotherapist who attended a Saturday lecture I gave on the topic of death anxiety. A few days later, she wrote in a letter, "I didn't expect the subject to come up in my work now since I'm a counselor at Reed College and our students are usually in good physical health, but my first appointment Monday morning was with a student who had been raped 2 months ago. She has been suffering from many disagreeable and painful symptoms since then. She made the comment with an embarrassed laugh. If I'm not dying of one thing, I'm dying of another. It was probably, at least in part, because of your remarks that the interview turned towards her fear of dying, and that being raped and dying used to be things she thought would happen only to other people. She now feels vulnerable and flooded with anxieties that used to be suppressed. She seemed to be relieved that it was all right to talk about being afraid to die, even if no terminal illness can be found in her body.

Psychotherapy sessions following even some passing encounter with death often offer much clinical data. Dreams, of course, are especially fertile sources of material. For example, one 30-year-old woman the night following the funeral of an old friend dreamed. I'm sitting there watching TV. The doctor comes over and examines my lungs with a stethoscope. I get angry and ask him what right he has to do that. He said I was smoking like a smokehouse. He said I have far advanced hourglass disease of my lungs. The dreamer doesn't smoke, but her dead friend smoked three packs a day. Her association to hourglass disease of the lungs was time is running out.

Denial plays a central role in a therapist's selective inattention to death in therapy. Denial is a ubiquitous and powerful defense. Like an aura, it surrounds the effect associated with death whenever it appears. One joke from Freud's vast collection has it that a man says to his wife, "If one of us two dies before the other, I think I'll move to Paris." Denial does not spare the therapist. And in the treatment process, the denial of the therapist and the denial of the patient enter into collusion. Many therapists though they have had long years of personal analysis have not explored and worked through their personal terror of death. They phobically avoid the area in their personal lives and selectively inattend to obvious death linked material in their psychotherapy practice. In addition to the denial of any single therapist, there is collective denial in the entire field of psychotherapy. This collective denial may be best understood by exploring why death has been omitted from formal theories of anxiety. Though anxiety plays an absolutely central role in both the theory and the everyday practice of dynamic psychotherapy, there is no place accorded to death in the traditional dynamic theories of anxiety. If we are to alter therapeutic practice to harness the clinical leverage that the concept of death provides, it will be necessary to demonstrate the role of death in the genesis of anxiety. There is no better way to begin than by tracing the evolution of psychonamic concepts of anxiety and attempting to understand the systematic exclusion of the concept of death.

Freud anxiety without death. Freud's ideas have so influenced the field that to a great extent the evolution of dynamic thought is the evolution of Freud's thought. Despite his extraordinary precience, however, I believe that in the area of death, he had a persistent blind spot which obscured for him some patently obvious aspects of man's inner world. I shall present some material to illustrate the way Freud avoided death in clinical and theoretical considerations. and then suggest some of the reasons behind this avoidance.

Freud's avoidance of death. Freud's first significant clinical and theoretical contribution appears in studies in hysteria which he wrote with Joseph Buer in 1895. It is a fascinating work and merits attention for it illustrates strikingly a selective inattention to death and it laid the foundation for the exclusion of death from the entire field of dynamic therapy which it spawned. The book presents five major cases. One Anna O by Ber and four by Freud. Several other cases in fragmentaryary form flit in and out of footnotes and discussion sections. Each patient begins therapy with fluoride symptoms which include paralysis, anesthesias, pain, ticks, fatigue, obsessions, sensations of choking, loss of taste and smell, linguistic disorganization, amnesia, and so forth. From a study of these five patients, Freud and Ber postulated an eeology of hysteria and a systematic form of therapy based on that eeteology. The five patients all suffered from some important emotional trauma experienced earlier in their lives. Ordinarily, Freud notes a trauma though disturbing produces no lasting effect because the emotions aroused by it are dissipated. Either they are abreacted, the individual under goes a catharsis by expressing the emotion in some effective way or worked through in some other way. Freud states that the memory of the dramas may enter what he called the great complex of associations. It comes alongside other experiences and then is worn away or rectified or subjected to reality testing by, for example, dealing with an insult by considering one's achievements and strengths. In these five patients, the trauma did not dissipate, but instead continuously haunted the victim, or as Freud put it, the hysteric suffers from reminiscences. Freud suggested that in his patients, memory of the trauma and the attended emotions were repressed from conscious thought. The first use of the concept of repression and the unconscious and thus were not subject to the normal processes of effect dissipation. The stifled effect persisted however with freshness and strength in the unconscious and found some conscious expression through conversion to physical symptoms. Hence conversion hysteria. The treatment implications are clear. One must enable the patient to remember the trauma and to give expression to the strangulated effect. Freud and Ber used hypnosis and later Freud used free association to help patients recapture the original offending memory and express the effect verbally and behaviorally. Freud's speculations about effect buildup and dissipation about the formation of symptoms and about a system of therapy resting on these assumptions are of landmark importance and adumbrate much of the dynamic theory and therapy that followed him. What is most gerine to my discussion is Freud's view about the source of the dysphoric effect, the nature of the original trauma. The theory of symptoms and the approach to therapy remain consistent throughout the text, but Freud's descriptions of the nature of the trauma responsible for the symptoms undergo a fascinating evolution from the first patient to the last. In his introduction, he states, "I can give no better advice to anyone interested in the development of a catharsis into psychoanalysis than to begin with studies in hysteria and thus follow the path which I myself have trodden."

In the first cases of the book, the traumas seem trivial. It strains belief that a person's profound neurotic state could result from ones being chased by a vicious dog or being hit with a stick by an employer or discovering a maid allowing a dog to drink water out of one's glass or being in love with one's employer and having to suffer the latter's unjust reproaches. As the book progresses, Freud's explanations of precipitating traumas become ever more dazzling in their sophistication. To him, his patients were, he came to believe, bedeled by archetypal concerns worthy of a Greek tragedy attention hatred of children, since they interfered with a wife's ability to minister to a dying husband, incestuous activity with a parent, a primal scene experience, and pleasure and ensuing guilt at the death of a sister whose husband the woman patient loved. These latter cases, the footnotes and Freud's letters all bear evidence of the inexraable direction of Freud's thinking about the source of anxiety. One, he gradually shifted the time of the real trauma responsible for anxiety to a period earlier in life, and two, he came to view the nature of the trauma as explicitly and exclusively sexual.

Freud's musings about the emotional traumas of his five patients gradually developed into a formal theory of anxiety. Anxiety was a signal of anticipated danger. The seed of anxiety was planted early in life when an important trauma occurred. The memory of the traumatic event was repressed and its attendant effect transformed to anxiety. An expectation of the trauma's recurrence or of some analogous danger could evoke anxiety. knew. What kind of trauma? What events are so fundamentally malignant that their echoes haunt an individual's entire life? Freud's first answer stressed the importance of the effect of helplessness. He said, "Anxiety is the original reaction to helplessness and is reproduced later on as a signal for help in the face of trauma. Then the task is to determine which situations call forth helplessness. Since the problem of anxiety is the very heart of psychoanalytic theory and since Freud boldly altered basic theory throughout his career, it is not surprising that his statements on anxiety are many varied and at times conflicting. Two primary origins of anxiety survive Freud's restless sifting. Loss of mother, abandonment and separation, and loss of the fallus, castration anxiety. Other major sources include super ego or moral anxiety, the fear of one's own self-destructive tendencies, and the fear of ego disintegration, of being overwhelmed by the dark, irrational night forces that reside within. Though Freud often mentioned other sources of anxiety, he placed his major emphasis on abandonment and castration. He believed that in everchanging guys, these two psychic cats and jammer kids to devil us through our waking lives and in our sleep provide the fuel for our two common nightmares of falling and of being chased. Always the archaeologist always searching for more basic structures, Freud suggested that castration and separation had a common feature loss. Loss of love of the ability to unite with mother. Chronologically, separation occurs first, templated, in fact, in the trauma of birth, the first moment of life. But Freud chose to consider castration as the generic primary source of anxiety. The earlier separation, he suggested, primed the individual for castration anxiety, which when it develops, subsumes the earlier anxiety experiences.

When one considers the database, the case material of the patients in studies in hysteria from which Freud's conclusions about anxiety and trauma spring, one is struck by an astonishing discrepancy between the case histories and Freud's conclusions and formulations. Death so pervades the clinical histories of these patients that only by a supreme effort of inattention could Freud have omitted it from his discussion of precipitating traumas. Of the five patients, two are discussed only briefly. One patient, Katarina, Freud's waitress at a vacation resort, was treated in a single session. The three major patients, Anna O, Frame, Emmy von N, and Frowline Elizabeth von R, the first dynamic case reports in psychiatric literature, are remarkable in that their clinical descriptions grown with references to death. Furthermore, it's likely that had Freud been specifically interested in death anxiety, he would have elicited and reported even more material on the theme of death. Anna O's illness, for example, first developed when her father fell ill and succumbed to that illness 10 months later. She nursed him indeifhaticably at first, but eventually her illness, consisting of bizarre altered states of consciousness, amnesia, linguistic disorganization, anorexia, and sensory and muscular conversion symptoms, resulted in her being removed from contact with her dying father. During the following year, her condition deteriorated badly. Buer noted Anna O's preoccupation with death. He commented, for example, that although she had bizarre and rapidly fluctuating disturbances in consciousness, the one thing that nevertheless seemed to remain conscious most of the time was the fact that her father had died. During Buer's hypnotic work with Anna O, she had terrifying hallucinations associated with her father's death. While nursing him, she had once fainted when she imagined she saw him with a death's head. During treatment, she once looked in the mirror and saw not herself, but her father with a death's head glaring at her. On another occasion, she hallucinated a black snake coming to attack her father. She tried to fight the snake, but her arm had fallen asleep, and she hallucinated her fingers turning to snakes, and each fingernail becoming a tiny skull. Buer considered these hallucinations emanating from her terror of death as the primal cause of her illness. He said, "On the last day of treatment, by the help of rearranging the room so as to resemble her father's sick room, she reproduced the terrifying hallucinations I have described and which constituted the root of her whole illness." Frame Emmy von N like Anna O developed her illness immediately following the death of the person to whom she was closest her husband. Freud hypnotized Frame von N and asked for important associations. She reeled off a litany of death related memories. Seeing her sister in a coffin at age seven, being frightened by her brother dressed as a ghost and by siblings throwing dead animals at her. Seeing her aunt in a coffin at age nine, finding her mother unconscious from a stroke age 15, and then at age 19, finding her dead, nursing a brother dying of tuberculosis, mourning at age 19, the death of her brother, witnessing the sudden death of her husband. In the first eight pages of the clinical case report, there are no fewer than 11 explicit references to death, dying, or corpses. Throughout the clinical description, Frame Emmy von N explicitly discusses her pervasive fear of death. The illness of the third patient, Frowine Elizabeth von R, incubated during the 18 months that she nursed her dying father and witnessed the inexraable deterioration of her family. One sister moved far away. Her mother suffered a severe illness. Her father died. Finally, following the death of a muchloved older sister, Frowine Elizabeth's illness erupted in full force. In the course of

Therapy, Freud, in order to accelerate the recall of old memories and effect, assigned the task of visiting her sister's grave in much the same way had rearranged his consulting room to resemble the room in which Anna O.'s father had died. Freud believed that anxiety is called forth by a situation that evokes an earlier long-forgotten situation of terror and helplessness. Surely the death-linked traumas of these patients evoked in them deep feelings of terror and helplessness. But in his journal of each case, Freud either neglects entirely the theme of death or simply draws attention to the generalized stress caused by each patient's loss. His formulations focused on the erotic components of each patient's trauma. Thus, when Frowline Elizabeth's sister died, Freud helped her to recognize that in the pit of her mind, she rejoiced and subsequently was overcome with guilt because her sister's husband, whom she coveted, was now free to marry her. An important discovery. The unconscious, a residue of primitive wishes buried in the cellar of the mind because they were unfit for the sunlight, escaped briefly into consciousness and caused great anxiety, which was ultimately bound by conversion symptomatology. No doubt Freud uncovered in each of his patients important conflicts. It is what he omitted that bears scrutiny.

The death of a parent, a spouse, or some close associate is more than generalized stress. It is more than loss of an important object. It is a knock at the door of denial. If, as Freud speculated, Frowline Elizabeth thought, even for a fleeting moment, when her sister died, "Now her husband is free again, and I can be his wife." Then most certainly she also shuddered with the thought, "If my darling sister dies, then I too will die." Like Frowine Elizabeth at her sister's death, so Anna O. at her father's or Frame Emmy von Nen at her husband's, each must have caught at a deep level and just for an instant a glimpse of her own death. In his subsequent formulations regarding the sources of anxiety, Freud in a most curious fashion continued to overlook death. He settled on loss, castration, and abandonment—the loss of the penis and the loss of love. His posture here is uncharacteristic. Where is the intrepid archaeological excavator? Freud always drilled for bedrock, for the earliest origins, the dawn of life, the ways of primitive man, the anti-deluvian primal horde, the fundamental drives and instincts. Yet before death, he pulled up short. Why did he not take one more obvious step toward the common denominator of abandonment and castration? Both concepts rest on ontological bedrock. Abandonment is inextricably entangled with death. The abandoned primate always perishes. The fate of the outcast is invariably social death followed quickly by physical death. Castration, if taken in the figurative sense, is synonymous with annihilation. If taken literally, and Freud alas meant it literally, then it also leads to death since the castrated individual cannot thrust his seed into the future, cannot escape extinction. In *Inhibitions, Symptoms and Anxiety*, Freud briefly considered the role of death in the ecology of the neurosis, but dismissed it as superficial. I shall later discuss the topsyturvy analytic view of what constitutes depth and superficiality.

In a passage that has been quoted countless times by theoreticians, Freud describes why he omits the fear of death from consideration as a primary source of anxiety. He wrote, "It would seem highly improbable that a neurosis could come into being merely because of the objective presence of danger without any participation of the deeper levels of the mental apparatus. But the unconscious seems to contain nothing that could give any content to our concept of the annihilation of life. Castration can be pictured on the basis of the daily experience of the feces being separated from the body or on the basis of losing the mother's breast at weaning. But nothing resembling death can ever have been experienced. Or if it has, as in fainting, it has left no observable traces behind. I am therefore inclined to adhere to the view that the fear of death should be regarded as analogous to the fear of castration and that the situation to which the ego is reacting is one of being abandoned by the protecting superego, the powers of destiny, so that it has no longer any safeguard against all the dangers that surround it." The logic falters badly here. First, Freud insists that since we have had no experience of death, it can have no representation in the unconscious. Have we had an experience with castration? No direct experience, Freud acknowledges. But he states that we experience other losses that are experientially equivalent: the daily separation of feces or weaning experience. Surely the feces-weaning-castration linkage is not more logically compelling than the concept of an innate intuitive awareness of death. In fact, the argument whereby death is replaced by castration as a primary source of anxiety is so untenable that I feel uncomfortable attacking it, much as if I were fighting an obviously crippled opponent. For example, consider the obvious point that women too have anxiety. The gymnastic efforts required to apply castration theory to women are truly the supreme hijinks of analytic metapsychology.

Melanie Klein was explicitly critical of Freud's curious inversion of primacy. She said the fear of death reinforces castration fear and is not analogous to it. Since reproduction is the essential way of counteracting death, the loss of the genital would mean the end of the creative power which preserves and continues life. Klein also disagreed with Freud's position that there is no fear of death in the unconscious. Accepting Freud's later postulate that there is in the deepest layers of the unconscious a death instinct, Thanatos, she argued that a fear of death also residing in the unconscious operates in opposition to this instinct. Despite the descent of Klein as well as of Rank and Adler and others who mounted guerrilla opposition, Freud persisted in his views and began a cult of death denial in generations of therapists. The major analytic textbooks reflect and perpetuate this trend. Otto Fenichel states that because the idea of death is subjectively inconceivable, every fear of death covers other unconscious ideas. Robert Waller omits a consideration of death entirely, while Ralph Greenson briefly discusses death from the perspective of Thanatos, Freud's death instinct, and then dismisses it as a curiosity, a bold but unstable theory. Only gradually, and by workers outside the Freudian tradition, or who rapidly found themselves outside, was the necessary corrective supplied.

Why did Freud exclude death from psychodynamic theory? Why did he not consider the fear of death as a primary source of anxiety? Obviously, the exclusion is not mere oversight. The fear of death is neither profound nor an elusive concept, and Freud could hardly have failed to consider and then to dismiss deliberately the issue. He is explicit about it in 1923 when he said, "The high-sounding phrase 'every fear is ultimately the fear of death' has hardly any meaning and at any rate cannot be justified." His argument proceeds along the same unconvincing lines as before: that it is not truly possible to conceive of death. Some part of the ego always remains a living spectator. Once again, Freud arrives at the unsatisfying conclusion that the fear of death, like the fear of conscience, is a development of the fear of castration. Note, too, that Freud's inattention to death is limited to discussions of the formal theory of anxiety, repression, and the unconscious. In short, to the inner workings, the cogs, bearings, and energy cell of the mental mechanism.

At the age of 64, in *Beyond the Pleasure Principle*, Freud made a place for death in his model of the mind. But even in this formulation, he spoke not of a primary dread of death, but instead of a "will to death," Thanatos, designated as one of the two primary drives. Wherever he allowed himself free rein, he speculated boldly and energetically about death. For example, in a short, penetrating essay written at the end of the First World War, "Our Attitude Toward Death," he discussed the denial of death and man's attempt to vanquish death through the creation of immortality myths. Earlier, I cited some of his comments about how life's transience increases its poignancy and richness. He was mindful of the role death plays in the shaping of life. Writing, "Would it not be better to give death the place in reality and in our thoughts which is its due and to give a little more prominence to the unconscious attitude toward death which we have hitherto so carefully suppressed. This hardly seems an advance to higher achievement but rather in some respects a backward step, a regression. But it has the advantage of taking the truth more into account and of making life more tolerable for us. Once again, to tolerate life remains, after all, the first duty of all living beings. Illusion becomes valueless if it makes this harder for us. We recall the old saying *si vis pacem, para bellum*—if you want to preserve peace, arm for war. It would be in keeping with the times to alter it: *para mortem*. If you want to endure life, prepare yourself for death. If you want to endure life, prepare yourself for death."

Freud believed that the task of a therapist was to help a patient endure life. Freud's entire therapeutic career was devoted to that end. Yet, aside from this maxim, he remained mute forever about preparing for death, about the role of the concept of death in psychotherapy. Why? One can only go so far in pointing out what Freud overlooked in commenting upon his blind spots until one begins to look back uneasily over one's shoulder. Perhaps his vision was greater than ours. It was in many other respects. Perhaps the issue is so simplistic that he never felt the necessity to provide the full argument for his position. We are well advised, I believe, to consider carefully the reasons behind Freud's position. I believe he omitted death from dynamic theory for profound reasons that flow from two sources: one, an outmoded theoretical model of behavior, and the other, a relentless quest for personal glory.

Freud's Inattention to Death: Theoretical Reasons

When Freud was 75 years old, he was asked who had most influenced him. Without hesitation, he answered, as he always had answered, Brücke. Ernst Brücke had been Freud's physiology professor in medical school and his mentor during his brief research career in neurophysiology. Brücke was a forbidding man with a Prussian iron will and steel-blue eyes, much feared by Viennese medical students. At exam time, each student was allotted several minutes for oral questioning. If a student missed the first question on an examination, Brücke would sit for the rest of the allotted time in stern silence, impervious to the desperate entreaties of the student and the dean who was present. Freud, Brücke finally found a student worthy of his interest, and the two worked closely together in the neurophysiological laboratory for several years. Brücke was a primary force behind the ideological school of biology that was founded by Hermann von Helmholtz and that dominated Western European medical and basic scientific research in the latter part of the 19th century. The basic Helmholtzian position, Brücke's legacy to Freud, was clearly delineated in a statement by another of the founders, Emil du Bois-Reymond. He said, "No other forces than the common physical-chemical ones are active within the organism. That in those cases which cannot at the time be explained by these forces, one has either to find the specific way or form of their action by means of the physical-mathematical method or to assume new forces equal in dignity to the chemical-physical forces inherent in matter reducible to the force of attraction and repulsion." The Helmholtzian position is thus deterministic and antivitalistic. Man is a machine activated by chemical-physical mechanisms. Brücke stated in his 1874 lectures in physiology that though organisms differ from machines in assimilative power, they are nonetheless phenomena of the physical world moved by forces according to the principle of the conservation of energy. The number of forces propelling the organism seems large only in the presence of ignorance. Brücke said progress in knowledge reduces them to two: attraction and repulsion. All this applies as well to the organism, man.

Freud adopted this mechanistic Helmholtzian model of the organism and applied it to constructing a model of the mind. At 70, he said, "My life has been aimed at one goal: to infer how the mental apparatus is constructed and how forces interplay and counteract in it." Hence, it is apparent what Freud owed Brücke. Freudian theory, often ironically assailed as irrational, is deeply rooted in traditional biophysical-chemical doctrine. Freud's dual instinct theory, the theory of libidinal energy conservation and transformation, and his unyielding determinism antedate his decision to become a psychiatrist. All have their analogue in Brücke's mechanistic view of man. With this background in mind, we may return with greater understanding to the question of Freud's exclusion of death from his formulations of human behavior.

Duality, the existence of two inextricably opposed basic drives, was the bedrock upon which Freud built his metapsychological system. Helmholtzian doctrine called for duality. Recall Brücke's statement: the fundamental forces active within the organism are two: attraction and repulsion. The theory of repression, the starting point of psychoanalytic thought, calls for a dualistic system. Repression requires conflict between two fundamental forces. Throughout Freud's career, he attempted to identify the pair of basic antagonistic drives that propel the human organism. His first proposal was hunger and love, as incarnated in the struggle between the preservation of the individual organism and the perpetuation of the species. Most analytic theory rests on this antithesis. The struggle between ego and libido instincts was, in Freud's earlier theory, the cause of repression and the source of anxiety. Later, for reasons not relevant to this discussion, he realized that this duality was untenable, and he espoused another dualism, a fundamental dualism grounded in life itself, between life and death: Eros and Thanatos. Freudian metapsychology and psychotherapy, however, are based on the first dual instinct theory. Neither Freud nor his students, with the single exception of Norman O. Brown, reformulated his work on the basis of life-death duality, and most of his followers discarded the second instinct theory because it led to a position of great therapeutic pessimism. They either remained with the first libido-ego preservation dialectic or drifted into a Jungian instinctual monism, a position that undermines the theory of repression.

Death is not yet. It is an event to be—an event located in the future. To imagine death, to be anxious about it, requires a complex mental activity: the planning and the projection of self into the future. In Freud's deterministic schema, the unconscious forces that clash and whose vector determines our behavior are primitive and instinctual. There is no place in the psychic power cell for complex mental acts where the future is imagined and feared. Freud is close to Nietzsche's position, which considers conscious deliberation entirely superfluous to the production of behavior. Behavior, according to Nietzsche, is determined by unconscious mechanical forces. Conscious consideration follows behavior rather than precedes it. One's sense of governing one's behavior is entirely illusion. One only imagines oneself to be choosing behavior in order to satisfy one's will to power, one's need to perceive oneself as an autonomous, deciding being. Death then can play no role in Freud's formal dynamic theory. Since it is a future event that has never been experienced and cannot be truly imagined, it cannot exist in the unconscious and thus cannot influence behavior. It has no place in a view of behavior reducible to the opposition of two opposing primal instincts. Freud became a prisoner of his own deterministic system and could discuss the role that death plays in the generation of anxiety and in man's perspective on life in only one of two ways: he could work outside his formal system in footnotes or off-the-record essays like "Thoughts for the Times and War and Death" and "The Theme of the Three Caskets." Or he could cram death into his system by either subsuming the fear of death under some more primal castration fear or by considering the will to death as one of the two fundamental drives underlying all behavior. To proclaim death a fundamental drive does not solve the problem. It fails to consider death as a future event. It overlooks the importance in life of death as a beacon, a destination, a final terminal that has the power either of stripping life of all meaning or of beckoning one into an authentic form of being.

Freud's Inattention to Death: Personal Reasons

To discover why Freud continued to cling to a theoretical system that obviously cramped his soaring intellect and forced him into contorted positions, I must turn to a brief study of Freud the man. The work of an artist, mathematician, geneticist, or novelist speaks for itself. It is a luxury, often an entertaining, interesting luxury, occasionally an intellectually enlightening one, to study the personal lives and motivations of artists and scientists. But when one considers a theory that purports to lay bare the deepest levels of human behavior and motivation, and when the data supporting that theory emanate in large part from the self-analysis of one man, then it becomes not a luxury but a necessity to study that man as deeply as possible. Fortunately, there is no scarcity of data. Probably more is known about the person of Freud than about any other modern historical figure with the possible exception of Woody Allen. Indeed, there is so much biographical material on Freud, ranging from Ernest Jones's exhaustive three-volume, 1,450-page *The Life and Work of Sigmund Freud*, to lay biographies, published recollections of former patients, to volume after volume of published correspondence, that one may, with careful picking and choosing, defend any number of outrageous hypotheses about his character structure. Therefore, *caveat emptor*.

I believe that there is much to suggest that at the core of Freud's consuming determination was his unquenchable passion to attain greatness. Jones's biography centers on that theme. Freud was born in a caul, an unbroken amniotic sack, an event that in folklore has always predicted fame. His family believed that he was destined for fame. His mother, who never doubted it, called him "my golden Siggy" and favored him above all her children. He wrote later, "A man who has been the indisputable favorite of his mother keeps for life the feeling of a conqueror, that confidence of success that often induces real success." The belief was fanned by early prophecies. One day in a pastry shop, an elderly stranger informed Freud's mother that she had brought a great man into the world. A minstrel in an amusement park, selected Freud from among the other children, and predicted that he would one day become a government minister. Freud's obvious intellectual gifts also reinforced the belief. He always stood at the head of his class at the gymnasium. In fact, according to Jones, he occupied such a privileged place that he was hardly ever questioned. It wasn't long before Freud ceased to question his destiny. In his adolescence, he wrote a boyhood friend that he had received an outstanding grade on a composition and continued, "You didn't know you were exchanging letters with a German stylist. You had better keep them carefully. One never knows."

The most interesting statement in this regard is to be found in a letter to his fiancée written when he was 28 years old and had yet to enter the field of psychiatry. "I have just carried out one resolution which one group of people as yet unborn and fated to misfortune will feel acutely. Since you can't guess whom I mean, I will tell you. They are my biographers. I have destroyed all my diaries of the past 14 years with letters, scientific notes, and the manuscripts of my publications. Only family letters were spared. Yours, my dear one, were never in danger. All my old friendships and associations passed again before my eyes and mutely met their doom. All my thoughts and feelings about the world in general, and in particular, how it concerned me, have been declared unworthy of survival. They must now be thought all over again. And I jotted down a great deal, but the stuff simply enveloped me as the sand does the Sphinx, and soon only my nostrils would show above the mass of paper. I cannot leave here, and cannot die before ridding myself of the disturbing thought of who might come by the old papers. Besides, everything that fell before the decisive break in my life, before our coming together and my choice of calling, I have put behind me. It has long been dead, and it shall not be denied an honorable burial. Let the biographers chaff. We won't make it too easy for them. Let each one of them believe he is right in his conception of the development of the hero. Even now, I enjoy the thought of how they will all go astray."

In his quest for greatness, Freud searched for the great discovery. His early letters describe a dizzying profusion of ideas that he entertained and discarded. He, according to Jones, just missed greatness by not pursuing his early neurophysiological work to its logical conclusion, the establishment of the neuron theory. He once again missed it in his work with cocaine. Freud described this incident in a letter that begins, "I may here go back a little and explain how it was the fault of my fiancée that I was not already famous at an early age." Freud continues, mentioning how one day he had casually mentioned to a physician friend, Carl Koller, his own observation of cocaine's anesthetic properties, and then had left town for a long visit with his fiancée. By the time Freud returned, Koller had already conducted decisive surgical experiments and gained fame as the discoverer of local anesthesia.

Few men have been endowed with intellectual powers comparable to Freud's. He had great imagination, limitless energy, and indomitable courage. Yet, as he entered full professional adulthood, he found his path to success unfairly and capriciously blocked. Brücke had to inform Freud that because of anti-Semitism in Vienna, there was virtually no hope of his having a successful academic career. University support, recognition, promotion were all closed to him. Freud, at the age of 27, was forced to abandon his research and earn his living as a practicing physician. He studied psychiatry and entered private medical practice. The great discovery was now his only chance of achieving fame.

Freud's sense that time and opportunity were slipping away no doubt explains his injudiciousness in the cocaine incident. He read that South American natives gained strength from chewing the cocaine plant. He introduced cocaine into his clinical practice and in an address to the Viennese medical society lauded the drug's beneficial effects on depression and fatigue. He prescribed cocaine for many of his patients and urged friends, even his fiancée, to use it. When, as they soon did, the first reports of cocaine addiction appeared, Freud's credibility before the Viennese medical society plummeted. This incident accounts, at least in some small part, for the Viennese academic community's lack of responsiveness to Freud's later discoveries. Psychology began to absorb him completely; unraveling the structure of the mind became, as Freud put it, his mistress. He soon generated a comprehensive theory of the psychogenesis of hysteria. His hopes for glory depended on the success of this theory. When contradictory clinical evidence appeared, he was crushed. Freud described this setback in a letter to his friend Wilhelm Fliess in 1897. "The hope of eternal fame was so beautiful, and so was that of certain wealth, complete independence. All that depended on whether hysteria succeeded or not. Piecemeal observations were of little import."

Freud's quarry was nothing less than an all-encompassing model of the mind. In 1895, when still midway between neurophysiologist and psychiatrist, Freud felt that the discovery of a model of the mind was at hand. He wrote in a letter, "The barriers suddenly lifted, the veils dropped, and it was possible to see from the details of neurosis all the way to the very conditioning of consciousness. Everything fell into place. The cogs meshed. The thing really seemed to be a machine which in a moment would run of itself. The three systems of neurons, the free and bound states of quantity, the primary and secondary processes, the main trend and the compromised trend of the nervous system, the two biological rules of attention and defense, the indications of quality, reality, and thought, the state of the psychosexual group, the sexual determination of repression, and finally the factors determining consciousness as a perceptual function. The whole thing held together and still does. I can naturally hardly contain myself with delight."

For the discovery to satisfy Freud's requirements fully, two features were necessary: one, that the model of the mind be a comprehensive one that met Helmholtzian scientific requirements, and two, that it be an original discovery. The Freudian basic schema of the mind—the existence of repression, the relationship between conscious and unconscious, the basic biological substrate of thought and affect—was a creative synthesis, not novel in its components. Schopenhauer and Nietzsche had blazed a bold trail, but novel in its thoroughness and in its applicability to many human activities, from dreaming and fantasy to behavior, symptom formation, and psychosis. Of his predecessors, Freud somewhere said, "Many people have flirted with the unconscious, but I was the first to marry it." The energy component of Freud's model, the sexual force or libido—a constant amount of energy that proceeds through predetermined, well-defined stages of development during infancy and childhood, that may be bound or unbound, that may be affected onto objects, that may overflow, be dammed up, or be displaced, that is the source of thought, behavior, anxiety, and symptoms—is entirely original. It was the big discovery, and Freud clung to it fiercely. For the sake of the libido theory, he sacrificed his relationships with his most promising disciples who deviated because they refused to accept his absolute insistence on the new discovery, the central role of libido in human motivation.

Obviously, the role of death in human behavior, either as a source of anxiety or as a determinant of motivation, had little appeal to Freud. It met none of his personal dynamic requirements. It was not an instinct, though Freud in 1920 was to postulate that it was, and did not fit into a mechanistic Helmholtzian model, nor was it novel. It was old hat, Old Testament in fact, and it was not Freud's aim to join a long procession of thinkers stretching back to the beginning of time. Eternal fame, as he was wont to put it, did not lie there. Eternal fame would be his from discovering a heretofore unknown source of human motivation, the libido. There seems little question that Freud correctly delineated an important factor in human behavior. Freud's was an error of over-caféination. His fierce investment in the primacy of libido was overdetermined. He elevated one aspect of human motivation to a position of absolute primacy and exclusivity and under that aspect subsumed everything human for all individuals and for all times.

Counter Theories

Counter theories soon appeared. Freud's most creative students took issue with libido theory. And by 1910, Carl Jung, Alfred Adler, and Otto Rank had all chosen to leave the good graces of the master rather than accept his mechanistic dual instinct view of human nature. Each of these defectors proposed another source of motivation. Jung posited a spiritual life force monism. Adler emphasized the child's concern about survival and his or her smallness and helplessness in the face of a macroscopic adult world and an enveloping universe. Rank stressed the importance of death anxiety and suggested that the human being was ever twisting between two fears: the fear of life and its intrinsic isolation and the fear of death. These viewpoints and the contributions of such latter-day theoreticians as Rollo May, Irvin Yalom, and Becker all supplement but do not replace the Freudian structural theory. Freud's great contribution was his formulation of a dynamic model of the mind. To introduce death, both a fear of death and an embracement of death, into Freud's dynamic model is merely to reintroduce it. Death has always been there beneath castration, beneath separation and abandonment. In this one instance, Freud and the subsequent analytic tradition remained too superficial. Subsequent theorists have provided a corrective force and so served to deepen our view of the human being.

Chapter 3: The Concept of Death in Children

Our concerns about death and modes of dealing with death anxiety are not surface phenomena that are easy either to delineate or to apprehend. Nor do they arise *denovo* in adulthood. Rather, they are deeply rooted in the past and extensively transfigured through a lifetime preoccupied with security and survival. The study of the child provides an unparalleled opportunity to study in pristine form the human being's grapple with death. To study the child's confrontation with mortality, the child's recognition of death, his or her terror, evasions, and fortifications, and subsequent development in the face of the fear of death is the purpose of this chapter.

There is, to my mind, a marked discrepancy between the importance of death to the child and the attention accorded death in child developmental scholarship. The relevant literature is meager and, when compared with the voluminous literature on other child development issues, seems at best perfunctory. Empirical studies of the child's concept of death are particularly rare. Psychoanalytically oriented clinicians have on occasion attempted to study the issue but, as we shall see, with a bias that often undermines accuracy of observation. Furthermore, much of the pertinent material is generally found in old publications, often out of the mainstream of the child development or the child psychiatric literature. We owe much to Sylvia Anthony, who so ably reviewed and analyzed the research and observational literature in her monograph, *The Discovery of Death in Childhood and After*. Both my clinical work and survey of the work of others lead me to several conclusions:

One, when behavioral scientists choose to investigate the issue closely, they invariably discover that children are extraordinarily preoccupied with death. Children's concerns about death are pervasive and exert far-reaching influence on their experiential worlds. Death is a great enigma to them, and one of their major developmental tasks is to deal with fears of helplessness and obliteration, whereas sexual matters are secondary and derivative.

Two, not only are children profoundly concerned with death, but these concerns begin at an earlier age than is generally thought.

Three, children go through an orderly progression of stages in awareness of death and in the methods they use to deal with their fear of death.

And four, children's coping strategies are invariably denial-based. It seems that we do not, perhaps cannot, grow up tolerating the straight facts about life and death.

Pervasiveness of Death Concern in Children

Freud believed that the silent sexual researches, the preoccupation with the question "Whence?" was a pervasive concern of children and constituted the foundation of the generation gap existing between child and adult. There is ample evidence, however, that the question "Whither?" also intensely occupies one's mind as a child and buzzes in one's ear throughout life. One can face it, fear it, ignore it, repress it, but one cannot be free of it. Few parents or observers of young children have not been surprised by the emergence of sudden, unexpected questions from a child about death. Once, when my 5-year-old son and I were strolling silently along the beach, he suddenly turned his face up to me and said, "You know, both my grandfathers died before I ever met them." It seemed like a tip-of-the-iceberg statement. I was certain that he had long pondered the issue silently. I asked him, as gently as I could, how often he thought about things like that, about death, and I was staggered when he replied in a strangely adult voice, "I never stopped thinking about it." Another time, on the occasion of his brother's departure to college, he commented artlessly, "There's just three of us at home now: you and me, and Mommy. I wonder who will be the first to die." A 4 1/2-year-old child said suddenly to her father, "Every day I'm afraid of dying. I wish I'd never grow old, for then I'd never die." A 3 1/2-year-old girl asked to have a stone put on her head so that she would stop growing and wouldn't have to grow old and die. A little girl, four years old, wept for 24 hours when she learned that all living things die. Her mother was unable to calm her by any other means than a silent promise that she, the little girl, would never die. A few days after the death of her paternal grandmother, a 4-year-old child came into the kitchen of the family's apartment and saw on the table a dead goose whose bloody head hung down motionless from the long neck. The child, who had heard of the death of her grandmother but had shown no special reaction, now looked anxiously for a short time at the goose and said to her mother, "Is that what you call dead?" Erik Erikson reports the case of a 4-year-old child whose grandmother died and who had an epileptiform attack the night after he saw her coffin. A month later, he found a dead mole, asked about death, and again had convulsions. Two months later, he had a third series of convulsions after accidentally crushing a butterfly in his hand.

The artless nature of a child's questions can take one's breath away. The young child asks straight out, "When are you going to die? How old are you? How old are people when they die?" The child asserts, "I want to live to be a thousand years old. I want to live to be the oldest person on earth." These are the thoughts of an age of innocence and may be stimulated by a death—the death of a grandparent, an animal, perhaps even a flower or a leaf. But often they arise unprompted by any external stimulus. The child merely vents the internal concerns upon which he or she has long meditated. Later, as the child learns to see the emperor's new clothes, he or she will also come to believe that death is a matter of no great concern.

By administering a story completion test to 98 children ages 5 to 10, Anthony has provided an objective measure of children's death concern. The stories were open-ended and without explicit reference to death. Example: "When the boy went to bed at nighttime, what did he think about?" or "A boy went to school. When playtime came, he didn't play with the others, but stayed all alone in the corner. Why?" In completing the stories, the children evinced considerable preoccupation with death or annihilation. Approximately 50% of the children referred in their story completions to death, funerals, killings, or ghosts. When slightly inferential answers were also included ("he got run over" or "she lost one of her children"), the proportion rose to over 60%. For example, children answered the question, "When the boy went to bed at nighttime, what did he think about?" with such responses as "Someone would come in his room and kill him," or "Snow White, I haven't seen her, but I've seen her dead in a storybook," or "Someone was coming into his house. His father died and then he died too." One story told of a magic fairy asking a child if he wanted to be grown up or remain young for a long time, perhaps forever. Contrary to common belief that the child is impatient to grow up and become strong and effective, over 35% of the children expressed in their story completions a preference for staying young since they linked growing old to death.

Concept of Death: Stages

Thus, with ample evidence of children's concern with death, I shall consider the ontogeny of the concept of death. Many investigators have noted that children's thoughts and fears about death and their methods of coping with that fear are specific to certain stages of development.

Impediments to Knowing What the Child Knows About Death

There is a great deal that stands in the way of our knowing what the very young child knows about death. Consequently, much controversy exists in the field.

Lack of Language and Capacity for Abstract Thought

The very young child's lack of language is a formidable barrier to adults' understanding the child's inner experience. Therefore, assumptions, often highly biased ones, are made by professionals about what the child knows and does not know. Another factor is that developmentalists, especially Jean Piaget, have demonstrated that very young children lack the capacity for abstract thought. Even at 10 years old, the child is in a stage of concrete mental operations and is just beginning to take proper account of what is potential or possible. Since death, one's personal death, being and non-being, consciousness, finality, eternity, and the future are all abstract concepts, many developmental psychologists have concluded that young children have no accurate concept of death whatsoever.

Freud's Stand

Another important factor influencing professional views about the young child's concept of death has been the strong stand of Freud, who was convinced that the young child does not grasp the true implications of death. Since Freud considered the very early years of life as the ones most instrumental in shaping character, it was precisely for this reason that he considered death as an unimportant motif in psychic development. These passages from *The Interpretation of Dreams* convey his position:

"The child's idea of being dead has nothing much in common with ours apart from the word. Children know nothing of the horrors of decay, of freezing in the ice-cold grave, of the terrors of eternal nothingness—ideas which growing-up people find it so hard to tolerate, as is proved by all myths of the future life. The fear of death has no meaning to a child. Hence it is that he will play with the dreadful word and use it as a threat against a playmate. 'If you do that again, you'll die like Franz.' It was actually possible for a child who was over 8 years old at the time, coming home from a visit to the natural history museum, to say to his mother, 'I'm so fond of you, Mommy. When you die, I'll have you stuffed and I'll keep you in this room so that I can see you all the time.' So little resemblance is there between a child's idea of being dead and our own. I was astonished to hear a highly intelligent boy of 10 remark after the sudden death of his father, 'I know father's dead, but what I can understand is why he doesn't come home to supper.' To children who moreover are spared the sight of the scenes of suffering which precede death, being dead means approximately the same as being gone, not troubling the survivors anymore. A child makes no distinction as to how this absence is brought about, whether it is due to a journey, to a dismissal, to an estrangement, or to death. When people are absent, children do not miss them with any great intensity. Many mothers learn this to their sorrow when, after being away from home for some weeks on a summer holiday, they are met on their return by the news that the children have not once asked after their mommy. If their mother does actually make the journey to that undiscovered country, from whose bourn no traveler returns, children seem at first to have forgotten her, and it is only later on that they begin to call their dead mother to mind."

Thus, in Freud's view, the child, even at the age of eight or nine, knows little and hence fears little about death. Freud, in his formulations about the child's basic concerns, relegated death to a position relatively late in development and assigned sexual concerns an earlier and primary position. His conclusions about the role of death in personal development were highly influential and resulted in the issue being prematurely sealed off for a generation. Not only are there, as I discussed in the last chapter, personal and theoretical reasons for Freud's error, but methodological ones as well. He never worked directly with young children.

Adult Bias

Bias is another important barrier to knowing what the child knows about death. Whether the study is observational, psychometric, or projective, an adult must collect and interpret the data, and that adult's personal fear and denial of death frequently contaminate the results. Adults are reluctant to speak to children about death. They avoid the topic. They accept surface data unquestioningly because they are unwilling to probe into a child farther. They systematically misperceive a child's experience, and they always err in the direction of assuming that a child has less awareness of death and less anguish therefrom than is the case.

A widely cited research inquiry into children's fears by Reema Leulse and Mary Monk is illustrative of the role of bias. The authors studied an extensive sample (n=482) of normal children aged 6 to 12 with the objective of determining the nature and the extent of children's fears. But because they felt it would have been impossible to conduct hundreds of interviews of children, they interviewed the mothers instead. The mothers considered the two fear items most closely related to death ("getting sick," "having an accident or dying," or "worries about health") to be of minimal concern. Only 12% of the mothers rated the first item as an important concern and 16% the second. By contrast, 44% rated snakes as an important concern and 38% rated school marks similarly. The authors then selected a subsample (n=192) and interviewed the children as well as the mothers. The results demonstrated that in general mothers underestimated the frequency of children's fears. The two death-related items showed particularly high discrepancies. On these items, mother and child agreed on their answers in only 45% of the cases. Of the disagreements, 90% were the result of a mother's underestimating the child's concerns about death. Mothers also underestimated to the same degree other items more inferentially related to death ("anyone in the family getting sick or dying," "germs," "fires"). The findings suggest that mothers tend to be unaware of the degree to which their children are concerned with death.

Another study reports the reactions in a children's hospital to the death of John F. Kennedy. The researchers note that highly trained hospital staff members were unexpectedly unreliable in observing children's reactions to death. These staff members differed widely, not only in their observations of these reactions but also in their opinions about how much information children should be given and how much emotional stress children could be expected to tolerate. Piaget, who has worked with children his entire professional life, felt that psychological testing, even of a highly sophisticated genre, often yields incomplete or deceptive data, and that—and most clinicians would agree—the most satisfactory mode of inquiry is a general examination or a clinical interview. Yet there are precious few reports of in-depth interviews with children in the literature. One's nurturing instinct is aroused at the sight of the young of almost any mammalian species, ranging from kittens, puppies, and colts to humans. It is difficult to go against biological grain to expose a child to the naked truth about death, and this difficulty is, I believe, the major factor behind the dearth of professional inquiry. In fact, I have serious doubts whether a research project whose design included explicit questioning of young children about death would today even obtain clearance from a human subjects research committee. Without question, such a project would encounter strong opposition from parents. Consequently, the inquiries are generally inferential and often superficial. There are only a few reports of inquiries based on direct interviews, and the most thorough of these are several decades old. Maria Nagy and Sylvia Anthony reported on work done in the 1940s. Nagy, who was known as "Auntie Death" to the children at the school where she conducted her researches, asked children to draw pictures about death, to write compositions about death, and to discuss verbally their thoughts about death. Anthony asked for definitions to death-linked words and used a story completion test. Paul Schilder and David Wechsler in 1935 administered a series of death-related pictures to children and asked for their reactions. Though the pictures were explicit, indeed macabre, the authors made concessions to the sensitivities of the children by accepting and reporting the reactions at face value. Had the subjects been adults, the researchers would never have condoned this procedure. Instead, they would have probed, investigated, and interpreted the responses at great depth.

What the Child Is Taught

There is one other obstacle to knowing what the child knows about death. A child's state of knowing about death rarely exists long in nascent form. Adults are extraordinarily anguished at the sight of a child grappling with the idea of death and rush in to spare the child. The child perceives the adult's anxiety and accordingly discovers that it is imperative to suppress death concerns. There will be little genuine relief from his or her parents. Many parents, despite considerable enlightenment and firm resolve to provide honest instruction, waver in the face of a child's distress. Anthony reports a brief, illustrative conversation between a 5-year-old child and his university professor mother.

Child: "Do animals come to an end, too?"

Mother: "Yes, animals come to an end, too. Everything that lives comes to an end."

Child: "I don't want to come to an end. I should like to live longer than anyone on earth."

Mother: "You need never die. You can live forever."

Generally, parents attempt to assuage a child's fears by offering some form of denial: either some idiosyncratic denial system or a socially sanctioned immortality myth. What an investigator often discovers then is not a child's natural inclination, but a complex amalgam consisting of a child's awareness, anxiety, and denial intermingled with an adult's anxiety and denial defenses. What the child should and should not be told is an issue I shall discuss elsewhere. But we must understand why we choose various courses of death education. Is it for the child's benefit or the adult's? Emma Ferman, who closely studied young children who had lost a parent, concluded that, "Concrete information about death was helpful to them at certain points, and that the child's task was made more difficult when the adults in their environment wittingly or unwittingly misrepresented or obscured the objective facts."

First Awareness of Death

When does the child first know about death? Several sources of data are available, all of which are inhibited by the impediments I've described: careful longitudinal observations by parents or trained observers; psychological tests, primarily word definitions (e.g., "dead," "life," "living"); story completions; TAT (Thematic Apperception Test); analysis of children's drawings; systematic observations made by staff of a hospital or residential home; and case reports of child therapists or adult therapists who furnish retrospective data.

Death and the Development of Language

The more objective measures rely on the child's mastery of language. Anthony attempted to answer the question, "When does the child know about death?" by asking 83 children to define the word "dead" inserted into a test of general vocabulary. The responses of 100% of the children seven or older and of two-thirds of the six-year-olds indicated comprehension of the meaning of the word, though they often included in their definitions phenomena not logically or biologically essential. Only three of the 22 children six or younger were

totally ignorant of the meaning of the word. Another objective approach to the problem is to study the child's development of the concept of living or of life. Young children seem to have much confusion about the properties of living entities. Jay Sully noted in 1895 that young children consider all apparently spontaneous movements as a sign of life and accordingly consider such objects as fire or smoke to be alive. PGE considered that the animism of children which he felt paralleled the animism of primitive man falls into four stages. At first, inanimate objects are generally considered to have life and will. At about the beginning of the seventh year, the child attributes life only to things that move. From the 8th to 12th year, the child attributes life to things that move by themselves. And afterward, the child's view increasingly becomes the adult view. The child goes through a great deal of confusion in trying to understand what lives or has life and what is inanimate. For example, in one study over 1/3 of 7 to 8-year-old children believed that a watch or a river lives. 3/4s felt that the moon lives whereas 12% felt that a tree does not live.

The confusion of the child is probably enhanced by confusing messages from the environment. The child is never educated clearly and precisely about these matters by adults. He or she is confused by dolls and mechanical toys which simulate life. Poetic license and language is another source of confusion. Clouds race across the sky. The moon peeps in at the window. The brook dances to the sea.

As a footnote, PJ considered the subject of death to be instrumental in the development of mature concepts of causality. In the early thought of the child, motivation is considered the source and explanation of the existence of things and every cause is coupled with a motive. When the child becomes aware of death, that system of thought undergoes an upheaval. Animals and people die and their deaths cannot be explained as a result of their motives. Gradually, children begin to understand that death must be a law of nature, a law that is uniform and impersonal.

Observations of children. These studies of linguistic development have prompted many developmentalists and clinicians to date the child's awareness of death to a time much later than is indicated by the direct observations that I shall now consider. Perhaps researchers are making unnecessarily stringent evidential demands. Is there any reason that a child must be able to define living or for that matter dead in order to know in his bones that he, like insects, animals, or other people, will one day cease to be. Researchers who study very young children almost invariably conclude that they have considerable traffic with death. The theoretical objection that the child younger than 8 to 10 cannot comprehend abstract concepts begs the question. As Castenbomb and Eisenberg point out, "Between the extremes of no understanding and explicit integrated abstract thought, there are many ways by which the young mind can enter into a relationship with death."

Despite a certain vagueness, the phrase "enter into a relationship with death" is serviceable. The very young child thinks about death, is fearful of it, is curious about it, registers death-related perceptions that stay with him or her all his life, and erects magic-based defenses against death. Casten Bomb and Eisenberg described some observations of David, an 18-month-old child who discovered a dead bird in his yard. The boy appeared stunned, and his face, according to his parents, was set in a frozen, ritualized expression resembling nothing so much as the stylized Greek dramatic mask for tragedy. David was a typical toddler who tended to pick up and examine everything he could reach. In this instance, however, he crouched closely to the bird, but made no effort to touch it. A few weeks later, he found another dead bird. This time, he picked up the bird and insisted through gestures which included an imitation of a bird flying that the bird be placed back on a tree limb. When his parents placed the dead bird in the tree, and the bird, alas, did not fly, David repeatedly insisted that the bird be placed in the tree. A few weeks later, the boy's attention focused on a single fallen leaf, and he became deeply engaged in trying to place it back on the tree. When he failed to reverse the leaf's fate, he instructed his father to restore the leaf to the tree. Because David was not able to speak, one cannot be certain of the precise nature of his inner experience. But his behavior suggests that he was grappling with the concept of death. Certainly, there is no question that the exposure to death elicited unprecedented and unusual behavior.

Xandoor Brandt, a psychologist, reports an incident involving his son, Michael, aged 2 years, 3 months. Michael, who had been weaned from his bottle for a year, began waking up several times a night screaming hysterically for a bottle. When questioned, Michael insisted he must have a bottle, or "I won't make contact. I'll run out of gas. My motor won't run, and I'll die." His father says that on two occasions immediately prior to Michael's night awakenings, a car had run out of gas, and in the child's presence, there had been much discussion of how the motor had died and how a battery had gone dead. Michael seemed convinced, his father concludes, that he had to keep on drinking fluid or else he too would die. Michael's visible death concerns had begun even earlier in life when he saw a photograph of a dead relative and directed an endless stream of questions toward his parents about the status of this relative. Michael's story indicates that death can be a source of significant distress for the very young child. Furthermore, as was true with the previous case, Michael at a very early age recognized death as a problem. Perhaps, as Castenbomb suggests, the first vital problem and a prime stimulus to continued mental development.

Gregory Rocklin, on the basis of several play sessions with a series of normal children aged 3 to 5, concludes too that the child at an early age learns that life has an end and that death will come for himself or herself as well as for those upon whom he or she depends. He wrote, "My own studies have shown that the knowledge of death, including the possibility of one's own death, is acquired at a very early age and far sooner than is generally supposed. By the age of 3 years, the fear of one's own death is communicable in unequivocal terms. How much earlier than 3 years of age this information is acquired is a matter of tenuous speculation. Communication with a younger child on the subject is unlikely. It also would be much too fragmentary. What is more important is that in a child 3 years old, death as a fear, as a possibility, has already begun to produce significant effects. The evidence is readily available," Rockland states, "to whoever is willing to listen to children and observe their play. Children the world over play games of death and resurrection. Opportunities to learn about death are abundant. A trip to the meat market tells any child more than he or she wishes to know. Possibly no experience is required. Possibly, as Max Sheller claims, each of us has intuitive knowledge of death. Regardless of the source of the knowledge, however, one thing is certain. The tendency is deep-seated in each of us, even in early life, to deny death. Knowledge is relinquished when desire opposes it. When reality intrudes forcibly, the fledgling death-denial defenses falter, allowing anxiety to break through."

Rocklin describes a three-and-a-half-year-old boy who for several months had been asking his parents when he or they would die. He was heard to mutter that he himself would not die. Then his grandfather died. This grandfather lived in a distant city and was barely known to the child. The child began having frequent nightmares and regularly delayed going to sleep. He apparently equated going to sleep and death. He asked whether it would hurt to die and commented that he was afraid to die. His play indicated a preoccupation with illness, death, killing, and being killed. Though it is difficult to know with assurance what death means to the inner world of the pre-operational child, it seemed that this child associated it with considerable anxiety. Death meant being put in the sewer, being hurt, disappearing, vanishing down the drain, rotting in the graveyard.

Another child, aged four, also lost a grandfather who died on his third birthday. The boy insisted that his grandfather was not dead. Then when he was told that his grandfather had died of old age, he wanted reassurance that his mother and father were not old and told them that he would not get older. Part of the transcription of this play session reveals clearly that this four-year-old had entered into a relationship with death. "Last night, I found a dead bee. Did it look dead? He got killed. Someone stepped on him and it got dead. Dead like people are dead. They're dead, but they're not like dead people. Nothing like dead people. Is there a difference? People are dead, and bees are dead, but they're put in the ground and they're no good. People are no good. After a long time, he'll get alive. The bee, but not a person. I don't want to talk about it. Why? Because I have two grandfathers alive. Two? One. What happened to one? He died a long time ago. A hundred years ago. Will you live long, too? 100 years. Then what? I'll die perhaps. All people die. Yes, I will have to. That's sad. I have to anyway. You have to? Sure. My father is going to die. That's sad. Why is he? Never mind. You don't want to talk about it. I want to see my mother now. I'll take you to her. I know where dead people are. In cemeteries. My old grandfather is dead. He can't get out. You mean where he is buried? He can't get out. Never."

Melanie Klein, on the basis of her experience in analyzing children, concludes that the very young child has an intimate relationship with death. A relationship that antidates by a considerable period his or her conceptual knowledge of death. The fear of death, Klein states, is part of the infant's earliest life experience. She accepts Freud's 1923 theory that there is a universal unconscious drive toward death, but argues that if the human being is to survive, then there must be a counterbalancing fear of loss of life. Klein considers the fear of death as the original source of anxiety. Sexual and superego anxiety are thus late comers and derivative phenomena. She states, "My analytic observations show that there is in the unconscious a fear of annihilation of life. I would also think that if we assume the existence of a death instinct, we must also assume that in the deepest layers of the mind, there is a response to this instinct in the form of fear of annihilation of life. The danger arising from the inner working of the death instinct is the first cause of anxiety. The fear of being devoured is an undisguised expression of the fear of total annihilation of the self. The fear of death enters into castration fear and is not analogous to it. Since reproduction is the essential way of counteracting death, the loss of the genital would mean the end of the creative power which preserves and continues life." Klein's argument that concern about reproduction flows from death fear is, I believe, formidable and brings into question traditional analytic views of what is primary in the mental life of the individual.

Kurt Eisler, who early in the psychoanalytic movement thought deeply about death, arrived also at the conclusion that the child's early preoccupation with sexuality is a derivative inquiry secondary to an earlier and terrifying awareness of death. He wrote, "Refined research into this matter might show that the child's inquiry into the generative processes, that is, the facts of life, is a secondary edition of an earlier and short-lasting inquiry into death. Possibly the child turns away from such an inquiry because of the accompanying horror, and because of the utter hopelessness and ensuing despair about any possible progress in his investigation."

Other workers who have observed children closely have arrived at the conclusion that the young child, regardless of whether theoretically he or she is intellectually equipped to understand death, grasps the essence of the matter. Anna Freud, working with young children in the London Blitz, wrote, "It can be safely said that all the children who were over two years at the time of the London Blitz realized the house will fall down when bombed and that people are often killed or get hurt in falling houses." She described a 4 1/2-year-old child who acknowledged his father's death. The child's mother wished the children to deny their father's death, but the child insisted, "I know all about my father. He has been killed and he will never come back." Furman worked with a large number of children who had lost a parent and she concluded that during their second year of life, children could achieve a basic understanding of death. The understanding of death is enhanced by some type of earlier experience that helps the child form the necessary mental category. Furman cites the following example. Susie was barely three years old when her mother died. After being told this sad news, Susie soon asked, "Where is Mommy?" Her father reminded her of the dead bird they had found and buried not too long ago. He explained that Mommy too had died and had to be buried. He would show her where whenever Susie wished. One month later, Susie reported to her father, "Jimmy," the neighbor's six-year-old son told me that my Mommy would come back soon because his Mommy said so. I told him, 'That's not true because my Mommy is dead, and when you're dead, you can't ever come back.' That's right, Daddy, isn't it?"

A mother reported this interaction with a child of 3 years and 9 months. Jane has received no religious instruction and so far never met death in connection with any human being of her acquaintance. A few days ago, she began asking questions about death. The conversation began by Jane asking if people came back again in the spring like flowers. A week or so before, she had been very upset by her favorite flower dying, and they had consoled her by saying they would return in the spring. I answered that they do not return the same but different, possibly as babies. This answer obviously worried her. She hates change and people getting old, for she said, "I don't want Nan to be different. I don't want her to change and grow old. Then will Nan die. Shall I die too? Does everyone die?" On my saying yes, she broke into really heartbreaking tears and kept on saying, "But I don't want to die. I don't want to die." She then asked how people died, if it hurt, whether when they were dead, they opened their eyes again, whether they spoke, ate, and wore clothes. Suddenly, in the midst of all these questions and tears, she said, "Now I will go on with my tea," and the matter was temporarily forgotten. It is interesting to note the troubled, uncertain responses of this mother, who a short time previously had managed with little difficulty to answer her daughter's questions about birth and where babies come from. She ended the proceeding report, "It took me all unawares. Although I expected the questions about birth, etc., those about death I hadn't thought of yet, and my own ideas are very hazy." Obviously, a child perceives such a parent's anxiety and confusion along with any verbal comforting reassurances the parent may provide.

Other reports of conversations with parents give the flavor of the child's fear and curiosity about death. For example, lately at bath time, Richard, 5 years 1 month, has begun to whimper and be miserable about dying. Yesterday, as he swam up and down in his bath, he played with the possibility of never dying, of living to a thousand. Today, he said, "I might be alone when I die. Will you be with me, but I don't want to be dead ever. I don't want to die." Some days previously, when he had seemed afraid of not knowing how to die, his mother had told him he need not worry, because she would die first, so he would know how it was done. This seemed to reassure him.

In a controversial essay, Adam Mau makes some intriguing speculations about the infant's early awareness of death. The infant's first task, Mau reasons, is to differentiate between self and environment, to know being as the opposite of non-being. As the baby waivers back and forth between consciousness and unconsciousness, between sleep and wakefulness, he or she comes to have a sense of these two states. What is the infant's mental experience during a night terror? Mau suggests that the infant may be experiencing fear and awareness of non-being. Lying in a dark, quiet room and deprived of both sight and hearing, the infant may be panicked by a half-heard, disembodied sensation. Max Stern, who studied night terrors, arrived at a similar conclusion. The child is terrified of nothingness.

Why does the infant delight in the game of throwing toys from a high chair? The infant who can find an accommodating partner to return the toy will generally persist in the game until the partner retires in fatigue. Perhaps this delight stems from erotic pleasure in muscular movement. Perhaps it is a manifestation of what Robert White calls the drive for effect, the inherent pleasure in mastering one's environment. Mau suggests that the infant is fascinated by disappearance and reappearance which, in the thought and behavior available to the infant, are material symbols of the concepts of being and non-being. Indeed, White's effect drive may be a derivative of the infant's attempt to vanquish non-being. These speculations resonate with an enormous body of child developmental literature on object permanence, a thorough discussion of which would take me too far afield. Briefly, though, the child cannot appreciate the disappearance of an object until he or she has established its permanence. Permanence has no meaning without an appreciation of change, destruction, or disappearance. Thus, the child develops the concept of permanence and change in tandem. Furthermore, there is an intimate relationship between object permanence and a sense of self-permanence. The same type of oscillation, the pairing of permanence, aliveness, being, and disappearance, non-being, death, is essential in the development of the child.

"All gone" is one of the first phrases in the child's vocabulary. And "all gone" is a common theme in childhood fears. Children note how a chicken disappears at meal time, or once the plug is pulled, how the bath water becomes all gone, or how the feces is flushed away. Rare is the child who does not fear being devoured, flushed away, or sucked through the drain. Analytic literature notes the unconscious equation of feces and corpse. Perhaps it's time for psychotherapists to reconsider the dynamics of the toilet training conflict because more than anal eroticism or stubborn resistance may be involved to the child. Toilet training raises fears about physical integrity and survival. When the child realizes that eternal recurrence of vanished objects is not the order of the day, then the child searches for other strategies to protect himself or herself from the threat of non-being. The child becomes the master rather than the victim of "all gone." The child pulls out the bathtub plug, flushes objects down the toilet, gleefully blows out matches, is delighted to assist mother by pressing the pedal of the garbage pail. Later, the child disperses death either symbolically in games of cowboys and Indians or literally by extinguishing life in insects. Indeed, Karen Horney felt that the hostility and the destructiveness of a child are directly proportional to the extent to which that child feels his or her survival is endangered.

Once the child knows, what happens to the knowing? The known does not remain known. Matilda McIntyre, Carol Angel, and Lauren Stumpler inquired of 598 children whether a dead pet knows that its owner misses it. And they found that seven-year-olds are far more inclined than our children of 11 and 12 to accept death's finality and irreversibility. A related finding was reported by Irving Alexander and Arthur Adlerstein who tested the GSR (galvanic skin response) of a large number of children ages 5 to 16 who were exposed to a series of death-related words interspersed among a series of neutral words. They divided the children into three groups: childhood (5 to 8), pre-adolescence or latency (9 to 12), and adolescence (13 to 16). The results indicated that the young children and the adolescents had a much greater emotional response to death-related words than had the latency-aged subjects. The authors concluded that latency is a benign period, the golden age of childhood. As they put it, "Children at this age seem to be too much involved in the routine of life and its attendant pleasures to be concerned with the concept of death."

I believe that there is a less pollyannish way of explaining these results: that the child at an early age stumbles upon the true facts of life, that the child's solitary researches lead him or her to the discovery of death. But the child is overwhelmed by the discovery and experiences primal anxiety. Though the child searches for reassurance, he or she must deal with death. He or she may panic in the face of it, deny it, personify it, scoff at it, repress it, displace it, but deal with it, the child must. During latency, the child learns or is taught to negate reality. And gradually, as the child develops efficient and sophisticated forms of denial, awareness of death glides into the unconscious and the explicit fear of death abates. The carefree days of pre-adolescence, the golden age of latency, do not diminish death anxiety but result from it. Though in latency one acquires much general knowledge, at the same time one retreats from knowledge about the facts of life. And it is the awareness of death as much as infantile sexuality that is latent. During adolescence, childhood denial systems are no longer effective. The introspective tendencies and the greater resources of the adolescent permit him or her to face once again the inevitability of death, to bear the anxiety, and to search for an alternate mode of coping with the facts of life.

Stages of knowing. A working model of the child's subsequent development of the concept of death depends upon the open question of when he or she first knows about death. Either the child gradually develops an awareness and understanding of death or, as I believe, the child is caught in a jerky process of knowing too much too early and then finds ways to repress that knowledge, to unknow, until gradually the child is prepared to accept that which he or she originally knew. There is no certainty in this matter. There exists no conclusive evidence for either viewpoint. I consider the stages that succeed a child's first knowledge of death as based on denial. Inherent in the concept of denial is the existence of former knowledge. One can only deny that which is known. If a listener chooses not to accept the arguments I have posited in support of former knowledge, then he or she must read "approximations to knowledge" where I say "denial."

Denial. Death is temporary diminution, suspended animation, or sleep. Many children old enough to talk report that they consider death to be reversible or temporary or to be a diminution rather than a cessation of consciousness. This view receives considerable reinforcement from the ubiquitous television cartoons that show characters blown apart, flattened, crushed, or mutilated in an endless number of ways and then finally and miraculously reconstituted. Nash reported some illustrative interview excerpts.

SC, 4 years 8 months. "It can't move because it's in the coffin." Interviewer: "If it weren't in the coffin, could it move?" Child: "It can eat and drink."

SJ, 5 years 10 months. "Its eyes were closed. It lay there so dead. No matter what one does to it, it doesn't say a word." Interviewer: "After 10 years, will it be the same as when it was buried?" Child: "It will be older then. It will always be older and older. When it is 100 years old, it will be exactly like a piece of wood." Interviewer: "How will it be like a piece of wood?" Child: "That I couldn't say. My little sister will be 5 years old now. I wasn't alive yet when she died. She will be so big this time. She has a small coffin, but she fits in the small coffin." Interviewer: "What is she doing now, do you think?" Child: "Lying down. Always just lies there. She's still so small. She can't be like a piece of wood. Only very old people." Interviewer: "What happens there under the earth?"

BJ, 4 years, 11 months. "He cries because he's dead." Interviewer: "But why should he cry, child?" Child: "Because he's afraid for himself."

TP, 4 years 10 months. "A dead person is just as if he were asleep. Sleeps in the ground, too." Interviewer: "Sleeps the same as you do at night or otherwise?" Child: "Well, closes his eyes, sleeps like people at night, sleeps like that, just like that." Interviewer: "How do you know whether someone is asleep or is dead?" Child: "I know if they go to bed at night and don't open their eyes. If somebody goes to bed and doesn't get up, he's dead or ill." Interviewer: "Will he ever wake up?" Child: "No. Never. A dead person only knows if somebody goes out to the grave or something. He feels that somebody is there or is talking. He feels the flowers put on his grave. The water touches the sand. Slowly he hears everything. Auntie, does the dead person feel it if it goes deep into the ground? That is the water." Interviewer: "What do you think? Wouldn't he like to come away from there?" Child: "He would like to come out, but the coffin is nailed down." Interviewer: "If he weren't in the coffin, could he come back?" Child: "He couldn't root up all that sand."

HG, 8 years 5 months. "People think dead persons can feel." Interviewer: "And can't they?" Child: "No, they can't feel like sleep. Now I sleep. I don't feel it except when I dream." Interviewer: "Do we dream when we're dead?" Child: "I think we don't. We never dream when we're dead. Sometimes something flashes out, but not half as long as a dream."

LB, 5 years 6 months. "His eyes were closed." Interviewer: "Why?" Child: "Because he was dead." Interviewer: "What's the difference between sleeping and dying?" Child: "Then they bring the coffin and put him in it. They put the hands like this when a person is dead." Interviewer: "What happens to him in the coffin?" Child: "The worms eat him. They bore into the coffin." Interviewer: "Why does he let them eat him?" Child: "He can't get up any longer because there's sand on him. He can't get out of the coffin." Interviewer: "If there weren't sand on him, could he get out?" Child: "Certainly. If he wasn't very badly stabbed, he would get his hand out of the sand and dig. That shows that he still wants to live."

TD, 6 years 9 months. "My sister's godfather died and I took hold of his hand. His hand was so cold. It was green and blue. His face was all wrinkled together. He can't move. He can't clench his hands because he's dead. And he can't breathe." Interviewer: "His face." Child: "It has goose flesh because he's cold. He's cold because he's dead and cold everywhere." Interviewer: "Does he feel the cold? Or was it just that his skin was like that?" Child: "If he's dead, he feels too. If he is dead, he feels a tiny little bit. When he's quite dead, he no longer feels anything."

GP, 6 years. "He stretched out his arms and lay down. You couldn't push down his arms. He can't speak. He can't move. Can't see. Can't open his eyes. He lies for 4 days." Interviewer: "Why for 4 days, child?" Child: "Because the angels don't know yet where he is. The angels dig him out, take him with them. They give him wings and fly away."

These statements are most informative. One is struck by the internal contradictions, by the shifting levels of knowing that are apparent even in these short excerpts. The dead feel, but they do not feel. The dead grow but somehow stay the same age and fit in the same size coffin. A child buries a pet dog but leaves food on the grave because the dog may be a little hungry. The child seems to believe in several stages of death. The dead can feel a tiny little bit or may have dream flashes. But one who is quite dead no longer feels anything. Incidentally, these quotations are offered by Nash as proof that a child either considers death as temporary or denies it completely by equating it with departure or sleep. Once again, observer bias seems evident to me. These passages indicate that the children had considerable knowledge. There is nothing temporary or incomplete about being eaten by worms, by remaining forever under the dirt, about being quite dead and no longer feeling anything.

The child's equation of sleep and death is well known. The state of sleep is the child's closest experience of being non-conscious and the only clue the child has to what it is like to be dead. In Greek mythology, Death (Thanatos) and Sleep (Hypnos) were twin brothers. This association has implications for sleep disorders. And many clinicians have suggested that death fear is an important factor in insomnia both for adults and children. Many fearful children regard sleep as perilous. Recall the childhood prayer: "Now I lay me down to sleep. I pray the Lord my soul to keep. If I should die before I wake, I pray the Lord my soul to take."

The statements Nash collected also make it crystal clear that children, even with imperfect knowledge, consider death dreadful and frightening. Horrifying indeed are the ideas of being trapped in a nailed-down coffin, crying for oneself under the earth, lying buried for a hundred years and then turning into wood, being eaten by worms, feeling the cold, turning blue and green, or being unable to breathe. These children's views of death are sobering, especially for parents and educators who prefer to ignore the unpleasantness of the entire subject. "What they don't know won't hurt them" is the rationale behind officially sanctioned silence. Yet, what children do not know, they invent. And as we see in these examples, the inventions are more hideous than the truth. I shall have more to say about death education later, but for now, it is evident that the beliefs of children about death are terrifying indeed, and that children feel compelled to find ways to set their minds at ease.

As a footnote, it's worth mentioning that these early views of death remain in the unconscious with astonishing persistence. Elliot Jacques, for example, describes this dream of a middle-aged claustrophobic patient: "She was lying in a coffin. She had been sliced into small chunks and was dead. But there was a spiderweb-thin thread of nerve running through every chunk and connecting with her brain. As a result, she could experience everything. She knew she was dead. She couldn't move or make a sound. She could only lie in the claustrophobic dark and silence of the coffin."

Denial. The two basic bulwarks against death. The child has two basic defenses against the terror of death. Defenses that date from the very beginning of life: deep belief both in his or her personal inviolability and in the existence of a uniquely personal ultimate rescuer. Though these beliefs are abetted by explicit parental and religious instruction in afterlife myths, in an all-protecting God, and in the efficacy of personal prayer, they are also grounded in the infant's early life experience.

Specialness. Each of us, first as child and then as adult, clings to an irrational belief in our specialness. Limits, aging, death may apply to them but not to oneself, not to me. At a deep level, one is convinced of one's personal invulnerability and imperishability. The origins of this primeval belief or defense, as Jules Masserman terms it, are to be found in the dawn of life. For each of us, early life is a time of intense egocentricity. One is the universe. There are no boundaries between one and other objects and beings. One's every whim is satisfied without personal effort. One's thought results in the deed. One is templated with a sense of specialness, and one summons this ready belief as a shield against death anxiety.

The ultimate rescuer. Hand-in-hand with this anthropocentric delusion (and I do not use the word in a pejorative sense, for it is a widely shared, perhaps universal, delusion) is a belief in the ultimate rescuer. This belief too is grounded in the dawn of life, in the time of the shadowy figures, the parents, those wondrous appendages of the child's who are not only powerful movers but eternal servants as well. The belief in the external servant is reinforced by the parents' caring watchfulness during infancy and childhood. Time and time again, the child ventures too far, encounters the cruel picket fence of reality, and is rescued by enormous maternal wings which enfold him or her in body warmth. The beliefs in specialness and the ultimate rescuer serve the developing child well. They are the absolute foundation of the defense structure that the individual erects against death terror. Upon them are erected other secondary defenses which in the adult patient often obscure the original defenses as well as the nature of the primal anxiety. These two basic defenses are deeply ingrained. Witness their persistence in terms of immortality myths and the belief in a personal god in virtually every major religious system, and persist into adulthood to exert a powerful influence, as I shall discuss in the next chapter, upon character structure and symptom formation. It is important to underscore that the psychodynamic value or meaning of religion does not necessarily obviate the intrinsic truth of religious views. Or, as Victor Frankl puts it, "To satisfy precocious sexual curiosity, we invent the story that storks deliver babies. But it does not follow from this that storks do not exist."

Denial. The belief that children do not die. One common solace that children avail themselves of early in life is a belief that children have an immunity from death. The young do not die. Death occurs to the old, and old age is so very, very far away. Some illustrations.

S, aged 5 years 2 months. "Where's your mommy?" Mother: "In heaven. She died some time ago." S: "I think she was about 70." Mother: "She must have been 80 or 90." Mother: "No, only 70." S: "Men live till they're 99. When are you going to die?" Mother: "Oh, I don't know. When I'm about 70 or 80 or 90." S: "Oh, when I'm growing up, I shan't shave. And then I will have a beard, shan't I?" In a previous conversation, S said that he knew that men grew beards when they became very, very old. Later it became clear that he proposed to abstain from shaving in an effort to delay death indefinitely.

Ruth, 4 years 7 months. "Will you die, father?" Father: "Yes, but not before I grow old." Ruth: "Will you grow old?" Father: "Yes, Ruth." Ruth: "Shall I grow old, too?" Father: "Yes, Ruth." "Every day I'm afraid of dying. I wish I might never grow old, for then I would never die, would I?"

Interviewer: "Can a child die?" GM, age six. "No, boys don't die unless they get run over. If they go to a hospital, I think they come out living."

Eg, aged five. "I shall not die. When you are old, you die. I shall never die. When people get old, they die." Later, he says he will die when he gets very old. In response to story completion tests, most children give a preference for staying a child a long time rather than growing up quickly. A 9 1/2-year-old boy stated that he wanted to stop growing in order to remain a child because, as someone grows older, there's less life in him.

The actual death of a child, of course, poses severe problems for children, which they often resolve by making a distinction between dying and being killed. One boy stated, "Boys don't die unless they get stabbed or hit by a car." Another child said, "When you're 10 years old, I don't know how you could die unless someone kills you." Another, age six, "I won't die, but when you go out into the rain, you can die." All of these comments assuage anxiety by reassuring the child that death is not an immediate or, at least, not an unavoidable problem. Either death is relegated to old age, a time beyond imagination for the child, or else accidental death may occur, but only if one is very, very careless.

Denial. Personification of death. Most children between the ages of five and nine go through a period in which they anthropomorphize death. Death is given form and will. It is the boogeyman, the grim reaper, a skeleton, a ghost, a shadow, or it is simply associated with the dead. Illustrations abound, as these interviews demonstrate.

BG, 4 years 9 months. "Death does wrong." How does it do wrong? "Stabs you to death with a knife." What is death? "A man." What sort of a man? "Death man." How do you know? "I saw him." Where? "In the grass. I was gathering flowers."

BM, child, 6 years 7 months. "Death carries off bad children. Catches them and takes them away." What is he like? "White as snow. Death is white everywhere. It's wicked. It doesn't like children." Why? "Because it's badhearted. Death even takes away men and women, too." Why? "Because it doesn't like to see them." What is white about it? "The skeleton. The bone skeleton." But in reality, is it like that or do they only say so? "It really is too. Once I talked about it, and at night the real death came. It has a key to everywhere so it can open the doors. It came in, messed about everywhere. It came over to the bed and began to pull away the covers. I covered myself up well. It couldn't take them off. Afterwards, it went away."

PG, 8 years 6 months. "Death comes when somebody dies and comes with a scythe, cuts him down and takes him away. When death goes away, it leaves footprints behind. When the footprints disappeared, it came back and cut down more people. And then they wanted to catch it and it disappeared."

BT, 9 years 11 months. "Death is a skeleton. It is so strong it could overturn a ship. Death can't be seen. Death is in a hidden place. It hides in an island."

VP, 9 years 11 months. "Death is very dangerous. You never know what minute he's going to carry you off with him. Death is invisible, something nobody has ever seen in all the world. But at night, he comes to everybody and carries them off with him. Death is like a skeleton. All the parts are made of bone. But then when it begins to be light, when it's morning, there's not a trace of him. It's that dangerous. Death."

MI, 9 years 9 months. "They always draw death with a skeleton and a black cloak. In reality, you can't see him. In reality, he's only a sort of spirit. Comes and takes people away. He doesn't care whether it's a beggar or a king. If he wants to, he makes them die."

Though these accounts seem frightening, the process of death personification is an anxiety-allayer. The vision of a stalking skeleton emerging nightly from graveyard humus, grim though it be, is, in contrast to the truth, reassuring. As long as a child believes that death is brought by some outside force or figure, the child is safe from the really terrible truth that death is not external. That from the beginning of life, one carries within the spores of one's own death. Furthermore, if death is a sentient being, if, as the child said in the last illustration, "the situation is such that if he wants to, he makes them die," then perhaps death can be influenced not to want to. Perhaps, like the button maker in Ibsen's death metaphor in "Peer Gynt," death can be delayed, propitiated, or, who knows, even outwitted or defeated. In personifying death, the child recapitulates cultural evolution. Every primitive culture anthropomorphizes the blind forces of nature in an effort to experience greater control over its own destiny.

As a footnote, Coocher's 1974 study of death attitudes of American children does not corroborate Nash's findings with Hungarian children about the personification of death. Perhaps there are marked cultural differences, but the difference in methodology of the two studies makes comparisons difficult. In the American study, the interview was heavily structured with little probing or subject-interviewer interaction, whereas in the Hungarian project, the interview was far more open-ended, intensive, and personal. The anthropomorphic fear of death lingers with one all through life. Rare is the individual who does not at some level of awareness continue to harbor a fear of darkness, demons, ghosts, or some representation of the supernatural. Even a moderately well-made supernatural or ghost movie will, as filmmakers well know, strike deep cords in an audience.

Most children between the ages of five and nine go through a period in which they anthropomorphize death. Death is given form and will. It is the boogeyman, the grim reaper, a skeleton, a ghost, a shadow, or it is simply associated with the dead. Illustrations abound, as these interviews demonstrate.

Child, four years, 9 months. "Death goes wrong. How does it go wrong? Stabs you to death with a knife. What is death? A man. What sort of a man? Death man. How do you know? I saw him. Where? In the grass. I was gathering flowers."

Child 6 years 7 months. "Death carries off bad children. Catches them and takes them away. What is he like? White as snow. Death is white everywhere. It's wicked. It doesn't like children. Why? Because it's badhearted. Death even takes away men and women too. Why? Because it doesn't like to see them. What is white about it? The skeleton. The bone skeleton. But in reality, is it like that or do they only say so? It really is too. Once I talked about it. And at night the real death came. It has a key to everywhere so it can open the doors. It came in, messed about everywhere. It came over to the bed and began to pull away the covers. I covered myself up well. It couldn't take them off. Afterwards, it went away."

Child 8 years 6 months. "Death comes when somebody dies and comes with a scythe. Cuts him down and takes him away. When death goes away, it leaves footprints behind. When the footprints disappeared, it came back and cut down more people. And then they wanted to catch it and it disappeared."

Child 9 years 11 months. "Death is a skeleton. It is so strong it could overturn a ship. Death can't be seen. Death is in a hidden place. It hides in an island."

Child, 9 years, 11 months. "Death is very dangerous. You never know what minute he's going to carry you off with him. Death is invisible, something nobody has ever seen in all the world. But at night, he comes to everybody and carries them off with him. Death is like a skeleton. All the parts are made of bone. But then when it begins to be light, when it's morning, there's not a trace of him. It's that dangerous. Death."

Child, 9 years, 9 months. "They always draw death with a skeleton and a black cloak. In reality, you can't see him. In reality, he's only a sort of spirit. Comes and takes people away. He doesn't care whether it's a beggar or a king. If he wants to, he makes them die."

Chapter 3B. Denial. Personification of death. Denial. Taunting of death. The older child attempts to assuage fear of death by confirming his or her aliveness. Nine and 10-year-olds often taunt death. They jeer at their old enemy. A study of the language of school children revealed many death jibes that seemed hilariously funny to them. For example, "You're going to be burned or buried."