Existential psychotherapy by Irvin D. Yalom 06

existential isolation. The process of deepest inquiry, a process that Haidiger refers to as unconcealment, leads us to recognize that we are finite, that we must die, that we are free, and that we cannot escape our freedom. We also learn that the individual is inexorably alone.

As freedom and death are concepts that traditionally lie outside of the psychotherapist's domain, in early chapters, I felt it necessary to elaborate on their specific relevance to psychotherapy. The situation is different with isolation since it's a familiar concept and arises frequently in everyday therapy. In fact, isolation is so familiar and used in so many different fashions that my first task must be to define it in an existential context.

The clinician, it seems to me, encounters three different types of isolation: interpersonal, intrapersonal, and existential.

Interpersonal isolation, generally experienced as loneliness, refers to isolation from other individuals. It is a function of many factors: geographic isolation, the lack of appropriate social skills, heavily conflicted feelings about intimacy, or a personality style such as schizoid, narcissistic, exploitative, or judgmental that precludes gratifying social interaction. Cultural factors play an important role in interpersonal isolation. The decline of intimacy sponsoring institutions—the extended family, the stable residential neighborhood, the church, local merchants, the family doctor—has, in the United States at least, inexorably led to increased interpersonal estrangement.

Intrapersonal isolation is a process whereby one partitions off parts of oneself. Freud used the term isolation to describe a defense mechanism, especially apparent in obsessional neurosis, in which an unpleasant experience is stripped of its effect and its associative connections are interrupted so that it is isolated from ordinary processes of thought. Harry Stack Sullivan was particularly interested in the phenomenon by which one excludes experience from conscious awareness and/or makes parts of the psyche inaccessible to the self. He referred to this process as dissociation, abandoning the term repression and elevating it to a central position in his schema of psychopathology. In the contemporary psychotherapy scene, isolation is used not only to refer to formal defense mechanisms, but in a more casual way to connote any form of fragmentation of the self. Thus, intrapersonal isolation results whenever one stifles one's own feelings or desires, accepts oughts or shoulds as one's own wishes, distrusts one's own judgment, or buries one's own potential.

Intrapersonal isolation is a widely used and current paradigm of psychopathology. Modern theorists such as Horney, from Sullivan, Maslow, Rogers, and May all posit obstructions that occurring early in life act to derail the individual's natural development. Carl Rogers, in a discussion of Ludwig Binswanger's famous case of Alan West, clearly describes intrapersonal isolation. He wrote, "Though as a child she was wholly independent of opinion of others, she now is completely dependent on what others think. She no longer has any way of knowing what she feels or what her opinion is. This is the loneliest state of all, an almost complete separation from one's autonomous organism." Contemporary therapists focus closely on the goal of helping patients reintegrate previously split-off parts of themselves. In a research project that I described in chapter 6, successful patients were asked to rank order 60 factors in therapy according to degree of helpfulness. The single most frequently chosen item by far was discovering and accepting previously unknown or unacceptable parts of myself. To make oneself whole again is the goal of most psychotherapies, excluding symptom-oriented ones. Perls, for example, christened his approach Gestalt therapy to emphasize his dedication to the aim of wholeness. Note in this regard the common etymological root of whole, heal, healthy, hail.

In the remainder of this chapter, I shall focus on a third form of isolation: existential isolation. This is not to say that interpersonal and intrapersonal isolation are not crucial issues in clinical work. But if I'm to keep this treatise within manageable length, I must be content to recommend to the listener the relevant literature. There will be many occasions, however, when I shall refer to interpersonal and intrapersonal isolation, for they are closely related to existential isolation.

Interpersonal and existential isolation especially share a common boundary. The types of isolation are similar subjectively; that is, they may feel the same as and masquerade for one another. Frequently therapists mistake them and treat a patient for the wrong type of isolation. Furthermore, their boundaries are semi-permeable. Existential isolation, for example, is often kept within manageable bounds through interpersonal affiliation. All these issues will be discussed in due time. But first, existential isolation must be defined.

What is existential isolation? Individuals are often isolated from others and from parts of themselves. But underlying these splits is an even more basic isolation that belongs to existence. An isolation that persists despite the most gratifying engagement with other individuals and despite consummate self-knowledge and integration. Existential isolation refers to an unbridgeable gulf between oneself and any other being. It refers to an isolation even more fundamental: a separation between the individual and the world. Separation from the world. That seems to be the right phrase. Yet still it is vague.

One of my patients provided an embodied definition. She experienced periodic panic attacks that occurred whenever her relationship with a dominant other was endangered. When describing her experience, she said to me, "Remember the movie West Side Story when the two lovers meet and suddenly everything else in the world mystically fades away and they are absolutely alone with one another? Well, that's what happens to me at these times, except there's no one else there but me."

Another patient had a recurrent nightmare that dated back to early childhood and now in adulthood resulted in severe insomnia, in fact, in a sleep phobia, since he was terrified of going to sleep. The nightmare is unusual in that the dreamer himself suffered no harm. Instead, his world melted away, exposing him to nothingness. The dream went like this: "I am awake in my room. Suddenly, I begin to notice that everything is changing. The window frame seems stretched and then wavy. The bookcase is squashed. The doorknob disappears and a hole appears in the door which gets larger and larger. Everything loses its shape and begins to melt. There's nothing there anymore and I begin to scream."

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

Existential isolation is a veil of loneliness which has many approaches. A confrontation with death and with freedom will inevitably lead the individual into that veil.

Death and existential isolation. It is the knowledge of my death that makes one fully realize that no one can die with one or for one. Haidiger states that though one can go to his death for another, such dying for can never signify that the other has had his death taken away in even the slightest degree. No one can take the other's death away from him. Though we may be surrounded with friends, though others may die for the same cause, even though others may die at the same time (as in the ancient Egyptian practice of killing and burying servants with the pharaoh or in suicide pacts), still at the most fundamental level, dying is the most lonely human experience.

*Everyman*, the best-known medieval morality play, portrays in a powerful and simple manner the loneliness of the human encounter with death. Everyman is visited by Death, who informs him that he must take his final pilgrimage to God. Everyman pleads for mercy, but to no avail. Death informs him that he must make himself ready for the day that no man living may escape away. In despair, Everyman hurriedly casts about for help. Frightened and above all, isolated, he pleads to others to accompany him on his journey. The character Kindred refuses to go with him: "Ye be a merry man. Take good heart to you and make no moan. But one thing I warn you, by Saint Anne, as for me, ye shall go alone." As does Everyman's Cousin, who pleads that she is indisposed: "No, by our lady. I have the cramp in my toe. Trust not to me, for so God me speed, I will deceive you in your most need." He is forsaken in the same way by each of the other allegorical characters in the play: Fellowship, Worldly Goods, and Knowledge. Even his attributes desert him: Beauty, Strength, and Discretion. "When Death bloweth his blast, they all run from me full fast." Everyman is finally saved from the full terror of existential isolation because one figure, Good Deeds, is willing to go with him even unto death. And indeed, that is the Christian moral of the play. Good works within the context of religion provide a buttress against ultimate isolation. Today's secular Everyman, who cannot or does not embrace religious faith, must indeed take the journey alone.

Freedom and existential isolation: the loneliness of being one's own parent. To the extent that one is responsible for one's life, one is alone. Responsibility implies authorship. To be aware of one's authorship means to forsake the belief that there is another who creates and guards one. Deep loneliness is inherent in the act of self-creation. One becomes aware of the universe's cosmic indifference. Perhaps animals have some sense of shepherd and shelter, but humankind, cursed by self-awareness, must remain exposed to existence.

Eric Fromm believed that isolation is the primary source of anxiety. He especially emphasized the sense of helplessness inherent in the human being's basic separateness. As he put it, "the awareness of his aloneness and separateness, of his helplessness before the forces of nature and of society. All this makes his separate, disunited existence an unbearable prison. The experience of separateness arouses anxiety. It is indeed the source of all anxiety. Being separate means being cut off without any capacity to use my human powers. Hence to be separate means to be helpless, unable to grasp the world, things and people actively. It means that the world can invade me without my ability to react." This fused effect of loneliness, helplessness is an understandable emotional response to our finding ourselves inserted without our consent into an existence not of our choosing.

Haidiger uses the term "throwness" to refer to this state. Though one creates oneself, one's project, what one ultimately fashions for oneself is limited by one's having been thrown alone onto the easel of existence.

Defamiliarization. Not only do we constitute ourselves, but we constitute a world fashioned in such a way as to conceal that we have constituted it. Existential isolation impregnates the paste of things, the bedrock of the world. But it is so hidden by layer upon layer of worldly artifacts, each imbued with personal and collective meaning, that we experience only a world of everydayness, of routine activities, of the "they." We are surrounded at home in a stable world of familiar objects and institutions—a world in which all objects and beings are connected and interconnected many times over. We are lulled into a sense of cozy, familiar belongingness. The primordial world of vast emptiness and isolation is buried and silenced, only to speak in brief bursts during nightmares and mythic visions.

Yet there are moments when the curtain of reality momentarily flits open and we catch a glimpse of the machinery backstage. In these moments, which I believe every self-reflective individual experiences, an instantaneous defamiliarization occurs when meanings are wrenched from objects, symbols disintegrate, and one is torn from one's moorings of atomicity. Albert Camus, in an early work, described such a moment when he was in a hotel room in an alien country: "Here I am defenseless in a city where I cannot read the signs, without friends to speak to, in short without diversion. In this room, penetrated by the sounds of a strange city, I know that nothing will draw me toward the more delicate light of a home or another cherished place. Am I going to call out, cry out? Strange faces would appear. And now the curtain of habit, the comfortable tissue of gestures and words, wherein the heart grows sluggish, rises slowly, and finally unveils the pale face of anxiety. Man is face to face with himself. I defy him to be happy."

In these moments of deep existential anguish, one's relationship to the world is profoundly shaken. One of my patients, a highly successful, hard-driving executive, described such an incident. It lasted only a few minutes, yet was so powerful that it retained its vividness 40 years later. At the age of 12, he was sleeping outside looking at the sky and suddenly felt himself separated from mother earth and drifting between the stars. "Where was he? Where did he come from? Where did God come from? Where did something rather than nothing come from?" He felt overcome with aloneness, with helplessness, and with groundlessness. Though I find it hard to believe that lifelong decisions are made in an instant, he insists that then and there he decided he would make himself so renowned and mighty that he would never again have this feeling.

Of course, this empty, lost, disenfranchising experience is not out there; it is within us, and no external stimulus is necessary to find it. All that is required is an earnest inward search. Robert Frost phrases it beautifully: "They cannot scare me with their empty spaces / Between stars—on stars where no human race is. / I have it in me so much nearer home / To scare myself with my own desert places."

When one falls into one's own desert places, the world is suddenly unfamiliar. At these times, Kurt Reinhardt says, "something utterly mysterious intervenes between him and the familiar objects of his world, between him and his fellow men, between him and all his values. Everything which he had called his own pales and sinks away, so that there is nothing left to which he might cling. What threatens is nothing, no thing, and he finds himself alone and lost in the void." But when this dark and terrible night of anguish has passed, man breathes a sigh of relief and tells himself it was nothing after all. He has experienced nothingness.

Haidiger uses the term "uncanny," "not at home," to refer to the state in which one loses one's sense of familiarity in the world. When one's "Dasein" is totally involved in the familiar world of appearance and has lost contact with one's existential situation, Haidiger considers one to be in the "everyday fallen mode." Anxiety serves as a guide to lead one back, by way of uncanniness, to awareness of isolation and nothingness. Haidiger said it this way: "As Dasein falls, anxiety brings it back from its absorption in the world. Everyday familiarity collapses. Being-in enters into the existential mode of the 'not at home.' Nothing else is meant by our talk of uncanniness."

In another passage, Haidiger states that when one is brought back from absorption in the world and objects are divested of their meaning, one experiences anxiety at confronting the world's loneliness, mercilessness, and nothingness. Haidiger refers to objects in the world as "ready-to-hand" or "present-at-hand" depending upon whether the object is considered equipment or is grasped in pure essence. He explained, "The threatening does not come from what is ready-to-hand or present-at-hand, but rather from the fact that neither of these says anything any longer. The world in which I exist has sunk into insignificance."

Anxiety is anxious in the face of the nothing of the world. But this does not mean that in anxiety we experience something like the absence of what is present-at-hand within the world. The present-at-hand must be encountered in just such a way that it does not have any involvement whatsoever, but can show itself in an empty mercilessness. This implies, however, that our concernful awaiting finds nothing in terms of which it might be able to understand itself. It clutches at the nothing of the world. Thus, to escape uncanniness, we use the world like a tool and absorb ourselves in the diversions provided by Maya, the world of appearances.

The ultimate dread occurs when we confront nothing. In the face of nothing, no thing and no being can help us. It is at that moment when we experience existential isolation in its fullness. Both Kierkegaard and Haidiger were fond of wordplay involving nothing. "Of what is man afraid?" "Of nothing."

The Italian filmmaker Antonioni was a master at portraying defamiliarization. In many of his films, for example, *The Eclipse*, objects are seen in stark clarity with a kind of cold mysteriousness. They are detached from their meaning, and the main character simply drifts past them, unable to act, while everyone around her goes on busily using them.

Defamiliarization involves more than objects in the world. Other entities invented to provide structure and stability, such as roles, values, guidelines, rules, ethics, can similarly be stripped of meaning. In chapter 5, I described a simple disidentification exercise in which individuals list answers to the question, "Who am I?" on cards and then meditate upon the experience of giving up, one by one, each of these roles (e.g., a man, a father, a son, a dentist, a walker, a reader of books, a husband, a Catholic, or Bob). By the time the exercise is completed, the individual has divested himself or herself of all roles and becomes aware that being is independent of accidents and that one persists, as Nietzsche said, "even after the last cloudy streak of evaporating reality." Some of the fantasies reported by subjects at the end of the exercise, such as a disembodied spirit gliding in a void, suggest clearly that role divestment propels one into an experience of existential isolation.

Experiences where one is alone and everyday guidelines are suddenly stripped away have the power to evoke a sense of the uncanny, of not being at home in the world. The hiker who loses his or her way, the skier who suddenly finds himself or herself off the trail, the driver who in a dense fog can no longer see the road. The individual in these situations often experiences a rush of dread—a dread independent of the physical threat involved, a lonely dread that is a wind blowing from one's own desert place, the nothing that is at the core of being. Uncanny are the social explosions that suddenly uproot the values, ethics, and morals that we have come to believe exist independently of ourselves: the Holocaust, mob violence, the Jonestown mass suicide, the chaos of war. All of these strike horror in us because they are evil. But they also stun us because they inform us that nothing is as we have always thought it to be, that contingency reigns, that everything could be otherwise than it is, that everything we consider fixed, precious, good can suddenly vanish, that there is no solid ground, that we are not at home here or there or anywhere in the world.

Growth and existential isolation. The word "exist" implies differentiation: *ex* = out, *sistere* = to stand. The process of growth, as Rank knew, is a process of separation, of becoming a separate being. The words of growth imply separateness, autonomy, self-governing, self-reliance, standing on one's own feet, individuation, being one's own person, independence. Human life begins with a fusion of ovum and sperm, passes through an embryonic stage of complete physical dependence on the mother into a phase of physical and emotional dependency on surrounding adults. Gradually the individual establishes boundaries demarking where he or she ends and others begin and becomes self-reliant, independent, and separate. Not to separate means not to grow up. But the toll of separating and growing up is isolation. The tension inherent in this dilemma is, in Rank's term, the human being's universal conflict. As he said, "becoming an individual entails a complete, a fundamental and eternal and insurmountable isolation."

Fromm makes the same point in *Escape from Freedom*. He wrote, "To the extent to which the child emerges from that world, it becomes aware of being alone, of being an entity separate from all others. This separation from a world which, in comparison with one's own individual existence, is overwhelmingly strong and powerful and often threatening and dangerous, creates a feeling of powerlessness and anxiety. As long as one was an integral part of that world, unaware of the possibilities and responsibilities of individual action, one did not need to be afraid of it. When one has become an individual, one stands alone and faces the world in all its perilous and overpowering aspects." To relinquish a state of interpersonal fusion means to encounter existential isolation with all its dread and powerlessness. The dilemma of fusion-isolation, or as it is commonly referred to, attachment-separation, is the major existential developmental task. This is what Otto Rank meant when he emphasized the importance of birth trauma. To Rank, birth was symbolic of all emergence from embeddedness. What the child fears is life itself.

It becomes clear now that existential isolation and interpersonal isolation are intricately interwoven. Emergence from interpersonal fusion thrusts the individual into existential isolation. A dissatisfying state of fusion existence or too early or too tentative emergence leaves the individual unprepared to face the isolation inherent in autonomous existence. The fear of existential isolation is the driving force behind many interpersonal relationships and is, as we shall see, a major dynamic behind the phenomenon of transference. The problem of relationship is a problem of fusion-isolation. On the one hand, one must learn to relate to another without giving way to the desire to slip out of isolation by becoming part of that other. But one must also learn to relate to another without reducing the other to a tool, a defense against isolation. Bugental, in his discussion of the problems of relatedness, plays on the word "apart." The human being's basic interpersonal task is to be at once a part of and apart from.

Interpersonal and existential isolation are way stations for each other. One must first separate oneself from the other in order to encounter isolation. One must be alone to experience aloneness. But as I shall now discuss, it is the facing of aloneness that ultimately allows one to engage another deeply and meaningfully.

Isolation and relationship. The experience of existential isolation produces a highly uncomfortable subjective state and, as is the case with any form of dysphoria, is not tolerated by the individual for long. Unconscious defenses work on it and quickly bury it out of the purview of conscious experience. The defenses must work without respite because the isolation is within one, always waiting to be recognized. The waves of the ether, as Martin Buber says, "roar on always but for most of the time we have turned off our receivers."

How does one shield oneself from the dread of ultimate isolation? One may take a portion of the isolation into oneself and bear it courageously or, to use Haidiger's term, resolutely. As for the rest, one attempts to give up singleness and to enter into a relationship with another—with either a being like oneself or a divine being. The major buttress against the terror of existential isolation is thus relational in nature. And my discussion of the clinical manifestations of existential isolation must perforce center on interpersonal relationships. In accent, however, I shall differ from traditional discussions of interpersonal psychology. I shall focus not on such needs as security, attachment, self-validation, satisfaction of lust or power, but instead shall view relationships according to how they assuage fundamental and universal isolation.

No relationship can eliminate isolation. Each of us is alone in existence. Yet aloneness can be shared in such a way that love compensates for the pain of isolation. A great relationship, says Buber, "breaches the barriers of a lofty solitude, subdues its strict law, and throws a bridge from self-being to self-being across the abyss of dread of the universe." I believe that if we are able to acknowledge our isolated situations in existence and to confront them with resoluteness, we will be able to turn lovingly toward others. If, on the other hand, we are overcome with dread before the abyss of loneliness, we will not reach out toward others, but instead will flail at them in order not to drown in the sea of existence. In this instance, our relationships will not be true relationships at all, but out-of-joint miscarriages, distortions of what might have been. We will not relate to others with a full sense of them as like ourselves—as sentient beings, also alone, also frightened, also carving out a world of atomicity from the paste of things. We behave toward other beings as toward tools or equipment. The other, now no longer an "other" but an "it," is placed there within one's circle of world for a function. The fundamental function, of course, is isolation denial, but awareness of this function is too close to the lurking terror. Greater concealment is needed. Meta-functions emerge, and we constitute relationships that provide a product (e.g., power, fusion, protection, greatness, or adoration) that in turn serves to deny isolation. There is nothing novel in this psychic defensive organization. Every explanatory system of behavior posits some core conflict that is encrusted with layers of protective and concealing dynamisms. These miscarried relationships, with their products, their functions, and their meta-functions, constitute what clinicians refer to as interpersonal psychopathology. I shall describe the clinical picture of many forms of pathological relationship and discuss the existential dynamics of each. But in order to understand fully what relationship is not, it is necessary first to apprehend what, in the best of ways, a relationship can be.

Need-free love. A relationship at its best involves individuals who relate to one another in a need-free fashion. Yet, how is it possible to love another for the other and not for what that other provides for the lover? How can we love without using, without a quid pro quo, without a mere sale of infatuation, lust, admiration, or self-service? Many wise thinkers have addressed this question, and I shall begin by reviewing their contributions.

Martin Buber, "In the beginning is the relation." Thus proclaimed Martin Buber, a philosopher and theologian whose patriarchal appearance, complete to piercing gaze and full white beard, augmented the power of his philosophical pronouncements. Buber has had an extraordinary impact on both religious philosophy and modern psychiatric theory. His posture is an unusual one, straddling Jewish mystical thought and Hasidism on the one hand and modern relational theory on the other. His proclamation "In the beginning is the relation" is rooted in these traditions. Buber was part of a mystical tradition that believes that every individual is part of the covenant. Each contains a divine spark that, in concert, reveal the holy presence. Thus, every individual is united in that each has a cosmic spiritual association to the universe. Buber believed that longing for relationship was innate and given and that "in his mother's womb every man knows that he is related to the universe and forgets it at birth." The child has a drive for contact, originally tactile, and then optimal contact with another being. The child knows of no "I." He knows of no other state of being than relation. Man, Buber stated, "does not exist as a separate entity. Man is a creature of the 'between.'"

There are two basic types of relationships, thus two types of "in-betweenness," which Buber characterized: I-Thou, sometimes translated as I-You, and I-It. The I-It relationship is the relationship between a person and equipment—a functional relationship, a relationship between subject and object, wholly lacking mutuality. The I-Thou relationship is a wholly mutual relationship involving a full experiencing of the other. It differs from empathy (imaginatively viewing a situation from the other's perspective) because it is more than an "I" attempting to relate to an "other." There is no "I" as such, but only the basic word "I-Thou." Relation is reciprocity. Not only is the "Thou" of the I-Thou relationship different from the "It" in the I-It relationship, and not only are the natures of the I-Thou and the I-It relationships vastly different, but there is even a more fundamental difference. The very "I" is different in the two situations. It is not the "I" that has preeminent reality, an "I" that can decide to relate to "Its" or "Thous" that are objects floating into one's field of vision. No, the "I" is "betweenness." The "I" appears and is shaped in the context of some relationship. Thus, the "I" is profoundly influenced by the relationship with the "Thou." With each "Thou" and with each moment of relationship, the "I" is created anew.

When relating to "It," whether to a thing or to a person made into a thing, one holds back something of oneself. One inspects it from many possible perspectives, one categorizes it, analyzes it, judges it, and decides upon its position in the grand scheme of things. But when one relates to a "Thou," one's whole being is involved. Nothing can be withheld. As Buber put it, "the basic word I-Thou can be spoken only with one's whole being. The concentration and fusion into a whole being can never be accomplished by me. Can never be accomplished without me. I require a You to become becoming I. I say You."

If one relates to another with less than one's whole being, if one holds something back (by, for example, relating through greed or anticipation of some return), or if one remains in the objective attitude, a spectator, and wonders about the impression one's actions will make on the other, then one has transferred an I-Thou encounter into an I-It one. If one is to relate truly to another, one must truly listen to the other, relinquish stereotypes and anticipations of the other, and allow oneself to be shaped by the other's response. Buber's distinction between genuine and pseudo listening obviously has important implications for the therapeutic relationship.

To relate to another in a need-free fashion, one must lose or transcend oneself. My favorite illustration of an I-Thou relationship is Buber's description of himself and his horse when he was a youth: "When I was 11 years of age, spending the summer on my grandparents' estate, I used as often as I could do it unobserved to steal into the stable and gently stroke the neck of my darling, a broad dapple horse. It was not a casual delight, but a great, certainly friendly, but also deeply stirring happening. If I am to explain it now, beginning from the still very fresh memory of my hand, I must say that what I experienced in touch with the animal, was the other, the immense otherness of the other, which however did not remain strange like the otherness of the ox and the ram, but rather let me draw near and touch it. When I stroked the mighty mane, sometimes marvelously smooth combed, at other times just as astonishingly wild, and felt the life beneath my hand, it was as though the element of vitality itself bordered on my skin. Something that was not I, was certainly not akin to me. Palpably the other, not just another, really the other itself. And yet it let me approach, confided itself to me, placed itself elementally in the relation of Thou and Thou with me. The horse, even when I had not begun by pouring oats for him into the manger, very gently raised his massive head, ears flicking, then snorted quietly, as a conspirator gives a signal meant to be recognizable only by his fellow conspirator. And I was approved. But one time, I do not know what came over the child. At any rate, it was childlike enough. It struck me about the stroking, what fun it gave me, and suddenly I became conscious of my hand. The game went on as before, but something had changed. It was no longer the same thing. And the next day, after giving him a rich feed, when I stroked my friend's head, he did not raise his head."

The basic experiential mode of the I-Thou is dialogue, in which, according to Buber, either silently or spoken, each of the participants has in mind the other or others in their particular being and turns to them with the intention of establishing a living mutual relation between himself and them. Dialogue is simply the turning toward another with one's whole being. When the young Buber turned away from the horse, became aware of his hand and of how much pleasure the stroking afforded him, then dialogue vanished and monologue, and the I-It reigned. Buber termed this turning away from the other "reflection." In reflection, not only is one concerned with himself, but even more important, one forgets about the particular being of the other.

Victor Frankl makes a similar point when he deplores the present-day vulgarization of the concept of encounter. Frankl argues, and quite correctly I believe, that encounter as it often occurs in the basic encounter group is no encounter at all but instead self-expression, an adoration of affect discharge whose rationale is rooted in a psychological monadology which pictures the human being as a windowless cell, a creature who cannot transcend oneself, who cannot turn toward the other. Consequently, there is too often an emphasis on getting one's aggression out, on beating a pillow or a punching bag, on self-esteem, on using others to solve ancient problems, on self-actualization. Instead of turning toward the other, there is, as Buber would say, sequential monologues disguised as dialogue.

Buber asked for a great deal in an I-Thou relationship. Once, for example, he was visited by an unknown young man who ostensibly had come for a chat. Buber found out much later that the stranger had a hidden agenda, that he was "born by destiny" and was on the verge of a momentous personal decision. Though Buber treated him in a friendly, considerate fashion, he berated himself for not being there in spirit, and for omitting to guess the questions the man did not put. But is it possible always to turn toward the other with such intensity? Obviously not. And Buber stressed that though the I-Thou constituted an ideal toward which one should strive, nonetheless, it existed in only rare moments. One has to live primarily in the I-It world. To live solely in the Thou world would result in one's burning oneself up "in the white flame of the Thou." In Buber's words, "the It world is the world in which one has to live and also can live comfortably. The Thou moments appear as queer lyric dramatic episodes. Their spell may be seductive but they pull us dangerously to extremes. One cannot live in the pure present that is in the I-Thou. It would consume us and in all the seriousness of truth listen that is be in the I-Thou without it a human being cannot live but whoever lives only with that is not human." This plea for balance is reminiscent of Rabbi Hillel's well-known aphorism: "If I am not for myself, who will be? And if I am only for myself, what am I?"

I have cited Buber extensively because his formulation of a need-free love relationship is vivid and gripping. I cannot leave him without commenting upon an obvious tension between the fundamental position I have accorded to existential isolation and Buber's assertion that the human being does not exist as an "I" but is instead a creature of the "in-between." Since Buber held that the human being's basic mode of existence is relational, he would accord no place in his system for existential isolation; he would protest at my positing that isolation is a fundamental aspect of our existential situation, and even more vigorously would he protest at my citing his work as part of my discussion. Yet let me look at an important dream with which Buber began *Between Man and Man*: "A recurrent dream which visited him sometimes after an interval of several years all his life. The dream, which Buber called the dream of the double cry, begins with his finding himself alone in a vast cave or a mud building or on the fringes of a gigantic forest whose like I cannot remember having seen." Then something extraordinary occurs, like, for example, an animal tearing the flesh from his arm. "And then I cry out. Each time it is the same cry, inarticulate, but in strict rhythm, rising and falling, swelling to a fullness which my throat could not endure were I awake. Long and slow, quite slow and very long. A cry that is a song. When it ends, my heart stops beating. But then, somewhere far away, another cry mourns toward me. Another which is the same. The same cry uttered or sung by another voice. The responding cry is the critical event for Buber." As the reply ends, "a certitude, true dream certitude, comes to me that now it has happened. Nothing more. Just this. And in this way now it has happened. If I should try to explain it, it means that that happening which gave rise to my cry has only now with the rejoinder really and undoubtedly happened." Buber held that our basic mode of existence is relational, and in this dream, which he cited as a truth-giving vision, existence begins with the appearance of the relationship, the responding cry. Yet the dream text can with grace be interpreted differently. One begins not in relationship but alone in an uncanny place. One is attacked and frightened. One cries out, and in anticipation of a reply, one's heart stops beating. The dream speaks to me of fundamental isolation and suggests that our existence begins with a solitary, lonely cry, anxiously awaiting a response.

Abraham Maslow. Abraham Maslow, who died in 1970, has had immense influence on modern psychological theory. More than any other person, he must be regarded as the progenitor of humanistic psychology, a field that, as I discussed in the initial chapter, overlaps existential psychology at many points. Maslow is destined, in my view, to be rediscovered many times before the richness of his thought is fully assimilated.

One of Maslow's fundamental propositions was that an individual's basic motivation is oriented toward either deficit or growth. Psychoneurosis, he thought, is a deficiency disease resulting from a lack of fulfillment, beginning early in life, of certain basic psychological needs (i.e., safety, belongingness, identification, love, respect, prestige). Individuals who have these needs satisfied are growth-oriented. They are able to realize their own innate potential for maturity and self-actualization. Growth-oriented individuals, in contrast to those with a deficiency orientation, are far more self-sufficient and far less dependent upon their environment for reinforcement or gratification. In other words, the determinants that govern them are not social or environmental, but inner. As Maslow wrote, "the laws of their own inner nature, their potentialities and capacities, their talents, their latent resources, their creative impulses, their needs to know themselves and to become more and more integrated and unified, more and more aware of what they really are, of what they really want, of what their call or vocation or fate is to be."

Growth-motivated and deficiency-motivated individuals have different types of interpersonal relations. The growth-motivated person is less dependent, less beholden to others, less needful of others' praise and affection, less anxious for honors, prestige, and rewards. He or she does not require continual interpersonal need gratification and, in fact, may at times feel hampered by others and prefer periods of privacy. Consequently, the growth-motivated individual does not relate to others as sources of supply but is able to view them as complex, unique, whole beings. The deficiency-motivated individual, on the other hand, relates to others from the point of view of usefulness. Those aspects of the other that are not related to the perceiver's needs are either overlooked altogether or regarded as an irritant or a threat. Thus, as Maslow said, "love is transformed into something else and resembles our relationships with cows, horses, and sheep as well as with waiters, taxi cab drivers, porters, policemen, or others whom we use."

Accordingly, Maslow described two types of love that are consonant with these two types of motivation: deficiency and growth. D-love (deficiency love) is selfish love or love-need, whereas B-love (for the being of another person) is being-love or unselfish love. B-love, he felt, is not possessive and is admiring rather than needing. It is a richer, higher, more valuable subjective experience than D-love. D-love can be gratified, whereas the concept of gratification hardly applies at all to B-love. B-love has within it a minimum of anxiety, hostility. But there can, of course, be anxiety for the other. B-lovers are more independent of each other, more autonomous, less jealous or threatened, less needful, more disinterested, but also simultaneously more eager to help the other towards self-actualization, more proud of the other's triumphs, more altruistic, generous, and fostering. B-love, in a profound sense, creates the partner, provides self-acceptance and a feeling of loveworthiness which enhances continued growth.

Eric Fromm, in his jewel of a book, *The Art of Loving*, addressed the question with which Buber and Maslow struggled: What is the nature of need-free love? Indeed, it is striking and reassuring that these three seminal thinkers, each deriving from different backgrounds (theology, philosophy, experimental and social psychology, and psychoanalysis), arrived at similar conclusions. Fromm's starting point is that the human being's most fundamental concern is existential isolation, that the awareness of separateness is the source of all anxiety, and that our major psychological task throughout the ages has been the overcoming of separateness. Fromm discusses several historical attempts at solution: creative activity, the union of artist with material and product, or orgiastic states (religious, sexual, drug-induced), and conformity with customs and beliefs of the group. All of these attempts fall short, according to Fromm, who said the unity in productive creative work is not interpersonal. The unity achieved in orgiastic fusion is transitory. The unity achieved by conformity is only pseudo-unity. Hence, they are only partial answers to the problem of existence. The full answer lies in the achievement of interpersonal union of fusion with another person in love. What Fromm meant by the full answer is not clear, but I assume it to be the most satisfactory answer. Love does not take away our separateness; that is a given of existence and can be faced but never erased. Love is our best mode of coping with the pain of separateness.

Buber, Maslow, and, as we shall see, Fromm arrived at similar formulations of need-free love, but they started from different positions about the schema of love in the individual's life. Buber assumed that a state of love was the human being's natural state in existence and that isolation was a fallen state. Maslow regarded love both as one of the innate human needs and potentials. Fromm considered love as a mode of coping or, as he said, an answer to the problem of existence—a view close to my position in this book.

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

Fromm traces the individual development of love from early childhood when one experiences being loved for what one is, or perhaps more accurately, because one is. Later, between 8 and 10, a new factor enters the child's life: awareness that one produces love by one's own activity. As the individual overcomes egocentricity, the needs of the other become as important as his or her own, and gradually the individual transforms the concept of love from being loved into loving. Fromm equates being loved with a state of dependency in which, by remaining small, helpless, or good, one is rewarded by being loved. Whereas loving is an effective, potent state. As Fromm said, "infantile love follows the principle: I love because I am loved. Mature love follows the principle: I am loved because I love. Immature love says: I love you because I need you. Mature love says: I need you because I love you."

Fromm's point that love is an active, not a passive, process has extraordinary importance for the clinician. Patients complain of loneliness, of being unloved and unlovable. But the productive work is always to be done in the opposite realm: their inability to love. Love is a positive act, not a passive effect. It is giving, not receiving; a standing in, not a falling for. A distinction must be made between giving and depleting. An individual with a hoarding, a receptive, or an exploitative orientation will feel depleted or impoverished by giving. One with a marketing orientation will feel cheated by giving and not receiving. But for the mature, productive person, giving is an expression of strength and abundance. In the act of giving, one expresses and enhances one's aliveness. As Fromm said, "When one gives, he brings something to life in the other person, and this which is brought to life reflects back to him. In truly giving, he cannot help receiving that which is given back to him. Giving makes the other person a giver also, and they both share in the joy of what they have brought to life." Note how close this is to what Buber said: "Relation is reciprocity. My Thou acts on me as I act on it. Our students teach us. Our works form us. Inscrutably involved, we live in the currents of universal reciprocity."

As a footnote, Fromm describes five basic types of interpersonally based character structure: receptive, exploitative, hoarding, marketing, and productive. The first four, the nonproductive types, believe that the source of all good is outside them and that they must endeavor to get it by accepting, taking, preserving, or exchanging respectively. The productive type is motivated from within and is a growth-motivated, actualized individual.

In addition to giving, mature love implies other basic elements: concern, responsivity, respect, and knowledge. To love means to be actively concerned for the life and the growth of another. One must be responsive to the needs (physical and psychic) of the other. One must respect the uniqueness of the other, to see him as he is and to help him to grow and unfold in his own ways for his own sake and not for the purpose of serving oneself. But one cannot fully respect the other without knowing that other deeply. True knowledge of the

Other from beliefs is possible only when one transcends one's self-concern and sees the other person in the other's own terms. One needs to listen and to experience empathically, though Fromm doesn't use that word. That is, one needs to enter and become familiar with the private world of the other, to live in the other's life and sense the other's meanings and experiences. Note again how Fromm and Buber converge. Compare Fromm's loving and Buber's dialogue and genuine presuppositionalist listening.

It is important to the clinician to think of love as attitude, something characteristic of the lover's orientation to the world rather than in terms of the lover's relationship to his or her love object. Too often we make the mistake of considering exclusive attachment to one person as proof of the intensity and purity of the love. But such a love is, in Fromm's terms, symbiotic love or overinflated egotism, and in the absence of caring for others is invariably destined to cave in on itself.

Needless love is instead an individual's mode of relating to the world. A 40-year-old highly successful executive once consulted me because he had fallen in love with a woman and was in the throes of deciding whether to leave his wife and children in therapy. After only a few sessions, he became impatient and highly critical of me for general inefficiency and for my failure to offer him a systematic, well-planned course of action. Soon, this criticism led us into his highly judgmental attitude toward people in general. In therapy, we proceeded to investigate not the immediate decision he faced, but his lack of love toward his world at large. Therapy proved of benefit to him by focusing, as effective therapy generally does, on the unexpected.

The most fundamental type of love Fromm believes is brotherly love, an experience of union with all individuals which is characterized by its very lack of exclusivity. The Bible stresses that the object of love should be the frail, the poor, the widow, the orphan, the stranger. These do not serve a purpose, and to love them is to love in a needless, brotherly fashion.

I began this section with the question, "How is it possible to relate to another in a need-free fashion?" Now, in the light of Buber, Maslow, and Fromm's similar conclusions, I shall describe the characteristics of a mature need-free relationship, and then use this prototype to illuminate, by contrast, the nature of various miscarried relationships.

One, to care for another means to relate in a selfless way. One lets go of self-consciousness and self-awareness. One relates without the overarching thought, "What does he think of me?" or "What's in it for me?" One does not look for praise, adoration, sexual release, power, or money. One relates in the moment solely to the other person. There must be no third party, actual or imagined, observing the encounter. In other words, one must relate with one's whole being. If part of oneself is elsewhere, for example, studying the effect that the relationship will have upon some third person, then to that extent, one has failed to relate.

Two, to care for another individual means to know and to experience the other as fully as possible. If one relates selflessly, one is free to experience all parts of the other rather than the part that serves some utilitarian purpose. One extends oneself into the other, recognizing the other as a sentient being who has also constituted a world about himself or herself.

Three, to care for another person means to care about the being and the growth of the other. With one's full knowledge gleaned from genuine listening, one endeavors to help the other become fully alive in the moment of encounter.

Four, caring is active. Mature love is loving, not being loved. One gives lovingly to the other. One does not fall for the other.

Five, caring is one's way of being in the world. It is not an exclusive, elusive, magical connection with one particular person.

Six. Mature caring flows out of one's richness, not out of one's poverty; out of growth, not out of need. One doesn't love because one needs the other to exist, to be whole, to escape overwhelming loneliness. One who loves maturely has met these needs at other times in other ways, not the least of which was the maternal love which flowed toward one in the early phases of life. Past loving, then, is the source of strength. Current loving is the result of strength.

Seven. Caring is reciprocal. To the extent one truly turns toward the other, one is altered. To the extent one brings the other to life, one also becomes more fully alive.

Eight. Mature caring is not without its rewards. One is altered. One is enriched. One is fulfilled. One's existential loneliness is attenuated. Through caring, one is cared for. Yet these rewards flow from genuine caring; they do not instigate it. To borrow Frankl's felicitous wordplay, the rewards ensue but cannot be pursued.

Existential isolation and interpersonal psychopathology. If we fail to develop the inner strength, the sense of personal worth and firm identity that enables us to face existential isolation, to say "so be it," and to take anxiety into ourselves, then we will struggle in oblique ways to find safety. In this section, I shall examine these safety-seeking methods and their clinical manifestations. For the most part, they are relational; that is, they involve interpersonal relationships. But as we shall see, in each instance, the individual does not relate to, that is, does not care for, the other, but instead uses the other for a function.

The terror, the direct awareness of existential isolation, and the psychic defensive structure that we elaborate to assuage anxiety are all unconscious. One knows only that one cannot be alone, that one desperately wants from others something that one is never able to obtain, and that try as one might, something always goes wrong with one's relationships.

Yet another solution lies in the direction of sacrificing selfhood. One gains relief from isolation, anxiety through immersion in some other individual, cause, or pursuit. Thus, individuals are, as Kierkegaard said, twice in despair: to begin with, in a fundamental existential despair, and then further in despair because, having sacrificed self-awareness, they don't even know they are in despair, existing in the eyes of others.

"The worst thing about being alone, the thought that drives me bananas, is that at that moment no one in the world may be thinking about me." So declared a patient in a group session who had been hospitalized because of panic attacks when alone. There was, among the other patients in this inpatient therapy group, instantaneous agreement with this experience. One 19-year-old, who had been hospitalized for slashing her wrists following the breakup of a romantic relationship, said simply, "I'd rather be dead than alone." Another said, "When I'm alone, that's when I hear voices. Maybe my voices are a way not to be alone." An arresting phenomenological explanation of hallucination.

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

The same dynamic speaks in the child's incessant plea, "Watch me. Look at me." The presence of the other is required to make reality real. Here, as elsewhere, I cite the child's experience as interior manifestation, not as cause of an underlying conflict.

Lewis Carroll, in *Through the Looking-Glass*, wonderfully expressed the stark belief held by many patients that "I exist only so long as I am thought about." Alice, Tweedledum, and Tweedledee come upon the Red King sleeping. "He's dreaming now," said Tweedledum. "And what do you think he's dreaming about?" "Alice," said nobody, "can guess that." "Why, about you?" Tweedledum exclaimed, clapping his hands triumphantly. "And if he left off dreaming about you, where do you suppose you'd be?" "Where I am now, of course," said Alice. "Not you," Tweedledum retorted contemptuously. "You'd be nowhere. Why, you're only a sort of thing in this dream. If that there King was to wake," added Tweedledum, "you'd go out, bang, just like a candle." "I shouldn't!" Alice exclaimed indignantly. "Besides, if I'm only a sort of thing in this dream, what are you?" "I should like to know." "Ditto," said Tweedledum. "Ditto, Ditto!" cried Tweedledum. He shouted this so loud that Alice couldn't help saying, "Hush, you'll be waking him, I'm afraid, if you make so much noise." "Well, it's no use you're talking about waking him," said Tweedledum, "when you're only one of the things in his dream. You know very well you're not real." "I am real!" said Alice, and began to cry. "You won't make yourself a bit realer by crying," Tweedledum remarked. "There's nothing to cry about." "If I wasn't real," Alice said, half laughing through her tears, "it all seemed so ridiculous. I shouldn't be able to cry." "I hope you don't suppose those are real tears," Tweedledum interrupted in a tone of great contempt.

One patient in a therapy group commented that once she had been in therapy for several months and years later had the chance to meet her therapist. She was devastated because the therapist took 45 seconds to remember who she was. She then turned toward the group therapist and asked, "Will you always remember me? I can't go on if you won't." She was a high school teacher and was able gradually to accept the cruel fact that just as she would forget her students long before they forgot her, so it was with therapists. The therapist and the teacher are more important to the patient and the student than the other way around. Still, this does not preclude the fact that, as I shall discuss later, when the therapist is with the patient, it is a full, deep presence.

Later in the same session, the patient commented that she was beginning to understand why suicide had always appeared to be a compelling option for her. She believed that if she committed suicide, others would remember her for a very, very long time. This is an excellent example of suicide as a magical act, which I described in chapter 2. There is, in her view of suicide, no idea of death. On the contrary, she clasped suicide as a way to defeat death, as one may do, provided one believes that one can continue to live if one exists in the consciousness of another.

By searching for love, the neurotic individual flees from the dimly recognized sense of isolation and hollowness at the center of being. By being chosen and valued, one feels affirmed in one's being. The pure sense of being, of "I am," of being the source of things, is too frightening in its isolation. Therefore, one denies self-creation and chooses to believe that one exists in so far as one is the object of others' consciousness. This solution is doomed to fail on several counts. The relationship generally fails because the other, in time, wearies of affirming the existence of the individual. Furthermore, the other senses that he or she is being not loved but needed. The other never feels wholly known and wholly embraced because the individual relates only to a part—the part that serves the function of affirming his or her existence. The solution fails because it is only a stopgap. If one cannot affirm oneself, then one continually needs affirmation by the other. One is permanently distracted from facing one's fundamental isolation. The solution fails also because one misidentifies the problem. One considers it to be that one is unloved, whereas in actuality it is that one is unable to love. As we have seen, loving is more difficult than being loved and requires greater awareness and acceptance of one's existential situation.

The individual who needs the affirmation of others to feel alive must avoid being alone. True solitude comes too close to the anxiety of existential isolation, and the neurotic individual avoids it at all costs. Isolated space is people with others. Isolated time is extinguished, killed with busyness. Solitary confinement has always been a particularly grim punishment. Others combat isolation by escaping from the present, solitary moment. They comfort themselves with blissful memories of the past, even though at the time their experiences may have been far from blissful, or they project themselves into the future by enjoying the imagined spoils of as yet unrealized projects.

The recent swell of interest in meditation stems in part from its novelty and from a sense of mastery. It is rare indeed for the individual in the Western world simply to be with himself or herself and to experience, rather than dispatch, time. We have been taught to do several things at once: smoking, chewing, listening, driving, watching television, reading. We value time-saving machines, and we apply these machine values to ourselves. What can we do, however, with the time that we save, except to find other ways to kill it?

When one's primary motive in engaging others is to ward off loneliness, then one has transformed the other into equipment. Not infrequently, two individuals will each serve each other's primary function, and like socket and prong, fit snugly together. Their relationship may be so mutually functional that it remains stable. Yet, such an arrangement cannot help but be growth-stunting, since each partner is known and knows the other in only a partial manner. These relationships resemble A-frame dwellings where the component walls support each other. Remove one partner or strengthen one in psychotherapy, and the other falls. Ordinarily, however, there is no such mutual fulfillment of needs. At some level, one realizes one is being used rather than engaged and searches elsewhere for a more fulfilling partner.

A 35-year-old patient of mine, obsessed with the fear of loneliness, was plagued by the vision of eating alone at 63. She was consumed by the search for a permanent bond. Though she was an attractive, vivacious woman, one man after another met her, and after a short encounter, broke off the relationship. They were driven away, I believe, both by the intensity and desperation of her love need and by an awareness that she had little love to give. An important clue to an understanding of her dynamics was to be found in her other interpersonal relationships. Highly judgmental, she rapidly and contemptuously dismissed all those who were not potential mates. When treating a patient who has difficulty establishing an enduring relationship, it is always rewarding for the therapist to inquire deeply about the texture of the patient's other, less intense relationships. Love problems are not situation-specific. Love is not a specific encounter, but an attitude. A problem of not being loved is more often than not a problem of not loving.

A particularly clear example of relating to others to avoid confronting isolation occurred in the treatment of Charles, the patient with cancer who was introduced into an outpatient psychotherapy group. Charles began therapy because he wanted to improve his relationships with people. He had always been withdrawn and aloof and had settled comfortably into this distant mode of relating to others. The advent of his cancer and the prognosis of a 2-year life expectancy resulted in his feeling of great isolation and catalyzed his efforts to get closer to others. The illustrative incident I shall describe began when one member, Dave, informed the group that because of his job in service training requirements, he would have to leave town and the group for several months. Dave was highly upset by this move, as were all the other members aside from Charles. The group members shared with Dave their feelings of sorrow, anger, and disappointment.

I quote from the group summary. The summaries were mailed to the members after each meeting. The floor gradually shifted to Charles by my pointing out that he was responding to Dave only in a problem-solving fashion, and I wondered what his feelings were. This opened up a truly remarkable episode in the group. For quite some period of time, Charles denied having any feelings whatsoever about Dave's leaving the group. We tried to milk feelings out of him without success and wondered whether or not he would want people to miss him if he were leaving. That too didn't get anywhere. I pointed out to him that once he had stated he had a pain in the chest when people left the group, and he underplayed that by saying that was only once. I kept pressing and said that once was enough, but he smiled and laughed and pushed us all away.

After a while, then Charles told the group, almost as though it were in passing, that he had learned from his medical checkup that his cancer was doing much better than could possibly have been expected. We then learned that, in fact, his medical checkup had been on that very day. Dave asked him, "Why didn't you tell us before?" Charles's excuse was that he wanted to wait until Lena came. Lena arrived a few minutes late. I told him that I didn't see why he couldn't have told us and then told Lena again when she came. Then Charles said a really remarkable thing. Now that he thinks his cancer is getting better, he suddenly finds he doesn't want to meet people any longer and he finds himself withdrawing.

Fusion. The human being's universal conflict is that one strives to be an individual, and yet being an individual requires that one endure a frightening isolation. The most common mode of dealing with this conflict is through denial. One elaborates a delusion of fusion and proclaims, in effect, "I am not alone. I am part of others." And so one softens one's ego boundaries and becomes part of another individual or of a group that transcends the individual.

Individuals whose major orientation is toward fusion are generally labeled dependent. They live, as Arieti puts it, for the dominant other and are likely to suffer extraordinary distress in the event of separation from the dominant other. They submerge their own needs. They seek to find out what the others wish and make those wishes their own. Above all, they wish to avoid offense. They choose safety and merger over individuation.

Kaiser's description of such individuals is particularly clear. He said, "Their behavior seems to suggest, 'Do not take me seriously. I do not belong to the category of adults and cannot be counted as such.' They are playful, but not like someone who likes to play, but like someone who doesn't want or doesn't dare to appear serious and matter-of-fact. Distressing and even tragic events are mentioned laughingly or in a hurried, nonchalant way, as if it were not worthwhile to waste time on them. There is also a readiness to talk of their own shortcomings with an inclination to exaggerate. Achievements and successes are put in a ridiculous light or the report of them is followed by a compensatory enumeration of failures. Their talk frequently might appear chopped up by quick, transitionless shifts in topic. By taking unusual liberties like blurting out naive questions or using baby talk, they indicate that they want to be put into the category 'non-adult' and should not be counted among the grown-up people."

Kaiser describes the clinical behavior of a patient particularly bent on merger with a more powerful figure. For eight months, G had been seeing a man in his late 30s who appeared ready to do whatever he understood was being requested of him. Whenever G had wanted to switch the appointment to another day or another hour, the patient's answer invariably had been, "Certainly, doctor. Certainly." He was always on time, but never seemed to mind if G were delayed. When, during the hour, the sun came out and shone into the patient's eyes, he never would have dared to draw the drapes and lower the blinds. He sat in silence, painfully blinking and twisting his neck until G remarked on it. The patient then would respond as if G had asked him to let the blinds down. "Certainly, doctor. Certainly," he would say, jumping up from his chair and unhooking the cord. "This way, doctor, is this too much?"

Fusion as an answer to existential isolation provides a construct by which many clinical syndromes may be understood. Consider, for example, transvestism. Ordinarily, men with transvestism are understood to be motivated by castration anxiety. There is such a threat in being a man, in competing for women with other men, that the man opts out of competition by dressing as a woman, at which point his castration anxiety, assuaged by self-inflicted castration, is able to achieve genital sexual release. However, Rob, whom I discussed in chapter 4, illustrates how fusion may be a central organizing dynamic.

Rob had cross-dressed since he was 13, first using the clothes of his sister and then those of his mother. Too frightened of males to develop relationships with them and too fearful of rejection to approach females, Rob had always been extraordinarily isolated. His fantasies while cross-dressing were always nonsexual and always variations on a fusion theme. He simply imagined going up to a group of women who would welcome him into their company and consider him one of them. His interpersonal style in a therapy group reflected his desire for merger: docile, obsequious, pleading for attention from the members, but especially from the therapist, whom he exalted.

During the course of the therapy group, Rob received an eye-opening education on the possibilities of relationship. He became fully aware, I believe for the first time, of the extent of his isolation. "I'm neither here nor there, neither man nor woman, isolated from everybody," he said one session. For a while, his anxiety and the incident of cross-dressing increased markedly. Gradually, as he developed social skills and related in meaningful ways, at first to the group members and then to individuals in his life environment, all transvestite desires left him.

There is, of course, a heavy overlap between the concept of escaping existential isolation through fusion and the concept of escaping the terror of death through belief and immersion of oneself in an ultimate rescuer. Not only Rob, but many of the clinical examples of the defense of the ultimate rescuer in chapter 4 are descriptive too of fusion. Both concepts describe a mode of escaping anxiety by escaping individuation. In both, one looks for solace outside the self. What differentiates the two is the impetus (isolation anxiety or death anxiety) and the ultimate goal (the search for ego boundary dissolution and merger or the search for a powerful intercessor). The distinction is, of course, academic. Generally, motivations and defensive strategies coexist in the same individual.

Fusion eliminates isolation in a radical fashion. By eliminating self-awareness, blissful moments of merger are unreflective. The sense of self is lost. The individual cannot even say, "I have lost my sense of self," because there is, in fusion, no separate "I" to say that. The wonderful thing about romantic love is that the questioning, lonely "I" disappears into the "we." Love, as Kent Bach comments, is the answer when there is no question.

To lose self-consciousness is often comforting. Kierkegaard said, "With every increase in the degree of consciousness and in proportion to that increase, the intensity of despair increases. The more consciousness, the more intense the despair." One may also shed one's isolating sense of self by fusing not with another individual, but with a thing, a group, a cause, a country, a project. There is something enormously compelling in merging with a larger group.

Kaiser first became aware of this during an ice skating show when two performers, dressed identically, skated a complicated number in perfect unison. After the applause, they nonchalantly and indifferently adjusted their ties and simultaneously looked at their watches. Their post-applause synchronization excited the audience even more, and Kaiser along with them. And he reflected upon the joys of ego boundary softening. He said, "Uniformity of movement and synchronization of movement, if both come close enough to perfection, attract, thrill, and fascinate an audience. No matter whether or not the movements performed by a single individual would in themselves be pleasing, a single well-trained soldier going through the steps and paces, the turns and halts of his drill, may please the eyes of the training officer. In the eyes of any outsider, he looks ridiculous. If a whole battalion moves over the parade ground, all in step, breaking up the larger columns into smaller groups, all making the turn at exactly the same moment, turning again and forming one long straight line and maintaining this unbroken front, marching and pivoting around and then on one short signal freezes on the spot so that all the arms and legs, the helmets, canteens, and rifles are suddenly at rest, all in exactly the same position, with not even a single bayonet deviating in direction from all the others, then even an ardent anti-militarist cannot help being gripped by this spectacle. And what grips him is certainly not the beauty of right angles and straight lines, but the image, or rather the idea of the many, acting as though animated by one mind."

To be like everyone else, to conform in dress, speech, customs, to have no thoughts or feelings that are different saves one from the isolation of selfhood. Of course, the "I" is lost, but so is the fear of aloneness. The enemies of conformity are, of course, freedom and self-awareness. The conforming fusion solution to isolation is undermined by the questions, "What do I want? What do I feel? What is my goal in life? What do I have in me to express and fulfill?" In the age-old struggle between self-expression and safety in fusion, it is usually the self that is compromised for the sake of isolation avoidance. The lure of the group is powerful indeed. The Jonestown tragedy demonstrates, to take one of countless examples, the power of the group. Identification with the group offered the members a haven from the fear of isolated existence—a product so valuable that they were willing to sacrifice everything for it: their worldly goods, their family, friends, country, and eventually their lives.

Mysticism, which involves heightened, marvelous moments of oneness with the universe, is also an instance of ego loss. Fusion with another individual, with a group or cause, with nature or with the universe always involves a loss of self. It is a pact with Satan and eventuates in existential guilt—that guilt, grief which laments the unlived life in each of us.

Sadism. The fusion-seeking individual who is dependent, obsequious, self-sacrificing, who will bear pain, who in fact enjoys pain because it dispels solitude, who in short is anything the other wishes in return for the safety of merger, has a curious counterpart. One who seeks to dominate the other, to humiliate the other, to inflict pain, to make oneself the absolute master over the other seems very different from the dependent fusion seeker. Yet, as Fromm points out, both tendencies are the outcomes of one basic need, springing from the inability to bear the isolation and weakness of one's own self. The sadistic person needs his object just as much as the masochistic needs his. The difference between the masochist and the sadist is between user and used. One seeks security by being swallowed by another; the other by swallowing someone else. In both cases, existential isolation is assuaged either through losing one's separateness and isolation or through enlarging oneself by the incorporation of others. That's why masochism and sadism often oscillate within an individual. They are different solutions to the same problem.

Sex and isolation. Freud introduced the concept of the symbol in psychic organization in chapter 5 of *The Interpretation of Dreams*. He describes various symbols that represent a sexual theme, either the sexual organs or some sexual act. The idea of one thing standing in for another could be carried too far, Freud warns. A cigar is not always a symbol for a penis; sometimes a cigar is just a cigar. But Freud doesn't go far enough in his warning. It is possible that sex may be a symbol of something else. If the deepest, ultimate concerns of the human being are existential in nature and relate to death, freedom, isolation, and meaninglessness, then it is entirely possible that these fears may be displaced and symbolized by such derivative concerns as sexuality. Sex may be used in the service of repression of death anxiety.

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

In chapter 5, I described a young woman with advanced cervical cancer who found that her disease not only did not discourage male suitors, but on the contrary seemed to increase their numbers and their sexual appetites. Ellen Greenspan described research demonstrating that women with severe breast cancer, in comparison with an age-matched healthy cohort, had a higher incidence of illicit sexual fantasies.

There is something gloriously magic about the lure of sex. It is a powerful bulwark against the awareness and the anxiety of freedom, since we, when under the spell of sex, have no sense whatsoever that we constitute our world. On the contrary, we are captured by a powerful external force. We are driven, enchanted, we fall for. We can resist the lure, delay it, or give into it. But we have no sense of choosing or creating our sexuality. It feels outside of us; it has a force of its own and seems bigger than life.

Sexually compulsive individuals in therapy report, as they get better, a sense of bleakness about their lives. The world is mundanized, and they ask, "Is this all there is?" Compulsive sexuality is also a common response to a sense of isolation. Promiscuous sexual coupling offers a powerful but temporary respite to the lonely individual. It is temporary because it is not relatedness but only a caricature of relationship. Compulsive sex breaks all the rules of true caring. The individual uses the other as equipment. He or she uses and relates to only a part of the other. To relate in this mode means that one forms a relationship, and the quicker the better, to have sex rather than the converse situation of sex both as a manifestation and a facilitation of a deeper relationship.

The sexually compulsive individual is the example par excellence of one who does not relate to the whole being of the other. On the contrary, he relates only to that part which serves to meet his need. Our language well reflects this attitude, as when we speak of "a piece of ass," "a jock," "a stud." The stark language of sex—laying, making, screwing, turning a trick, scoring—denotes deceit, aggression, manipulation, almost anything, in fact, but caring and relatedness. Above all, sexually compulsive individuals do not know their partners. In fact, it is often to their advantage not to know the other and to keep most of themselves hidden. Therefore, they show and see only those parts that facilitate seduction and the sexual act.

One of the hallmarks of sexual deviancy is that one individual relates not to another whole person, but to some part of another. A fetishist, for example, has a relationship not with a woman (all published cases of fetishists are males), but with some part or some accouterment of a woman—for example, a shoe, a handkerchief, a piece of underlo. One observer of human relationships went so far as to say, "If we make love to a woman without relating to her spirit, we are fetishists, even if in the physical act, we use the proper body orifice."

Should, therefore, the thoughtful therapist deplore any sexual encounter that falls short of a true and caring interpersonal encounter? Is there then no place for sex as an act of uncommitted adult play? These questions are, to a large extent, ethical and moral, and the therapist does well to avoid making pronouncements on issues that lie outside of his or her field of expertise. But the therapist does have something of value to say in the case of those who relate sexually to others only in a partial, function-oriented manner. An essential part of the definition of sexual deviancy is that behavior is fixed and exclusive. That is, the deviant can relate sexually only in a prescribed, deviant manner. Not only is rigid, exclusive sexual behavior indicative of deeper pathology, but such behavior cannot help but result in a sense of self-contempt and existential guilt.

Kierkegaard drew an arresting sketch of such a situation in *The Diary of a Seducer*, wherein the protagonist devotes his entire self to the seduction and abuse of a young girl. Though he is successful in his aims, he pays a heavy price for his spoils. His life becomes empty, his spirit impoverished. Thus, the sexually compulsive individual neither knows nor engages the other. He never concerns himself with the other's growth. Not only does he never have the other fully in sight, but he never loses sight of himself in the relationship. He does not exist "between," but always observes himself. Buber termed such an orientation "reflection" and bemoaned a sexual relation where the partners do not engage in a full, authentic dialogue, but live in a world of monologue, a world of mirrors and mirroring.

Buber's description of erotic man is particularly picturesque. "Many years I have wandered through the land of men and have not yet reached an end of studying the varieties of the erotic man. There a lover stamps around and is in love only with his passion. There one is wearing his differentiated feelings like metal ribbons. There one is enjoying the adventures of his own fascinating effect. There one is gazing and raptured at the spectacle of his own supposed surrender. There one is collecting excitement. There one is displaying his power. There one is pining himself with borrowed vitality. There one is delighting to exist simultaneously as himself and as an idol very unlike himself. There one is warming himself at the blaze of what has fallen to his lot. There one is experimenting and so on and on all the manifold monologists with their mirrors in the apartment of the most intimate dialogue." Thus one is in love with passion. One collects excitement and trophies. One warms oneself at the blaze at what has fallen to his lot. But what one does not do is to relate authentically to oneself or to another.

Many of these themes are illustrated in the dreams of Bruce, a sexually compulsive patient I described in chapters five and six. Toward the end of therapy, as he was emerging from a sexually driven mode of relating, Bruce began to turn his attention to the problems. "If I do not attempt to screw women, what do I do with them? And what do I do with men? What are people for, anyway?" That last question, "What are people for, anyway?" emerges in one form or another in the treatment of all patients who begin to change their modes of relating from "I-it" to "I-thou."

Three dreams heralded at this stage in Bruce's therapy. The first: "I was lying in bed with my 14-year-old son. We were fully dressed, but I was trying to have sex with him, but I couldn't find his vagina. I woke up sad and frustrated." This dream graphically depicts Bruce's dilemma about relationships. Is there any other way than genitally? The dream seems to say that you can relate to someone, even to someone you care for very much.

The second: "I was playing tennis with a woman, but every ball I hit came back to me rather than to her. It was as if there were an invisible glass backboard instead of a net separating the two of us." The imagery is clear. Bruce was presumably engaging someone else in tennis, but in fact was relating only to himself. The other person was extraneous in the game, and furthermore, even though he tried to reach her, he could not.

The third: "I wanted to be close to Paul, an acquaintance, but I kept bragging about how much money I had, and he got angry. Then I tried to put my cheek next to his, but our beards were so rough that we hurt one another." Bruce had companions in activity—basketball, tennis, and bowling chums—but had never had a close male friend. He was dimly aware of his yearning for closeness, but as the dream illustrates, could find no way to relate to men except in a competitive fashion.

Other forms of miscarried relationship. We try to escape the pain of existential isolation in a variety of ways. We soften ego boundaries and attempt to fuse with another. We attempt to incorporate another. We take something from the other that makes us feel larger, more powerful, or cherished. The common interpersonal theme in these attempts, and in a number of others which I shall now discuss, is that the individual is not with the other person. Instead, the individual uses the other person as equipment to serve a function, and a mutually enriching relationship never occurs. Instead, there is some form of misalliance, a relational miscarriage, which can only stifle growth and evoke existential guilt.

As the sheer variety of unauthentic modes of relationship defies any exhaustive classificatory scheme, I shall describe a few common modes observed in clinical work.

The other as elevator. Barry was a 35-year-old engineer with the engineer syndrome. He was stiff, cold, and isolated. He displayed no emotion whatsoever and was generally aware of emotion only after he took note of a physiological cue—a knot in the stomach, tears, clenched fist, and so forth. His major goal in therapy was to get in touch with his feelings and to be able to establish a love relationship with another. A physically attractive man, he had little problem attracting the attention of women, but was not able to develop a relationship further. Either he found a woman undesirable and dismissed her, or he found her desirable but was too anxious to pursue her.

Finally, after many hard months of therapy, Barry began dating and then living with Jamilia, a young woman whom he found very attractive. It immediately became apparent, however, that he invested little of himself in the relationship. He discussed in therapy his new problem of going to bed very early. Did it mean, he wondered (and this type of isolation from his feelings was highly characteristic), that he was already bored with Jamilia, or did it mean that he felt so comfortable with her that he allowed himself to relax with her? "How can you find out?" I asked. "What happens when you ask yourself whether you love Jamilia?" Barry responded with unusual conviction for him that he cared for Jamilia very much. Still, he decided it was best to hold himself back so as not to arouse her hopes unduly. He explained that the relationship would never evolve into a long-term one because Jamilia didn't quite match up to what he had been looking for in a woman. The main reason was that her social skills were not highly enough developed. She was not sufficiently articulate. She was too inhibited and too socially introverted. He knew that he didn't speak well and wanted very much to marry a woman with greater verbal dexterity. Since he learned well by imitating, he had hoped to improve as a result of contact with such a woman. He also expected a woman to provide him with a less restricted social life. Furthermore, he worried that if the two of them spent too much time alone and became very loving, then he would give all his caring to her and would never have any to give to others.

Barry's statements illustrate many of the most common problems that preclude the development of an authentic loving relationship. The most basic one is that the raison d'être of Barry's mode of relating was to serve a function. Barry began from a position of extreme need and searched for someone to minister to this need. His need was for elevation, and he searched for a partner who would be elevator, teacher, therapist, and purveyor of social life. Barry often talked despairingly of his long, fruitless search for a relationship. I felt that his use of the word "search" provided a key to understanding his problem. One, after all, does not find a relationship; one forms a relationship. Barry approached Jamilia in an inorganic rather than organic fashion. Not only did he view her as an "it," an object, as equipment to provide a particular product, but he viewed the relationship as static and inorganic, an entity that was there almost fully formed from the beginning rather than as a developing process.

Another patient voiced the same theme when he said that the closer he got to another person, the more unattractive that person became, both physically and emotionally. As he physically approached a woman, he could see her faint skin blemishes, her varicosities, and the bags under her eyes. As he got to know her well, he became increasingly bored by her diminishing stock of anecdotes and facts. In such an inorganic approach to relationship, one views the other as an object with certain fixed properties and depletable resources. What one does not consider is that, as Buber reminds us, in a genuine organic relationship, there is reciprocity. There is no unchanging eye observing and measuring the other. The eye in the encounter is altered, and the other, the "thou," is altered as well.

Barry viewed love as an exhaustible commodity. The more he offered to one person, the less he would have for others. But as Fromm has taught us, this marketing approach to love makes no sense. Engaging others always leaves one richer, not poorer. Barry had always experienced intense anxiety at the prospect of approaching women who he felt matched his standards. Often he ruminated for hours on the proper approach. He would start to call a woman, hand on the phone, number half dialed. He would flush with anxiety and hang up the receiver. Other therapists had unsuccessfully attempted to afford Barry anxiety relief through behavioral approaches. In psychotherapy, no progress occurred when we approached the problem from the obvious vantage point—that is, that Barry feared competition from other men and rejection from obviously attractive women. There was, however, considerable progress when we explored the ways that Barry used or wished to use the other. At a deep level, Barry knew that he was not encountering, but violating, the other. He didn't want her, but wanted something from her. His anxiety was guilt because of the anticipated transgression against another and fear that the other would discover his motives.

How many people are in the room? In a mature caring relationship, one relates with one's whole being to the other. If one holds back part of oneself in order to observe the relationship or the impact one has upon the other, then to that extent one has failed to relate. Buber describes the situation that develops when two individuals who retain full self-consciousness try to relate. "Let us now imagine two men whose life is dominated by appearance sitting and talking together. Call them Peter and Paul. Let us list the different configurations which are involved. First there is Peter as he wishes to appear to Paul and Paul as he wishes to appear to Peter. Then there is Peter as he really appears to Paul—that is, Paul's image of Peter—which in general does not in the least coincide with what Peter wishes Paul to see. And similarly there is the reverse situation. Further, there is Peter as he appears to himself and Paul as he appears to himself. Lastly, there are the bodily Peter and the bodily Paul. Two living beings and six ghostly appearances which mingle in many ways in the conversation between the two. Where is there room for any genuine interhuman life?"

One may fail to relate by relating only partly to the other and partly to some fantasized other person or persons. In assessing the nature of my relationship with a patient, I find it helpful to inquire of myself how many people are in the room. Am I, for example, thinking not only of the patient but also of how clever I will sound when I present this patient at a conference or of the interesting clinical material which I can use to communicate more effectively with my readers? I pose the same questions to my patient. Is the patient really relating to me or to some ghostly figures from the past? As the patient describes to me his important relationships, I wonder how many people are in each relationship. Are there only two people involved, or three, or a whole auditorium filled with people?

Camus was a master of portraying in his novels characters who could not love but who feigned love for some ulterior purpose. In his first novel, *A Happy Death* (unpublished during his lifetime), Camus's protagonist says, "I saw that what had attached him to Marta was vanity, not love. What he had loved in Marta were those evenings when they would walk into the movie theater and men's eyes turned towards her. That moment when he offered her to the world. What he had loved in her was his power and his ambition to live." That moment when he offered her to the world—that captures it precisely. There were never two people in the relationship. He related not to Marta, but to others through Marta.

Similarly, Ken, a patient of mine who had deep-seated problems in relating authentically to women, dreamed profusely, but never had a dream with only two people in it. An illustrative tagalong dream in the middle of our work: "I was with a woman in my old bedroom in San Francisco at 2:30 in the morning. My brother and father were watching through the window. I wasn't too interested in the woman or the love making. I kept my father and brother waiting for an hour and let them in at 3:30." Important associations to the dream included his attempts to identify the woman. He realized that he was quite uninterested in her. She resembled a young cheerleader he had seen that day at a football game, the kind of girl he never had the nerve to approach when he was in college. She also resembled a girl, Christine, he had dated in high school. He and a friend had both dated the same girl for several months, a situation that he found both uncomfortable and exhilarating. Finally, he and his friend joined forces and pressured Christine into choosing one of them as her steady boyfriend. Christine chose Ken, much to his delight. However, within only a few weeks, the bloom had faded. Ken lost interest in Christine and ended their relationship. He was never interested in her in the first place. He was interested only in her function, in his competition with his friend. Ken had always viewed his father and brother as competitors, first for his mother and then for other women. In the dream, his being with a woman and keeping his father and brother waiting outside enviously for an hour until 3:30 (which, incidentally, was the time of our regular therapy hour) was

A way of besting them through a woman. Ken could not be with men either. He related to me, to his brother and father, to all male friends in a highly competitive fashion. When he was with me, for example, he was so convinced that I wanted to subjugate him that for months he withheld any important material he felt would give me an edge over him. His only male friends were talented but did not evoke competition, since their talent lay in some entirely different field, music, art, or athletics.

On the night following the analysis of this dream, Ken had a series of short dreams, all illuminating some aspect of the work to be done in relationships. In the first dream, he went to a ski lodge and met several of his male friends who greeted him warmly. Then he found himself sitting next to them in a room where he was waiting to take his final real estate examinations. Ken was a realtor. After a long wait, the exams were passed out. But immediately the instructor, his therapist, announced the exam was cancelled. They had come to the wrong place on the wrong day. This dream underscored Ken's fusion of friendship and competition. The work ahead in therapy would entail disentangling the two.

The second dream fragment was that Ken saw himself on a jumbo jetliner. He often, as do many dreamers, symbolized therapy as a journey on some vehicle. He strolled along in the aisle on the plane and was astounded to discover several hidden compartments, all of which were full of people, although he saw them for the first time, he somehow knew that these people had been there all along. Obviously, this dream represented another crucial task in therapy, the discovery of the others in the world.

His last dream that night was but a fragment, simply an image of a large toucan bird. Ken had no associations whatsoever to this bird. But my association to toucan was to can, a representation of the work in pairing that lay before Ken.

This bad faith mode of relating to others is so common that examples abound in everyday life and everyday therapy. For example, the woman who purposefully takes a new boyfriend to a gathering where she knows her old boyfriend will be is obviously not with her new friend. Carl, another patient, was with a new girlfriend when he received an angry, demanding phone call from his previous one. In a derisive manner, he held the phone away from his ear, pointing it to his new friend so that she too could hear. Each of an individual's relationships reflects the others. It is rare, I believe, for one to be able to relate in bad faith to some individuals and in an authentic, caring way to a select few. Carl's new friend was deeply troubled at his treatment of a previous friend. She suspected, and rightly so, that the telephone episode was an ominous portent of her future relationship with him.

Being with the other for the sake of another, is particularly transparent in group therapy, a mode of therapy ideally suited to uncover and work through bad faith in interpersonal relationships. A graphic example unfolded over several weeks in one of my therapy groups. Ron, a 40-year-old married patient, systematically made extra group contacts with every one of the members. Even though he and the rest of the members realized that such socializing often impeded therapy, Ron invited some members to go sailing, others to go skiing, and others to dinner, and became intensely romantically involved with one, Irene. Extragroup socializing is usually destructive in group therapy only when it's surrounded by a conspiracy of silence. In this group, therapy ground to a halt because Ron refused to discuss his extra group contacts, especially those with Irene. He saw nothing wrong with them and steadfastly refused to examine the meaning of his behavior. In one session, the group discussed his inviting my female co-therapist for a skiing weekend. Enormous pressure was placed on him to examine his behavior, and he left the session confused and shaken. On his way home, Ron suddenly remembered that in his childhood, his favorite story had been Robin Hood. Following an impulse, he drove to the children's section of the nearest public library and reread the story. Only then did the meaning of his behavior make sense. What he loved about the Robin Hood legend was the rescuing of individuals, especially women, from tyrants. That motif had played a powerful role in his life, beginning with edible struggles in his family. He had started a successful business by first working for someone else and then setting up a competitive firm and enticing his ex-boss's employees to work for him. So too with his wife whom he had married not so much because of love for her but to rescue her from a tyrannical father. Similarly the pattern unfolded in the group. He was strongly motivated to wrench the other members even the co-therapist from my grasp. The other members gradually expressed their deep dismay at having been mere pawns in Ron's struggle with me. When his predominant inauthentic mode of relationship was laid bare and fully understood, Ron began to confront the question of what else are people for. He spent several months working on his relationship with each of the members, save Irene. He clung tightly to her, and even when it was clear that he had made all the progress possible for him in that group, he resisted termination because at an unconscious level, he wanted to be present so as to protect her from me. He eventually terminated, and a few months later, Irene did as well. At that point, without the tyrant in the picture, Ron's love waned quickly, and he ended the relationship. A full caring relationship is a relationship to another, not to any extraneous figure from the past or the present. Transference, paritaxic distortions, ulterior motives and goals, all must be swept away before an authentic relation with another can prevail.

Chapter nine. Existential isolation and psychotherapy. Existential isolation has several major implications for psychotherapists. It provides them with a frame of reference that explains many complex puzzling phenomena, explanations that therapists through clarifying and interpretive comments attempt to convey to their patients. The concept of existential isolation also provides the rationale for an important therapeutic maneuver, isolation confrontation. Finally, a consideration of existential isolation sheds considerable light upon that enormously important and complex phenomenon, the therapist-patient relationship.

A guide to understanding interpersonal relationships. Individuals who are terrified of isolation generally attempt to assuage that terror through an interpersonal mode. They need the presence of others to affirm their existence. They long to be swallowed by others greater than they or they seek to alleviate their sense of lonely helplessness by swallowing others. They attempt to elevate themselves through others. They search for multiple sexual bondings, a caricature of authentic relating. In short, the individual who is flooded with isolation anxiety reaches out desperately for help through a relationship. The individual reaches out not because he or she wants to, but because he or she has to. And the ensuing relationship is based on survival, not on growth. The tragic irony is that those who so desperately need the comfort and pleasure of an authentic relationship are the very ones least able to form such a relationship.

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

The group therapy situation offers a particularly rich arena for these patterns of distorted relationship to manifest themselves as in the following clinical cameo. Eve had been attending a therapy group for 6 months and had gradually created, as patients always do, the same type of interpersonal pattern in the group that she inhabited outside it. She was a marginal figure, passive, easily forgettable. No one took her seriously. She didn't apparently take herself seriously and seemed content with being the group mascot. Over the Christmas holiday, when the group was unusually small since some members had gone out of town, Eve began the session by describing her discomfort at such a small group. She wasn't sure. She said she was up to an intense session. She continued to discuss in a characteristically detached manner her feelings about a small group. Finally, another woman member said she couldn't bear to listen to Eve anymore. No one in the group felt that Eve was talking to them. Eve always spoke to an empty space in the group as though there was no one else present in the room. The members then commented that Eve engaged no one in the group, that no one really knew her, that she remained hidden from view, and that consequently none of the others allowed her to matter to them. I asked Eve if she could try to engage any of the members. She compliantly went around the group and discussed in a platitudinous manner her feelings toward each person. "How would you rank?" I asked, "your comments to each member on a 1 to 10 risk-taking scale?" "Very low," she ventured. "About 2 to three." "What would happen," I said, "if you were to move up a rung or two?" She replied that she would tell the group that she was an alcoholic. This was indeed a revelation. She had told no one before. I then tried to help her open herself even more by asking her to talk about how she felt coming to the group for so many months and not being able to tell us that. As a general principle of therapy technique, it is always preferable to approach disclosure of a big secret by helping the patient to reveal more about the disclosure (horizontal or meta disclosure) rather than asking for more of the specific details of the secret (vertical disclosure). Thus, the patient may be enabled to make himself fully known to the others in the immediate moment. Eve responded by talking about how lonely she felt in the group, how cut off she was from every person in the room, but she was flushed with shame about her drinking. She could not, she insisted, be with others or make herself known to others because of her drinking. I turned Eve's formula around. Here the real therapeutic work began. She didn't hide herself because she drank, but she drank because she hid herself. She drank because she was so unengaged with the world. Eve then talked about coming home, feeling lost and alone, and at that point doing one of two things: either slumping into a revery where she imagined herself very young and being cared for by the big people or assuaging the pain of her lostness and loneliness with alcohol. Gradually, Eve began to understand that she was relating to others for a specific function—to be protected and taken care of—and that in the service of this function she was relating only partially. She saw only part of another individual and chose to disclose only those parts of herself that she felt would not drive away a protector. After obtaining a clear view of how others viewed her behavior, Eve also was able to learn how her behavior made others feel. This feature is one of the real strengths of the group therapy approach. Though it is possible for the individual therapist to supply this information to a patient, the great diversity of feedback from a larger group is far more informative and powerful. She discovered that her neediness did not elicit the caring she sought. Quite the contrary, her reluctance to engage others with her whole self resulted in her not mattering to them. Eve failed to get what she wanted because she needed it too much.

There is, as this vignette illustrates, considerable therapeutic potential in the understanding of current relationships, of which the therapist-patient relationship is the most accessible for study and is, in ways I shall discuss shortly, enormously effective in therapy. The patient's relationships with others should, however, always be investigated. Relationships among patients in treatment, therapy group, inpatient, halfway house, day hospital, and so on, rarely develop into long-lasting, rewarding friendships outside of therapy. Nonetheless, through such relationships, patients will display interpersonal pathology. In ways I have already described, therapists may use this firsthand data as a guide to understanding the specific form of their patients' misaligned relationships and to help patients to recognize the nature of their interpersonal behavior, its impact upon others, and their responsibility for their own isolation. In treatment, relationships also provide a dress rehearsal for a patient's future relationships in the real world. A low-risk venture in which he or she can test out new modes of relating.

Thus far I have described the uses of in-therapy relationships. But they are more than a forum for pathology display or a dress rehearsal. They are also real relationships with real people which contain something in and for themselves that is meaningful and healing. Some patients enter a psychiatric ward and initiate little contact with others. They speak when spoken to. They stay in their rooms whenever possible. They occupy themselves with thinking, sorting things out in their minds, rug crocheting, reading, and so on. Patients proffer many reasons for such withdrawal, such as depression, fear of rejection, or nothing in common with others. But one common reason is the feeling that there is no point in investing energy into something that will perforce be evanescent. A patient says that a relationship with another patient cannot last, that they travel in different circles, forgetting the circles they share, the terrestrial orbit, the life cycle. Why then get involved? Others point out that they cannot bear losses and they prefer to cultivate only those relationships that have the potential to become long-term friendships. These arguments have persuasive features. After all, one of the problems of modern life is its impermanence, its lack of stable institutions and social networks. Indeed, what point is there in cultivating yet another impermanent vacation cruise relationship?

A clinical case provides us some insight into this issue. Anna, a borderline patient who had been hospitalized following a suicide gesture, was an exceptionally isolated and embittered young woman. One fundamental question she pondered continuously was, "What are people for?" She avoided engagement with others in group meetings because she said that she refused to indulge in the phoniness surrounding superficial relationships. Whenever she reached out to another or expressed any kind of sentiment, her inner voice soon reminded her of the fact that she was being phony and that verily nothing she said was a true feeling. Anna felt lonely and frightened. She was always the outsider, walking down the cold, dark street, observing and coveting the warm lights and cozy gatherings in other people's homes. In her small group sessions, I consistently urged her to attempt to engage with others. "Stop analyzing, stop reflecting upon yourself," she was advised. "Just try to extend yourself to others in the group. Try to enter their experiential world. Try to open yourself up as much as possible and and don't ask why." During a particularly intense group meeting, Anna became deeply involved with several members, indeed weeping with and for one of them. Toward the end of this meeting, Anna was asked to describe what her experience had been like over the past hour. Effective use of the here and now in therapy always entails two processes: sheer experiencing and the subsequent examination of that experience. Anna noted that she had been alive for an hour, swept along in life, involved with others, and unaware of herself and of her sense of desolation. For an hour, she had been inside life rather than outside, staring at it through a chilly window pane. Anna's experience during the group supplied an answer to her question, "What are people for?" She could, for a short time, appreciate that relationships enrich one's inner world. Though she would shortly, I was certain, try to take away the experience by labeling it phony, she had nonetheless experienced how a relationship can bridge the gulf of isolation. One is altered through an encounter with another, even a brief encounter. One internalizes the encounter. It becomes an internal reference point, an omnipresent reminder of both the possibility and the reward of a true encounter.

A striking example of the lasting impact of a brief encounter is provided by Bertrand Russell who in 1913 met Joseph Conrad. "At our very first meeting," he wrote, "we talked with continually increasing intimacy. We seemed to sink through layer after layer of what was superficial till gradually both reached the central fire. It was an experience unlike any other that I have known. We looked into each other's eyes, half appalled and half intoxicated to find ourselves together in such a region. The emotion was as intense as passionate love and at the same time all embracing. I came away bewildered and hardly able to find my way among ordinary affairs." Though Russell spent but a few hours with Conrad, he reports that he was never the same again. That something of the moment of their touching remained always with him and played an instrumental role in shaping his attitudes toward war, minor misfortunes, and his subsequent human relations.

It is possible to err in the opposite direction, to avoid enduring intimate relationships by involving oneself only in brief encounters, and the therapist must be attuned to this possibility. But one must also bear in mind that no relationship offers a guarantee of permanency. Because a relationship may have no future reality, why strip it of its current reality? Indeed, individuals who elect to relate only to a select few are most likely those who have the most difficulty engaging others. Their dread of isolation will be so great that, as I have described, they sabotage the possibility of relationship. Those on the other hand who are likely to extend themselves continuously and in an authentic fashion to others will through the peopling of their inner world experience a tempering of their existential anxiety and be able to reach out to others in love rather than to grasp at them in need.

Confronting the patient with isolation. Another important step in treatment consists of helping the patient to address existential isolation directly, to explore it, to plunge into his or her feelings of lostness and loneliness. One of the fundamental facts that patients must discover in therapy is that though interpersonal encounter may temper existential isolation, it cannot eliminate it. Patients who grow in psychotherapy learn not only the rewards of intimacy but also its limits. They learn what they cannot get from others. Some years ago, in a project I described in chapter 6, my colleagues and I studied a number of successful psychotherapy patients and attempted to determine which aspects of their therapy experience had been most helpful to them. Of 60 items administered for a rank-ordering Q sort procedure, the one bearing on the limitations of intimacy, "recognizing that no matter how close I get to other people, I must still face life alone," was highly ranked by many patients and overall ranked 23rd of the 60 items.

There is, of course, no solution to isolation. It's a part of existence, and we must face it and find a way to take it into ourselves. Communion with others is our major available resource to temper the dread of isolation. We are all lonely ships on a dark sea. We see the lights of other ships, ships that we cannot reach, but whose presence and similar situation affords us much solace. We are aware of our utter loneliness and helplessness. But if we can break out of our windowless monad, we become aware of the others who face the same lonely dread. Our sense of isolation gives way to a compassion for the others, and we are no longer quite so frightened. An invisible bond unites individuals who participate in the same experience, whether it be a life experience shared in time or place, for example, attending the same school, or simply as a member of an audience at some event. But compassion and its twin, empathy, require a certain degree of equilibrium. They cannot be constructed on panic. One must begin to confront and tolerate isolation to be able to use the available resources to cope more fully with one's existential situation. God offers relief from isolation for many, but as Alfred North Whitehead asserted, isolation is a condition of true spiritual belief. Quote, "Religion is what the individual does with his own solitariness, and if you are never solitary, you are never religious." End quote. Part of the therapist's task consists of helping the patient confront isolation, an enterprise that first generates anxiety, but ultimately catalyzes personal growth.

In The Art of Loving, Fromm wrote that the ability to be alone is the condition for the ability to love, and in those days in the United States before the 1960s and transcendental meditation suggested modes of solitary concentration upon consciousness. Clark Mustakis, in his essay on loneliness, made the same point. The individual, in being lonely, if let be, will realize himself in loneliness and create a bond or sense of fundamental relatedness with others. Loneliness, rather than separating the individual or causing a break or division of self, expands the individual's wholeness, perceptiveness, sensitivity, and humanity. Many others corroborate that isolation must be experienced before it can be transcended. Camus, for example, said, "When a man has learned—and not on paper—how to remain alone with his suffering, how to overcome his longing to flee, then he has little left to learn." Similarly, Robert Hobson said, "To be a human being means to be lonely. To go on becoming a person means exploring new modes of resting in our loneliness." I like the phrase "exploring new modes of resting in our loneliness." It's an arresting description of the task of the therapist. Yet the phrase contains the germ of the clinical problem. Rather than rest, the psychotherapy patient writhes in loneliness. The problem seems to be that the rich get richer and the poor get poorer. Those who can confront and explore their isolation can learn to relate in a mature, loving fashion to others. Yet only those who can already relate to others and have attained some modicum of mature growth are able to tolerate isolation. Robert Bolandorf, for example, demonstrated that the higher an individual's level of self-actualization (measured by the Personal Orientation Inventory), the less isolation anxiety (measured by the anxiety scale of the IGP inventory) that individual experienced when placed in 16-hour solitary confinement. Otto Will, from the perspective of his long experience treating disturbed adolescents and young adults, observed that individuals from loving, reciprocally respectful families are able with relative ease to grow away from their families and to tolerate the separation and the loneliness of young adulthood. What happens to those who grow up in tormented, highly conflicted families? One might expect that they would kick up their heels with joy at the prospect of dancing away from such a family. But the opposite occurs. The more disturbed the family, the harder it is for progeny to leave. They are ill-equipped to separate and cling to the family for shelter against isolation anxiety.

The therapist must find a way to help a patient confront isolation in a dosage and with a support system suited to that patient. Some therapists, at an advanced stage of therapy, once other sources of anxiety are worked through and the therapeutic relationship has become positive and robust, advise or prescribe periods of self-enforced isolation during the course of therapy. There are two possible benefits of such isolation. First, important material may be generated. Recall Bruce, the patient in chapter 5, who as a result of a few hours' isolation, became aware of his terror of loneliness and death, which he had all his life avoided through workaholism and compulsive sexuality. Secondly, the patient discovers hidden resources and courage. Linda Sherby describes a patient whose symptoms were frenzied activity and an unsatisfying dependent posture toward would-be relationships. In an effort to break through an impasse, the therapist suggested to the patient that she spend 24 hours alone in a motel, cut off from all distractions, people, television, books, and so on, except for writing a diary of her thoughts and feelings. The major outcome, and it was of considerable import for this patient, was that she learned she could tolerate isolation without panic. The patient's notes are explicit in this regard: "I'm still amazed at how together my head must be. Perhaps it's too soon for me to decompensate, but it's been 9 hours so far, and I don't think I'm going to crash." Toward the end of the 24 hours, she wrote to her therapist, "It is obvious I am not going to go berserk, and I expect you knew that all along. The sadness is becoming a part of me, and I doubt that it will be so easy to run from it again."

Several years ago, my colleagues and I performed an experiment that adventitiously demonstrated the degree to which personal growth is catalyzed by isolation. In an effort to test the impact of affect arousal in a weekend encounter group upon long-term individual therapy, we sponsored weekend group experiences at a country inn for three groups of patients: two experimental effect-arousing Gestalt groups and one control Zen meditation group. We attempted to measure the impact of the Gestalt group experience on the subjects and assumed that the non-effect-arousing meditation group would serve as a relatively stable control condition. The results indicated otherwise. There were unplanned, non-specific variables that vastly influenced the outcome. One of the important non-specific variables was the experience of isolation. Many individuals in both the experimental and the control groups reported that a significant facet of their experience was that they were removed from their familiar surroundings and encountered isolation. Indeed, several of the women subjects said that the weekend was the first time in years, in one instance 20 years, that they had been separated from their families and had spent a night alone without their husbands in bed beside them and their children sleeping nearby. The impact of the confrontation with isolation was so strong that for some it dwarfed the significance of the effect arousal, the variable under scrutiny.

The practice of meditation offers another avenue to isolation awareness. Though meditation therapists and teachers do not often conceptualize the benefit of meditation precisely in this manner, I believe that one of the primary growth-inducing factors in meditation is that it permits individuals, in an anxiety-reduced state (that is, anxiety-relieving muscular relaxation, posture, breathing, mind cleansing), to face and to transcend the anxiety they associate with isolation. Individuals learn to face what they fear the most. They are asked to plunge into isolation and, even more important, to plunge nakedly, without customary shields of denial. They are asked to let go rather than to achieve and acquire, to empty their minds rather than to categorize and analyze experience, and to respond to and harmonize with the world rather than to control and subdue it. Certainly, one of the explicit goals of the meditational state, one of the states one must achieve on the path to enlightenment (satori), is awareness that physical reality is in fact a veil obscuring reality and that only by reaching deep into one's isolation is one able to remove that veil. But recognition of the illusionary nature of reality, or as I described in chapter 6, awareness of one's constitutive function, invariably plunges one into a confrontation with existential isolation, into an awareness that not only is one isolated from others but, at the most fundamental level, isolated from the world as well.

Isolation and the patient-therapist encounter. It is the relationship that heals. I remember two maxims of psychotherapy that I learned in the very beginning of my training. I discussed the first: the goal of psychotherapy is to bring the patient to the point where he can make a free choice (in the section on freedom). The second: "it is the relationship that heals" is the single most important lesson the psychotherapist must learn. There is no more self-evident truth in psychotherapy. Every therapist observes over and over in clinical work that the encounter itself is healing for the patient in a way that transcends the therapist's theoretical orientation. If any single fact has been established by psychotherapy research, it is that a positive relationship between patient and therapist is positively related to therapy outcome. Effective therapists respond to their patients in a genuine manner. They establish a relationship that a patient perceives as safe and accepting. They display a nonpossessive warmth and a high degree of accurate empathy and are able to be with or grasp the meaning of a patient. Several reviews that summarize hundreds of research studies concur in this conclusion. Elsewhere in this book, I have cited empirical research, but generally in a highly selective manner and with much caution, either the research was scanty, poorly conceived or executed, or of doubtful relevance to the existential concern under discussion. In respect to the therapist-patient relationship, I shall also not fully cite the research literature, but for an entirely different reason: the overwhelming amount of high-quality research documenting the crucial importance of this relationship.

In the first chapter, I likened psychotherapy to an experience I had in a cooking class. What seems to make the vital difference in both Armenian eggplant dishes and in psychotherapy are the throw-ins, the off-the-record contributions. It is in the realm of the therapist-patient relationship that these throw-ins most frequently occur. During the course of effective psychotherapy, the therapist frequently reaches out to the patient in a human and deeply personal manner. Though this reaching out is often a critical event in therapy, it resides outside official ideological doctrine. It is generally not reported in psychiatric literature, usually because of shame or fear of censure, nor is it taught to students, both because it lies outside of formal theory and because it might encourage excesses.

An excellent illustration of the importance of the patient-therapist encounter is to be found in a book called Critical Incidents in Psychotherapy (1959), which described a number of incidents that therapists regarded as constituting turning points in therapy. A substantial majority of these critical incidents consist of a therapist's stepping outside of his or her professional role and engaging a patient in a deeply human fashion. A few examples:

1. "At this point, Tom, the patient, looked me in the eye and very clearly and slowly said, 'If you give me up, then there is no hope for me.' At this moment, I was overwhelmed with a complex and powerful set of emotions composed of sorrow, hatred, pity, and inadequacy. This sentence of Tom's became a critical incident for me. I was at that moment closer to him than I had ever been to any person on earth."

2. A therapist saw an acutely ill patient for an emergency session Saturday afternoon and, though the therapist was hungry and tired, continued the session for several hours.

3. A therapist met with a patient who during the course of therapy developed signs suggesting cancer. While she was awaiting the results of medical laboratory tests, which subsequently proved negative, he held her in his arms like a child while she sobbed and in her terror experienced a brief psychotic state.

4. A male therapist working with a young female patient who had such a powerful positive eroticized transference to him that therapeutic work was not possible disclosed to her some aspects of his personal life which permitted the patient to sort out real from distorted perceptions of him.

5. "For several sessions, a patient had been abusing a therapist by attacking him personally and by questioning his professional skills. Finally, the therapist exploded. I began pounding the desk with my fist and shouted, 'Damn it. Look, why don't you just quit the verbal diarrhea and let's get down to the business of trying to understand yourself and stop beating on me. Whatever faults I have, and I do have a lot of them, have nothing to do with your problems. I'm a human being, too, and today has been a bad day.'"

6. A patient had been abandoned in a desolate house perched on a cliff accessible only by a rickety wooden bridge. In extremis, she called her therapist who came to the house, crossed the bridge, consoled her, and drove her to her home.

The other critical incidents are similar. In each, the thrust is clearly toward a human encounter and away from artificial or ideologically prescribed handling of the patient. Corroborating illustrations of this phenomenon abound in the literature. In chapter 2, I discussed how in 1895, in Studies on Hysteria, Freud and Breuer overlooked considerable material relating to death. It is striking, too, that in his assessment of therapeutic mechanisms, Freud may have overlooked the importance of the patient-therapist encounter. He attributed therapeutic change entirely to hypnotic suggestion and to interpretive work which makes possible abreaction and release of a strangulated affect. Yet note the nature of Freud's therapeutic involvement, which he described in his case histories. He regularly gave some of his patients a massage and in one passage expressed his annoyance that the patient's menstrual period might make the massage impossible that day. On other occasions, he swung boldly, to use Buber's term, into the life of the patient by speaking to family members and by clarifying the patient's financial and marital prospects. At other times, Freud was authoritarian and harsh. In one memorable encounter, he adamantly told a patient that he would give her 24 hours to change her beliefs about the non-psychological causes of a symptom or she would have to leave the hospital.

Several years ago, I established a contract for reasons not germane to this discussion with a patient which stipulated that we both would write impressionistic summaries after each individual therapy hour, deliver them sealed to my secretary, and every few months read each other's notes. Later, we published these notes in the book Every Day Gets a Little Closer: A Twice Told Therapy. What impressed me very much was the discrepancy between my perceptions of an hour and those of the patient. The patient and I attended to and valued very different aspects of the therapy experience. What of my precious and elegant interpretations? Alas, she never even heard them. What she cherished were the small personal touches, a warm look, a compliment about the way she looked, my unwavering interest in her, my asking her opinion about a movie she had seen.

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

How does the therapeutic relationship heal? In the previous section, I suggested that the patients' in-therapy relationships (those in his or her current life or with other members of a therapy group or psychiatric hospital ward) have two types of therapeutic effect. One, that they are mediating in that they improve the quality of other future relationships by instructing patients about their maladaptive interpersonal behavior and by serving as dress rehearsals for new modes of relating. Two, they have value in and for themselves as real relationships. They affect interpersonal shifts. The same paradigm holds for the therapist-patient relationship. It heals by eliminating other relationships and also by virtue of affording a real relationship to the patient. Let us consider each mode in turn.

Patient-therapist relationship: illumination and facilitation of other relationships. The therapist, by helping a patient examine the therapist-patient relationship, illuminates and facilitates the patient's past or current relationships with those who in some symbolic way resemble the therapist. The use of the relationship to illuminate the past is the traditional transference approach to the patient-therapist relationship, where the patient transfers feelings and attitudes from important figures, especially parental ones, onto the person of the therapist. The patient dresses the therapist, who serves as a mannequin, with feelings that have been stripped from others. The relationship with a therapist is a shadow play reflecting the vicissitudes of a drama that transpired long ago. The analytic therapeutic goal of recapturing and illuminating events in early life is well served in this approach. There are two basic objections to working with relationships in this manner. First, as I discussed in chapter 7, there is no evidence that uncovering and understanding the past is mutative in therapy. The second is that viewing the therapist-patient relationship primarily in terms of transference negates the truly human and truly mutative nature of the relationship. There is much evidence for the argument that it is the real relationship that heals, and to view the therapist-patient relationship as a crate to transport the merchandise of healing insight, uncovering the events of early life, and so on, is to mistake the container for the contents. The relationship is the merchandise of healing. And as I have stressed earlier, the search for insight, the task of excavating the past are all interesting, seemingly profitable ventures that engage the attention of patient and therapist while the real agent of change, their relationship, is germinating.

Another use of the patient-therapist relationship is to help the patient understand current or future relationships. The patient almost invariably will distort some aspects of his or her relationship to the therapist. The experienced therapist, drawing from his or her own self-knowledge and wide experience of how others view him or her, is able to help the patient distinguish distortion from reality. The therapist may represent different things to different patients, but to most patients, he or she embodies images of authority, teacher, boss, parent, judge, supervisor, and so forth. By helping the patient improve his or her relationships to such individuals, the therapist performs a real service.

The real relationship between therapist and patient. There is enormous potential benefit in the patient's developing a real, as opposed to a transferential, relationship to the therapist. Rather than the relationship being an "as if" phenomenon, one that analyzed properly will facilitate other relationships, the therapist helps to heal by developing a genuine relationship with the patient. Kaiser, as I discussed earlier, believed that the individual beleaguered by isolation, the universal conflict, attempts to deal with it by affecting a fusion with another. To pave the way for fusion, the universal symptom, as Kaiser put it, arises. The universal symptom is duplicity or ingenuousness or transference and consists of both distorted perception of and behavior toward the therapist. Thus, the patient doesn't relate with his true self but engages the therapist in such a way as to escape isolation and to affect fusion. And the antidote to this universal conflict and symptom, Kaiser's answer was communication. He posited that quote, "It was the ability to communicate freely that prevented the universal conflict from forcing a person into the restrictive, delusionary pattern of neurosis." End quote. The therapist healed, Kaiser believed, simply by being with the patient. As he noted, successful therapy requires that the patient spends sufficient time with a person of certain personality characteristics. What personality characteristics? Kaiser cited four:

1. An interest in people.

2. Theoretical views on psychotherapy that do not interfere with his or her interest in helping the patient to communicate freely.

3. The absence of neurotic patterns that would interfere with the establishment of communication with the patient.

4. The mental disposition of receptiveness, being sensitive to duplicity or to the non-communicative elements in the patient's behavior.

Kaiser offers only one rule for the therapist: Communicate. All other requirements pertain not to what the therapist must do, but to what the therapist must be. Though Kaiser may overstate the matter, he nonetheless calls our attention to the essential cog in the process of therapeutic change. Psychotherapy for most patients is a cyclical process from isolation into relationship. Once a patient is able to relate deeply to a therapist and to relate to him or her as a real person, not as a hologram manufactured by technique, then he or she has already changed. The patient learns that the potential for love exists within oneself and experiences feelings that have lain dormant in dissociated realms for years or decades. Recall Buber's comments about the I-Thou relationship. When the "I" truly relates to another, it is changed. It is different from the previous "I." It experiences new aspects of itself. It opens up not only to the other, but to itself as well. No matter that the patient's relationship to the therapist is temporary, the experience of intimacy is permanent. It can never be taken away. It exists in one's inner world as a permanent reference point, a reminder of one's potential for intimacy. The discovery of self that ensues as a result of intimacy is also permanent. It scarcely needs to be said that the experience of an intimate encounter with a therapist has implications for the individual that extend beyond relationships with most other people. For one thing, the therapist is generally someone whom the patient particularly respects. But even more important, the therapist is someone, often the only one, who really knows the patient. To tell an individual all one's darkest secrets, all one's illicit thoughts, one's vanities, one's sorrows, one's passions, and still be fully accepted by that person is enormously affirmative.

Earlier I said psychotherapy is a cyclical process from isolation into relationship. It is cyclical because the patient, in terror of existential isolation, relates deeply and meaningfully to the therapist and then, strengthened by this encounter, is led back again to a confrontation with existential isolation. The therapist, out of the depth of relationship, helps the patient to face isolation and to apprehend his solitary responsibility for his own life—that it is the patient who has created his life predicament and that, alas, it is the patient and no one else who can alter it. The therapist leads the patient back to isolation in yet another way. Earlier I stressed that one priceless thing the patient learns in therapy is the limits of relationship. One learns what one can get from others. But perhaps even more important, one learns what one cannot get from others. As patient and therapist encounter one another on a human level, the former's illusions inevitably suffer. The ultimate rescuer is seen in the full light of day as only another person. After all, it is an isolating moment, but also, as Kenneth Fischer states, an illuminating one: quote, "When the pilgrim chances to think, 'Maybe no one knows. Perhaps we are all pilgrims.'" End quote. At the very least, the patient is liberated from searching in the wrong place. Optimally, he or she learns from the fullness of the encounter that patient and therapist, and everyone else, are brethren in their humanness and their irrevocable isolation.

The ideal therapist-patient relationship. If it is the therapist's primary task to relate deeply and fully to the patient, does then the therapist form an I-Thou relationship with each patient? Does the therapist love the patient in Maslow or Fromm's sense? Is there a difference between a therapist and a true friend? It is hard for a therapist to read or to write these questions without a certain uneasiness. "Squirm" is the word that springs to mind. There is an inescapable dissonance in the world of the therapist. No amount of polishing and lubricating make concepts like friendship, love, and I-Thou fit comfortably with other concepts like 50-minute sessions, $65 an hour, case conferences, and third-party payments. This incongruity is built into the therapist's and the patient's situation and cannot be denied or ignored.

There is one major aspect of a loving friendship or an I-Thou relationship which is perforce different in the therapist-patient relationship: reciprocity. The patient comes to the therapist for help. The therapist does not come to the patient. The therapist should have motivation, inclination, and ability to experience the patient as a person as fully as possible. The patient, by definition, has impaired ability to experience the other person fully and furthermore has another motive entirely: relief of suffering. Thus, the therapist has what Buber calls a detached presence. The therapist is able to be in two places at once: at his or her own side and at the patient's side. As Buber said, the therapist is able to be where he himself is and where the patient is. The patient cannot be but where he is. The therapist is interested in the "you" of the patient. Not only the "you" that is present, but the potential dormant "you." The therapist uses his or her intuitive sense of openness and closeness to the patient as a guide, seeking always to deepen the relationship. The patient, at the onset of therapy, has no can of a reciprocal attitude toward the therapist. The patient may ask or think questions about the therapist. But these inquiries are generally not in the service of reaching out to know or to bring out the full potential of the therapist, but rather to establish the latter's credentials or to ascertain whether he is going to fill the patient's needs. Occasionally, the patient's questions are part of a struggle for control in the relationship. The patient may feel less vulnerable in revealing himself or herself if the therapist is willing to self-disclose.

Also, Carlos Sean, in Love and Psychotherapy, describes the therapist-patient relationship as a special form of love, psychotherapeutic eros. This form of love has several distinctive features. It is, as I have already indicated, non-reciprocal. The lack of reciprocity, I should note, is not fixed. As therapy proceeds, the improving patient becomes increasingly aware and increasingly caring (that is, need-free caring) about the person of the therapist. Psychotherapeutic eros is indestructible, or as Carl Rogers put it, non-conditional. Other kinds of love can be eroded. A lover will ultimately cease to love when his or her love is not returned. Friends will part when they no longer have a great deal in common. Many circumstances exist that may result in estrangement between parent and child, teacher and student, worshipper and deity. But the mature therapist will care despite rebelliousness, narcissism, depression, hostility, and mendacity. In fact, one might say that the therapist cares because of these traits, since they reflect how much the individual needs to be cared for.

Another aspect of psychotherapeutic eros is that it implies a genuine caring for the person of the patient. In Sean's words, it is not a humanitarian love that the doctor should feel for the sick man simply as a sick man. Rather, he should have an authentic feeling of love for the particular individual who is before him, who is this man and not another, who is not a sick man but rather a man. Fromm and Buber all stressed that true caring for another means to care about the other's growth and to bring something to life in the other. The therapist must have this attitude toward the patient. The therapist's raison d'être is to be midwife to the

Birth of the patient's yet unlived life. The idea of bringing to life something in the other provides an important procedural strategy for the therapist. Buber distinguishes two basic modes of affecting another's attitude toward life. Either one tries to impose one's attitude and opinions upon another, and in such a way that the other deems them to be his or her own views, or one attempts to help another discover his or her own dispositions and experience his or her own actualizing forces. The first approach, Buber terms imposition, and is the way of the propagandist. The second approach is unfolding, and is the way of the educator and the therapist.

Unfolding implies that one uncovers what was there all along. The very term unfolding has rich connotations and stands in sharp contrast to other terms depicting the therapeutic process. For example, reconstruction, decondition, behavioral shaping, repairing. One helps the other unfold not by instruction, but by meeting, by existential communication. The therapist is not a director, not a shaper, but is instead a possibilitator.

Haidegger, in analogous fashion, speaks of two different modes of caring or solicitude. One can leap in for another, a mode of relating similar to imposition, and thus relieve another of the anxiety of facing existence, and in so doing, limit the other to inauthentic existence. Or one can leap ahead, a not wholly satisfying term, and liberate the other by confronting the other with his or her existential situation.

In summary, the therapist relates to the patient in a genuine, caring fashion and strives to achieve moments of authentic encounter. The therapist should be selfless in this endeavor, that is, concerned with the patient's growth and not with his or her personal needs. The therapist's caring should be indestructible and not dependent upon reciprocal caring by the patient. The therapist should be able to be both with himself or herself and with the patient, and should thus be able, in caring, to enter the patient's world and to experience it as the patient experiences it. This requires the therapist to approach the patient without presuppositions, to focus on the project of sharing the patient's experience without rushing in to judge or stereotype the patient.

Many of these aspects of the therapeutic relationship have been described by Rogers and his co-workers in their triad of therapist characteristics: empathy, genuineness, and positive unconditional regard. And considerable research evidence indicates that these characteristics facilitate positive therapy outcome. My chief concern about this characterization of therapist behavior is that others, despite Rogers' emphasis that the relationship must be genuine and deeply personal, often present it as a technique, as something the therapist does in therapy. Accordingly, there are technical manuals that teach student therapists methods of conveying empathy, genuineness, and positive regard. To an existential therapist, when technique is made paramount, everything is lost because the very essence of the authentic relationship is that one does not manipulate, but turns toward another with one's whole being.

Diagnosis. Many therapists have difficulty relating authentically to patients because of presuppositions and stereotypes. The training of therapists emphasizes diagnosis and classification. They are taught to objectify patients to arrive at an APA, American Psychiatric Association, code number that pins a patient like a specimen to an admission workup or an insurance form. And indeed, no responsible therapist can deny there is a place for diagnostic evaluation. For example, one needs to ascertain whether the patient has some organic illness or toxic condition that is affecting his or her psychological state. Or one needs to ascertain whether the patient is suffering from severe affective disorder of biochemical ideology, for example, endogenous depression or manic-depressive diathesis, which requires pharmacological treatment.

Even if a condition is primarily functional, the therapist needs to make other crude determinations. Is the patient's condition of such severity, for example, severe sociopathic character disturbance or well-systematized paranoid schizophrenia, that there is little likelihood of his or her benefiting from psychotherapy? For obvious reasons, the patient's destructive tendencies to self and others must be ascertained. Even beyond that, the therapist can make determinations about a patient's fragility and ability to tolerate closeness, which will provide important guidelines for the pace of therapy.

Beyond these relatively crude determinations, which serve the function of initial triage, further and finer diagnostic discriminations not only offer little help to the therapist, but often interfere with the formation of relationship. Intricate psychoanalytic diagnostic formulations about specific psychosexual dynamic organization are of little help to therapy and, to the extent to which they impede genuine listening, constitute a hindrance. Although some or most hysterical personalities, to take one example, exhibit certain specific behavioral patterns and are plagued by certain common dynamic conflicts, not all do so. The standard diagnostic formulation tells the therapist nothing about the unique person he or she is encountering. And there is substantial evidence that diagnostic labels impede or distort listening. Too often, diagnostic categorization is a stimulating intellectual exercise whose sole function is to provide the therapist with a sense of order and mastery. The major task of the maturing therapist is to learn to tolerate uncertainty. What is required is a major shift in perspective. Rather than strive to order the interview material into an intellectually coherent framework, the therapist must strive toward authentic engagement.

Therapist Self-Disclosure. A therapist who is to know a patient must do more than observe and listen. He or she must fully experience the patient. But full experience of the other requires that one open oneself up to the other. If one engages the other in an open and honest fashion, one experiences the other as the other is responding to that engagement. There is no way around the conclusion that the therapist who is to relate to the patient must disclose himself or herself as a person. The effective therapist cannot remain detached, passive, and hidden. Therapist self-disclosure is integral to the therapeutic process.

But how much of self does the therapist disclose? Personal life problems, all feelings toward the patient, boredom, fatigue, flatulence, clever therapeutic strategies. Is there, in this regard, no difference between a therapist and a close friend? Vexing problems indeed. Problems that, in the first several decades of psychotherapeutic practice, were never confronted since it had been settled early in the analytic movement that therapists should maintain emotional distance and objectivity, much as a surgeon dispassionately studies an ailing organ. Patients will develop strong feelings for therapists, warned Freud. But therapists must be on guard and suppress tender feelings. Therapists must realize that a patient's powerful feelings are, as Freud said, an unavoidable consequence of a medical situation, like the exposure of a patient's body or the imparting of a vital secret.

Why should a dispassionate role for the therapist be so strictly prescribed? First, Freud suggested that a therapist who has ceased to be objective will lose control of the situation and be swept along by what a patient wishes rather than by what a patient requires. As he said, "the patient would achieve her aim, but the doctor would never achieve his." What would happen to the doctor and the patient would only be what happened, according to the amusing anecdote, to the pastor and the insurance agent. The insurance agent, a freethinker, lay at the point of death, and his relatives insisted on bringing in a man of God to convert him before he died. The interview lasted so long that those who were waiting outside began to have hopes. At last, the door of the sick chamber opened. The freethinker had not been converted, but the pastor went away insured. So, in Freud's view, if therapists open themselves up to patients and involve themselves in normal human intercourse, they will sacrifice objectivity and hence effectiveness.

A second, more pervasive argument for therapist opacity is grounded in the view that transference is the lynchpin of psychotherapy. Freud believed, and the great majority of present-day psychoanalysts still believe, that analysis of transference is the paramount task of the therapist. As I discussed earlier, to Freud, transference was a living representation of what a patient had experienced early in life in ages too ancient to be fully accessible to memory. Thus, by observing, understanding, and helping the patient to work through transference—that is, to experience it, to recognize its inappropriateness to the current situation, and to discover the infantile sources of the transferential feeling—the therapist uncovers the deepest strata of the individual's life experience.

Given the key role of transference, it follows that the therapist should facilitate its development. The less the therapist's real self appears, the more readily does the patient transfer onto him feelings that belong elsewhere. This is, of course, the rationale for the traditional blank screen role of the therapist and for the peculiar seating arrangement of the psychoanalytic session, where the analyst remains behind the couch out of the patient's range of vision. This prescription against therapist self-disclosure paved the way for two generations of psychotherapy technique that argued against an authentic encounter between therapist and patient and insisted that the therapist's primary function, indeed sole function, was interpretation.

Even some early theorists, however, dissented with this view of the therapist's role. Sándor Ferenczi, one of Freud's first and most loyal disciples, argued that the detached, omniscient posture of the therapist interfered with therapeutic effectiveness. Ferenczi, especially during his later years, openly acknowledged to patients his fallibility. For example, in response to a justified criticism, he felt comfortable in saying, "I think you may have touched upon an area in which I am not entirely free myself. Perhaps you can help me see what's wrong with me." For the most part, however, it was not until the 1950s when the issue of the real, that is, the non-transference relationship, was discussed in psychiatric literature. Ralph Greenson and Milton Wexler's extensive review cites only two studies before 1950.

In 1954, in an informal discussion of transference, Anna Freud commented, "With due respect for the necessary strictest handling and interpretation of the transference, I feel still that we should leave room somewhere for the realization that analyst and patient are also two real people of equal adult status in a real personal relationship to each other. I wonder whether our at times complete neglect of this side of the matter is not responsible for some of the hostile reactions which we get from our patients and which we are apt to ascribe to true transference only. But these are technically subversive thoughts and ought to be handled with care."

Greenson and Wexler in 1969 gave some indication of the persistence of the traditional analytic view on this issue. They wrote, "Although one no longer hears elaborate debates in analytic circles as to whether it is a mortal technical sin to offer a Kleenex to a patient weeping over the recent death of a parent, it is still highly suspect to do anything which resembles being kind to the patient." Although Greenson and Wexler argued for a more human therapist-patient relationship, I believe that they used the wrong reasons. In their discussion of the drawbacks to excessive therapist detachment, they said, "Perhaps we should be more aware of the fact that persistent anonymity and prolonged effective atherosclerosis can also be seductive, but generally in the direction of inviting an irreversible and uninterpretable hostile transference and alienation." Thus, these analysts argued for greater therapist involvement out of technical considerations to keep the transference from becoming unworkable and to facilitate its analysis.

Incidentally, the previous quotation contains the curious phrase that "prolonged effective atherosclerosis can also be seductive." I assume what is meant is that it is easier and requires less investment of energy for therapists to remain emotionally uninvolved. Possibly so, but therapists pay a terrible price, as they themselves ultimately become deadened. Another professional hazard for therapists consists of using encounters with patients to avoid confronting and integrating their own isolation. Without such an integration, some therapists never develop the autonomy to engage in gratifying and enduring love relationships. Instead, their personal lives become a staccato of intense but transient 50-minute encounters.

To summarize, a singular focus on transference impedes therapy because it precludes an authentic therapist-patient relationship. First, it negates the reality of the relationship by considering the relationship solely as a key to understanding other, more important relationships. Secondly, it provides therapists with a rationale for personal concealment, a concealment that interferes with the ability to relate in a genuine fashion with patients.

Does this mean that therapists who faithfully maintain a detached, objectifying, interpretive posture toward patients are ineffective or even destructive? I believe that, fortunately, such therapists and such courses of therapy are exceedingly rare. Here lies the importance of the throw-ins in therapy. Therapists, despite themselves and often unbeknownst to themselves, reach out in a human manner in off-the-record moments.

What are other objections to therapist self-disclosure? Some therapists fear that if they open the door a little, patients will force it wider and demand more self-revelation. My personal experience is that this fear is unwarranted. I feel it is often important to reveal my immediate here-and-now feelings to the patient. I rarely find it necessary or particularly helpful to reveal many details of my personal past and current life. I have almost never found a patient whose demands escalate. The desire of the patient is not that the therapist be stripped, but that the therapist relate to him or her as a person and be entirely present in the immediate encounter.

How much to reveal, what guidelines to use. It is important to keep in mind the overriding goal: authentic relationship. One of the outstanding characteristics of psychotherapeutic ethos is the care for the other's becoming. Rollo May suggests the Greek term agape or the Latin karas, a love that is devoted to the welfare of the other. What is important then is that therapist self-disclosure be in the service of the growth of the patient. Self-expression on the part of the therapist, or total honesty, or spontaneity may each be a virtue in itself, but each is secondary to the overriding presence of agape. Therefore, it follows that therapists must keep some things to themselves, that they say nothing that may be destructive to a patient, that they respect the principle of timing and attend to the pace of therapy, to what a patient is or is not ready to hear.

The principle of self-restraint applies incidentally when we consider another objection to the therapist's involving himself or herself as a real person with the patient: loss of therapist objectivity with resulting excesses and irresponsible behavior. Perhaps the most flagrant excess is the therapist who, as a real person, becomes sexually involved with a patient. I have seen many patients who have had some prior sexual involvement with a therapist. My impression is that the experience is always destructive for the patient, and that invariably the therapist has violated the principle of agape love for the being and the becoming of the other. Such therapists heeded not their patients' needs but their own and offered wretchedly transparent rationalizations, such as a patient's need for sexual affirmation. I have yet to hear of a therapist becoming sexually involved with one who might really need sexual affirmation—that is, with one who is remarkably unattractive, physically deformed, or surgically mutilated.

Another reason for the therapist to remain hidden is the fear that self-disclosure would lay bare some of those incongruities in the therapy situation I spoke of earlier: fee for service, the 50-minute hour, the therapist's packed schedule. Will the patient ask, "Do you love me? If you really care for me, would you see me if I had no money?" Is therapy really a purchased relationship? It is true that these questions veer perilously close to that ultimate secret of the psychotherapist, which is that the encounter with the patient plays a relatively small role in the therapist's overall life. As in Tom Stoppard's play, Rosencrantz and Guildenstern Are Dead, a key figure in one drama becomes a shadow in the wings as the therapist moves immediately onto the stage of another drama. Indeed, this denial of specialness is one of the cruel truths and poorly kept secrets of therapy. The patient has one therapist. The therapist has many patients. The therapist is far more important to the patient than the patient to the therapist.

To my mind, there is only one response that therapists can make to such questions from patients: that when the therapist is with the patient, he or she is fully with the patient. The therapist strives to give his or her entire presence to the other. That is why earlier I stressed the importance of the immediate moment in an encounter. At the same time, the therapist must know that though the aim must be full encounter, he or she cannot continually relate at that level. Recall Buber: one cannot live in the pure present, that is, in the "I-Thou," it would consume us, but must repeatedly, during the hour, bring himself or herself back to full engagement in the present moment.

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

Part Four. Meaninglessness.