Existential psychotherapy by Irvin D. Yalom 02

Chapter 3B. Denial.

Personification of death. Denial. Taunting of death. The older child attempts to assuage a fear of death by confirming his or her aliveness. Nine and 10-year-olds often taunt death. They jeer at their old enemy. A study of the language of school children revealed many deaf jibes that seemed hilariously funny to them. For example, "You're going to be burned or buried. It's not the cough that carries you off. It's the coffin they carry you off in." "Now I lay me down to sleep, a bag of bananas at my feet. If I should die before I wake, you'll know it was the tummy ache." "The worms crawl in, the worms crawl out. You hardly know what it's all about."

Many children, especially boys, engage in feats of reckless daredevilry. Quite possibly some male adolescent delinquent behavior may reflect a persistence of this defense against death anxiety. Young girls do so much less commonly, either because of social role demands or because, as Mau suggests, they are less oppressed by death fears, owing to their knowledge of their biological role as mothers and hence creators.

Denial of death awareness in child psychiatric literature. In spite of the compelling and persuasive arguments and supporting evidence that children discover death at an early age and are pervasively concerned with it, one searches in vain for a reasoned inclusion of death fear in psychonamic formulations of personality development or in psychopathology. Why is there a discrepancy between clinical observation and dynamic theory? There are, I believe, a how and a why to consider.

How? I believe that death is excluded from psychonamic theory by a simple mechanism. Death is translated into separation, which assumes death's role in dynamic theory. John Bulby in his monumental work on separation presents convincing ethological, experimental, and observational evidence too extensive to be considered here that indicates that separation from the mother is a catastrophic event for the infant and that separation anxiety is clearly evident during the ages of 6 to 30 months. Bulby concludes, and this conclusion is widely accepted by clinicians, that separation is the primal experience in the formation of anxiety. Separation anxiety is the fundamental anxiety, and other sources of anxiety, including the fear of death, acquire emotional significance by equation with separation anxiety. In other words, death is fearful because it revokes separation anxiety.

Bulby's work, for the most part, is elegantly argued. Yet in his consideration of death anxiety, his imagination seems curiously curtailed. For example, he cites Ursil's research in which 400 children were asked about their fears. Ursil found that specific fears of becoming ill or dying were conspicuous for their infrequency. They were mentioned by none of the 200 children under 9 years of age and by only six of the 200 from 9 to 12. Bulby concludes from these data that fear of death in children under 10 is absent, that it is a later and learned fear, and that it is important because it is equated with separation. Ursil's research shows that what children do fear are animals, darkness, heights, or being attacked in the dark by such creatures as ghosts or kidnappers. What is not asked is the obvious question: What is the significance to children of darkness or ghosts or ferocious animals or being attacked in the dark? In other words, what is the underlying meaning, the mental representation of these fears?

Rolo May, in his lucid book on anxiety, argues that Ursil's study merely demonstrates that anxiety is converted into fear. The child's fears are often unpredictable and shifting and unrelated to reality. The child is more likely, for example, to fear remote animals like gorillas and lions than familiar ones. What appears as unpredictability on a superficial level is, May argues, quite consistent on a deeper one. A child's fears are objectivated forms of underlying anxiety. May discloses, "Quote, 'You remarked to me in personal conversation that these children's fears really expressed anxiety.' He was surprised that he had never seen this earlier. I think his not seeing it shows how hard it is to get out of our traditional ways of thinking.' Unquote."

Behavioral research has delineated many situations that arouse fear in human children. The same question may be asked of this experimental data. Why does the child fear strangers or a visual cliff (a glass table with what appears to be a chasm underneath it) or an approaching object looming or darkness? Obviously, each of these situations, as well as animals, ghosts, and separation, represents a threat to survival. Yet, with the exception of Melanie Klene and D.W. Winnicott, who emphasize that primal anxiety is anxiety about annihilation, ego dissolution, or being devoured, the question, "Why is the child fearful of these life-threatening situations?" is rarely asked. Child developmentalists or child analysts frequently draw highly inferential conclusions about the inner life of the child when it involves object relations or infantile sexuality. But in considering the child's conception of death, their intuition and imagination remain checked.

The evidence for the existence of separation anxiety is based on solid behavioral observations. Throughout the mammalian species, a child separated from its mother evinces signs of distress, both external motoric signs and internal physiological ones. There is also no doubt, as Bulby ably demonstrates, that separation anxiety is evident early in the life of the human infant and that concerns about separation remain a major motif in the inner world of adults. But what behavioral research cannot reveal is the nature of the young child's inner experience or, as Anna Freud puts it, the mental representation of the behavioral reaction. It is possible to know what evokes the apprehensiveness, but not what the apprehensiveness is. Empirical research demonstrates that the child is fearful when separated, but in no way demonstrates that separation anxiety is the primal anxiety from which death anxiety is derived at a level prior to thought and language. The child may experience the incipient anxiety of non-being, and that anxiety in the child, as in the adult, seeks to become fear. It is in the only language available to the older child, bound and transformed into separation anxiety.

Developmentalists assume the idea that a young child, say before the age of 30 months, could experience death anxiety because the child has little concept of a self that is separate from surrounding objects. But the same may be said about separation anxiety. What is it that the child experiences? Certainly not separation, because without a conception of self, the child cannot conceive of separation. What is it, after all, that is being separated from what? There are limits to our knowing about an inner experience that cannot be described, and in this discussion, I run the peril of adultomorphizing the child's thought. It must be kept in mind that the term "separation anxiety" is a convention, an agreed-upon term founded upon empirical research and refers to some ineffable inner state of apprehensiveness. But for the adult, it makes no sense whatsoever to translate death anxiety into separation anxiety or fear of loss of object, or to argue that death anxiety derives from a more fundamental separation anxiety. As I discussed in the previous chapter, one must distinguish between two meanings of fundamental: basic and chronological. First, even were we to accept the argument that separation anxiety is chronologically the first anxiety, it would not follow that death anxiety really is fear of object loss. The most fundamental basic anxiety issues from the threat of loss of self. And if one fears object loss, one does so because loss of that object is a threat or symbolizes a threat to one's survival. Why?

The omission of death fear from dynamic theory is obviously not oversight. Nor, as we have seen, is there substantial reason to justify translating this fear into other concepts. There is, I believe, an active repressive process at work. A process that stems from the universal tendency of mankind, including behavioral researchers and theoreticians, to deny death, to deny it both personally and in life's work. Others who have studied the fear of death have arrived at a similar conclusion. Anthony remarks, "The illogicality and the patent insensibility of child developmental researchers to the phenomenon of man's fear of death, which anthropology and history have demonstrated to be one of the most common and powerful of human motivations, can be attributed only to the conventional, that is, culturally induced repression of this fear by the writers themselves and those whose researchers they report." Charles Wall, in the same vein, comments, "It is a surprising and significant fact that the phenomenon of the fear of death or anxiety about it, thanatophobia as it is called, while certainly no clinical rarity, has almost no description in the psychiatric or psychoanalytic literature. It is conspicuous by its absence. Could this suggest that psychiatrists, no less than other mortal men, have a reluctance to consider or study a problem which is so closely and personally indicative of the contingency of the human estate? Perhaps they, no less than their patients, would seem to confirm Darashuk's observation that one cannot look directly at either the sun or death."

Death anxiety and the development of psychopathology. If death anxiety is a major factor in the development of psychopathology, and if coming to terms with the concept of death is a major developmental task of every child, then why do some individuals develop crippling neurotic disorders and others reach adulthood in relatively well-integrated fashion? There is no empirical research to help answer this question, and for the present, I can do no more than suggest possibilities. Undoubtedly, a number of factors interact in a complex fashion. There must be some ideal timing or sequence of developmental events. The child must deal with the issues at a pace compatible with his or her inner resources. Too much, too soon, obviously creates an imbalance. A child who is harshly confronted with death before having developed appropriate defenses may be severely stressed. Severe stress, unpleasant at all times of life, has for the young child implications that transcend transient dysphoria. Freud, for example, spoke of the disproportionately severe and enduring damage to the ego caused by massive trauma early in life and cited, by way of illustration, an experiment in biology which demonstrated the catastrophic effects on an adult organism caused by the tiny prick of a needle into the embryo at the very beginning of its development.

What type of trauma may be involved? Several obvious possibilities present themselves. Exposure to death in the child's environment is an important event. Some types of contact with death may, in proper dosage and in the presence of already existing ego resources, curious constitutional factors, and supportive adults who are themselves able to deal adaptively with death anxiety, result in inoculation. Whereas some types may exceed the child's capacity to shield himself or herself. Every child is exposed to death in encounters with insects, flowers, pets, and other small animals. And these deaths may be sources of puzzlement or anxiety and stimulate the child to discuss with his or her parents questions and fears about death. But for a child faced with the death of a human, the possibility of trauma is much greater. The death of another child is, as I have discussed, especially frightening because it undermines the consoling belief that only very old people die. The death of a sibling who is both young and important to the child is a major trauma. The child's reaction may be very complex, for several issues are involved: guilt emanating from sibling rivalry and from the pleasure of commanding more parental attention; loss and the evocation of fear of one's personal death. The literature deals primarily with the first issue, guilt, and occasionally with the second, loss, but almost never with the third.

For example, Rosen's vague and Bray present data that indicates that among schizophrenic patients, when compared with a normal population, with a manic-depressive sample, and with a general paretic sample, there is a significantly greater incidence of a sibling dying before a patient's sixth year. Rosen's vague offers the standard analytic interpretation of this result, namely that overwhelming guilt ensuing from inter-sibling hostility and incestuous feelings is a significant factor in the production of schizophrenic behavior patterns. To support this conclusion, he presents three brief, one-paragraph case reports. Despite the brevity of the reports and the selection from a huge sample of clinical material to support his thesis, there is evidence of fear of personal death in two of the three vignettes. One patient, who had lost his mother and two sibs early in life, responded strongly to the death of a cousin. Quote, "He was so deeply disturbed that he became ill and had to go to bed. He feared persistently that he was going to die. The doctor gave the diagnosis of a nervous breakdown. The patient soon began to display bizarre behavior of a schizophrenic kind." Another patient lost three brothers, the first when he was 6 years old. He developed a psychosis at 17, shortly after the death of the third brother. The only statement quoted from the patient suggests that more than guilt was involved in his reaction to the death. Quote, "I've heard his voice occasionally. I almost seem to be him at times. I don't know. There's some void that seems to be in the way. Well, how can I get over a void like his death? My brother's dead, and I'm well. I'm alive, but I don't know."

This highly selective form of case report proves nothing. I belabor the point to illustrate the problems of interpreting the research literature. Researchers and clinicians become grooved and have difficulty changing set, even when, as in this research, another explanation seems entirely plausible and consistent with the data. If one considers loss of a parent as well as loss of a sibling, then one finds in Rosenve's research that over 60% of schizophrenic patients suffered an early loss. Perhaps, then, schizophrenic patients have had too much, too soon. Not only did these patients have too much exposure to death, but because of the degree of pathology in the family environment, the families and the patients were particularly unable to cope with death anxiety. Harold Surles, as I will discuss in chapter 4, reached the same conclusions based on his psychotherapeutic work with adult schizophrenic patients.

The death of a parent is a catastrophic event for the child. The latter's reactions depend upon a number of factors: the quality of his relationship to the parent, the circumstances of the parent's death (was, for example, the child witness to a natural or a violent death?), the parent's attitude during his or her final illness, and the existence of a strong surviving parent and a network of community and family resources. The child suffers a deep loss and, furthermore, is extraordinarily beset with concern that his or her aggressive behavior or fantasies concerning the parent may have been instrumental in the latter's death. The role of loss and guilt is well known and has been competently discussed by others. Omitted from traditional bereavement literature, however, is a consideration of the impact of a parent's death upon the child's awareness of his or her own death. As I have emphasized previously, annihilation is the individual's primary dread and supplies much of the anguish in his or her reaction to the loss of another. Mau puts it well. He said, "At some level below true cognition, the child with naive narcissism knows that the loss of his parents is the loss of his tie to life. Total terror for his life rather than jealous possessiveness of a lost love object is the etiology of the distress of separation anxiety."

It is not difficult to demonstrate that psychiatric patients, neurotic and psychotic, have lost a parent more frequently than have individuals in the general population. But the implications of a parent's death for the child are so extensive that it is not possible for research to disentangle and to assign weight to all the separate components of the experience. It is known, for example, from animal experimentation that the young, if separated from their mothers, will develop an experimental neurosis and respond far more adversely to stress than to those who remain with their mothers. In humans, the immediate presence of a maternal figure lessens anxiety caused by unfamiliar events. It follows, then, that a child who has lost a mother is far more vulnerable to all the stresses he or she must face. The child is not only exposed to anxiety emanating from death awareness but suffers inordinately with anxiety from many other stresses—interpersonal, sexual, school-related—with which he or she is poorly able to cope. Thus, the child is likely to develop symptomatology and neurotic mechanisms of defense which will be layered one upon the other as he or she proceeds in life. The fear of personal death may rest at the deepest layers, breaking through in undisguised form, only rarely in nightmares or other expressions of the unconscious.

Josephine Hillgard and Martha Newman studied psychiatric patients who had lost a parent early in life and reported an intriguing finding which they termed the "anniversary reaction": a significant correlation between a patient's age at psychiatric hospitalization and his or her parent's age at death. In other words, when a patient is hospitalized, there is a greater than chance possibility that he or she will be the same age as his or her parent was when the latter died. For example, if a patient's mother died at the age of 30, the patient is at risk at the age of 30. Furthermore, the patient's oldest child is likely to be the same age as the patient was when the parent died. For example, a patient who was 6 years old when her mother died is at risk psychiatrically when her oldest daughter is 6 years old. Though the researchers did not raise the issue of death anxiety, it would seem possible that the death of the original mother hurled the child, the later patient, into a confrontation with contingency. The mother's death signaled to the child that she too must die. The child repressed this conclusion and its associated anxiety, which remained unconscious until triggered by the anniversary, by the patient attaining the age when her parent died.

The degree of trauma is to a large extent a function of a family's degree of anxiety about death. Children in many cultures participate in rituals surrounding the dead. They may have assigned roles in funerals or other death rituals. In the Fore culture of New Guinea, for example, children participate in the ritual devouring of a dead relative. Most likely, this experience is not catastrophic for the child because the adults participate in the activities without severe anxiety. It is a part of a natural, unself-conscious stream of life. However, if, as is often true in Western culture today, a parent experiences severe anxiety about the issue of death, then the child is given the message that there is much to fear. This parental communication may be especially important for those children who have severe physical illness. As Marian Breenidge and E. Lee Vincent put it, "The children feel the anxiety of their parents that they may die and hence tend to carry a vague uneasiness which healthy children do not experience."

The death education of children. Many parents, perhaps most in our culture, attempt gradually to escalate reality in regard to death education. Young children are shielded from death. They are explicitly misinformed. Denial is implanted early in life with tales of heaven or of return of the dead, or with assurances that children do not die. Later, when the child is ready to take it, a parent gradually increases the dose of reality. Occasionally, enlightened parents take a determined stand against self-deception and refuse to teach their children to negate reality. They find it difficult, however, when a child is frightened or anguished, to refrain from offering solace through some reality-negating reassurance, either a flat denial of mortality or a long journey afterlife myth.

Elizabeth Kubler Ross disapproves strongly of traditional religion's practice of indoctrinating children with fairy tales of heaven, God, and angels. Yet when she describes her work with children who are concerned about death, their own or their parents', it is obvious that she too offers denial-based consolation. She informs children that at the moment of death, one is transformed or liberated, like a butterfly, to a comforting, beckoning future. Although Kubler Ross insists that this is not denial, but instead is reality-based on objective research on life after death experiences, the empirical evidence remains unpublished. The current position of this remarkable therapist, who once confronted death unflinchingly, indicates how difficult it is to face death without self-deception. In so far as I can judge, Kubler Ross's objective data differ in no significant manner from traditional religion's knowing through faith.

There exist clear educational guidelines in our Western culture for such areas as physical development, information acquisition, social skills, and psychological development. But when it comes to death education, parents are very much on their own. Many other cultures offer some culturally sanctioned myths about death which, with no ambivalence or anxiety, are transmitted to the children. Our culture offers no identifiable guidelines for parents to follow, despite the universality of the issue and its crucial importance in the development of the child. Each family must determine, willy-nilly, what to teach their children. Often, the child is given information that is obscure, commingled with parental anxiety, and likely to be contradicted by other sources of information in the environment.

There is sharp disagreement about death education within the ranks of professional educators. Anthony recommends that parents negate reality to the child. She quotes Sandor Fenzi, who said that negation of reality is a transition phase between ignoring and accepting reality, and suggests that parents' failure to assist the child's denial may result in a neurosis in which death associations played a part. Anthony continues, "The arguments in favor of supporting reality acceptance are strong. Nevertheless, in this context, there is a danger in doing so. The knowledge that the denial is in itself an easing of acceptance may make the parents' task easier. He may anticipate a charge of unreliability of lying when the child's own need for denial is passed. If openly accused, he may answer, 'You could not take it.'"

Then, on the other hand, many professional educators accept Jerome Bruner's view that "any subject can be taught effectively in some intellectually honest form to any child at any stage of development" and attempt to assist the child's gradual, realistic understanding of the concept of death. He continued by saying that euphemisms—gone to sleep, went to heaven, is with the angels—are wafer-thin barricades against death fears and only bewilder the child. Ignoring the issue results in a fool's paradise for parents. Children do not ignore the issue and, as is true for sex, find other sources of information that are often unreliable or are even more frightening or bizarre than reality.

In summary, there is convincing evidence that children discover death at an early age, that they apprehend that life will ultimately be extinguished, that they apply this knowledge to themselves, and that as a result of this discovery, they suffer great anxiety. A major developmental task is to deal with this anxiety. And the child does so in two major ways: by altering the intolerable objective reality of death and by altering inner subjective experience. The child denies the inevitability and the permanence of death. He or she creates immortality myths or gratefully embraces myths offered by elders. The child also denies his or her own helplessness before the presence of death by altering inner reality. The child believes both in his or her personal specialness, omnipotence, and invulnerability, and in the existence of some external personal force or being that will deliver him or her from the fate that awaits all others. What is remarkable is, as Rockland states, not that children arrive at adult views of the cessation of life, but rather how tenaciously throughout life adults hold to the child's beliefs and how readily they revert to them. Thus, the dead are not dead. They rest. They slumber on in memorial parks to the sound of eternal music. They enjoy an afterlife in which they will ultimately be reunited with their loved ones. And regardless of what happens to others, one, as an adult, denies death for oneself. The mechanisms of denial are incorporated into one's lifestyle and character structure. The individual's burden, as an adult no less than as a child, is to deal with personal finiteness. And the study of psychopathology, to which I now turn, is the study of failed death transcendence.

Chapter 4. Death and Psychopathology.

The range of psychopathology, the types of clinical picture with which patients present, is so broad that clinicians require some organizing principle that will permit them to cluster symptoms, behaviors, and characterological styles into meaningful categories. To the extent that clinicians can apply some structuring paradigm of psychopathology, they are relieved of the anxiety of facing an incoherent situation, they develop a sense of recognition or of familiarity and a sense of mastery, which in turn engender in patients a sense of confidence and trust, prerequisites for a truly therapeutic relationship. The paradigm that I shall describe in this chapter rests, as do most paradigms of psychopathology, on the assumption that psychopathology is a graceless, inefficient mode of coping with anxiety. An existential paradigm assumes that anxiety emanates from the individual's confrontation with the ultimate concerns in existence. I shall present in this chapter a model of psychopathology based upon the individual's struggle with death anxiety and in later chapters models applicable to patients whose anxiety is more closely related to other ultimate concerns: freedom, isolation, and meaninglessness. Though for didactic purposes I must discuss these concerns separately, all four represent strands in the cable of existence, and all must eventually be recombined into a unified existential model of psychopathology.

All individuals are confronted with death anxiety. Most develop adaptive coping modes, modes that consist of denial-based strategies such as suppression, repression, displacement, belief in personal omnipotence, acceptance of socially sanctioned religious beliefs that detoxify death, or personal efforts to overcome death through a wide variety of strategies that aim at achieving symbolic immortality. Either because of extraordinary stress or because of an inadequacy of available defensive strategies, the individual who enters the realm called "patient" has found insufficient the universal modes of dealing with death fear and has been driven to extreme modes of defense. These defensive maneuvers, often clumsy modes of dealing with terror, constitute the presenting clinical picture. Psychopathology, in every system, is by definition an ineffective defense mode. Even defensive maneuvers that successfully ward off severe anxiety prevent growth and result in a constricted and unsatisfying life.

Many existential theorists have commented upon the high price exacted in the struggle to cope with death anxiety. Kierkegaard knew that "man limited and diminished himself in order to avoid perception of the terror, predition and annihilation that dwell next door to any man." Otto Rank described the neurotic as one who "refused the loan life in order to avoid the payment of the debt death." Paul Tillich stated that "neurosis is the way of avoiding non-being by avoiding being." Ernest Becker made a similar point when he wrote, "The irony of man's condition is that the deepest need is to be free of the anxiety of death and annihilation, but it is life itself which awakens it, and so we must shrink from being fully alive." Robert J. Lifton used the term "psychic numbing" to describe how the neurotic individual shields himself from death anxiety.

Naked death anxiety will not be easily apparent in the paradigm of psychopathology I shall describe. But that should not surprise us. Primary anxiety in pristine form is rarely visible in any theoretical system. The defensive structures exist for the very purpose of internal camouflage. The nature of the core dynamic conflict is concealed by repression and other dysphoria-reducing maneuvers. Eventually, the core conflict is deeply buried and can be inferred, though never wholly known, only after laborious analysis of these maneuvers. To take one example, an individual may guard himself from the death anxiety inherent in individuation by maintaining a symbiotic tie with mother. This defensive strategy may succeed temporarily, but as time passes, it will itself become a source of secondary anxiety. For example, the reluctance to separate from mother may interfere with attendance at school or the development of social skills. And these deficiencies are likely to beget social anxiety and self-contempt, which in turn may give birth to new defenses which temper dysphoria but not growth and accordingly generate additional layers of anxiety and defense. Soon, the core conflict is heavily encrusted with these epiphenomena, and the excavation of the primary anxiety becomes exceedingly difficult.

Death anxiety is not immediately apparent to the clinician. It is discovered through a study of dreams, fantasies, or psychotic utterances, or through the painstaking analysis of the onset of neurotic symptoms. For example, Lewis Leser and Thea Bry report that first phobic attacks, that are analyzed carefully, are invariably characterized by a breakthrough of death anxiety. The understanding of later attacks is confounded by the presence of elaborations, substitutions, and displacements. The derivative, secondary forms of anxiety are nonetheless real anxiety. An individual may be brought down by social anxiety or by pervasive self-contempt. And as we shall see in the next chapter, treatment efforts generally are directed toward derivative rather than toward primary anxiety. The psychotherapist, regardless of his or her belief system concerning the primary source of anxiety and the genesis of psychopathology, begins therapy at the level of the patient's concerns. For example, the therapist may assist the patient by offering support, by propping up adaptive defenses, or by helping to correct destructive interpersonal modes of interaction. Thus, in the treatment of many patients, the existential paradigm of psychopathology does not call for a radical departure from traditional therapeutic strategies or techniques.

Death anxiety: A paradigm of psychopathology. A clinical paradigm that I believe to be of considerable practical and heuristic value was adumbrated in the previous chapter. The child's mode of coping with the awareness of death is denial-based, and the two major bulwarks of that denial system are the archaic beliefs that one is either personally invulnerable and/or protected eternally by an ultimate rescuer. These two beliefs are particularly powerful because they receive reinforcement from two sources: from the circumstances of early life and from widespread culturally sanctioned myths involving immortality systems and the existence of a personal observing deity. The clinical expression of these two fundamental defenses became particularly clear to me one day when I saw two patients whom I shall call Mike and Sam in two successive hours. They provide a powerful study in the two modes of death denial. The contrast between the two is striking, and each, by illustrating the opposite possibility, sheds light on the dynamics of the other.

Mike, who was 25 years old and had been referred to me by an oncologist, had a highly malignant lymphoma. And though a new form of chemotherapy offered his only chance for survival, he refused to cooperate in treatment. I saw Mike only once, and he was 15 minutes late for that meeting. But it was readily apparent that the guiding motif of his life was individuation. Early in life, he had struggled against any form of control and developed remarkable skills at self-sufficiency. Since the age of 12, he had supported himself, and at 15, he moved out of his parental home. After high school, he went into contracting and soon mastered all aspects of the trade: carpentry, electrical work, plumbing, masonry. He built several houses, sold them at substantial profits, bought a boat, married, and sailed with his wife around the world. He was attracted to the self-sufficient, individualistic culture that he had found in an underdeveloped country and was preparing to immigrate when, 4 months before I saw him, his cancer was discovered.

The most striking feature of the interview was Mike's irrational attitude toward the chemotherapy treatment. True, the treatment was markedly unpleasant, causing severe nausea and vomiting, but Mike's fear exceeded all reasonable bounds. He couldn't sleep the night before treatment. He developed a severe anxiety state and obsessed about methods of avoiding treatment. What was it precisely that Mike feared about the treatment? He couldn't specify, but he did know that it had something to do with immobility and helplessness. He couldn't bear to wait while the oncologist prepared his medication for injection. It couldn't be done in advance since the dosage depended upon his blood count, which had to be examined before each administration. Most terrible of all, however, was the intravenous. He hated the penetration of the needle, the taping, the sight of the drops entering his body. He hated to be helpless and restrained, to lie quietly on the cot, to keep his arm immobile. Though Mike did not consciously fear death, his fear of therapy was an obvious displacement of death anxiety. What was truly dreadful for Mike was to be dependent and static. These conditions ignited terror. They were death equivalents, and most of his life he had overcome them by a consummate self-reliance. He believed deeply in his specialness and his invulnerability and had, until the cancer created a life that reinforced this belief. I could do little for Mike except to suggest to his oncologist that Mike be taught to prepare his own medications and be permitted to monitor and adjust his own intravenous. These suggestions helped, and Mike finished his course of treatment. He did not keep his next appointment with me, but called to ask for a self-help muscle relaxation cassette. He chose not to remain in the area for the oncological follow-up and decided to pursue his plans to immigrate. His wife so disapproved of his plan that she refused to go, and Mike set sail alone.

Sam was approximately the same age as Mike, but resembled him in no other way. He came to me in extremis following his wife's decision to leave him. Though he was not, like Mike, confronted with death in a literal sense, Sam's situation was similar on a symbolic level. His behavior suggested that he faced an extraordinarily severe threat to his survival. He was anxious to the point of panic. He wailed for hours on end. He couldn't sleep or eat. He longed for cease at any cost and seriously contemplated suicide. As the weeks passed, Sam's catastrophic reaction subsided, but his discomfort lingered. He thought about his wife continuously. He did not, as he stated, "live in life, but slunk about outside life." Passing time became a conscious and serious proposition. Crossword puzzles, television, newspapers, magazines were seen in their true nature as vehicles for filling the void, for getting time over with as painlessly as possible.

Sam's character structure can be understood around the motif of fusion, a motif dramatically opposed to Mike's of individuation. During the Second World War, Sam's family had, when he was very young, moved many times to escape danger. He had suffered many losses, including the death of his father when Sam was a pre-adolescent and the death of his mother a few years later. He dealt with his situation by forming close, intense ties, first with his mother and then with a series of relatives or adopted relatives. He was everyone's handyman and perpetual babysitter. He was an infeterate gift-giver, bestowing generous amounts of time and money on a large number of adults. Nothing seemed more important to Sam than to be loved and cared for. In fact, after his wife left him, he realized that he felt he existed only if he were loved. In a state of isolation, he froze, much like a terrified animal, into a state of suspended animation, not living, but not dying either. Once, when we talked about his pain following his wife's departure, he said, "When I'm sitting home alone, the most difficult thing is to think that no one really knows I'm alive." When alone, he scarcely ate or sought to satisfy any but the most primitive needs. He didn't clean his house. He didn't wash. He didn't read. Though he was a talented artist, he didn't paint. There was, as Sam put it, "no point in expending energy unless I'm certain it will be returned to me by another." He did not exist unless someone was there to validate his existence. When alone, Sam transformed himself into a spore, dormant until another person supplied life-restoring energy.

In his time of need, Sam sought help from the elders in his life. He flew across the country for the solace of a few hours in the home of adopted relatives. He received support by simply standing outside the house he and his mother had once lived in for 4 years. He ran up astronomical phone bills, soliciting advice and comfort. He received much support from his in-laws, who, because of Sam's devotion to them, threw their lot and love in with Sam rather than with their daughter. Sam's efforts to help himself in his crisis were considerable, but monotheistic. He sought in a number of ways to reinforce his beliefs that some protective figure watched over and cared for him. Despite his extreme loneliness, Sam was willing to take no steps to alleviate it. I made a number of practical suggestions about how he might meet friends: singles events, church social activities, Sierra Club events, adult education courses, and so forth. My advice, much to my puzzlement, went completely unheeded. Gradually, I understood. What was important for Sam was not, despite his loneliness, to be with others, but to confirm his faith in an ultimate rescuer. He was explicit in his unwillingness to spend time away from his home on singles or dating activities. The reason he was afraid of missing a phone call. One phone call from out there was infinitely more precious than joining dozens of social activities. Above all, Sam wanted to be found, to be protected, to be saved without having to ask for help, and without having to engineer his own rescue. In fact, at a deep level, Sam was made more uncomfortable by successful efforts to assume responsibility for helping himself out of his life predicament. I saw Sam over a 4-month period. As he became more comfortable through my support and through fusion with another woman, he obviously lost motivation for continued psychotherapeutic work, and we both agreed that termination was in order.

Two fundamental defenses against death. What do we learn from Mike and Sam? We see clearly two radically different modes of coping with fundamental anxiety. Mike believed deeply in his specialness and personal invulnerability. Sam put faith in the existence of an ultimate rescuer. Mike's sense of self-sufficiency was hypertrophied, while Sam did not exist alone but strove to fuse with another. These two modes are diametrically opposed, and though by no means mutually exclusive, they constitute a useful dialectic which permits the clinician to understand a wide variety of clinical situations. We meet Mike and Sam in a time of urgent experience. In neither man does the crisis elicit new defenses; in the starkest possible manner, it highlights the nature and the limitations of their modes of being. Extreme adherence to either an individuation or a fusion mode results in a characterological rigidity that is obviously maladaptive. Mike and Sam exhibit extreme styles that increase stress, prevent coping and growth. Mike refused to participate in a life-saving therapy and later refused follow-up evaluation. Sam's intense desire for all of his wife's attention was responsible for her decision to leave. His passion for fusion resulted in an augmentation of the pain of loneliness and in an inability to cope resourcefully with his new situation in life. Neither Mike nor Sam was able to grow in any way as a result of their crisis. Maladaptive and rigid behavior that precludes personal growth is by definition neurotic behavior.

In a crude, sweeping way, the two defenses constitute a dialectic: two diametrically opposed modes of facing the human situation. The human being either fuses or separates, embeds or emerges. He affirms his autonomy by standing out from nature, as Rank put it, or seeks safety by merging with another force. Either he becomes his own father, or he remains the eternal son. Surely this is what meant when he described man as either longing for submission or lusting for power. This existential dialectic offers one paradigm that permits the clinician to grasp the situation. There are many alternate paradigms, each with explanatory power. Mike and Sam have character disorders: schizoid and passive dependency, respectively. Mike can be viewed from the vantage points of a continued rebellious conflict with his parents, of counterdependency, of neurotic perpetuation of the Oedipal struggle, or of homosexual panic. Sam can be grasped from the vantage points of identification with mother and unresolved grief, or of castration anxiety, or from a family dynamic, one in which the clinician focuses attention on Sam's interaction with his wife. The existential approach is therefore one paradigm among many, and its raison d'être is its clinical usefulness. This dialectic permits the therapist to comprehend data often overlooked in clinical work. The therapist may, for example, understand why Mike and Sam responded so powerfully and manneristically to their painful situations, or why Sam balked at the prospect of improving his situation by the assumption of responsibility for himself. This dialectic permits the therapist to engage the patient on the deepest of levels. It is based on an understanding of primary anxiety that exists in the immediate present. The therapist views the patient's symptoms as a response to death anxiety that currently threatens, not as a response to the evocation of past trauma and stress. Hence, the approach emphasizes awareness, immediacy, and choice, an emphasis that enhances the therapist's leverage. I shall, in the remainder of this chapter, describe these two basic forms of death denial and the types of psychopathology that spring from them. Though many of the familiar clinical syndromes can be viewed and understood in terms of these basic denials of death, I make no pretense of an exhaustive classifying system that would suggest greater precision and comprehensiveness than is the case. Both beliefs in specialness and in an ultimate rescuer can be highly adaptive. Each, however, may be overloaded and stretched thin to a point where adaptation breaks down, anxiety leaks through. The individual resorts to extreme measures to protect himself or herself, and psychopathology appears in the form of either defense breakdown or defense runaway. For the sake of clarity, I shall first discuss each defense separately. I shall then need to integrate them again because they are intricately interdependent. The great majority of individuals have traces of both defenses woven into their character structures.

Specialness. No one has ever described the deep, irrational belief in our own specialness more powerfully or poignantly than Tolstoy, who, through the lips of Ivan Ilyich, says, "In the depth of his heart, he knew he was dying, but not only was he not accustomed to the thought, he simply did not and could not grasp it." The syllogism he had learned from Kizvet's logic: "Chaos is a man. Men are mortal. Therefore, Chaos is mortal," had always seemed to him correct as applied to Chaos, but certainly not as applied to himself. That Chaos, man in the abstract, was mortal, was perfectly correct, but he was not Chaos, not an abstract man, but a creature quite separate from all others. He had been little Vana, with a mama and a papa, with Mitcha and Vega, with the toys, a coachman and a nurse; afterwards with Kitanka and with all the joys, griefs, and delights of childhood, boyhood, and youth. What did Caes know of the smell of that striped leather ball Vana had been so proud of? Had Caes kissed his mother's hand like that, and did the silk of her dress rustle so for Caes? Had he rioted like that at school when the pastry was bad? Had Caes been in love like that? Could preside at a session as he did? Caesar really was mortal and it was right for him to die. But for me, little Vana Ivan Ilyich, with all my thoughts and emotions, it's altogether a different matter. It cannot be that I ought to die. That would be too terrible."

We all know that in the basic boundaries of existence, we are no different from others. No one, at a conscious level, denies that. Yet, deep, deep down, each of us believes, as does Ivan Ilage, that the rule of mortality applies to others, but certainly not to ourselves. Occasionally, one is caught off guard when this belief pops into consciousness and is surprised by one's own irrationality. Recently, for example, I visited my optometrist to complain that my eyeglasses no longer functioned as of yore. He examined me and asked my age. "48," I said, and he replied, "Yep, right on schedule." From somewhere deep inside, the thought welled up and hissed, "What schedule? Who's on schedule? You or others may be on a schedule, but certainly not I."

When an individual learns he or she has some serious illness, for example, cancer, the first reaction is generally some form of denial. The denial is an effort to cope with anxiety associated with the threat to life, but also it is a function of a deep belief in one's invulnerability. Much psychological work must be done to restructure one's lifelong assumptive world. Once the defense is truly undermined, once the individual really grasps, "My God, I'm really going to die," and realizes that life will deal with him or her in the same harsh way as it deals with others, he or she feels lost and, in some odd way, betrayed. In my work with terminally ill cancer patients, I have observed that individuals vary enormously in their willingness to know about their deaths. Many patients, for some time, do not hear their physician tell them their prognosis. Much internal restructuring must be done to allow the knowledge to take hold. Some patients become aware of their deaths and face death anxiety in staccato fashion: a brief moment of awareness, brief terror, denial, internal processing, and then preparedness for more information. For others, the awareness of death and the associated anxiety flood in with a terrible rush.

One of my patients, Pam, a 28-year-old woman with cervical cancer, had her myth of specialness destroyed in a striking fashion. After an exploratory laparotomy, her surgeon visited her and informed her that her condition was grave indeed and that her life expectancy was in the neighborhood of 6 months. An hour later, Pam was visited by a team of radiotherapists who had obviously not communicated with the surgeon and who informed her that they planned to radiate her and that they were going for a cure. She chose to believe her second visitors, but unfortunately, her surgeon, unbeknownst to her, spoke with her parents in the waiting room and gave them the original message, namely that she had 6 months to live. Pam spent the next few months convalescing at her parents' home in the most unreal of environments. Her parents treated her as though she were going to be dead in 6 months. They insulated themselves and the world from her. They monitored her phone calls to screen out unsettling communications. In short, they made her comfortable. Finally, Pam confronted her parents and demanded to know what in God's name was going on. Her parents told her about their conversation with the surgeon. Pam referred them to the radiotherapist, and the misunderstanding was quickly cleared up. Pam, however, was deeply shaken by the experience. The confrontation with her parents made her realize in a way that

A death sentence from the surgeon had not that she was indeed veering toward death. Her comments at this time are revealing.

"I did seem to be getting better and it was a happier situation, but they began to treat me like I was not going to live and I was stung into this terrible feeling of realization that they had already accepted my death. Because of an error and a miscommunication, I was already dead to my family and I started being dead and it was a very hard way back to get myself to be alive. It was worse later on as I was getting better than it was when I was very sick because when the family suddenly realized that I was getting better, then they left and went back to their daily chores. And I was still left with being dead and I couldn't handle it very well. I'm still frightened and trying to cross the boundary line that seems to be in front of me, the boundary line of am I dead or am I alive."

The point is that Pam truly understood what it meant to die. Not from anything her doctors told her, but from the crushing realization that her parents would continue to live without her, and that the world would go on as before, that, as she put it, the good times would go on without her.

Another patient with widespread metastatic cancer had arrived at the same point when she wrote a letter to her children instructing them how to divide some personal belongings of sentimental value. She had rather mechanically performed the other dreary administrative chores of dying, the writing of a will, the purchase of a burial plot, the appointment of an executive. But it was the personal letter to her children that made death real to her. It was the simple but dreadful realization that when her children read her letter, she would no longer exist. Neither to respond to them, to observe their reactions, to guide them. They would be there, but she would be nothing at all.

Another patient, after months of procrastination, arrived at the painful decision to discuss with her teenage sons the fact that she had advanced cancer and not long to live. Her sons responded with sadness, but with courage and self-sufficiency, a bit too much courage and self-sufficiency for her. In some far off place in her mind, she could feel some pride. She had done what a good parent must do, and they would pattern their lives along the lines she had laid out for them. But they took her death too well. And though she hated her irrationality, she was troubled because they would persist and thrive without her.

Another patient, Jan, had breast cancer that had spread to her brain. Her doctors had forewarned her of paralysis. She heard their words, but at a deep level felt smugly immune to this possibility. When the inexorable weakness and paralysis ensued, Jan realized in a sudden rush that her specialness was a myth. There was, she learned, no escape clause. She said all this during a group therapy meeting and then added that she had discovered a powerful truth in the last week, a truth that made the ground shake under her. She had been musing to herself about her preferred lifespan. 70 would be about right. 80 might be too old. And then suddenly she realized when it comes to aging and when it comes to dying, what I wish has absolutely nothing to do with it.

Perhaps these clinical illustrations begin to transmit something of the difference between knowing and truly knowing, between the everyday awareness of death we all possess and the full facing of my death. Accepting one's personal death means facing a number of other unpalatable truths, each of which has its own force field of anxiety. That one is finite. That one's life really comes to an end. That the world will persist nonetheless. That one is one of many, no more, no less. That the universe does not acknowledge one's specialness. That all our lives we have carried counterfeit vouchers. And finally, certain stark immutable dimensions of existence are beyond one's influence. In fact, what one wishes has absolutely nothing to do with it.

When an individual arrives at the discovery that personal specialness is mythic, he or she feels angry and betrayed by life. Surely this sense of betrayal is what Robert Frost had in mind when he wrote, "Forgive, O Lord, my little jokes on thee, and I'll forgive thy great big one on me." Many people feel that if they had only known, really known earlier, they would have lived their lives differently. They feel angry, yet the rage is impotent, for it has no reasonable object. The physician is incidentally often a target for displaced anger and especially for that of so many dying patients.

The belief in personal specialness is extraordinarily adaptive and permits us to emerge from nature and to tolerate the accompanying dysphoria, the isolation, the awareness of our smallness and the awesomeness of the external world, of our parents' inadequacies, of our creaturliness, of the bodily functions that tie us to nature, and most of all the knowledge of the death which rumbles unceasingly at the edge of consciousness. Our belief in exemption from natural law underlies many aspects of our behavior. It enhances courage in that it permits us to encounter danger without being overwhelmed by the threat of personal extinction. Witness the psalmist who wrote, "A thousand shall fall at thy right hand, 10,000 at thy left, but death shall not come nigh thee." The courage thus generated begets what many have called the human being's natural striving for competence, effect, power, and control. To the extent that one attains power, one's death fear is further assuaged and belief in one's specialness further reinforced. Getting ahead, achieving, accumulating material wealth, leaving works behind as imperishable monuments becomes a way of life which effectively conceals the mortal questions churning below.

Compulsive heroism. For many of us, heroic individuation represents the best that man can do in light of his existential situation. The Greek writer Nikos Kazantzakis was such a spirit and his Zorba was the quintessential self-sufficient man. In his autobiography, cousin Zakis cites the last words of the man who was his model for Zorba the Greek. "If any priest comes to confess me and give me communion, tell him to make himself scarce, and may he give me his curse. Men like me should live a thousand years." Elsewhere, through the lips of his Ulisses, cousin Zakis advises us to live life so completely that we leave death nothing but a burned out castle. His own tombstone on the ramparts of Heraklion bears the simple heroic epitaph, "I want nothing. I fear nothing. I am free."

Push it a bit farther, though, and the defense becomes overextended. The heroic pose caves in on itself, and the hero becomes a compulsive hero who, like Mike, the young man with cancer, is driven to face danger in order to escape a greater danger within. Ernest Hemingway, the prototype of the compulsive hero, was compelled throughout his life to seek out and conquer danger as a grotesque way of proving there was no danger. Hemingway's mother reports that one of his first sentences was "afraid of nothing." In an ironic way, he was afraid of nothing precisely because he, like all of us, was afraid of nothingness. The Hemingway hero thus represents a runaway of the emergent individualistic solution to the human situation. This hero is not choosing. His actions are driven and fixed. He doesn't learn from new experiences. Even the approach of death does not turn his gaze within or increase his wisdom. The Hemingway code contains no place for aging and diminishment, for they have the odor of ordinariness. In The Old Man in the Sea, Santiago meets his approaching death in a stereotyped way, the same way he faced every one of life's basic threats, by going out alone to search for the great fish.

Hemingway himself could not survive the dissolution of the myth of his personal invulnerability. As his health and physical prowess declined, as his ordinariness, in the sense that he, like everyone, must face the human situation, became painfully evident, he grew bereft and finally deeply depressed. His final illness, a paranoid psychosis with persecutory delusions and ideas of reference, temporarily bolstered his myth of specialness. All persecutory trends and ideas of reference flow from a core of personal grandiosity. After all, only a very special person would warrant that much attention, albeit malevolent attention, from his environment. Eventually, the paranoid solution failed, and left with no defense against the fear of death, Hemingway committed suicide.

Though it seems paradoxical that one would commit suicide because of a fear of death, it is not uncommon. Many individuals have said in effect that "I so fear death I am driven to suicide." The idea of suicide offers some cease from terror. It is an active act. It permits one to control that which controls one. Furthermore, as Charles Wall has noted, many suicides have a magical view of death and regard it as temporary and reversible. The individual who commits suicide to express hostility or to generate guilt in others may believe in the continued existence of consciousness so that it will be possible to savor the harvest of his or her death.

The workaholic. The compulsive heroic individualist represents a clear but not clinically common example of the defense of specialness which is stretched too thin and fails to protect the individual from anxiety or degenerates into a runaway pattern. A commonplace example is the workaholic. The individual consumed by work. One of the most striking features of a workaholic is the implicit belief that he or she is getting ahead, progressing, moving up. Time is an enemy not only because it is cousin to finitude, but because it threatens one of the supports of the delusion of specialness, the belief that one is eternally advancing. The workaholic must deafen himself or herself to time's message that the past grows fatter at the expense of a shrinking future. The workaholic life mode is compulsive and dysfunctional. The workaholic works or applies himself not because he wishes to but because he has to. The workaholic may push himself without mercy and without regard for human limits. Leisure time is a time of anxiety and is often frantically filled with some activity that conveys an illusion of accomplishment. Living thus becomes equated with becoming or doing. Time not spent in becoming is not living but waiting for life to commence.

Culture, of course, plays an important role in the shaping of the individual's values. Regarding activity, Florence Kluckhohn suggests an anthropological classification of value orientations that postulates three categories: being, being-in-becoming, and doing. The "being" orientation emphasizes the activity rather than the goal. It focuses on the spontaneous natural expression of the "isness" of the personality. "Being-in-becoming" shares with the "being" orientation an emphasis on what a person is rather than on what the person can accomplish but emphasizes the concept of development. Thus it encourages activity of a certain type. Activity directed toward the goal of the development of all aspects of the self. The "doing" orientation emphasizes accomplishments measurable by standards outside of the acting individual. Obviously, contemporary conservative American culture with its emphasis on "what does the individual do" and "getting things done" is an extreme doing culture. Still, in every culture, there are wide ranges of individual variation. Something within the workaholic individual interacts with the cultural standards in a manner that breeds a hypertrophied and rigid internalization of the value system. It becomes difficult for individuals to assume a bird's-eye view of their culture and to view their value system as one among many possible stances.

I had one workaholic patient who treated himself to a rare noonday walk as a reward for some particularly important accomplishment and was staggered by the sight of hundreds of people standing around simply sunning themselves. "What do they do all day? How can people live that way?" he wondered. A frantic fight with time may be indicative of a powerful death fear. Workaholic individuals relate to time precisely as if they were under the seal of imminent death and were scurrying to get as much completed as possible. Embedded in our culture, we accept unquestioningly the goodness and rightness of getting ahead.

Not too long ago, I was taking a brief vacation alone at a Caribbean beach resort. One evening I was reading, and from time to time I glanced up to watch the bar boy, who was doing nothing, save languidly staring out to sea. Much like a lizard sunning itself on a warm rock, I thought. The comparison I made between him and me made me feel very smug, very cozy. He was simply doing nothing, wasting time. I was, on the other hand, doing something useful, reading, learning. I was, in short, getting ahead. All was well until some internal imp asked the terrible question. Getting ahead of what, how, and even worse, why? Those questions were, and are still, deeply disquieting. What was brought home to me with unusual force was how I lull myself into a death-defeating delusion by continually projecting myself forward into the future. I do not exist as a lizard exists. I prepare. I become. I am in transit.

John Maynard Keynes puts it this way. "What the purposeful man is always trying to secure is a spurious and elusive immortality. Immortality for his acts by pushing his interest in them forward in time. He doesn't love his cat, but his cat's kittens, nor in truth, the kittens, but only the kittens' kittens, and so on, forward forever to the end of Katnum." Tolstoy in Anna Karenina describes the collapse of the upward spiral belief system in the person of Alexi Alexandrovich, Anna's husband, a man for whom everything has always ascended. A splendid career, a brilliant marriage. Anna's leaving him signifies far more than the loss of her. It is the collapse of a personal cosmos. As Tolstoy wrote, he felt that he was standing face to face with something illogical and irrational and did not know what was to be done. Alexi Alexandrovich was standing face to face with life, with the possibility of his wife's loving someone other than himself, and this seemed to him very irrational and incomprehensible, because it was life itself. All his life, Alexi Alexandrovich had lived and worked in official spheres having to do with the reflection of life. And every time he had stumbled against life itself, he had shrunk away from it. Now he experienced a feeling akin to that of a man who, while calmly crossing a precipice by a bridge, should suddenly discover that the bridge is broken and that there is a chasm below. That chasm was life itself. The bridge that artificial life in which Alexi Alexandrovich had lived. The chasm was life itself. The bridge that artificial life.

No one has said it more clearly. The defense, if successful, shields the individual from the knowledge of the chasm. The broken bridge, the failed defense, exposes one to a truth and a dread that an individual in midlife, following decades of self-deception, is ill-equipped to confront.

Narcissism. The person who copes with basic anxiety with a prepotent belief in his or her specialness will often encounter major difficulties in interpersonal relationships. If a belief in personal inviability is coupled, as it often is, with a corresponding diminished recognition of the rights and the specialness of the other, then one has a fully developed narcissistic personality. Fromm is supposed to have described the narcissistic personality by reporting a conversation between such an individual and a physician. The patient requested an appointment that day. The physician said it would not be possible since his schedule was filled. The patient exclaimed, "But doctor, I just live a few minutes from your office."

The narcissistic personality pattern is more blatantly apparent in the group therapy format than in individual therapy. In individual therapy, the patient's every word is listened to. Each dream, fantasy, and feeling is examined. Everything is given to the patient. Little reciprocation is asked, and months may go by before narcissistic features are evident. In the therapy group, however, the patient is required to share time, to understand and empathize with others, to form relationships, and be concerned about the feelings of others. The narcissistic pattern manifests itself in many ways. Some patients feel they may offend others, but are entitled to be exempt from personal criticism. They naturally feel that anyone with whom they fall in love will reciprocate in kind. They feel they shouldn't have to wait for others. They expect gifts, surprises, and concern, though they give none. They expect to be loved and admired for simply being there. In the therapy group, they feel they should receive maximum group attention and that it should be forthcoming without any effort expended on their part. They expect the group to reach out to them, though they themselves reach out to no one. The therapist must point out to such patients over and over again that there is only one time in life when this expectation is appropriate. When one is an infant and can demand unconditional love from mother without any question of reciprocation.

Hal, a patient in a therapy group, illustrates many of these points. He was a bright, exceedingly articulate physicist who entertained the group for months with spellbinding Faulknerian tales of his childhood in the South, consuming in the process about 40% of the time of an eight-person group. He was also sharp-tongued, but his sarcasm was so clever and colorful that the group members took no offense and allowed themselves to be entertained by him. Only gradually did the other members grow to resent his attention-seeking greed and hostility. They began to grow impatient with his tales, then to shift the focus off of Hal and onto other members, and finally to label him explicitly as a time and attention hog. Hal's anger intensified. It outgrew its casing of well-tempered sarcasm and erupted into a chronic, continuous stream of bitterness. His personal and professional life began to deteriorate. His wife threatened to leave him and his department chairman admonished him for relating poorly to his students. The group urged him to examine his anger. Repeatedly the group members asked him, "What are you angry about?" When he discussed some concrete event, they asked him to go down to a deeper level and to answer once again, "What are you angry about?" At the deepest level, Hal said, "I'm angry because I'm better than everyone here and nobody recognizes me for it. I'm smarter. I'm quicker. I'm better. And god damn it, nobody appreciates me. I should be rich, Arabian rich. I should be recognized as a Renaissance man, but I'm treated just like everybody else."

The group was useful to Hal in a number of ways. Simply helping him to excavate and air these feelings and to consider them rationally was an essential and enormously beneficial first step. Slowly the other members helped Hal to recognize that they too were sentient beings, that they too felt special, that they too wanted such attention and center stage. Others, Hal learned, were not simply wellsprings of appreciation and astonishment from which he could endlessly draw support for his own solipsism. Empathy was a key concept for Hal, and the group helped him experience his empathy by on occasion asking him to go around the group and guess what each of the other members were feeling. At first, Hal characteristically answered by guessing what each was feeling about him, but gradually he was able to sense what they were experiencing. For example, that they too wanted time or were angry, disillusioned, or pained. Narcissism is so integral that often a patient has difficulty finding a ledge outside his specialness on which to stand and observe himself.

Another patient who resembled Hal in many ways had his egocentricity brought home to him in a curious fashion. He had been in a therapy group for 2 years and made striking improvement, especially in his ability to love and to commit himself to another. I saw him in a debriefing session 6 months after termination and asked him if he could recall some particularly critical incident in his therapy. He singled out a session in which the group viewed a videotape of the previous meeting. He had been stunned at the discovery that he remembered only those parts of the meeting that focused on him. There were vast stretches of the session that he saw as though for the first time. Others had criticized him frequently for his self-centeredness, but it was only brought home to him, as are all important truths, when he discovered it for himself.

Aggression and control. Specialness as a primary mode of death transcendence takes a number of other maladaptive forms. The drive for power is not uncommonly motivated by this dynamic. One's own fear and sense of limitation is avoided by enlarging oneself and one's sphere of control. There is some evidence, for example, that those who enter the death-related professions—soldiers, doctors, priests, and morticians—may in part be motivated by a need to obtain control over death anxiety. For example, Herman Feifel has shown that though physicians have less conscious death concern than contrast groups of patients or of the general population, they have at deeper levels a greater fear of death. In other words, conscious death fears are allayed by the assumption of power, but deeper fears, which in part dictated the choice of profession, operate still.

When the dread is particularly strong, the aggressive drive is not contained by peaceful sublimation and it accelerates. Arrogance and aggression are not uncommonly derived from this source. Rank writes that "the death fear of the ego is lessened by the killing, the sacrifice of the other. Through the death of the other, one buys oneself free from the penalty of dying." Obviously, Rank refers to more than literal killing. More subtle forms of aggression, including domination, exploitation, or "soul murder," as Ibsen put it, serve the same purpose. But this mode of adaptation often decompensates into a runaway defense. Absolute power, as we have always known, corrupts absolutely. It corrupts because it does not do the trick for the individual. Reality always creeps in. The reality of our helplessness and our mortality. The reality that despite our reach for the stars, a creaturly fate awaits us.

The defense of specialness, faltering and anxiety. In discussing the specialness mode of coping with death fear, I have focused on maladaptive forms of the individualistic or agentic solution. A runaway heroic individualism with its attendant dread of any sign of human frailty. A compulsive workaholic solution. A depression ensuing from an interruption of the eternal spiral upward. A severe narcissistic character disorder with its accompanying problematic interpersonal ramifications and maladaptive, aggressive, and controlling lifestyles. But there is another, even more serious and intrinsic limitation to the defense of specialness. Many keen observers have noted that though great exhilaration may for some time accompany individualist expression and achievement, there comes a point where anxiety sets in. The person who emerges from embeddedness or stands out from nature must pay a price for his success. There is something frightening about individuation, about separating oneself from the whole, about going forward and living life as a separate, isolated being, about surpassing one's peers and one's parents. Many clinicians have written on the "success neurosis," a curious condition where individuals on the point of the crowning success for which they have long striven develop not euphoria but a crippling dysphoria which often ensures that they do not succeed. Freud refers to the phenomenon as the "wrecked by success" syndrome. Rank describes it as "life anxiety," the fear of facing life as a separate being. Maslow notes that "we shrink away from our highest possibilities as well as from our lowest" and terms the phenomenon the "Jonah complex" since Jonah, like all of us, could not bear his personal greatness and sought to avoid his destiny.

How is one to explain this curious self-negating human tendency? Perhaps it's a result of an entanglement of achievement and aggression. Some people use achievement as a method of vindictively surpassing others. They fear that others will become aware of their motives and retaliate when success becomes too great. Freud thought it had much to do with the fear of surpassing one's father and thereby exposing oneself to the threat of castration. Becker advances our understanding when he suggests that the terrible thing in surpassing one's father is not castration but the frightening prospect of becoming one's own father. To become one's own father means to relinquish the comforting but magical parental buttress against the pain inherent in one's awareness of personal finiteness. Thus, the individual who plunges into life is doomed to anxiety. Standing out from nature, being one's own father, or as Spinoza put it, one's own god, means utter isolation. It means standing alone without the myth of rescuer or deliverer and without the comfort of the human huddle. Such unshielded exposure to the isolation of individuation is too terrible for most of us to bear.

When our belief in personal specialness and inviability fails to provide the cease from pain we require, we seek relief from the other major alternative denial system. The belief in a personal ultimate rescuer. Otto Rank recapitulates ontogeny in both the physical and the social development of the individual. The development of the species is mirrored. In no social attribute is this fact more clearly evident than in the human belief in the existence of a personal omnipotent intercessor, a force or being that eternally observes, loves, and protects us. Though it may allow us to venture close to the edge of the abyss, it will ultimately rescue us. Rank characterizes this mythic figure as the "magic helper" and Masserman as the "omnipotent servant." In chapter 3, I traced the development of this belief system in early childhood. Like the belief in personal specialness, it is rooted in events of early life when parents seemed eternally concerned and satisfied one's every need. Certainly, humankind from the beginnings of written history has clung to the belief in a personal God. A figure that might be eternally loving, frightening, fickle, harsh, propitiated, or angered, but a figure that was always there. No early culture has ever believed that humans were alone in an indifferent world.

Some individuals discover their rescuer not in a supernatural being but in their earthly surroundings—either in a leader or in some higher cause. Human beings for millennia have conquered their fear of death in this manner and have chosen to lay down their freedom, indeed their lives, for the embrace of some higher figure or personified cause. Tolstoy was keenly aware of our need to manufacture a god-like figure and then to bask in the illusion of safety emanating from our creation. Consider in War and Peace, Rostov's battlefield ecstasy at the thought of the Tsar's proximity. Tolstoy wrote, "He was entirely absorbed in the feeling of happiness at the Tsar being near. His nearness alone made up to him by itself he felt for the loss of the whole day. He was happy as a lover is happy when the moment of the longed-for meeting has come. Not daring to look around from the front line. By an ecstatic instinct without looking around, he felt his approach. And he felt it not only from the sound of the tramping hooves of the approaching cavalcade. He felt it because as the Tsar came nearer, everything grew brighter, more joyful and significant, and more festive. Nearer and nearer moved this sun, as he seemed to Rostov, shedding around him rays of mild and majestic light. And now he felt himself infolded in that radiance. He heard his voice, that voice caressing, calm, majestic, and yet so simple. And Rostov got up and went out to wander about among the campfires, dreaming of what happiness it would be to die. Not saving the Emperor's life, of that he did not dare to dream, but simply to die before the Emperor's eyes. He really was in love with the Tsar and the glory of the Russian arms and the hope of coming victory. And he was not the only man who felt thus in those memorable days that preceded the battle of Austerlitz. Nine-tenths of the men in the Russian army were at that moment in love, though less ecstatically, with their Tsar and the glory of the Russian arms. As the Tsar came nearer, everything grew brighter, more joyful and significant, and more festive. Nearer and nearer moved this sun."

How beautifully clear is Tolstoy's depiction of the internal defensive ecstasy, not only of course of the Russian soldier, but of the legions of every man and every woman whom therapists see in everyday clinical work.

The rescuer defense and personality restriction. Overall, the ultimate rescuer defense is less effective than the belief in personal specialness. Not only is it more likely to break down, but it is intrinsically restrictive to the person. Later I shall report on empirical research that demonstrates this ineffectiveness. But it is an insight that Kierkegaard arrived at intuitively over 100 years ago. He has a curious statement contrasting the perils of venturing, emergence, individuation, specialness, and not venturing, fusion, embeddedness, belief in ultimate rescuer. He wrote, "It is dangerous to venture. And why? Because one may lose. Not to venture is shrewd. And yet by not venturing it is so dreadfully easy to lose that which it would be difficult to lose in even the most venturesome venture—oneself. For if I have ventured amiss, very well, then life helps me by its punishment. But if I have not ventured at all, who then helps me? And moreover, if by not venturing at all—in the highest sense, and to venture in the highest sense is precisely to become conscious of oneself—I have gained all earthly advantages and lose myself. What of that?" To remain embedded in another, not to venture, subjects one then to the greatest peril of all—the loss of oneself. The failure to have explored or developed the manifold potentials within oneself.

When too much is asked of the rescuer defense, a highly restricted life mode results, as in the case of Lena, a 30-year-old member of a therapy group. Lena was deeply depressed, flooded with suicidal ideation, and often lapsed into depressive stupors during which she stayed in bed for days on end. She lived an isolated existence, spending most of her time alone in her sparsely furnished room. Her personal appearance was striking in every aspect, from her long, careless blonde hair to her decorated jeans and combat fatigue jacket to her youthful posturing and gullibility. She resembled a girl in mid-adolescence. She had lost her mother at age five and her father at 12 and had grown exceedingly attached to her grandparents and other parent surrogates. As her grandparents grew old and infirm, she developed a horror of the telephone. The phone had been the messenger of her father's death, and she refused to answer it, lest it bring news of her grandparents' death.

Lena was overtly terrified of death and avoided any contact with death motifs, and she attempted to deal with her terror in a most ineffective and magical mode—a mode that I have seen many patients use. She attempted to elude death by refusing to live. Like Oscar in Günter Grass's *The Tin Drum*, she attempted to conquer time, to fix it permanently by remaining a child forever. She devoted herself to avoiding individuation and sought safety by attempting to submerge herself in a protector. An axiom of group therapy is that the members display in the here and now of the group their internal defenses as they interact with one another. Lena's defensive posture became exceedingly transparent as the group proceeded. Once she began a session by announcing that she had the previous weekend been involved in a serious automobile accident. She had gone to visit a friend in a city 150 miles away and through gross negligence had run off the road, overturned her car, and narrowly escaped death. Lena commented that it would have been so easy and desirable not to have regained consciousness. The group members responded accordingly. They felt concerned and frightened for Lena. They outdid one another in offering her nurturance. The group therapist responded in the same fashion until he began to analyze silently the process of the meeting. Lena was always dying, always frightening the group, always mobilizing massive concern from the other members. In fact, during her first months in the group, the members assumed the task of keeping Lena alive, keeping her eating, keeping her from suicide. The therapist wondered, "Does anything good ever happen to Lena?"

Lena's accident had occurred on the way to visit a friend. Suddenly, the therapist asked himself the question, "What friend?" Lena had relentlessly presented herself to the group as an isolated individual—son's friends, relatives, even acquaintances. And yet, she described driving 150 miles to see a friend. When the therapist asked the question, he learned that yes, Lena had a boyfriend, that yes, she had spent every weekend with him for months, and that yes, he wished to marry her. Yet, she had chosen not to share this information with the group. Her reasons were obvious. What was important to Lena was not growth, but survival, and survival seemed possible only by soliciting care and protection from the group and the therapist. Her major dilemma was how to retain protection in perpetuity. She must give no evidence of growth or change lest the group members and the therapist conclude she was well enough to terminate therapy.

During the course of the group therapy, Lena was highly threatened by incidents that challenged her major defensive system. That is the belief that help was out there and that only the continued presence of the deliverer ensured her safety. Lena's passion for fusion with the therapist resulted in many transference distortions that required continuous attention throughout therapy. She was exquisitely sensitive to any sign of rejection by him and reacted strongly to evidences of his mortality, fallibility, or unavailability. She more than the other members was alarmed and angry when he took vacations or became ill or was obviously mistaken or confused in the group. Much of the therapeutic work with patients who have a hypertrophied craving for an ultimate rescuer will, as I demonstrate in the next chapter, center about the analysis of transference, the collapse of the rescuer.

Through much of life, the belief in an ultimate rescuer provides considerable solace and functions smoothly and invisibly. Most individuals remain unaware of the structure of their belief system until it fails to serve its purpose or until, as Heidegger put it, there is a breakdown in the machinery. There are many possibilities for breakdown and many forms of pathology associated with the collapse of the defense.

Fatal illnesses. Perhaps the severest test for the effectiveness of the ultimate rescuer delusion is presented by fatal illness. Many individuals so stricken channel a great deal of energy into bolstering their belief in the presence and power of a protector. As the obvious candidate for the role of rescuer is the physician, the patient-doctor relationship becomes charged and complex. In part, the robe of rescuer is thrust upon the physician by the patient's wish to believe. In part, however, the physician dons the robe gladly because playing God is the physician's method of augmenting his belief in his personal specialness. Either way, the result is the same. The doctor becomes larger than life, and the patient's attitude to him or her is often irrationally obsequious. Commonly, patients with a fatal illness dread angering or disappointing their physicians. These patients apologize for taking a physician's time and are so flustered in a physician's presence that they forget to ask the pressing questions they have prepared. Some patients attempt to cope with this problem by preparing a written checklist of questions to ask the physician. To patients, it is so important that doctors retain their power that a patient will neither challenge nor doubt one. Many patients, in fact, in a highly magical way, permit physicians to maintain the role of the successful healer by concealing important information from them about their—the patients'—psychological and even physical distress. Often thus the physician is the last to know about the depth of a patient's despair. A patient who is perfectly able to talk openly to nurses or social workers about his anguish maintains a cheery, plucky face toward the physician who concludes that the patient is handling the situation as well as could be expected. Consequently, physicians are notoriously reluctant to refer terminally ill patients for psychological treatment.

Individuals differ in the tenacity with which they cling to denial. But eventually all denial crumbles in the face of overwhelming reality. Kübler-Ross, for example, reports that in her long experience, she has seen only a handful of individuals maintain denial to the moment of death. A patient's reaction to learning that no medical or surgical cure exists is catastrophic. He or she feels angry, deceived, and betrayed. At whom, however, can one be angry? At the cosmos? At fate? Many patients are angry at the doctor for failing them. Not for failing medically, but for failing to incarnate the patient's personal myth of an ultimate deliverer.

Depression. In his study of psychotically depressed individuals, Silvano Arieti describes a central motif, a life ideology that precedes and prepares the ground for depression. His patients lived a type of mediated existence. They lived not for themselves, but for either the dominant other or the dominant goal. Though the terminology differs, Arieti's description of these two ideologies coincides closely with the two defenses against the fear of death I have described. The individual who lives for the dominant goal is the individual who fashions his or her life around a belief in personal specialness and inviability. As I discussed earlier, depression often ensues when the belief in an ever-ascending spiral dominant goal collapses. To live for the dominant other is to attempt to merge with another whom one perceives as the dispenser of protection and meaning in life. The dominant other may be one's spouse, mother, father, lover, therapist, or an anthropomorphization of a business or a social institution. The ideology may collapse for many reasons. The dominant other may die, leave, withdraw love and attention, or prove too fallible for the task.

When patients recognize the failure of their ideology, they are often overwhelmed. They may feel that they have sacrificed their lives for a currency that has proven counterfeit. Yet they have available no alternative strategy for coping. Discussing a patient, Arieti puts it, "the patient has reached a critical point at which a realignment of psychodynamic forces and a new pattern of interpersonal relationships are due, but she is not able to muster them. This is her predicament. She is helpless. She either cannot visualize alternative cognitive structures that lead to recuperative steps or, if she is able to visualize them, they appear insurmountable. At other times, these alternatives do not seem unrealizable, but worthless, since she has learned to invest all her interest and desires only in the relationship that failed." The patient may attempt to reestablish the relationship or to search for another. If these attempts fail, the patient is without resources and feels both depleted and self-condemnatory. Restructuring a life ideology is beyond comprehension, and many patients, rather than question their basic belief system, conclude that they are too worthless or too bad to warrant the love and protection of the ultimate rescuer. Their depression is abetted furthermore by the fact that unconsciously suffering and self-abnegation function as a last desperate plea for love. Thus they are bereft because they have lost love, and they remain bereft in order to regain it.

Chapter 4b. Masochism. I have described a cluster of behaviors associated with the hypertrophied belief in the ultimate rescuer: self-effacement, fear of withdrawal of love, passivity, dependency, self-abnegation, refusal to accept adulthood, and depression at collapse of the belief system. When accented, each of these may produce a characteristic clinical syndrome. When self-abnegation dominates, the patient is referred to as masochistic.

Karen, a 40-year-old patient I treated for two years, taught me a great deal about the dynamics behind the urge to inflict pain on oneself. Karen entered therapy for a number of reasons: masochistic sexual propensities, an inability to achieve sexual pleasure with her straight boyfriend, depression, a pervasive inertia, and terrifying nightmares and hypnagogic experiences. In therapy, she rapidly developed a powerful positive transference. She devoted herself to the project of eliciting care and concern from me. Her masturbatory fantasies consisted of her becoming very ill, either with a physical disease like tuberculosis or a psychotic breakdown, and my feeding and cradling her. She delayed leaving my office so as to spend a few extra minutes with me, so as to have my signature. She saved her canceled checks with which she had paid my bills. She attempted to visit my lectures so as to catch sight of me. Nothing seemed to please her more than for me to be stern with her. In fact, if I expressed any irritation, she experienced sexual excitation in my office. In every way, she made me bigger than life and selectively ignored all of my obvious flaws. She read a book I had written with a patient in which I had been highly self-revealing about my own anxieties and limitations. But rather than to appreciate my limitations, her response was to admire me even more for the great courage I had shown in publishing such a book.

She responded similarly to signs of weakness or limitation in other important and powerful figures in her life. If her boyfriend became ill or evinced any sign of weakness, confusion, or indecision, she experienced much anxiety. She couldn't bear to see him falter. Once when he was severely injured in an auto accident, she became phobic about visiting his hospital room. She responded similarly to her parents and was sorely threatened by their increasing age and frailty. As a child, she had related to them through illness. "Being sick was the lie of my life," said Karen. She sought pain to get succor. On more than one occasion during her childhood, she spent weeks in bed with a fictitious disease. During adolescence, she became anorexic, only too glad to exchange physical starvation for the attention and solicitude it incited. Her sexuality joined in the pursuit for safety and deliverance. Force, restraint, strength, and pain aroused her, while weakness, passivity, even tenderness repulsed her. To be punished was to be protected. To be bound, confined, or restricted was wonderful. It meant that limits were being set and that some powerful figure was setting them. Her masochism was overdetermined. She sought survival not only through subjugation but also through the symbolic and magical value of suffering. A small death, after all, is better than the real thing.

Treatment was successful in alleviating the acute depression, the nightmares, the suicidal preoccupation. But there came a time when treatment with me seemed to impede further growth. Since to avoid losing me, Karen continued to emulate herself. I therefore set a termination date 6 months in the future and told her that after that time I would not see her again in treatment. Over the next few weeks, we weathered the storm of a severe recurrence of all symptomatology. Not only did her severe anxiety and nightmares return, but she had terrifying hallucinatory experiences consisting of gigantic swooping bats attacking her whenever she was alone. This was a period of great fear and despair for Karen. Her delusion of the ultimate rescuer had always protected her against the terror of death, and its removal left her overly exposed to dread.

"Wonderful poems," she wrote in her journal, mailed to me after termination of therapy, describing her terror graphically. "With death in my mouth, I speak to you, and maggots eating at my heart. In the cacophony of bells, my protests go unheard. Death is disappointment, a bitter bread. You cram it down my throat to stifle my screams." Karen's deeply entrenched and powerful belief that by merging with me, she could escape death was overtly expressed in this poem. "I would take death as my master, call his whip a gentle hand, and ride with him to those fell caves wherein he dwells, willingly forsake the ripe smell of summer, seed pods bursting with ebullient life, to sit with him on thrones of ice, and know his love."

As the termination date approached, Karen pulled out all stops. She threatened suicide if I would not continue treating her. Another poem expressed her mood and her threat. "Death is no pretense. It is as stark a reality as complete a presence as life itself. The other ultimate choice. I feel myself running into shadows, clothing myself in cobwebs, hiding from the reality you thrust at me. I want to hold up my dark cloak, death, and threaten you with it. Do you understand? I will wrap myself in this if you persist." Though I felt frightened by Karen's threats and provided her as much support as possible, I decided not to budge from my stand and maintained that at the end of the 6 months I would not continue to see her regardless of how ill she was. Our termination was to be final and irrevocable. No degree of distress on her part could influence it. Gradually, her efforts to merge with me subsided, and she turned toward the task at hand—how to use our final sessions as constructively as possible. It was only then, when she had relinquished all hope of my continued eternal presence, that she could work truly effectively in therapy. She allowed herself to know and to make known her strengths and her growth. She rapidly obtained a full-time position commensurate with her talents and skills. She had procrastinated finding this work for 4 years. She changed her demeanor and grooming radically from woe-begone waif to mature, attractive woman. Two years after termination, she asked to see me again because of the death of a friend. I agreed to meet with her for a single session and learned that not only had she maintained her changes but had undergone considerably more growth. It seems that one important thing for patients to learn is that though therapists can be helpful, there is a point beyond which they can offer nothing more. In therapy, as in life, there is an inescapable substrate of lonely work and lonely existence.

The rescuer defense and interpersonal difficulties. The fact that some individuals avoid the fear of death through a belief in the existence of an ultimate rescuer offers the clinician a useful frame of reference for some baffling interpersonal minuets. Consider the following examples of a common clinical problem. The patient who is enmeshed in a patently ungratifying, even destructive relationship and yet is unable to wrench free. Bonnie was 48 years old, had a severe circulatory disorder, Buerger's disease, and after a 20-year childless marriage, had been separated for 10 years. Her husband, a fervent outdoorsman, appeared to be a highly insensitive, self-centered autocrat who finally left Bonnie when her poor health made it impossible for her to accompany him on hunting and fishing expeditions. He provided her no financial support during the 10 years of separation, had affairs with numerous women, descriptions of which he did not fail to share with her, and visited Bonnie's house once every week or two, to use the washing machine.

To pick up recorded phone messages for the business phone he maintained there, and once or twice a year to have sexual relations with her. Bonnie, because of her strong moral standards, refused to date other men while she was still married. She continued to be obsessed with her husband, at times enraged at the sight of him, at times enamored of him. Her life diminished as she became ill, lonely, and tormented by his weekly washing machine visits. Yet she could neither divorce him, disconnect his phone, or terminate his laundry privileges.

Dolores had a long series of unsatisfying relationships with men, and finally at the age of 35 married an extraordinarily compulsive unsychologically minded individual. Before her marriage she had been in therapy because of chronic anxiety and douadal ulcer. After marriage her husband's controlling punctiliousness soon made her prenuptual anxiety state blissful in comparison. He kept time sheets for Dolores's weekend schedule. 9 to 10:15, gardening, 10:30 to noon, grocery shopping, etc., and a careful chart of her expenditures. He monitored all phone calls and rebuked her for spending time with anyone but him. Soon, Dolores was raw with anxiety and suppressed rage. Yet, she was terrorstricken at the very thought of separation or divorce.

Martha was 31 years old and desperate to marry and raise a family. For several years, she had been involved with a man who belonged to a mystical religious sect that taught him that the fewer commitments an individual makes, the greater is his freedom. Consequently, though he enjoyed Martha, he refused to live with her or make any long-term commitment to her. He was alarmed by her need for him, and the tighter she clutched, the less was he willing to promise. Martha was obsessed with binding him, and was pained beyond description at his lack of commitment. Yet, she felt addicted and was unable to wrench herself free. Each time she broke with him, she suffered a painful state of withdrawal, and finally, in depression or panic, reached for the telephone to call him. He during times of separation was maddeningly tranquil. He cared for her but could manage well without her. Martha was too consumed with him to search effectively for other relationships. Her major project in life was to extract a commitment from him. A commitment that reason and experience strongly suggested was not to be forthcoming.

Each of these three patients was involved in a relationship that was responsible for considerable anguish. Each realized that continuing in the relationship was self-destructive. Each tried in vain to wrench herself free. In fact, these feudal attempts constituted the major theme of therapy of each woman. What made disengagement so difficult? What welded each of them so tightly to another person? An obvious and a common thread runs through the concerns of the three patients, and it quickly became apparent when I asked each one to tell me what came to mind when she thought of separating from her mate.

Bonnie had a 20-year marriage to a husband who had made every decision for her. He was a man who could do everything and took care of her. Of course, as she was to learn when she separated, being taken care of restricted her growth and self-sufficiency. But it was so comforting to know that someone was always there to protect and rescue her. Bonnie had a serious illness and doggedly continued to believe even after 10 years separation, that her husband was out there taking care of her. Every time I urged her to reflect on life without his presence, and I speak here of symbolic presence, aside from the shared washing machine and a few mechanical coatal acts, there had been no meaningful physical presence for years. She became very anxious. What would she do in an emergency? Whom would she call? Life would be unbearably lonely without him. Obviously, he was a symbol that shielded her from confronting the harsh reality that there is no one out there, that the emergency is inevitable, and no person, symbolic or real, can obiate it.

Dolores, like Bonnie, was terrified of being alone. Though her husband was unspeakably restrictive, she preferred the prison of her marriage to, as she put it, the freedom of the streets. She would be nothing, she said, but an outcast, a soldier in the army of misfit women, searching for the occasional stray single man. Merely asking her in the therapy hour to reflect on a separation was sufficient to bring on a severe bout of anxious hyperventilation.

Martha permitted her life to be governed by the future. Whenever I asked her to meditate on what it would be like to give up her relationship with her uncommitted boyfriend, she always responded that all she could think of was eating alone at 63. When I asked her for her definition of commitment, she replied, "It's the assurance I'll never have to live alone or die alone." The thought of dining alone or going to the movies alone filled her with shame and dread. What was it that she really wanted from her relationship? "being able to get help without having to ask for it," she replied. Martha was tyrannized by the always present, desperate fear that she would be alone in the future. Like many neurotic patients, she did not really live in the present, but instead attempted to find the past, that is, the comforting bond with mother, in the future. Martha's fear and her need were so great that they ensured that she would not establish a gratifying relationship with a man. She was too frightened of loneliness to give up her current unsatisfying relationship, and her need was so obviously frenzied that she frightened away prospective partners.

For each of these women, then the bonding force was not the relationship per se, but the terror of being alone. And what was especially fearful about being alone was the absence of that magical powerful other who hovers about each of us observing anticipating our needs providing each of us with a shield against the destiny of death. That the belief in the ultimate rescuer may result in restrictive interpersonal relationships is illustrated exceptionally clearly in the relationship between some adults and aging parents.

Irene was 40 years old and had long had an intensely ambivalent relationship with her mother. The mother was hostile, demanding, and chronically depressed. And toward her, Irene felt, for the most part, loathing and great rage. Yet, when her mother complained about her living conditions, Irene invited her to move across the country in order to live with her. Though Irene was in therapy at the time, she did not discuss with the therapist her invitation to her mother until after she had sent the invitation. It would seem as though she was well aware of the self-destructive nature of her behavior, but was compelled to barrel ahead and did not wish anyone to dissuade her. Not long after her mother's arrival, Irene decompensated. She had severe bouts of anxiety, intractable insomnia, and an acute flare up of asthma. So long as we focused in therapy on her mother's guilt producing maneuvers, intrusiveness, and venomous disposition, we made no progress. That was not to come until we turned to another question. The question crucial to the understanding of many tortured relationships between adults and their parents. Why was mother so important to Irene? Why was it her responsibility and task to ensure mother's happiness? Why could she not separate herself from her mother? When I asked Irene to reflect on the texture of her life without her mother, her first association was interesting. Without mother, no one would care about what I eat. Mother was out there hovering somewhere over her right shoulder, watching, taking note of Irene's eating. At a conscious level, her mother's presence had always infuriated Irene. But now, as she looked deeper into it, it was reassuring. If mother monitored what she ate, then it followed that mother would in other ways ensure her daughter's well-being. Irene needed mother not only alive, but vigorous. Signs of infirmity, apathy, or depression in her mother were at a deep level distressing for Irene.

toward an integrated view of psychopathology. I have for didactic purposes focused separately on two major modes of coping with death anxiety and presented vignettes of patients who show extreme forms of one of these two basic defenses. But now it's time to integrate them. Most patients do not, of course, present with clear and monothematic clinical pictures. Generally, one doesn't construct a single ponderous defense, but instead uses multiple interlaced defenses in an attempt to wall off anxiety. Most individuals defend against death anxiety through both a delusional belief in their own inviability and a belief in the existence of an ultimate rescuer. Although I have thus far presented these two defenses as a dialectic, they are closely interdependent. Because we have an observing omnipotent being or force continuously concerned with our welfare, we are unique and immortal and have the courage to emerge from embeddedness. Because we are unique and special beings, special forces in the universe are concerned with us. Though our ultimate rescuer is omnipotent, he is at the same time our eternal servant.

Otto rank in a thoughtful essay entitled life fear and death fear posited a basic dynamic that illuminates the relationship between the two defenses. Rank felt that there is in the individual a primal fear that manifests itself sometimes as a fear of life, sometimes as a fear of death. By fear of life, rank meant anxiety in the face of a loss of connection with a greater whole. The fear of life is the fear of having to face life as an isolated being. It is the fear of individuation, of going forward, of standing out from nature. Rank believed that the prototypical life fear was birth, the original trauma and the original separation. By fear of death, Rank referred to the fear of extinction, of loss of individuality, of being dissolved again into the whole. Rank stated that between these two fear possibilities, these poles of fear, the individual is thrown back and forth all his life. The individual attempts to separate himself, to individuate, to affirm his autonomy, to go forward, to fulfill his potential. Yet there comes a time when he develops fear in the face of life. Individuation, emergence, or as I put it in this chapter, affirmation of specialness are not duty-free. They entail a fearful lonely sense of unprotectedness. A sense that the individual assuagages by reversing direction. One goes backward, relinquishes individuation, finds comfort in fusing, in dissolving oneself, in giving oneself up to another. Yet the comfort is unstable because this alternative evokes fear also. The fear of death, relinquishment, stagnation, and finally inorganicity. Between these two poles of fear, life fear and death fear, the individual shuttles throughout life.

Though the paradigm I offer here of the dual defenses of specialness and the ultimate rescuer is not identical with ranks life fear death fear dialectic they obviously overlap. Ranks poles of fear correspond closely to the inherent limits of the defenses I have described. Life anxiety emerges from the defense of specialness. It is the price one pays for standing out unshielded from nature. Death anxiety is the toll of fusion. When one gives up autonomy, one loses oneself and suffers a type of death. Thus, one oscillates. One goes in one direction until the anxiety outweighs the relief of the defense and then one moves in the other direction.

This oscillation may be demonstrated in some of the clinical material I have already presented. Consider Lena, who avoided anxiety by choosing to be frozen in adolescence. She continuously sought to merge herself with some rescuer. Yet she was often terrified by her situation. She clung to others, but stubbornly rebelled against them. She craved closeness. Yet when it was offered, she fled. Much of her energy seemed to be directed toward avoiding life anxiety with its change and growth. She sought peace, comfort, and safety. Yet when she got them she was engulfed in death anxiety. She abhored sleep or any stillness and to avoid either engaged in frenzied activity often for example driving aimlessly all night.

Then there was Karen who was masochistic and chose to emulate herself if necessary to obtain my embrace but she too was frightened of her objective. merging with another meant comfort and safety, but it also meant the loss of herself. One of her poems clearly illustrates her dilemma. "I want to shake like a dog out of water to free myself from your influence. I was too free with you, let you too near my heart, and got stuck like flesh to icy metal. Warm to me and let me go. To free myself, I must tear flesh, make wounds that will not heal. Is that what you want from me?"

Emergent fusion oscillation is often displayed particularly clearly in family therapy sessions where the major problem centers around a teenager's preparing to leave home. In one such family I treated, Dawn, the 19-year-old identified patient, was ostensibly fed up with his parents controlling his life. Among his spasmotic efforts to be his own man was his insistence that his parents not participate in his choice of college or in the college admission procedure. However, he procrastinated too long to gain admission to the colleges of his choice and decided to live at home and attend a local junior college. Dawn's continued presence at home resulted in a chaotic family environment. He was wildly ambivalent about freedom. Though painfully sensitive to any of his parents' actions that suggested limitation of his freedom, he covertly but unmistakably asked for curtailment. He persisted in playing the stereo at a deafening pitch till late in the night. He demanded the use of the family car, but gunned it, tires screeching out of the driveway, and often returned it with a gas tank so empty that it offered his father at best a slim chance of making it to a service station the next morning. He demanded money for dating, but inadvertently left condoms on his dresser for his strict Mormon parents to find. Dawn insisted on freedom, but would not take it. On numerous occasions, he angrily left home to seek harbor with a friend for a few days, but he never seriously explored getting his own apartment. His parents were wealthy, but he wouldn't allow them to pay his apartment rent, nor would he pay it himself. He had sufficient funds from summer work, but refused to spend these since he wished to save for a time when he might really need the money. Though Dawn yearned and fought for freedom, he simultaneously said to his parents, "I'm immature, irresponsible. Take care of me. But pretend I didn't ask you."

Dawn's parents were by no means disinterested bystanders in this drama. Dawn was the oldest child. His leaving home signified a milestone in his parents' life cycle. Dawn's father, a fiercely competitive workaholic, was especially threatened by this milestone. It uncovered the illusory nature of his specialness project. It signified personal diminishment, the beginning of a new, less vital, less useful stage of life. It signified displacement and decline, and lurking beyond both, death. Dawn's mother, whose major identity was that of mother and housekeeper, was similarly threatened by Dawn's departure. She feared loneliness and the loss of meaning in her life. Consequently, Dawn's parents, in the subtlest of ways, impeded his growth. They prepared him for life as an autonomous adult. Is that not the goal of the successful parent? Yet pleaded Satoci, "Don't grow up. Don't leave us. Stay young forever." and so shall we.

Another individual oscillating between emergence and fusion was Rob, a 30-year-old successful business executive who consulted me because of his transvestism. He had crossdressed always in private since adolescence and the pattern had until the present always been egoonic. That is the urge seemed to come from the very center of himself. Crossdressing provided much pleasure and he wished to do it. Recently, however, the behavior seemed to be taking over. He was often anxious and was aware of having to cross-dress to relieve anxiety. The symptom demanded more. It wanted him to appear in public as a woman. It wanted him to shave all his body hair, which he did, and finally to cut off his penis and become a woman. Thus, he was anxious either way. Anxious if he did not cross-dress and anxious if he did. Ordinarily, psychotherapists understand the transvestite patient by assuming that the sexual perversion is an attempt to ward off castration anxiety. The symptom of crossdressing serves two functions. It is a symbolic castration, that is, if one is already castrated, one is safe from attack and at the same time permits the individual to have some form of genital satisfaction. This paradigm had for Rob some explanatory power. It clarified, for example, why he could masturbate only when dressed in women's clothes and fantasizing himself as a woman. Yet, it left much unexplained, and an existential paradigm provided a broader view of Rob's behavior.

Rob's fantasies were rarely explicitly sexual. Generally, he imagined himself as a woman being greeted and admired by a group of women who accepted him into their circle. They would accept him for his looks or simply for his person, but would require of him no specific act. He wished to blend in with them, to be one of them, to be a practical nurse, a housekeeper, or a typist. He commented that what was particularly important was not having to perform. He was so weary of the stress inherent in being a man, of competing, standing out, struggling, showing his skill. The crossdressing hid much preoccupation with and fear of death. Rob's mother had died slowly and painfully from cancer when he was a teenager, and for over 14 years he had continued to dream of her. Crossdressing was a symbol of merging with mother and with all women. The transvestite act for most of his life had bound the anxiety inherent in individuation. Always a high achiever, Rob had long ago surpassed his father, but in doing so had to face what Rank calls life fear. Rob had always responded to this anxiety of individuation by a fantasy life in which fusion through the mechanism of crossdressing was the dominant theme. However, the defense of crossdressing was no longer effective. It evoked too much death fear, and Rob was terrified that his fantasies would take over, that he would lose himself in that fusion.

The attempt to assuage individuation anxiety through sexual merger is common. The successful man who devotes himself utterly to power, to getting ahead, standing out, and making a name for himself, must at some point come face to face with the lonely unprotectedness inherent in individuation. Often this point is reached on business trips. When a hard striving man can no longer channel his energies and attention into his work, when he must slow down in an unfamiliar setting, he often experiences terrible loneliness and deep frenzy. He searches for sex, not a loving embrace from a woman, which would stir up fears of losing himself. He searches for manipulative sex, a sexual union that permits him to continue to control life and limit awareness, but that provides a pus for isolation and the underlying death anxiety. The relationship is of course a charade and at some deep level the individual recognizes his inauthentic mode of encountering another. The ensuing guilt joins the anxiety and results in greater isolation and frenzy and in the need for still another woman sometimes within minutes of leaving the first.

Sexual activity as a mode of assuaging death anxiety is often clinically observed. Patricia Mckeline Hearn has reported a series of such incidents. The sexually conservative woman who returns home for the funeral of a parent or some close relative and takes with her a diaphragm and uncharacteristically engages in a sexual relationship with a stranger or a casual friend. Or the man who has had a severe coronary and on the way to the hospital fondles his wife's breasts and presses for some sexual exchange. or the man who with a child dying of leukemia becomes highly promiscuous. Another clinical example is provided by Tim, a 30-year-old patient whose wife was dying of leukemia. Tim began therapy not because of overt grief, but because of an alarming degree of sexual preoccupation and compulsivity. He had led a monogous life prior to his wife's illness. But as she approached death, he began compulsively to visit pornography films and singles bars, running great risks of public exposure, and masturbated several times a day, often while in bed with his dying wife. On the night of his wife's funeral, he sought out a prostitute. Tim's grief and his fear of his own death were easily discernible beneath the sexual compulsivity. His dreams, which I shall describe in the next chapter, give clear evidence of such concerns.

A striking example of the relationship between sex and death occurred when a patient of mine developed widespread inoperable cancer of the cervix. Despite her obvious pain and cexia, she had no end of suitors. More, she said, than she had ever had during her bloom. Her mates were dealing with death fears countly. They reported an exhilaration at being so close to the hub of life, or as one put it, to the bowels of the earth. They were, I believe, elated to come so close to death, to spew in its face, and to emerge each time intact and unscathed. The patient had a different motivation. Despite intense pelvic pain, she had a powerful craving for sex. She was so close to death and so terrified of the loneliness of dying that she was engulfed by the need to merge with another person. Alan Greenberger studied women with terminal cancer and on the basis of TAT scores reports a significantly high incidence of illicit sexuality themes.

The task of satisfying both needs for separateness and autonomy and for protection and merger and of facing the fear inherent in each is a lifelong dialectic that govern one's inner world. It is a task that begins in the first months of life when the child who first is symbiotically merged with the mother and thereafter has an ever diminishing emotional dependence on her must in order to develop a sense of identity of wholeness and separateness disengage and differentiate from the mother a task referred to by Margaret Morer as separation individuation. The cost of neurotic adaptation, the attempt to escape from death anxiety is at the core of the neurotic conflict. Behavior becomes neurotic when it is extreme and rigid and hypertrophy of either of the major defenses against death results, as we have seen, in some form of neurotic adaptation. The neurotic lifestyle is generated by a fear of death. But in so far as it limits one's ability to live spontaneously and creatively, the defense against death is itself a partial death. That is what rank meant when he said that the neurotic refuses the loan of life to escape the debt of death. He buys himself free from the fear of death by daily partial self-destruction. But self-restriction is not the end of the cost of neurotic adaptation. Because of guilt, the neurotic individual cannot escape scot-free, even with the remnants of a life. Traditionally, guilt is defined as the feeling that ensues from a real or fantasized transgression against another. It was Kirkagard and later Rank and Tillage who called attention to another source of guilt, the transgression against oneself, the failure to live the life allotted to one. As rank put it, when we protect ourselves from a too intensive or too quick living out or living up, we feel ourselves guilty on account of the unused life, the unlived life in us. Repression is thus a double-edged sword. It provides safety and relief from anxiety while at the same time it generates life restriction and a form of guilt. Henceforth referred to as existential guilt. In chapter 6, I shall explore existential guilt in depth.

Thus far, I have discussed wellenated neurotic adaptations to death anxiety. Let me now turn briefly to the consideration of the more primitive fragmentaryary defenses against death anxiety that are found in schizophrenia.

Schizophrenia and the fear of death. Though evidence is mounting that many forms of schizophrenia have an important biochemical component, there can be no evasion of the fact that schizophrenia is also a tragic human experience, one that can be apprehended from both a longitudinal, historical, and a cross-sectional phenomenological perspective. Crushing developmental stresses have contributed to the development of the schizophrenic patients world view and he or she inhabits a terrifying and chaotic experiential world. Perhaps no contemporary therapist has made a more concerted and heroic effort to comprehend and explicate the world of the schizophrenic patient than has Harold Surls who treated deeply psychotic patients for many years at Chestnut Lodge in Rockville, Maryland. In 1958, he wrote a deeply insightful but neglected article entitled Schizophrenia and the inevitability of death expressing his views on the psychonamics of the schizophrenic patient. Sirill's thesis is summarized in this passage. The ostensibly prosaic fact of the inevitability of death is in actuality one of the supremely potent sources of man's anxiety and the feeling responses to this aspect of reality are among the most intense and complex which it is possible for us to experience. The defense mechanisms of psychiatric illness, including the oftentimes exotic appearing defenses found in schizophrenia, are designed to keep out of the individual's awareness, among other anxietyprovoking aspects of inner and outer reality, this simple fact of life's finitude. Surls submits that the dynamics of the schizophrenic patient like those of the neurotic patient may be fully understood only from the perspective of the patients response to the inevitability of his or her death. Obviously, the schizophrenic patients defenses are more exotic, more extreme, and more disabling than those of the neurotic patient. Furthermore, the schizophrenic patient has an early life experience far more devastating than that of the neurotic patient. But the existential nature of human reality makes brothers and sisters of us all. Though the magnitude of the threat or the characteristics of the response differ, it is human finitude that bedevils the schizophrenic no less than the neurotic. Surls states this brilliantly. To be sure, schizophrenia can be considered a result of exotic, warping experiences in the past, predominantly in infancy and early childhood. But it can equally, accurately, and with greater clinical usefulness, the writer thinks, be seen as consisting in the use of certain defense mechanisms learned very early to cope with present-day sources of anxiety. And of these latter, none is more potent than the existential circumstance of life's finitude. In essence, then the hypothesis here is that schizophrenia can be seen from one among various other possible vantage points as an intense effort to ward off or deny this aspect of the human situation. The author wishes to make quite clear that in his experience, the fact of death's inevitability has a more than merely tangential relation to schizophrenia. That is, it is not a matter of the patient becoming able, as he grows free here from his schizophrenia, to turn his attention yonder to that great life circumstance of the inevitability of death, a circumstance which had previously lay inertly at the periphery of or even quite totally beyond his ken. On the contrary, the author's clinical work has indicated that the relationship is a much more central one than that. It is a matter rather of the patients having become and having long remained schizophrenic. And reference here of course is to largely or wholly unconscious purposiveness in order to avoid facing among other aspects of internal and external reality the fact that life is finite.

Traditional case histories of schizophrenic patients have always stressed their bleak conflicted early childhoods and the severe pathology of their early family environments. But how would it be if a patient's real case history, an existential case history were written? Part of a psychiatric examination includes a mental status inquiry where the interviewer attempts to discover whether the patient is oriented for time, place, and person. Surl hypothesizes what one patient would respond were he or she to be truly oriented. "I am Charles Brennan, a man who is now, this being April 15th, 1953, 51 years of age, who is living here in Chestnut Lodge, a psychiatric hospital in Rockville, Maryland, who has been living in a series of psychiatric hospitals constantly for 8 years now, who has been seriously ill for over 25 years with a mental illness which has robbed me of any realistic prospect considering my present age of ever being able to marry and have children and which quite possibly will require my being hospitalized for the remainder of my life. I'm a man who was once a member of a family which included two parents and seven children, but who has seen over the years a crushing series of tragedies strike this family. Years ago, my mother died in a state of long-standing mental illness. One of my brothers developed a mental illness as a young man requiring extended hospitalization. Another brother committed suicide. Still another brother was killed in action in the Second World War. And a third was murdered only recently at the height of his legal career by a mentally ill client. My remaining parent, my father, is now elderly, a man pathetically far removed from the strong man he used to be. and death cannot be far off for him." There is something stark and shocking about this particular case history. But perhaps more shocking yet is the knowledge that a similarly tragic case history, one that focuses not on early development, education, military service, object relations, sexual practices, but on the existential facts of life can be written for every patient and indeed for every therapist.

Surls described the course of therapy of a flidly psychotic patient whom he treated for several years. At first, the patient showed "quote abundant evidence of a richly detailed, fascinatingly exotic and complex, extremely rigorously defended delusional system replete with all manner of horrendous concepts ranging from brutal savagery to witchcraft and to the intricate minations of science fiction.qu." Though the patients world experience was terrifying, Surls noted that she expressed little concern about those givens that are terrifying to all humans, such as illness, aging, and inescapable death. She dealt with these issues with explicit and massive death denial. "Quote, 'There's no reason for anybody in the world to be unhappy or miserable today. They have antidotes for everything. People don't die, but in actuality are simply changed, moved about from place to place, or are made the unwitting subjects of motion pictures.'"

After 3 and 1/2 years of psychotherapy, the patient began to develop a reality based view of life and to accept that life, including human life, is finite. During the months before this realization, she had shown evidence of a last-ditch intensification of her delusional defenses against the recognition of death's inevitability. As Suros wrote, she came to spend most of her time picking up dead leaves and the occasional dead birds and small animals which hours of searching revealed and buying all sorts of articles from the stores in the nearby community. Then by various alchemy-like processes, attempting to bring these to one or another form of life, it became very clear, and she herself substantiated this, that she felt herself to be God, selecting various dead leaves and other things to be brought to life. Many times the psychotherrapeutic sessions were held out on the hospital grounds. The therapist sat on a bench while she went on with her day-long scrutinizing of the lawn nearby. But as these months wore on, toward the end of this period of denial of death, she came to express more and more openly a feeling of despair about this activity. Then there came an autumn day when, during the session, patient and therapist sat on benches not far apart, and gazed together at the leaf strewn lawn. She let it be known to go in nonverbal ways that she was filled with mellowess, tenderness, and grief. she said with tears in her eyes in a tone as of resignation to a fact that simply has to be accepted. "I can't turn those leaves into sheep, for instance." The therapist replied, "I gather that you're realizing perhaps that it's this way with human life, too, that as with the leaves, human life ends in death." She nodded. Yes. This realization marked the beginning of solid therapeutic progress. The patient gradually relinquished her major defense against death, her belief in her own omnipotence and invulnerability. She realized that she was not God and that we human beings are mortal. This showed that the very foundation of her paranoid schizophrenic illness was now crumbling. an illness which had involved her yearslong conviction, for example, that both her deceased parents were still living.

Though the defenses of this woman and of other schizophrenic patients whom Sorl describes are extreme and exceedingly primitive, they are nonetheless homologous to the defensive patterns found in neurotic patients. The paranoid patient, for example, evinces in delusions of grandeur and omnipotence, one of the primary modes of evading death, a belief in one's own specialness and immortality. Many, if not all, schizophrenic patients are unable to experience themselves as fully alive. No doubt this deadness is a function of the global repression of all effect in the schizophrenic patient. But it may also serve sirs suggests an additional defensive purpose. Being dead may protect the patient from death. A limited death is better than the real death. One need not fear death if one is dead anyway. But all of us must face death. If the fear of death is a core dynamic in the schizophrenic patient, we must answer the riddle why it is that the schizophrenic patient is brought down by this ubiquitous fear. Surls suggests several reasons. First, the anxiety of facing death is infinitely greater in those who do not have the strengthening knowledge of personal wholness and of whole participation in living. A person sir writes cannot bear to face the prospect of inevitable death until he has had the experience of fully living and the schizophrenic has not yet fully lived. Norman Brown in his extraordinary book life against death makes a similar statement. Quote "only he who can affirm birth can affirm death. The horror of death is the horror of dying with unlived lives in our bodies. unquote." This thesis that death anxiety is greatly heightened by life failure has considerable implications for therapy and is discussed in the following chapter.

A second reason that the schizophrenic is overwhelmed by death anxiety is that the patient has suffered enormous losses so early in development that he or she has not been able to integrate them. Owing to having an immature ego, the patient reacts to the losses pathologically, generally by a reinforcement of subjective infantile omnipotence, which serves to negate the loss. One cannot suffer loss if one is the whole world. Thus, not having been able to integrate losses in the past, the patient is unable in the present to integrate the prospect of the greatest of all losses, the loss of oneself and of everyone one knows. The patients primary shield against death then is a sense of omnipotence, a key feature in any schizophrenic illness.

A third source of intense death anxiety emanates from the nature of the schizophrenic patients early relationship to mother, a symbiotic union from which the patient has never emerged, but in which he or she continues to oscillate between a position of psychological merger and a state of total unrelatedness. The patients experience of relating to mother is not unlike negotiating a magnetic field. Veer too close and be suddenly sucked in, move away too far and drift away into nothingness. The symbiotic relationship requires for its maintenance that neither party experience himself or herself as independently whole. Each needs the other to complete his or her wholness. Thus, the patient never develops the sense of wholness necessary to experience life fully. Furthermore, the schizophrenic patient perceives that the symbiotic relationship is absolutely necessary to survival. The patient needs protection against any threats to the relationship. And among those threats, none is as dangerous as his or her and his or her mother's intense ambivalence. The child has a sense of profound helplessness in feeling the deepest hate toward the person whom he or she most deeply loves. The child is helpless too in the face of the knowledge that this same person loves and hates him or her with great intensity. This helplessness requires continued maintenance of the fantasy normal only in infancy of personal omnipotence. Nothing would so completely destroy the sense of personal omnipotence than the acceptance of the inevitability of death and the schizophrenic patient clings to his or her denial of death with a fierce desperation.

An existential paradigm of psychopathology research evidence. In this chapter, I postulate that though denial of death is ubiquitous and though the specific modes of death denial are highly varied, there are two major bull works of denial. Belief in personal specialness and belief in an ultimate rescuer. These defenses originate early in life and greatly influence the individual's character structure. An individual believing strongly in an ultimate rescuer and striving toward fusion, merger or embeddedness will look for strength outside of himself or herself. Will take a dependent supplicant pose toward others, will repress aggression, may show masochistic trends, and may become deeply depressed at the loss of the dominant other. The individual oriented toward specialness and inviolability and striving toward emergence, individuation, autonomy or separateness may be narcissistic, is often a compulsive achiever, is likely to direct aggression outward, may be self-reliant to the point of rejecting necessary appropriate help from others, maybe harshly unaccepting of his or her own personal frailties and limits, and is likely to show expansive, sometimes grandiose trends.

There is no direct empirical evidence for the existence of this emergence embeddedness dialectic, but neither is there any for other clinical psychopathology paradigms posited by Freud, Sullivan, Horny, From or Young. Clinical paradigms always emerge intuitively and are justified and validated by their clinical usefulness. However, analogous personality constructs have been posited and closely studied along two robust avenues of inquiry. Laboratory research on cognitive styles and personality research on locus of control.

Cognitive style. Herman Witken in 1949 identified two basic perceptual modes. field dependence and field independence which seem analogous to ultimate rescuer and specialness personality organization. In the field dependent mode, analogous to the ultimate rescuer style, the individual's perception is strongly dominated by the global organization of the field. In the field independent mode, analogous to the specialness style, parts of the field are experienced as discrete from the background. A great deal of research has demonstrated that a tendency toward one or the other modes of perception is a consistent and pervasive characteristic of an individual's functioning across a wide variety of perceptual tasks. The field dependent individual is unable to keep foreground apart from environmental context whereas the field independent individual has no difficulty with these tasks. Thus, the tests demonstrate a stylistic tendency of the individual which as it turns out is not limited to perception but is a pervasive cognitive style evident in the individual's intellectual activities, body concept and sense of separate identity.

As a footnote, there are many perceptual tests that can be used to demonstrate this phenomenon. For example, in the body adjustment test, an individual is placed in a chair that can be tilted right or left and the chair is placed in a small room that can also be tilted right or left. The subject is asked to make his or her body upright with respect to gravity while the room about him or her is tilted. The field dependent individuals are not able to separate themselves from the position of the surrounding room. In other words, if the room is tilted, they will tilt themselves accordingly and report that they are upright even though their bodies may be objectively tilted as much as 45°. The field independent subjects are regardless of the position of the surrounding room able to bring their bodies close to the true upright. Thus, the field dependent individuals seem to have a fusion of body and field, whereas the field independent individuals seem to have an immediate sense of the separateness of their bodies from the background. In an analogous test, the individual is presented with a luminous rod and frame, the only objects visible in a darkened room, and asked to place the rod to the true upright position regardless of the tilt of the frame. The embedded figures test asks an individual to study some complex designs in which are embedded some particular simple figures. The field dependent individuals cannot perceive the simple figure while for the field independent individual the simple figure is obvious and pops out of the design.

Intellectual activities. The field dependent individual does less well than the field independent one at solving problems that require the isolation of a central element from its context. Such tendencies are called cognitive styles. There is a consistent tendency at one extreme for experience to be global and diffuse and at the other for it to be delionated and structured. Witkin refers to these poles of cognitive style as global and articulated respectively. It is important however to underscore the fact that the world is not people by two kinds of being. Scores on cognitive style show continuous distribution rather than bipolar distribution.

Body image. Not only do the styles of an individual influence what is perceived out there, but they also influence experience within. Tests of body image, for example, draw a person tests strongly suggest that the way an individual perceives his or her body is significantly related to his or her performance on perceptual and cognitive tests. Individuals with a field dependent global style demonstrate little detail, unrealistic representation of proportion and body parts and little attempt at sex role representation. Field independent articulated individuals show clear representation of proportion and sex differences.

Identity. Persons with a field independent cognitive style give evidence of a developed sense of separate identity. That is to say, they have an awareness of needs, feelings, attributes that they recognize as their own and that they identify as distinct from those of others. On the other hand, individuals with a field dependent cognitive style rely heavily on external sources for definition of their attitudes, judgments, sentiments, and of their views of themselves. For example, studies have demonstrated that field dependent persons look at the face of the adult examiner much more frequently than do field independent ones. Furthermore, field dependent persons are better at recognizing faces of those whom they have seen earlier and more often have dreams concerned with their own relation to the experimentter. As a further note, a field dependent individual who is placed in an autokinetic situation changes his or her judgment about the movement of a point of light in conformance with the suggestion of a planted confederate. The autokinetic situation asks an individual to look at a stationary point of light in a dark room and to estimate how much this point of light has moved. The light itself doesn't move, but the individual may be more or less influenced by estimates of experimental subjects or confederates who precede him or her in the experiment.

Cognitive style and death denial. The field dependent individual defined experientially closely resembles the clinical characterization of the individual oriented toward the existence of an ultimate rescuer. The field independent person resembles one oriented toward a belief in personal specialness. The field dependence and field independence dialectic is derived entirely from empirical studies of perceptual and cognitive function but is devoid of subjective content. I would submit that the existential dialectic described herein is related to this empirical dialectic in the same way that dread is related to galvanic skin response. The existential dialectic provides the personal meaning, the phenomenological experience of the individual who is categorized according to one of these cognitive styles.

Let me carry the analogy farther and compare the empirical linkage between cognitive style and psychopathology with the observations made earlier in this chapter about the psychopathology associated with each of the major defenses against death anxiety.

Psychopathology and cognitive styles. The individual's cognitive style is closely related to choice of psychological defense and to the form of psychopathology. Field dependence independence is a continuum at both extremes of which psychopathology occurs. Furthermore, psychopathology takes quite different forms at the two extremes. A field dependent individual with personality disturbances is likely to have severe identity problems with symptoms often considered suggestive of deep-seated problems of dependence, pacivity, and helplessness. Several studies indicate that such a patient develops symptoms related to lack of development of a sense of separate identity such as alcoholism, obesity, inadequate personality, depression, and psychophysiological reactions. For example, asthma. A psychotic patient is likely to hallucinate as compared with a field independent one who is likely to be delusional. A field independent individual who develops pathology is likely to show outward aggression, delusions, expansive and euphoric ideas of grandeur, paranoid syndromes, and depressive compulsive character structures.

Interesting observations have also been made about differences between field dependent and field independent persons who enter psychotherapy. The major difference centers around the transference. As one could predict, a field dependent patient tends to develop a quick and highly positive transference to the therapist and to feel better earlier than a field independent patient. A field dependent patient tends to fuse with the therapist whereas a field independent one is likely to be much more cautious in the development of a relationship with the therapist. A field independent patient comes to the first session with an articulated account of and ideas about his or her problems. Whereas a field dependent patient is non-specific. A field dependent individual readily accepts the therapist's suggestions and solicits support from him or her and attempts to prolong the sessions owing to feelings of anxiety at the end of the hour. The cognitive style of the psychotherapist is an important determinant of the psychotherrapeutic context. Psychotherapists who are themselves field independent tend to favor either a direct or passive observational approach to a patient whereas field dependent therapists favor personal and mutual relationships with their patients.

The similarities are obvious. Extremity either in field dependency or in orientation toward an ultimate rescuer results in pathology characterized by passivity, dependency, orality, lack of autonomous function, inadequacy. An extreme field independence or specialness may result in pathological expansiveness, paranoid syndromes, aggression or compulsivity. These observations receive additional support from another line of inquiry, locus of control, an empirically derived personality paradigm that also closely resembles the specialness ultimate rescuer clinical paradigm locus of control.

Beginning with the work of Joseph Rotter and EJ Jerry Ferris, many researchers have been interested in a paradigm of personality that investigates whether the individual has either an internal or an external locus of control. Does one feel that one controls the events of one's life or does one feel that these events occur independently of one's actions? Most of the research in internal external control is based on an instrument, the IE scale, developed by Rotter in 1966 and used in several hundred research studies since that time. The IE internal external scale is a 23 item forced choice self- assessment questionnaire. Some sample paired items. A people are lonely because they don't try to be friendly. B. There's not much use in trying too hard to please people. If they like you, they like you. A what happens to me is my own doing. B. Sometimes I feel that I don't

have enough control over the direction my life is taking.

There is also a form for preschool children with such items as when you get a hole in your pants. Is that A because you tore them or B because they wore out? And if you had a shiny new penny and lost it, would that be A because you dropped it or B because there was a hole in your pocket?

Internals have an internal locus of control and feel they control their personal destiny. Externals place control external to themselves and look outside themselves for answers, support, and guidance. Internals differ from externals in a vast number of ways. Internals tend to be more independent, more achieving, more politically active, and have a greater sense of personal power. They are more power seeking. They direct their efforts toward gaining mastery over their environment.

Internal patients hospitalized for tuberculosis know more about their condition, are more inquisitive about the disease and their situation, and indicate that they are not satisfied with the amount of information they're getting from physicians and nurses. When given TAT cards and subtly prompted by the tester, internals are far less open to suggestion and influence than our externals. In general, then internals acquire more information and are better at retaining and utilizing it to control their own world. Internals are less suggestible and are more independent and more reliant upon their own judgment. They, in contrast to externals, evaluate information on the basis of its merit rather than responding on the basis of the prestige or expertise of the source of the information. Internals are more likely to be high achievers and more likely to delay gratification so as to attain larger rewards at a later date.

Externals are far more suggestible, tend more often to be smokers or to take high risks at gambling and are lower in achievement, dominance, and endurance and higher in desiring suck from others and self-abasement. These characterizations and the previous ones about field independence or believers in specialness and field dependence or believers in the rescuer are clearly similar. We may integrate these findings by imagining a continuum with field dependency, external locus of control, and orientation toward an ultimate rescuer on one pole, and field independence, internal locus of control, and orientation toward personal specialness on the other.

A position on either extreme end of the continuum is highly correlated with clinically evident psychopathology. Much research, however, indicates that one pole of the continuum constitutes a personality organization that is less effective and more likely to result in psychopathology. Individuals at the field dependent, the external locus of control pole, are more likely to have demonstrable psychopathology than individuals at the field independent or internal locus of control pole. Individuals with high external locus of control scores are more likely to feel inadequate, to be more anxious, hostile, fatigued, confused, and depressed, to have less vigor and resiliency. Severely impaired psychiatric patients are more likely to be externals. Schizophrenics are far more likely to be externals. A great deal of research demonstrates a strong relationship between external locus of control and depression. These research findings accord with clinical experience. More individuals seek therapy because of the failure of the rescuer defense. Dependency cravings, low self-esteem, self-contempt, helplessness, masochistic trends, depression because of the loss or threat of loss of their dominant other than because of specialness breakdown.

One team of investigators reported a positive correlation between the external locus of control mode and death anxiety. In other words, the external mode seemed a less effective shield against death anxiety than did the internal mode. However, another experiment using different death anxiety instruments failed to replicate these findings. The defense of belief in an outside deliverer seems inherently limited. Not only does it not entirely contain primal anxiety, but by its very nature, it spawns additional pathology. The belief that one's life is controlled by external forces is associated with a sense of powerlessness, ineffectualness, and low self-regard. One who does not rely on or believe in oneself limits accordingly one's acquisition of information and skills and may relate to others in an ingratiating manner. It is readily apparent that low self-esteem, a tendency towards self-abasement, few skills in which to build a sense of self-worth, and unsatisfying interpersonal relationships all prepare the soil for psychopathology.

Chapter 5, Death and Psychotherapy. The leap from theory to practice is not easy.