Existential psychotherapy by Irvin D. Yalom 03

Chapter 5. Death and Psychotherapy.

The leap from theory to practice is not easy. In this chapter, I shall transport us from metaphysical concerns about death to the office of the practicing psychotherapist and attempt to extract from those concerns what is relevant to everyday therapy.

The reality of death is important to psychotherapy in two distinct ways. Death awareness may act as a boundary situation and instigate a radical shift in life perspective, and death is a primary source of anxiety. I shall discuss the application of each way in turn to the technique of therapy.

Death as a boundary situation.

A boundary situation is an event and urgent experience that propels one into a confrontation with one's existential situation in the world. A confrontation with one's personal death, my death, is the nonpareil boundary situation and has the power to provide a massive shift in the way one lives in the world. Though the physicality of death destroys an individual, the idea of death can save him. Death acts as a catalyst that can move one from one state of being to a higher one, from a state of wondering about how things are to a state of wonderment that they are. An awareness of death shifts one away from trivial preoccupations and provides life with depth and poignancy and an entirely different perspective.

Earlier, I considered illustrative examples from literature and clinical records of individuals who, after a confrontation with death, have undergone a radical personal transformation. Tolstoy's Pierre in *War and Peace* and Ivan Ilyich in *The Death of Ivan Ilyich* are obvious instances of personality change or personal growth. Another striking illustration is everyone's favorite miraculously transformed hero, Ebenezer Scrooge. Many of us forget that Scrooge's transformation was not simply the natural result of "hule warmth" melting his icy countenance. What changed Scrooge was a confrontation with his own death. Dickens' ghost of the future, ghost of the Christmas yet to come, used a powerful form of existential shock therapy. Scrooge was permitted to observe his own death, to overhear members of the community discuss his death and then dismiss it lightly, and to watch strangers quarreling over his material possessions, including even his bed sheets and nightshirt. Scrooge then witnessed his own funeral. And finally, in the last scene before his transformation, Scrooge knelt in the churchyard and examined the letters of his name inscribed on his tombstone.

Death confrontation and personal change. Mechanism of action.

How does death awareness instigate personal change? What is the inner experience of the individual thus transformed? Chapter 2 presents some data that indicates the type and the degree of positive change that some terminal cancer patients have undergone. Interviews with these patients provide insights into some of the mechanisms of change.

"Cancer cures psychoneurosis." One patient had disabling interpersonal phobias that almost miraculously dissolved after she developed cancer. When asked about this cure, she responded, "Cancer cures psychoneurosis." Although she tossed this statement off almost flippantly, there is an arresting truth in it. Not the dismal truth that death eliminates life with all its attendant sorrows, but the optimistic truth that the anticipation of death provides a rich perspective for life concerns. When asked to describe her transformation, she stated that it was a simple process. Having faced and, she felt, conquered her fear of death, a fear that had dwarfed all her other fears, she experienced a strong sense of personal mastery.

Existence cannot be postponed. Eva, 45 years old and deeply depressed, had advanced ovarian cancer and was highly conflicted about whether she should take one last trip. In the midst of our therapeutic work, she reported this dream. "There was a large crowd of people. It looked something like a Cecil B. DeMille scene. I can recognize my mother in there. They were all chanting, 'You can't go. You have cancer. You are ill.' The chanting went on and on. Then I heard my dead father, a quiet, reassuring voice, saying, 'I know you have lung cancer like me, but don't stay home and eat chicken soup waiting to die like me. Go to Africa. Live.'" Eva's father had died many years ago of a lingering cancer. She last saw him several months before his death and had sorrowed not only at her loss but at the way he died. No one in the family had dared tell him about his cancer, and the symbol of staying home and eating chicken soup was apt. His remaining life and his death were unenlightened and unheroic. The dream bore powerful counsel. Eva heeded it well and altered her life dramatically. She confronted her physician and demanded all available information about her cancer and insisted that she share in the decisions made about her treatment. She reestablished old friendships. She shared her fears with others and helped them share their grief with her. She did take that last journey to Africa, which, though it was cut short by illness, did leave her with the satisfaction of having drunk deeply from life until the last draft.

The matter can be summed up simply. Existence cannot be postponed. Many patients with cancer report that they live more fully in the present. They no longer postpone living until sometime in the future. They realize that one can really live only in the present. In fact, one cannot outlive the present. It always keeps up with you. Even in the moment of looking back over one's life, even in the last moment, one is still there experiencing living. The present, not the future, is the eternal tense.

I remember a 30-year-old patient who was obsessed by the vision of herself as an old woman spending Christmas alone. Haunted by this vision, she spent much of her adult life in frantic pursuit of a mate, so frantic a pursuit that she frightened away any prospective suitors. She rejected the present and devoted her life to rediscovering the security of early childhood. The neurotic obliterates the present by trying to find the past in the future. It is, of course, paradoxical, and I shall have more to say on this later, that it is the person who will not live who is most terrified of dying. Why not ask, like a well-filled guest, leave the feast of life?

Another individual, a university professor, as a result of a serious bout with cancer, decided to enjoy the future in the immediate present. He discovered with astonishment that he could choose not to do those things he didn't wish to do. When he recovered from his surgery and returned to work, his behavior changed strikingly. He divested himself of onerous administrative duties, immersed himself in the most exciting aspects of his research, eventually attaining national prominence, and—let this be a lesson to us all—never attended another faculty meeting.

Fran was chronically depressed and fearful and had for 15 years been locked into a highly unsatisfying marriage, which she could not bring herself to end. The final obstacle to separation was her husband's extensive home aquarium. She wished to remain in the house so that her children could keep their friends and remain in the same school. Yet she could not undertake the 2 hours of time needed for the daily feeding of the fish. Nor could the huge aquarium be moved except at enormous expense. The problem seemed insoluble. On such trifling issues is a life sacrificed. Fran then developed a malignant form of bone cancer, which brought home to her the simple fact that this was her one and only life. She said that she suddenly realized that time's clock runs continuously and that there are no timeouts when it stops. Though her illness was so severe that her need for her husband's physical and economic support were very great indeed, she was nonetheless able to make the courageous decision to separate—the decision she had postponed for a decade.

Death reminds us that existence cannot be postponed and that there is still time for life. If one is fortunate enough to encounter his or her death and to experience life as the possibility of possibility, as Kierkegaard said, and to know death as the impossibility of further possibility, as Heidegger said, then one realizes that as long as one lives, one has possibility. One can alter one's life until, but only until, the last moment. If, however, one dies tonight, then all of tomorrow's intentions and promises die stillborn. That is what Ebenezer Scrooge learned. In fact, the pattern of his transformation consisted of a systematic reversal of his misdeeds of the previous day. He tipped the caroler he had cursed. He donated money to the charity workers he had spurned. He embraced the nephew he had scorned. He gave coal, food, and money to Cratchit, whom he had tyrannized.

Count your blessings.

Another mechanism of change, energized by a confrontation with death, was well illustrated by a patient who had cancer that had invaded her esophagus. Swallowing became difficult. Gradually, she shifted to soft foods, then to puréed foods, then to liquids. One day in a cafeteria, after having been unable even to swallow some clear broth, she looked around at the other diners and wondered, "Do they realize how lucky they are to be able to swallow? Do they ever think of that?" She applied this simple principle to herself and became aware of what she could do and could experience: the elemental facts of life, the changing seasons, the beauty of her natural surroundings, seeing, listening, touching, and loving. Nietzsche expresses this principle in a beautiful passage: "Out of such abysses, from such severe sickness, one returns newborn, having shed one's skin, more ticklish and malicious, with a more delicate taste for joy, with a more tender tongue for all good things, with merrier senses, with a second dangerous innocence in joy, more childlike, and yet a hundred times subtler than one has ever seen before."

"Count your blessings." How rarely do we benefit from that simple homily? Ordinarily, what we do have and what we can do slips out of awareness, diverted by thoughts of what we lack or what we cannot do, or dwarfed by petty concerns and threats to our prestige or our pride systems. By keeping death in mind, one passes into a state of gratitude, of appreciation for the countless givens of existence. This is what the Stoics meant when they said, "Contemplate death if you would learn how to live." The imperative is not then a call to a morbid death preoccupation, but instead an urging to keep both figure and ground in focus so that being becomes conscious and life becomes richer. As Santayana put it, "the dark background which death supplies brings out the tender colors of life in all their purity."

Disidentification.

In everyday clinical work, the psychotherapist encounters individuals who are severely anxious in the face of events that do not seem to warrant anxiety. Anxiety is a signal that one perceives some threat to one's continued existence. The problem is that the neurotic person's security is so tentative that he or she extends his or her defensive perimeter a long way into space. In other words, the neurotic not only protects his or her core but defends many other attributes—work, prestige, role, vanity, sexual prowess, or athletic ability—with the same intensity. Many individuals become inordinately stressed, therefore, at threats to their career or to any of a number of other attributes. They believe, in effect, "I am my career," or "I am my sexual attractiveness." The therapist wishes to say, "No, you are not your career. You are not your splendid body. You are not your mother or father or wise man or eternal nurse. You are yourself. Your core essence. Draw a line around it. The other things, the things that fall outside, they are not you; they can vanish, and you will still exist." Unfortunately, such self-evident exhortations, like all self-evident exhortations, are rarely effective in catalyzing change. Psychotherapists look for methods to increase the power of the exhortation.

One such method I have used with groups of cancer patients as well as in the classroom is a structured disidentification exercise, which was suggested to me by James Bugental. The procedure is simple and takes approximately 30 to 45 minutes. I choose a quiet, peaceful setting and ask the participants to list on separate cards eight important answers to the question, "Who am I?" I then ask them to review their eight answers and to arrange their cards in order of importance and centricity—the answers closest to their core at the bottom, the more peripheral responses at the top. Then I ask them to study their top card and meditate on what it would be like to give up that attribute. After approximately 2 to 3 minutes, I ask them, by some quiet signal like a bell (less distracting), to go on to the next card and so on until they have divested themselves of all eight attributes. Following that, it is advisable to help the participants integrate by going through the procedure in reverse. This simple exercise generates powerful emotions. I once led 300 individuals in an adult education workshop through it, and even years afterward, participants gratuitously informed me how momentously important the procedure had been to them.

Disidentification is an important part of Roberto Assagioli's system of psychosynthesis. He tries to help an individual reach his center of pure self-consciousness by asking him to imagine shedding in a systematic way his body, emotions, desires, and finally intellect. The individual with a chronic illness who copes well with his or her situation often spontaneously goes through this process of disidentification. One patient whom I remember well had always closely identified herself with her physical energy and activities. Her cancer gradually weakened her to the point where she could no longer backpack, ski, or hike, and she mourned these losses for a long time. Her range of physical activities inexorably diminished, but eventually, she was able to transcend her losses. After months of work in therapy, she was able to accept the limitations, to say, "I cannot do it without a sense of personal worthlessness and futility." Then she transmuted her energy into other forms of expression that were within her limits. She set feasible final projects for herself, completing personal and professional unfinished business, expressing unvoiced sentiments to other patients, friends, doctors, and children. Much later, she was able to take another major step: to disidentify even with her energy and impact and to realize that she existed apart from these, indeed apart from all other qualities.

Disidentification is an obvious and ancient mechanism of change. The transcendence of material and social accoutrements has long been embodied in aesthetic traditions but is not easily available for clinical use. It is the awareness of death that promotes a shift in perspective and makes it possible for an individual to distinguish between core and accessory, to reinvest one and to divest the other.

Death awareness in everyday psychotherapy.

If we psychotherapists accept that awareness of personal death can catalyze a process of personal change, then it is our task to facilitate a patient's awareness of death. But how? Many of the examples I have cited are of individuals in an extraordinary situation. What about the psychotherapist treating the everyday patient who doesn't have terminal cancer, or who is not facing a firing squad, or who has not had a near-fatal accident? Several of my cancer patients posed the same question. When speaking of their growth and what they had learned from their confrontation with death, they lamented, "What a tragedy that we had to wait till now, till our bodies were riddled with cancer, to learn these truths."

There are many structured exercises that the therapist may employ to simulate an encounter with death. Some of these are interesting, and I shall describe them shortly. But the most important point I wish to make in this regard is that the therapist doesn't need to provide the experience. Instead, the therapist needs merely to help the patient recognize that which is everywhere about him or her. Ordinarily, we deny or selectively inattend to reminders of our existential situation. The task of the therapist is to reverse this process, to pursue these reminders, for they are not, as I have attempted to demonstrate, enemies, but powerful allies in the pursuit of integration and maturity.

Consider this illustrative vignette. A 46-year-old mother takes the youngest of her four children to the airport, where he departs for college. She has spent the last 26 years rearing her children and longing for this day. No more impositions, no more incessantly living for others, no more cooking dinners and picking up clothes, only to be reminded of her futile efforts by dirty dishes and a room in new disarray. Finally, she is free. Yet, as she says goodbye, she unexpectedly begins sobbing loudly. And on the way home from the airport, a deep shudder passes through her body. "It's only natural," she thinks. "It's only the sadness of saying goodbye to someone she loves very much." But it is more than that. The shudder persists and shortly turns into raw anxiety. What could it be? She consults a therapist. He soothes her. "It is but a common problem, the empty nest syndrome. For so many years, she has based her self-esteem on her performance as mother and housekeeper. Suddenly, she finds no way to validate herself. Of course, she is anxious. The routine, the structure of her life have been altered, and her life role and primary source of self-esteem have been removed." Gradually, with the help of Valium, supportive psychotherapy, an assertiveness training women's group, several adult education courses, a lover or two, and a part-time volunteer job, the shudder shrinks to a tremble and then vanishes altogether. She returns to her pre-morbid level of comfort and adaptation.

This patient, treated by a psychiatric resident some years ago, was part of a psychotherapy outcome research project. Her treatment results could only be described as excellent. On each of the measures used—symptom checklists, target problem evaluation, self-esteem—she had made considerable improvement. Even now, in retrospect, it seems clear that the psychotherapist fulfilled his function. Yet, I also look upon this course of treatment as a misencounter, as an instance of missed therapeutic opportunities. I compare it with another patient I saw recently in almost precisely the same life situation. In the treatment of this patient, I attempted to nurse the shudder rather than to anesthetize it. The patient experienced what Kierkegaard called "creative anxiety," and her anxiety led us into important areas. It was true that she had problems of self-esteem. She did suffer from the "emptiness syndrome," and she also was deeply troubled by her great ambivalence toward her child. She loved him but also resented and envied him for the chances in life she had never had. And, of course, she felt guilty because of these ignoble sentiments. We followed her shudder, and it led us into important realms and raised fundamental questions. It was true enough that she could find ways to fill her time. But what was the meaning of the fear of the empty nest? She had always desired freedom, but now, having achieved it, was terrified of it. Why?

A dream helped to illuminate the meaning of the shudder. Her son, who had just left home for college, had been an acrobat and a juggler in high school. Her dream consisted simply of herself holding in her hand a 35mm photographic slide of her son juggling. The slide was peculiar, however, in that it was a slide in movement. It showed her son juggling and tumbling in a multitude of movements all at the same time. Her associations to the dream revolved around time. "The slide captured and framed time and movement. It kept everything alive but made everything stand still. It froze life. Time moves on," she said, "and there's no way I can stop it. I didn't want John to grow up. I really treasured those years when he was with us. Yet, whether I like it or not, time moves on. It moves on for John, and it moves on for me as well. It's a terrible thing to understand, to really understand." This dream brought her own finiteness into clear focus. And rather than rush to fill time with distractions, she learned to wonder at and to appreciate time and life in richer ways than she previously had. She moved into the realm that Heidegger describes as "authentic being." She wondered not at the way that things are, but that things are.

In my judgment, therapy helped the second patient more than the first. It would not be possible to demonstrate this conclusion on standard outcome measures. In fact, the second patient probably continued to experience more anxiety than the first did, but anxiety is a part of existence, and no individual who continues to grow and to create will ever be free of it. Nevertheless, such a value judgment evokes many questions about the therapist's role. Is the therapist not assuming too much? Does the patient engage his or her services as a guide to existential awareness? Or do not most patients say, in effect, "I feel bad. Help me feel better"? And if this is the case, why not use the speediest, most efficient means at one's disposal, for example, pharmacological tranquilization or behavioral modification? Such questions, which pertain to all forms of treatment based on self-awareness, cannot be ignored, and they will emerge again and again in this text.

In the treatment of every patient, situations arise that, if sensitively emphasized by the therapist, would increase the patient's awareness of the existential dimensions of his or her problems. The most obvious situations are the stark reminders of finitude and the irreversibility of time. The death of someone close will, if the therapist persists, always lead to an increased death awareness. There are many components to grief: the sheer loss, the ambivalence and guilt, the disruption of a life plan, and all need to be thoroughly dealt with in treatment. But, as I stressed earlier, the death of another also brings one closer to facing one's own death. And this part of the grief work is commonly omitted. Some psychotherapists may feel that the bereaved is already too overwhelmed to accept the added task of dealing with his or her own finitude. I think, however, that assumption is often an error. Some individuals can grow enormously as a result of personal tragedy.

The death of another and existential awareness.

For many, the death of a close fellow creature offers the most intimate recognition one can have of one's own death. Paul Lansberg, discussing the death of a loved one, says, "We have constituted an 'us' with the dying person, and it is in this 'us.' It is through the specific power of this new and utterly personal being that we are led toward the living awareness of our own having to die. My community with that person seems to be broken off. But this community, in some degree, was I myself. I feel death in the heart of my own existence." John Donne made the same point in his famous sermon: "And therefore never send to know for whom the bell tolls. It tolls for thee."

The loss of a parent brings us in touch with our vulnerability. If our parents could not save themselves, who will save us? With parents gone, nothing stands between ourselves and the grave. On the contrary, we become the barrier between our children and death. The experience of a colleague after the death of his father is illustrative. He had long been expecting his father's death and bore the news with equanimity. However, as he boarded an airplane to fly home for the funeral, he panicked. Though he was a highly experienced traveler, he suddenly lost faith in the plane's capacity to take off and land safely, as though his shield against precariousness had vanished.

The loss of a spouse often evokes the issue of basic isolation. The loss of the significant other, sometimes the dominant other, increases one's awareness that try as hard as we may to go through the world two by two, there is nonetheless a basic aloneness that we must bear. No one can die one's own death with one or for one. A therapist who attends closely to a bereaved patient's associations and dreams will discover considerable evidence of the latter's concern with his or her own death.

For example, a patient reported this nightmare on the night after learning that his wife had inoperable cancer. "I was living in my old house, a house that had been in the family for three generations. A Frankenstein monster was chasing me through the house. I was terrified. The house was deteriorating, decaying. The tiles were crumbling and the roof leaking. Water leaked all over my mother." (His mother had died 6 months ago.) "I fought with him. I had a choice of weapons. One had a curved blade with a handle like a scythe. I slashed him and tossed him off the roof. He lay stretched out on the pavement below, but he got up and once again started chasing me through the house." The patient's first association to the dream was, "I know I've got 100,000 miles on me." The symbolism of the dream seemed clear. His wife's impending death reminded him that his life, like his house, was deteriorating. He was inexorably pursued by death, personified, as in his childhood, by a monster who could not be halted.

Another patient, Tim, whose wife had terminal cancer, had this dream the night after she, near death, had had to be hospitalized because of severe respiratory problems. "I had just returned from some type of trip and found that I was pushed into some back room area. Someone had done me in. It was all filled with old stuffed furniture, plywood, dusty, and everything was covered with chicken wire. There was no exit. It reminded me of Sartre's play. I felt stifled. I couldn't breathe. Something was bearing in on me. I picked up some plywood box or crate that was crudely built. It hit against the wall or floor and had a crushed corner. That crushed corner really stuck out in my mind. It sort of blazed. I decided to take it up with the boss at the very top. 'I'll go right up to the top and complain. I'll go to the vice president.' I then went up an extremely elegant stairway that had mahogany rails and marble floors. I was angry. I had been shuffled aside. They put it to me. Then I became confused about who I should complain to." Tim's associations to the dream indicated clearly that his wife's impending death hurled him into a confrontation with his own. The outstanding image in the dream, the blazing crushed corner of the plywood box, reminded him of the crushed body of his automobile after a serious accident in which he had almost been killed. The plywood box also reminded him of the plain coffin he would have to order for his wife, according to Jewish burial ritual. In the dream, it is he who finds himself in his wife's situation. He too cannot breathe. He too is pushed aside, trapped, crushed by something bearing down upon him. The major effect of the dream was anger and bafflement. He felt angry at the things happening to him. Yet to whom could he issue a complaint? He awoke deeply confused about who upstairs would be the proper person to consult.

In therapy, this dream opened up important vistas. It enabled the patient, who had been previously in a panic state, to sort out his feelings and to work on each cluster in a more meaningful way. He had been overwhelmed with death anxiety, with which he had attempted to cope by physically avoiding his wife and by compulsive sexuality. For example, he masturbated several times a day in bed next to his wife. I described this patient briefly in chapter 4. As we worked overtly on his anxiety about his own death, he was finally able to remain near his wife, comforting her by holding her, and in so doing, avoiding a considerable measure of guilt that would have ensued after her death. After the death of his wife, therapy focused both on the loss of his wife and on his own existential situation, which his wife's death helped him to see more clearly. For example, he had always been achievement-oriented, but after his wife's death began to ask, "For whom am I working? Who will see it?" Slowly, Tim began to glimpse what his wife's constant nurturing and his obsession with sex had obscured for him: his isolation and his own finitude. He was highly promiscuous after his wife's death, but gradually he grew disenchanted with the sexual chase and began to grapple with the question of what he wanted to do in life for himself. An enormously fertile period in therapy began, and in the course of the succeeding months, Tim made substantial personal change.

The loss of a son or daughter is often the bitterest loss of all to us, and we simultaneously mourn our child and ourselves. Life seems to hit us at such a time on all fronts at once. Parents first rail at the injustice in the universe, but soon begin to understand that what seemed injustice is in reality cosmic indifference. They also are reminded of the limit of their power. There is no time in life when they have greater motivation to act and yet are helpless. They cannot protect a defenseless child. As night follows day, the bitter lesson follows that we, in our turn, will not be protected. The psychiatric grief literature doesn't emphasize this dynamic but instead often focuses on the guilt thought to be associated with unconscious hostility that parents experience at the death of a child. Richard Gardner studied parental bereavement empirically by systematically interviewing and testing a large sample of parents whose children suffered from some type of fatal illness. Though he confirmed that many parents suffered considerable guilt, his data indicated that the guilt, rather than emanating from unconscious hostility, was four times more commonly an attempt by the parent to assuage his or her own existential anxiety—to attempt to control the uncontrollable. After all, if one is guilty about not having done something one should have done, then it follows that there is something that could have been done, a far more comforting state of affairs than the hard existential facts of life. The loss of a child has another portentous implication for the parents. It signals the failure of their major immortality project. They will not be remembered. Their seed will not take root in the future.

Milestones.

Anything that challenges the patient's permanent view of the world can serve as a fulcrum with which the therapist can wedge open the patient's defenses and permit him a view of life's existential innards. Heidegger emphasizes that "only when machinery suddenly breaks down do we become aware of its functioning." Only when defenses against death anxiety are removed do we become fully aware of what they shielded us from. Therefore, the therapist who looks may find existential anxiety lurking when any major event, especially an irreversible one, occurs in the patient's life. Marital separation and divorce are prime examples of such events. These experiences are so painful that therapists often make the error of focusing attention entirely on pain alleviation and miss the rich opportunity that reveals itself for deeper therapeutic work.

For some patients, the commitment to a relationship rather than the termination of one acts as a boundary situation. Commitment carries with it the connotation of finality. And many individuals cannot settle into a permanent relationship because that would mean, "This is it. No more possibilities, no more glorious dreams of continued ascendancy." In chapter 7, I shall discuss how irreversible decisions evoke existential anxiety precisely because they exclude other possibilities and confront the individual with the impossibility of further possibility.

The passage into adulthood is often particularly difficult. Individuals in their late teens and early 20s are often acutely anxious about death. In fact, a clinical syndrome in adolescence called the "terror of life" has been described. It consists of marked hypochondriasis and preoccupation with the aging of the body, with the rapid passage of time, and with the inevitability of death. Therapists who treat medical residents, to take one example, sometimes note considerable existential anxiety in the 30-ish individual who is finally completing training and must for the first time shed a student identity and face the world as a grown-up. I have long observed that psychiatric residents, upon nearing completion of training, go through a period of major inner turmoil. A turmoil that has roots reaching far below such immediate concerns as finances, selection of an office, and establishment of referral networks for private practice.

Jacques, in his wonderful essay "Death and the Midlife Crisis," stresses that the individual in midlife is especially bedeviled by the thought of death. This is the time of life when a person may become preoccupied with the thought, often unconscious, that he or she has stopped growing up and has begun to grow old. Having spent the first half of life in the achievement of independent adulthood, one may reach the prime of life, young called age 40, the noon of life, only to become acutely aware that death lies beyond. As one 36-year-old patient, who had become increasingly aware of death in his analysis, put it, "Up till now, life has seemed an endless upward slope with nothing but the distant horizon in view. Now suddenly I seem to have reached the crest of the hill, and there stretching ahead is the downward slope with the end of the road in sight. Far enough away, it's true, but there is death observably present at the end." Jacques remarked upon the difficulty of working through the layers of death denial and gave an example of how he helped one patient become aware of death by analyzing his inability to mourn the death of friends.

A threat to one's career or the fact of retirement, especially in individuals who had believed that life was an ever-ascending spiral, can be a particularly potent catalyst for increasing one's awareness of death. A recent study of individuals making a midlife radical career shift suggests that most of them had made the decision to drop out or to simplify their lives in the context of a confrontation with their existential situation.

Simple milestones such as birthdays and anniversaries can be useful levers for the therapist. The pain elicited by these signs of the passage of time runs deep and, for that reason, is generally dealt with by reaction formation in the form of a joyous celebration. Sometimes mundane reminders of aging offer an opportunity for increased existential awareness. Even a penetrating look in the mirror can open the issue. One patient told me that she said to herself, "I'm just a little gnome. I'm the same little Isabelle inside, but outside I'm an old lady. I'm 16 going on 60. I know it's perfectly all right for others to age, but somehow I never thought it would happen to me." The appearance of old people's characteristics such as the loss of stamina or senile plaques on the skin, stiff joints, wrinkles, balding, or even the recognition that one enjoys old people's pleasures—watching, walking, serene, quiet times—may act as a spur to death awareness. The same may be said about looking at old photographs of oneself and noting how one resembles one's parents when they were considered old, or seeing friends after long intervals and noting how they have aged.

The therapist who listens carefully will be able to use any of these everyday occurrences, or the therapist may tactfully contrive such situations. Freud, as I described in chapter 1, had no qualms about requesting Fräulein Elizabeth to meditate at the sight of her sister's grave. A careful monitoring of dreams and fantasies will invariably provide material to increase death awareness. Every anxiety dream is a dream of death. Frightening fantasies involving such themes as unknown aggressors breaking into one's home always, when explored, lead to the fear of death. Discussions of unsettling television shows, movies, or books may similarly lead to essential material.

Severe illness is such an obvious catalyst that no therapist should let this opportunity pass by unmined. Grof and Halifax studied 200 patients who had had near-death experiences through sudden illness or accident and found that a substantial number (25%) had a new and powerful sense of death's omnipresence and nearness. One of his subjects commented, "I used to think death would never happen, or if it did, I'd be 80 years old. But now I realize it can happen anytime, any place, no matter how you live your life." A person has a very limited perception of death until he's confronted with it. Another described his death awareness in these terms: "I have seen death in life's pattern and affirmed it consciously. I'm not afraid to live because I feel that death has a part in the process of my being." Though a few of Grof's subjects reported an increased terror of death and a greater sense of vulnerability, the great majority reported that their increased death awareness had been a positive experience, resulting in a greater sense of life's preciousness and a constructive reassessment of their life's priorities.

Artificial aids to increase death awareness.

Though the naturally occurring reminders of death's presence are numerous, they are not, therapists often find, sufficiently potent to combat a patient's ever-vigilant denial. Consequently, many therapists have sought vivid techniques to bring patients to face the fact of death. In the past, intentional and unintentional reminders of death were far more common than they are today. It was precisely for the purpose of reminding one of life's transients that a human skull was a common furnishing in a medieval monk's cell. John Donne, the 17th-century British poet and clergyman, wore a funeral shroud when he preached "Look to Eternity" to his congregation. And earlier, Montaigne, in his splendid essay "That to Philosophize is to Learn How to Die," had much to say on the subject of intentional reminders of our finitude. "We plant our cemeteries next to churches and in the most frequented parts of town in order," says Montaigne, "to accustom the common people, women and children, not grow panicky at the sight of a dead man, and so that the constant sight of bones, tombs, and funeral processions should remind us of our condition."

"To feasts. It once was thought slaughter lent added charms, mingling with foods the sight of combatants in arms, and gladiators fell amid the cups to pour onto the very tables their abundant gore. And the Egyptians, after their feasts, had a large image of death shown to the guests by a man who called out to them, 'Drink and be merry, for when you are dead, you will be like this.' So I have formed the habit of having death continually present, not merely in my imagination, but in my mouth, and there is nothing that I investigate so eagerly as the death of men. What words, what look, what bearing they maintained at that time, nor is there a place in the histories that I note so attentively. This shows in the abundance of my illustrative examples. I have indeed a particular fondness for this subject. If I were a maker of books, I would make a register with comments of various deaths. He who would teach men to die would teach them to live."

Some therapists who have used LSD as an aid to psychotherapy speculate that an important mechanism of action is that LSD brings the patient into a dramatic confrontation with death. Other therapists have suggested that shock therapy (electrical, metrazol, and insulin) has its effect through a death-rebirth experience. Some encounter group leaders have used a form of existential shock therapy by asking each member to write his or her own epitaph or obituary. Destination labs held for harried business executives commonly begin with this structured exercise: "On a blank sheet of paper, draw a straight line. One end of that line represents your birth, the other end your death. Draw a cross to represent where you are now. Meditate upon this for 5 minutes." This short, simple exercise almost invariably evokes powerful and profound reactions.

"Calling out," an exercise suggested by James Bugental, is used in large groups to increase awareness of finitude. The members are divided into triads and assigned a conversational task. Each individual's name is written on a slip of paper, placed in a bowl, and then randomly chosen and called aloud. An individual whose name is called stops talking and turns his back to the others. Many participants report that as a result of this exercise, they have an increased awareness of the arbitrariness and the fragility of existence.

Some therapists and encounter group leaders have used a guided fantasy technique to increase death awareness. Individuals are asked to imagine their deaths: Where will it occur? When? How? Describe a detailed fantasy. Imagine your funeral. A philosophy professor describes a number of exercises that he employs in the classroom to increase death awareness. For example, students are requested to write their obituaries, their real obituary and their ideal one, to record their emotional responses to a tragic story of the death of a six-year-old orphan, and to write the script for their own deaths. A life cycle group experience offered by Elliot Aronson and Anne Drifus at the National Training Laboratory Summer Program at Bethel, Maine, helped the participants to focus on the major issues in each stage of life. In the time devoted to old age and death, these participants spent days living like old people. They were instructed to walk old, to dress old, to powder their hair, and attempt to play elderly people they have known well. They visited a local cemetery. They walked alone in a forest, imagined passing out, dying, being discovered by friends, and being buried.

Several death awareness workshops have been reported that employ structured exercises designed to provide the individual with an encounter with his or her death. For example, W.M. Whan describes a workshop consisting of a single 8-hour, 8-member group session with the following format:

1. Members complete a death anxiety questionnaire and discuss anxiety-provoking items.

2. Members, in a state of deep muscle relaxation, fantasize in great detail, with awareness of all five senses, their own comfortable death.

3. Members are asked to construct a list of their values and then asked to imagine a situation in which a life-saving nuclear fallout shelter is able to save only a limited number of people. Each member has to make an argument, on the basis of his or her value hierarchy, why he or she should be saved. This exercise was, according to the authors, designed to recreate Kübler-Ross's stage of bargaining.

4. Again, in a state of muscle relaxation, the members are asked to fantasize their own terminal illnesses, their inability to communicate, and finally their own funerals.

Interaction with the dying.

As intriguing as many of these exercises are, they nonetheless are make-believe. Though one can be drawn into such an exercise for a period of time, denial quickly sets in, and one reminds oneself that one still exists, that one is merely observing these experiences. It was precisely because of the persistence and ubiquity of denial to assuage dread that several years ago I started to treat individuals with a fatal illness—individuals who were continually in the midst of urgent experience and could not deny what was happening to them. My hope was not only to be useful to these patients but to be able to apply what I learned to the treatment of the physically healthy patient. It is difficult to phrase that sentence because the very essence of this approach is that from the very beginning of life, dying is a part of living. Consequently, I shall use the phrase "everyday psychotherapy" or, better perhaps, "psychotherapy of those not imminently dying."

Group therapy sessions with terminal patients are often powerful with the evocation of much affect and the sharing of much wisdom. Many patients feel that they have learned a great deal about life but are frustrated in their efforts to be helpful to others. One patient put it, "I feel I have so much to teach, but my students will not listen." I have searched for ways to expose everyday psychotherapy patients to the wisdom and power of the dying and shall describe some limited experience with two different approaches:

1. Inviting everyday psychotherapy patients to observe meetings of a group of terminally ill patients.

2. Introducing an individual with terminal cancer into an everyday psychotherapy group.

Observation of a terminal cancer group by everyday psychotherapy patients.

One patient who observed a meeting of the group of cancer patients was Karen, whom I discussed in chapter 4. Karen's major dynamic conflict was her pervasive search for a dominant other, an ultimate rescuer, which took the form of psychic and sexual masochism. Karen would limit herself or inflict pain on herself if necessary to gain the attention and protection from some superior figure. The meeting she observed was particularly powerful. One patient, Eva, announced to the group that she had just learned she had a recurrence of cancer. She said that she had done something that morning that she had long postponed: she had written a letter to her children giving instructions about the division of minor sentimental items. In placing the letter in her safe deposit box, she realized with a clarity she had never before attained that indeed she would cease to be. As I described in chapter 4, she realized that when her children read that letter, she would not be there to observe or to respond to them. She wished, she said, that she had done her work on death in her 20s rather than waiting until now. Once, one of her teachers had died. Eva was a school principal, and rather than concealing the death from the students, she realized how right she had been to hold a memorial service and openly discussed death—the death of plants, animals, pets, and humans—with the children. Other group members too shared their moments of full realization about their deaths and some discussed the ways they had grown as a result of that realization. An interesting debate developed as one member told about a neighbor who had been perfectly healthy and had died suddenly during the night. "That's the perfect death," she said. Another member disagreed and, in a few moments, had presented compelling reasons that that type of death was unfortunate. The dead woman had had no time to put her affairs in order, to complete unfinished business, to prepare her husband and her children for the death, to treasure the end of life, as some of the members in the group had learned to do. "Just the same," the first quipped, "that's still the way I'd like to die. I've always loved surprises."

Karen reacted strongly to the meeting she had observed. It was immediately thereafter that she arrived at the many deep insights about herself I described in chapter 4. For example, she realized that because of her fear of death, she had sacrificed much of her life. She had so feared death that she had organized her life around the search for an ultimate rescuer. Therefore, she had feigned illness during her childhood and stayed sick in adulthood to remain near her therapist. While observing the group, she realized with horror that she would have been willing to have cancer in order to be in that group and sit next to me, perhaps even hold my hand. The group ended with a

handholding period of meditation. When I pointed out the obvious, that is that no relationship is eternal, that I, as well as she would die, she said that she felt she would never be alone if she could die in my arms. The evocation and the subsequent working through of this material helped move Karen into a new phase of therapy, especially into a consideration of termination, an issue that previously she had never been willing to broach.

Another everyday therapy patient who observed the group was Susan, the wife of an eminent scientist who when she was 50 had sued her for divorce. In her marriage, she had lived a mediated existence, serving him and basking in his accomplishments. Such a life pattern, not uncommon among wives of successful husbands in these days, had certain inevitable tragic consequences. First, she didn't live her life. In her effort to build up credit with the dominant other, she submerged herself. She lost sight of her wishes, her rights, and her pleasure. Secondly, because of the sacrifice of her own strivings, interests, desires, and spontaneity, she became a less stimulating partner and was considerably more at risk for divorce.

In our work, Susan passed through a deep depression and gradually began to explore her proactive feelings, not the reactive ones to which she had always limited herself. She felt her anger, deep, rich, and vibrant. She felt her sorrow not at loss of her husband but at the loss of herself all those years. She felt outraged at all the restrictions to which she had consented. For example, to ensure that her husband had optimal working conditions at home, she wasn't permitted to watch television, to speak on the phone, to garden while he was home. His study looked out on the garden and her presence distracted him. She ran the risk of being overcome with regret for so much wasted life and the task of therapy was to enable her to revitalize the remainder of her life. After 2 months of therapy, she watched a poignant meeting of the cancer group, was moved by the experience, and immediately plunged into productive work, which finally permitted her to understand that the divorce might be salvation rather than requiem. After therapy, she moved to another city and several months later wrote a debriefing letter which included, "First of all, I've thought that those women with cancer need not be reminded of the inevitability of death. That the awareness of death helps them to see things and events in their proper proportions and corrects our ordinarily poor sense of time. The life ahead of me may be very short. Life is precious. Don't waste it. Make the most of every day in the ways you value. Reappraise your values. Check your priorities. Don't procrastinate. Do I, for one, have wasted time. Every once in a while in the past, I'd feel vividly that I was only a spectator or an understudy, watching the drama of life from the wings, but always hoping and believing that one day I'd be on the stage myself. Sure enough, there had been times of intense living, but more often than not, life seemed just a rehearsal for the real life ahead. But what if death comes before the real life has started? It would be tragic to realize when it's too late, that one has hardly lived at all."

Chapter 5B. Introduction of a patient facing death into an everyday psychotherapy group. Death's rather like a certain kind of lecturer, wrote the novelist John Fowls. You don't really hear what is being said until you're in the front row. Some time ago, I attempted to seat the seven members who were all everyday psychotherapy patients of a therapy group in the very first row by introducing into the group Charles, a patient with an incurable cancer.

Much data exists on this experiment. I wrote a detailed summary after each meeting, including a review both of the narrative flow and of process, and mailed it to the group members, a technique I have used in groups for many years. In addition to these summaries, I have my own personal records of the group. Furthermore, since 10 psychiatric residents observed each meeting through a one-way mirror and discussed the meeting after each session, this group was heavily studied. From all these observations and records, I shall select and discuss some of the most salient issues arising in the first 12 months after Charles entered the group.

The group was an outpatient psychotherapy one meeting once weekly for an hour and a half. It was an open group. As members improved and graduated, new members were introduced. At the time when Charles entered, two members had been in the group for 2 years and four others had been there for periods of time ranging from 3 to 18 months. The age range was from 27 to 50. The types of psychopathology of the members would generally be considered neurotic or characterologic, though two members had borderline traits.

Charles was a 38-year-old divorced dentist who 3 months before consulting me had learned that he had a form of cancer for which there was no medical or surgical cure. In our initial interview, he stressed that he didn't feel that he needed any help in coping with his cancer. He had spent many days in medical libraries familiarizing himself with the course, the treatment, and the prognosis of his cancer. He arrived with a graph that he had drawn of his projected clinical course and had concluded that he had approximately 1 and a half to 3 years of good, useful life ahead of him, and following that a rapid one-year decline.

I remember having two strong impressions during that initial interview. First, I marveled at his lack of manifest feelings. He seemed detached, as though he were talking about some stranger who had had the misfortune to contract a rare disease. Secondly, though, I was jarred by his isolation from feeling. I was also struck by the fact that his detachment was serving him extraordinarily well in this instance. He stressed that he needed no help in dealing with his fear of death, but wished assistance in getting more out of the life remaining to him. His cancer had caused him to take stock of the pleasures he was getting in life, and he realized that aside from his work, he received few important gratifications. He especially wanted help in improving the quality of his relationship with other people. He felt distant from others and missed the personal closeness that he perceived so many others to enjoy. His relationship to a woman with whom he had lived for 3 years was severely strained, and he urgently wanted to be able to express and receive the love that existed between them only in cryales.

I had been looking for some time for a person with cancer to introduce into a general psychotherapy group, and Charles looked to be the perfect candidate. He wanted help in the very areas where the therapy group can most provide it. Furthermore, I suspected that he would be of enormous assistance to others in the group. It was evident that Charles was not in the habit of asking for help. His request was creaking and awkward, but at the same time it was urgent and sincere and could not be refused.

The therapy of seven individuals interlocked in the network of a therapy group is highly complex. And over the next 12 months, a marvelously intricate series of interpersonal and intrapersonal issues arose, were worked upon, and occasionally were worked through. I cannot, of course, describe all these events, and shall instead place the beacon of attention upon Charles, and upon the impact he and the other members had on one another. To leap ahead of myself, I wish to state that the presence of an individual facing death did not bring the therapy group down. The atmosphere of the group did not become morbid. The feeling tone did not become blackened silk or the perspective limited and fatalistic. Charles gained a great deal from his work in the group and in a number of ways his situation deepened the level of discourse for each of the other members. The group did not become monolithic, but discussed the same wide array of life issues. In fact, there were times when mass denial was in operation, and for weeks on end, Charles's cancer seemed all but forgotten by the members.

Self-disclosure is essential in psychotherapy, in group, no less than in individual therapy. At the same time, it is important that the members not experience the group as a forced confessional. Consequently, in my orientation session with Charles before he entered the group, I was careful to inform him, as I inform all incoming members, that to gain help from the group, he would need to be wholly honest about both his physical condition and his psychological concerns, but that he should be so at his own pace. Charles, accordingly, attended the group for 10 weeks before informing the group about his cancer. In retrospect, his decision to withhold this information was wise. The group never experienced Charles as a cancer patient, but instead as a person who had cancer.

One of the basic axioms of interactional group therapy is that the group develops into a social microcosm for each of the members. Each person sooner or later begins to relate to the other members in the group in the same manner that he relates to individuals outside the group. Each person thus carves out his or her own characteristic interpersonal niche. That rapidly occurred with Charles. In his first few meetings, the group members began to note that he seemed either disinterested nor critical and judgmental of many of their statements. They gradually learned that he was isolated, that he had difficulty getting close to people, that he could not experience or express his feelings, and that he was self-critical. He was especially impatient and condescending to the women in the group. He considered one a gadfly, childish, or on other occasions a lightweight, whose opinion did not matter a great deal to him. He was impatient with another woman because of her lack of a logical train of thought, and he generally dismissed her intuitive comments as interference, or as white noise in the system. On one occasion, when the other three men in the group were absent, Charles was almost entirely silent, not considering it worth his while to participate in a totally female group. The recognition, the understanding, and the resolution of his attitudes toward the female members were important in helping him to understand some of the basic issues of conflict between him and the woman with whom he lived.

Although these issues were salient to Charles's interpersonal conflict and led him into the areas upon which he wanted to work, there remained a great deal of puzzlement in the group. Periodically over Charles's first several meetings, members would remark that they didn't really know Charles, and that he seemed hidden, unreal, and distant to them. Another axiom of group therapy is that when someone is keeping an important secret, he or she tends to be globally inhibited. The individual with the secret not only withholds the core secret, but becomes careful about traversing any avenue that might conceivably lead to it. Eventually, in the 10th session, the members and the therapists encouraged Charles to share more of himself, and he then discussed his cancer in much the same way that he had presented it in his pregroup individual sessions, detached, matter-of-fact, and with considerable scientific detail.

The group members responded to Charles's disclosure in highly individual fashion. Several talked about his courage and about the type of model he provided for them. One man was especially impressed at the way Charles talked about his goal of wanting to get as much as he could from the life remaining to him. This patient, Dave, became aware of how much he himself postponed life and of how little he savored his present life. Two members had severe and inappropriate reactions. One, Lena, whom I described briefly in chapter 4, had lost both parents at an early age and had remained thereafter terrified of death. She sought for the protection of an ultimate rescuer and remained passive, dependent, and childlike. Lena predictably became frightened and responded in an angry, almost bizarre fashion by assuming that Charles had the same type of cancer that had caused her mother's death, and then in a highly inappropriate fashion described to the group in lurid detail the debilitating physical changes that had occurred in her mother. The other patient, Sylvia, a 40-year-old woman with massive death anxiety, immediately flared up angrily at Charles's passivity in the face of his disease. She berated him for not having investigated other possible sources of help: faith healers, leotril, Philippine psychic surgeons, mega vitamins, and so forth. When one of the other members of the group came to Charles's rescue, a heated argument ensued. Sylvia was so frightened by Charles's cancer that she attempted to pick a fight in the hope that it would provide her with reasons to drop out of the group. Throughout the year, Sylvia's responses to Charles continued to be tumultuous. Her continued contact with him evoked great anxiety which resulted in brief decompensation and eventual cubrious resolution. As Sylvia's clinical course illustrates vividly some important principles in the management and working through of death anxiety, I shall describe her treatment thoroughly later in this chapter.

Over the next four weeks, several important events occurred in the group. One of the members, a pediatric nurse, described for the first time her close relationship with one of her patients, a 10-year-old child who had died a few months previously. She was painfully aware of the fact that even in the short space of 10 years, that child had lived more fully than she. The death of the child in concert with Charles's terminal illness propelled her into trying to break out of her self-imposed restrictions and to increase the depth of her own life. Another patient, Dawn, had been locked in a transferent struggle with me for many months. Although he felt strong yearnings for my guidance and counsel, he felt himself defying me in a number of destructive ways. For example, he systematically arranged on many occasions to meet each of the members of the group outside for some type of social interaction. Although we had discussed on several occasions the fact that this sabotaged the work of the group, Dawn nonetheless felt that it was important for him to develop allies in the group against me. After Charles revealed to the group that he had cancer, Dawn began to feel quite differently toward me, and the tension and the antagonism between us seemed visibly less. Dawn mentioned how much I had changed over the weeks since Charles had entered the group. He stated that he couldn't easily put it into words, but then suddenly blurted out, "Somehow I know now that you're not immortal." He was able to discuss in detail some of his ultimate rescuer fantasies, the belief that I was infallible, that I was able to plot out his future with great certainty. He was able to express his anger at my apparent unwillingness to give him what I was capable of giving. Charles's presence reminded Dawn that I, as well as he, had to face death, that we were all united and equal in that way, that as Emerson somewhere said, "Let us keep cool, for it will all be won in a hundred years." Suddenly his battle with me seemed foolish and trivial, and he and I soon became allies rather than combatants.

Lena's relationship to Charles was extraordinarily complex. She first found herself full of anger at him because of her anticipation of his leaving her as her mother and father had done. She began to recall for the first time the events of her mother's death when Lena was five and repeatedly relived the experience in her mind. Her mother had become very emaciated before death. And during Charles's first few months in the group after his disclosure, Lena became anorexic and lost an alarming amount of weight. Lena's dynamics became much clearer. She felt so overwhelmed by the death of people close to her that she chose a state of suspended animation. Her formula was: no friendships, no losses. She had four aged grandparents and lived in daily expectation of news of their death. Her dread was so great that she deprived herself of the pleasures of knowing and being close to them. She said once in the group, "I wish they'd all hurry up and die and get it over with." Gradually she broke the pattern and in a poignant manner allowed herself to reach out to Charles. She gingerly began to touch him by, for example, helping him off with his coat at the beginning of a meeting. Throughout, Charles remained the most important person in the group for Lena. And by accepting the fact that the deep pleasure she had in being close to him was worth the pain of the eventual separation, she was gradually able to establish other important relationships in her life. Eventually, she was to profit considerably from the group experience with Charles. During their time together in the group, she regained her lost weight, her suicidal yearnings disappeared, her depression lifted, and after three years of unemployment, she obtained a responsible and gratifying job.

Another member derived another type of benefit from sitting in the front row. She was divorced and had two small children, and generally felt suffused with resentment and impatience toward them. Only occasionally, when one of them was injured or sick, was she able to reach her positive, tender feelings. Her relationship with Charles brought home to her in vivid fashion the passage of time and the finiteness of life. Gradually, she was able to dip into the well of loving feelings toward her children without provocation of illnesses, accidents, or other stark reminders of mortality.

Although deep emotion was experienced in the group, there was never more affect present than could be assimilated and worked through. In large part, no doubt, this was a function of Charles's style. He rarely showed or appeared to experience deep affect. This was highly functional for the group work, to the extent that it allowed titration of affect. Emotion emerged slowly and in manageable degrees. Eventually, however, the time came for Charles's emotion-stifling style to come under direct surveillance. One meeting, a couple of months after Charles's revelation to the group, is particularly illustrative. Charles seemed pressured and began the meeting in an unusual way by stating that he had some specific questions he wished to ask the therapist. The questions were general, and his expectations of precise, authoritative answers were unrealistic. He asked for some specific techniques in order to overcome his distance from others. And he asked for a specific recommendation about how to resolve a conflict with his girlfriend. Charles posed these questions after the fashion of an efficient engineer and obviously anticipated answers in kind. The group attempted to respond to Charles's questions, but he insisted on hearing from the group leader and impatiently dismissed the other members. They refused to be silenced, however, and shared their feelings of hurt and annoyance at being shut out. One member gently asked if the frantic quality of Charles's questions related to his sense of time running out and to a need to increase the efficiency of the process in the group. Gently, gradually, the group helped Charles talk about what had been brewing deep inside him over the past few days. With tears in his eyes, he revealed that he had been terribly shaken up by a couple of events. He had watched a long television movie on the death of a child from cancer and had, in connection with his profession as dentist, attended a long and gruesome conference on oral cancer. With this information, the group turned again to Charles's unusual behavior in the meeting. His insistence on a precise answer to his questions from the therapist was an expression of his wish to be taken care of. He went about it indirectly, he said, because he feared expressing effusive feelings openly. If effusive, smothering sentiments were offered to him, he felt he would be mortified. Charles's initial questions were answered in the meeting not through content, that is through specific suggestions by the therapist, but through an analysis of process, that is through an analysis of his relationships to others. He learned that problems of intimacy with others, including his ex-wife and his girlfriend, were related to his stifling of his affect, his fear of effusive sentiments by others, his judgmentalism and dismissal of peers in the hopes of getting a systems-oriented solution from authority.

A few weeks later, a similar episode occurred that corroborated and reinforced this instruction for Charles. He started the meeting in an obviously belligerent way. He was often upset by the amount of alimony he had to pay and he remarked on a newspaper article that day demonstrating how women and divorce lawyers were exploiting helpless men. He then extended these remarks to the women in the group and in general belittled their contributions. When the group once again explored what had been happening to him, Charles described some highly emotional events of the last two days. His only child had just left home for college, and their last day together had been disappointing to Charles. He had so much wanted to tell his son how much he loved him. Yet they passed their last meal together in silence, and Charles felt despair at having lost this precious opportunity. Since his son's departure, Charles had been preoccupied with what's next, with everything seems terminal, and he felt that he was entering into a new and final phase of life. He didn't fear death or pain, Charles said. What he really feared was disability and helplessness. Obviously, everyone shared Charles's fear of disability and helplessness. Yet it had a particular terror for Charles, whose dread of helplessness was evident in his reluctance to reveal vulnerability or to ask for help. In this particular meeting, rather than come to the group with an open description of his pain and a request for help, Charles had begun with a belligerent distancing manner. His cancer would one day render him physically dependent on others, and he lived in dread of that day. Gradually, the group helped delay that dread by on numerous occasions affording him the opportunity to disclose his feelings of vulnerability and to request help from the others.

One of the members of the group, Ron, who had been in the group for over 2 years, was obviously well enough to graduate and had been deliberating termination for some time. Furthermore, he was romantically involved with Irene, one of the female members, and as long as he was present, she found it difficult to make good use of the group. Whenever members of a therapy group form a subgroup or diad, and develop an allegiance to that subgroup, which surpasses in importance their dedication to the primary task of the large therapy group, then therapeutic work becomes seriously impaired. This point had been reached with Ron and Irene, and at one meeting I not only supported Ron's decision to terminate the group, but urged him to do so in such a forthright manner that it hastened his decision to terminate.

The meeting after Ron's departure was tumultuous. Another axiom of small therapy groups is that members of a group who are exposed to a common stimulus will have highly individual responses to that stimulus. There can only be one possible explanation for this phenomenon. Each of the members has a different internal world. Thus, the investigation of varying responses to the same stimulus often provides a high yield in therapy. The responses of Sylvia and Lena were especially striking. Both were extraordinarily threatened. They believed that I had kicked Ron out of the group, a view that was not held by the other members. Furthermore, they saw my decision as extremely arbitrary and unfair. They were angry, yet they feared to express their anger, lest they too be thrown out of the group. The work done on these feelings led into an investigation of Sylvia's and Lena's major defensive structures, a belief in deliverance by an ultimate rescuer. Both were so terrified of being abandoned by me that they took great pains to appease and placate me. In order to stay near me, they both at an unconscious level resisted getting well, and at a conscious level declined to report to the group any change that might be construed as positive. Charles's presence in the group brought much closer to the four their fears of abandonment, and beneath that, of death. Both Lena and Sylvia gradually realized that they had overreacted to the situation, that Ron's departure was the proper decision for Ron and for the group, and that no one else felt fearful about being thrown out of the group. Eventually, they understood that their reaction to this incident was reflective of their general behavior, of their dependency, their fear of abandonment, and their self-crippling tendencies.

Charles's reaction to Ron's leaving was also very strong, as was his later reaction to other members in the group preparing to terminate. He said that it actually provoked a physical pain right in the middle of his chest. It was as though something were being wrenched away from him, and he felt extremely threatened at the possible dissolution of the group. In one meeting, Charles, the same Charles who a few months previously had said that he was sterile emotionally and that no one meant anything to him, told the group how much they meant to him, and with tears streaming down his face, thanked them for, as he put it, saving his life.

On one occasion, a young man in the group made the curious statement that he envied Charles for having a fatal illness. If he too had a fatal illness, he might be plunged into making something more of his life. The group was quick to remind the young man he did indeed have a fatal illness, and that the difference between Charles and the others was simply the difference between sitting in the front rather than in the back row. Frequently Charles attempted to bring that point home to the others in the group. On one memorable occasion, one of the older members lamented that he had wasted his life. There had been so many missed opportunities, so many undeveloped potential friendships, so many untapped career possibilities. He was full of self-pity and avoided experiencing the present by a remorseful trudging about in the past. Charles was especially effective by pointing out forcefully to him that while he had not wasted his life, he was at that very moment in the process of wasting it. The group of members would from time to time suddenly be reminded that Charles had cancer and was going to die in the not too distant future. Periodically each was thrown into a confrontation with Charles's death and his or her own as well. One member who had always denied death commented that Charles's hunger for life, his courage, and his mode of dealing with his death had given her strength and a model for both living and dying.

At the time of this writing, Charles continues to be an active member of the group. He has long outlived his prognosis and is in good physical condition. Moreover, he has achieved his original goals in therapy. He feels more human and is no longer isolated. He relates far more openly and intimately with others. He entered couples therapy with his girlfriend and his relationship to her vastly improved. His presence in the group has touched almost all the members in profound ways. Their experience with Charles shifted each of them from a preoccupation with a relatively narrow band of existence toward a desire to plunge into life in all its breadth and intensity.

Death as a primary source of anxiety. The concept of death provides the psychotherapist with two major forms of leverage. I have discussed the first: that death is of such momentous importance that it can, if properly confronted, alter one's life perspective and promote a truly authentic immersion in life. The second, to which I shall now turn my attention, is based on the premise that the fear of death constitutes a primary source of anxiety, that it is present early in life, is instrumental in shaping character structure, and continues throughout life to generate anxiety that results in manifest distress and in the erection of psychological defenses.

First, some general therapeutic principles. It is important to keep in mind that death anxiety, though it is ubiquitous and has pervasive ramifications, exists at the deepest levels of being, is heavily repressed, and is rarely experienced in its full sense. Death anxiety per se is not easily evident in the clinical picture of most patients, nor does it often become an explicit theme in the therapy, especially not in brief therapy, of most patients. Some patients are, however, suffused with overt death anxiety from the very onset of therapy. There are also life situations in which the patient has such a rush of death anxiety that the therapist, try as he or she might, cannot evade the issue. Furthermore, in long-term intensive therapy which explores deep levels of concern, explicit death anxiety is always to be found and must be considered in the therapeutic process.

Since death anxiety is so intimately tied to existence, it has a different connotation from anxiety in other frames of reference. Though the existential therapist hopes to alleviate crippling levels of anxiety, he or she does not hope to eliminate anxiety. Life cannot be lived, nor can death be faced, without anxiety. Anxiety is guide as well as enemy and can point the way to authentic existence. The task of the therapist is to reduce anxiety to comfortable levels and then to use this existing anxiety to increase a patient's awareness and vitality. Another major point to keep in mind is that even though death anxiety may not explicitly enter the therapeutic dialogue, a theory of anxiety based on death awareness provides the therapist with a frame of reference, an explanatory system that may greatly enhance his or her effectiveness.

Repression of death anxiety. In chapter 2, I described a head-on automobile collision where, had circumstances been less fortunate, I would have lost my life. My response to that accident serves as a transparent model for the workings of death anxiety and neurotic reactions. Recall that within a day or two, I no longer experienced any explicit death anxiety, but instead noted a specific phobia surrounding luncheon discussions. What happened was that I handled death anxiety by repression and displacement. I bound anxiety to a specific situation. Rather than being fearful of death or of nothingness, I became anxious about something. Anxiety is always ameliorated by becoming attached to a specific object or situation. Anxiety attempts to become fear. Fear is fear of something. It has a location in time and space. And because it can be located, it can be tolerated and even managed. One may avoid the object or develop some systematic plan of conquering one's fear. Fear is a current sweeping over one's surface. It does not threaten one's foundation.

I believe that this course of events is not uncommon. Death anxiety is deeply repressed and not part of our everyday experience. Gregory Zilborg, in speaking of the fear of death, said, "If this fear were constantly conscious, we should be unable to function normally. It must be properly repressed to keep us living with any modicum of comfort." No doubt the repression and subsequent invisibility of death anxiety is the reason that many therapists neglect its role in their work. But surely the same state of affairs applies to other theoretical systems. The therapist always works with tracings of and defenses against primal anxiety. How often, for example, does an analytically oriented therapist encounter explicit castration anxiety?

Another source of confusion is that the fear of death can be experienced at many different levels. One may, for example, consider death dispassionately and intellectually. Yet this adult perception is by no means the same as the dread of death that resides in the unconscious. A dread that is formed early in life at a time prior to the development of precise conceptual formulation. A dread that is terrible and incoherent and exists outside of language and image. The original unconscious nucleus of death anxiety is made more terrifying yet by the accretion of a young child's horrible misconceptions of death. As a result of repression and transformation, existential therapy deals with anxiety that seems to have no existential reference. Later in this chapter, I shall discuss patients who have much overt death anxiety and also how layers of explicit death anxiety must always be reached through long and intensive therapy. But even in those courses of therapy where death anxiety never becomes explicit, the paradigm based on death anxiety may enhance the therapist's effectiveness. The therapist is provided with a frame of reference that greatly enhances his or her effectiveness.

As nature abhors a vacuum, we humans abhor uncertainty. One of the tasks of the therapist is to increase the patient's sense of certainty and mastery. It is a matter of no small importance that one be able to explain and order the events in our lives into some coherent and predictable pattern. To name something, to locate its place in a causal sequence, is to begin to experience it as under our control. No longer then is our internal experience or behavior frightening, alien, or out of control. Instead, we behave or have a particular inner experience because of something we can name or identify. The "because" offers one mastery or a sense of mastery that phenomenologically is tantamount to mastery. I believe that the sense of potency that flows from understanding occurs even in the matter of our basic existential situation. Each of us feels less fetal, less helpless, and less alone. Even when, ironically, what we come to understand is the fact that each of us is basically helpless and alone in the face of cosmic indifference.

In the previous chapter, I presented an explanatory system of psychopathology based on death anxiety. The importance of such an explanatory system is as important for the therapist as it is for the patient. Every therapist uses an explanatory system, some ideological frame of reference to organize the clinical material with which he or she is faced. Even if the therapist's explanatory system is so complex and abstract and so rooted in unconscious structures that it cannot be explicitly transmitted to the patient, it nonetheless enhances the therapist's effectiveness in numerous ways. First, a belief system provides therapists with a sense of security for the same reasons that explanation is useful to patients. By allowing the therapist to control and not be overwhelmed by a patient's clinical material, a belief system enhances a therapist's self-confidence and sense of mastery and results in the patient's developing trust and confidence in the therapist, an essential condition for treatment. Furthermore, a therapist's belief system often serves to augment his or her interest in a patient, an interest that vastly facilitates the development of the necessary therapist-patient relationship. For example, I believe that the search for a genetic causal explanation, that is, why from the standpoint of a patient's past history is that patient the way he or she is, is a wrong steer in the therapeutic process. Nevertheless, the explanation of the past often serves an important function in therapy. It provides therapist and patient with a joint purposeful project, an intellectual bone to gnaw upon which brings them together and keeps them cemented to one another while the real agent of change, the therapeutic relationship germinates and matures. The therapist's belief system provides consistency to his or her remarks to patients. It permits the therapist to know what to explore and what not to push so that he or she doesn't confuse a patient. Even if the therapist does not make full and explicit interpretations about the unconscious roots of a patient's problems, the therapist may still with subtlety and good timing make comments that at a deep, unspoken level click with the patient's unconscious and allow the latter to feel completely understood. A belief system that is deeply rooted, grounded in fact in the deepest levels of being has the particular advantage of conveying to the patient that there are no taboo areas, that any topic may be discussed, and furthermore that his deepest concerns are not idiosyncratic but are shared by all human beings. The therapist's sense of certainty issuing from an explanatory system of psychopathology has a benefit for therapy which is curvilinear in nature. There is an optimal amount of therapist certainty. Too little and too much are counterproductive. Too little certainty, for reasons already discussed, retards the formation of the necessary level of trust. Too much certainty, on the other hand, becomes rigidity. The therapist rejects or distorts data that will not fit into his system. Furthermore, the therapist avoids facing and helping the patient to face one of the core concepts in existential therapy: that uncertainty exists and that all of us must learn to coexist with it.

Interpretive options, an illustrative case study. In chapter 4, I described some general existential dynamics underlying common clinical syndromes involving death anxiety. I shall present here specific interpretive options in a case of compulsive sexuality. Bruce was a middle-aged male and had since adolescence been continually, as he put it, "on the prowl." He had had sexual intercourse with hundreds of women, but had never cared deeply for any of them. Bruce did not relate to a woman as to a whole person, but as a piece of ass. The women were more or less interchangeable. The important thing was bedding a woman, but once orgasm was reached, he had no particular desire to remain with her. It was not unusual, therefore, once a woman had left for him to go out searching for another, sometimes only minutes later. The compulsive quality of his behavior was so clear that it was evident even to him. He was aware often of needing or having to pursue a woman when he didn't wish to.

Now, Bruce could be understood from many perspectives, none of which had exclusive hegemony. The Oedipal overtones were clearly evident. He desired but feared women who resembled his mother. He was usually impotent with his wife. The closer he came in his travels to the city his mother inhabited, the stronger was his sexual desire. Furthermore, his dreams groaned with incestuous and castration themes. There was also evidence that his compulsive heterosexuality was powered by the need to handle the eruption of unconscious homosexual impulses. Bruce's self-esteem was severely impaired, and the successful seduction of women could be understood as an attempt to bolster his self-worth. Still, another perspective: Bruce had both a need and a fear of closeness. The sexual encounter, at once closeness and caricature of closeness, honored both the need and the fear. During more than eight years of analysis and several courses of therapy with competent therapists, all of these explanations and many others besides were explored fully but without effect on his compulsive sexual drive.

During my work with Bruce, I was struck by the rich unministial themes. Bruce's compulsivity could be understood as a shield against confrontation with his existential situation. For example, it was apparent that Bruce was fearful of being alone. Whenever he was away from his family, Bruce took great pains to avoid spending an evening alone. Anxiety can be a useful guide. And there are times when the therapist and patient must openly court anxiety. Accordingly, when Bruce had increased his ability to tolerate anxiety, I suggested that he spend an evening entirely alone and record his thoughts and feelings. What transpired that night was exceedingly important in his therapy. Raw terror is the best term for the experience. He encountered for the first time since childhood his fear of the supernatural. By sheer chance there was a brief power failure, and Bruce grew terrified of the dark. He imagined that he saw a dead woman lying on the bed resembling the old woman in the film *The Exorcist*. He imagined that he saw a death's head in the window. He feared that he might be touched by something, perhaps a hand of a skeleton, all dressed in rags. He gained enormous relief from the presence of a dog, and for the first time realized the strong bond between some individuals and their pets. "What is needed," he said, "is not necessarily a human companion, but something alive near you."

The terror of that evening was gradually, through the work of therapy, transformed into insight. Spending an evening alone made the function of sex abundantly clear. Without the protection of sex, Bruce encountered massive death anxiety. The images were vivid: a dead woman, a skeleton's hand, a death's head. How did sex protect Bruce from death? Through a number of ways, each of which we analyzed in therapy. Sexual compulsivity, like every symptom, is overdetermined. For one thing, sex was a form of death defiance. There was something frightening about sex for Bruce. No doubt, sex was deeply entangled with buried incestuous yearnings, and with fears of retaliatory castration, and by castration, I mean not literal castration, but annihilation. Thus, the sexual act was counterphobic. Bruce stayed alive by jamming his penis into the vortex of life. Viewed in this way, Bruce's sexual compulsivity dovetailed with his other passions: parachuting, rock climbing, and motorcycling. Sex also defeated death by reinforcing Bruce's belief in his personal specialness. Bruce stayed alive, in one sense, by being the center of his universe. Women revolved about him all over the world. Women adored him. They existed for him alone. Bruce never thought of them as having independent lives. He imagined they remained in suspended animation for him, that like Joseph K.'s flagellators in Kafka's *The Trial*, they were there for him every time he opened their doors, and that they froze into immobility when he didn't call upon them. And of course, sex served the function of preventing the conditions necessary for a true confrontation with death. Bruce never had to face the isolation that accompanies the awareness of one's personal death. Women were something alive and near, much like the dog on the night of his terror. Bruce was never alone. He was always in the midst of a frenetic effort to fuse with a woman, searching for a woman, or just having left a woman. Thus, his search for a woman was not truly a search for sex, nor even a search powered by infantile forces, by the stuff from which, as Freud liked to say, sex will come. But instead, it was a search to enable Bruce to deny and to assuage his fear of death.

Later in therapy, an opportunity arose for him to go to bed with a beautiful woman who was the wife of his immediate boss. He deliberated about this chance and discussed it with a friend who counseled him against taking it because it might have destructive ramifications. Bruce also knew that the toll he would have to pay in anxiety and guilt would be prohibitive. Finally, with a mighty wrench, he, for the first time in his life, decided to forego the sexual conquest. In our next therapy hour, I agreed with him that he was acting indeed in his best interests. His reaction to his decision was enlightening. He accused me of taking his life's pleasures away from him. He felt done for, finished. The following day, at a time when he could have had a sexual assignation, he read a book and sunbathed. "This is what Yalom wanted," he thought, "for me to grow old, sit in the sun, and bleach like an old dog turd." He felt lifeless and depressed. That night he had a dream that illuminates better than any dream I have ever known, the use of dream symbolism. I had a beautiful bow and arrow. I was proclaiming it as a great work of art that possessed magical qualities. You and X, a friend, differed and pointed out that it was just a very ordinary bow and arrow. I said, "No, it's magic. Look at those features and these." Pointing at two protuberances, you said, "No, it's very ordinary," and you proceeded to demonstrate to me how simply the bow was constructed, how simple twigs and bindings accounted for its shape.

What Bruce's dream illustrates so beautifully is another way that sex is death-defeating. Death is connected with banality and ordinariness. The role of magic is to allow one to transcend the laws of nature, to transcend the ordinary, to deny one's creaturely identity, an identity that condemns one to biological death. His phallus was an enchanted bow and arrow, a magic wand lifting him above natural law. Each affair magically constituted a mini-life. Although each of his affairs was a maze ending in a cul-de-sac, his affairs, all of them taken together, provided him with the illusion of a constantly lengthening lifeline. As we worked through the material generated by his taking these two stands: spending time alone, and not accepting a sexual invitation, a great deal of insight ensued to illuminate not only his sexual pathology, but many other aspects of his life. For example, he had always related to others in a highly limited sexual way. When his sexual compulsiveness waned, he began for the first time to confront the question, "What are people for?" A question that launched a valuable exploration of Bruce's confrontation with existential isolation. I shall discuss this phase of Bruce's therapy in chapter 9. Indeed, Bruce's course of therapy illustrates the interdependence of all the ultimate concerns. Bruce's decision and his subsequent reluctance to accept that decision to pass up a sexual invitation was the tip of the iceberg of another extraordinarily important existential concern: freedom, and especially of the issue of assuming responsibility, the theme of chapter 6. Lastly, Bruce's eventual relinquishment of his sexual compulsion confronted him with another ultimate concern: meaninglessness. With the removal of his major detra, Bruce began to confront the problem of purpose in life, the subject of chapter 9.

Death anxiety in long-term therapy. Though brief courses of therapy often entirely circumvent any explicit consideration of death anxiety, any long-term intensive therapy will be incomplete without working through awareness and fear of death. As long as a patient continues to attempt to ward off death through an infantile belief that the therapist will deliver him or her from it, then the patient will not leave the therapist. "As long as I am with you, I will not die" is the unspoken refrain that so often emerges in late stages of therapy. May Stern, in an important article, describes six patients mired in an interminable analysis. In each instance, the working through of death anxiety brought the analysis to a successful conclusion. One representative patient was a 30-year-old obsessive-compulsive male with symptoms of insomnia, nightmares, hypochondriasis, and the obsessive fantasy occurring in sexual relations that he was being sat upon and breathed into. Much analytic work has been done on Oedipal and pre-Oedipal levels. The meaning of his symptoms in terms of castration anxiety, incestuous feminine identification, pre-genital regression, oral incorporation, and so forth had been explored, but without therapeutic effect. Only when the analyst moved to a deeper level, the meaning of his symptoms in the context of death fear, did the clinical picture alter. Finally, transference material referring to a wish to get from the analyst a magical formula elicited the

interpretation that he conceived of analysis as protection against fear of death and that no one was able to protect him against inevitable death. This interpretation effected a surprising, almost dramatic turn. It brought into analysis his permanent fears of dying manifested in his hypochondriacal complaints, his desperate struggle with the fear of nothingness in the beginning of his latency period, and his wish to stay forever in analysis."

Another patient who had many self-destructive symptoms, gambling, drinking, continual quarreling, and masochistic sexual trends also had had little success in a lengthy analysis. "In analysis, no technical device was able to make him give up acting out the fantasy that by his perverse activities he would arouse the anger of the analyst, which to him meant being beaten. Any interpretation by the analyst was used for gratification of his wish to be scolded and beaten. Silence was interpreted as the sullen response of the angered father." His analysis seemed to have reached an impasse.

Finally, the therapist interpreted that through fusion with the analyst father, he wanted to win protection against death. This interpretation brought out a wealth of material hitherto withheld. He said, "Death is and always was around me." He remembered having thought a lot about death as a child. He said, "I have solved my fear of death through submission. Being raped anally is protection against death." He resented that this had not been pointed out to him earlier.

In this case, as in the first, the working through of transference was the via rea to the subterranean layers of death anxiety. The historical view of transference, that is, the transfer of affect from some prior nexus to a current one, is of only limited value in the actual process of therapy. What is important is the immediate here-and-now function of the patient's distortion. Stern's patient learned that he used the therapist as a shield against current death awareness and fear. Gradually he confronted his death and grew to understand that not only his transference but his symptoms too represented infantile magical ways of warding off death. For example, drinking represented symbolic ecstatic fusion with mother as a defense against death.

Each of these patients underwent subsequent marked improvement. But the author was careful to note that, "The dramatic turn in the treatment situation of these patients might be due to the fact that the interpretation of fear of death was introduced after years of tedious working through, after a possible termination of the analysis had appeared on the horizon."

In every neurotic individual, there is a substratum of death anxiety which can be worked through in extensive therapy. A process that the therapist facilitates by interpreting both the patient's symptoms and the transference as an attempt to cope with death. Death cannot be ignored in an extensive venture of self-exploration because a major task of the mature adult is to come to terms with the reality of decline and diminishment.

The Divine Comedy, which Dante wrote in his late 30s, may be understood on many allegorical levels, but certainly it reflects its author's concern about his personal death. The opening verses describe the fearful confrontation with one's own mortality that frequently occurs in midlife. "In the middle of the course of our life, I came to myself within a dark wood, having lost the direct way. Ah, how difficult it is to describe what that wood was like. Thick and savage and harsh, just the thought of which renews my fear."

Individuals who have had significant emotional distress in their lives, and whose neurotic defenses have resulted in self-restriction, may encounter exceptionally severe difficulty in midlife, the time when aging and impending death must be recognized. The therapist who treats a patient in midlife must remind himself or herself that much psychopathology emanates from death anxiety.

Jacques, in his essay on the midlife crisis, states this clearly. He wrote, "A person who reaches midlife either without having successfully established himself in marital and occupational life or having established himself by means of manic activity and denial with consequent emotional impoverishment is badly prepared for meeting the demands of middle age and getting enjoyment out of his maturity. In such cases, the midlife crisis and the adult encounter with the conception of life to be lived in the setting of an approaching personal death will likely be experienced as a period of psychological disturbance and depressive breakdown. Or breakdown may be avoided by means of a strengthening of manic defenses with a warding off of depression and persecution about aging and death, but with an accumulation of persecutory anxiety to be faced when the inevitability of aging and death eventually demands recognition. The compulsive attempts in many men and women reaching middle age to remain young. The hypochondriacal concern over health and appearance. The emergence of sexual promiscuity in order to prove youth and potency. The hollowness and lack of genuine enjoyment of life and the frequency of religious concern are familiar patterns. They are attempts at a race against time."

Death Anxiety as a Major Symptom: A Case Study

Often therapists encounter patients for whom death anxiety plays so central and explicit a role that no inferential leaps are needed. These patients are often trying, because their therapists, once they realize that there is no getting around the issue of death, become uncomfortably aware that they have no conceptual tools to guide them in their work.

Such a patient was Sylvia, who was mentioned earlier in this chapter as a member of the therapy group into which Charles, the patient with advanced cancer, was introduced. Sylvia was a divorced, 36-year-old, wealthy architect who had been in psychotherapy on and off over the previous 10 years. She was alcoholic, chronically depressed, anxious, obese, lonely, and subject to a wide variety of psychophysiological complaints, including headaches, urticaria, back pain, hearing difficulties, and asthma. She was involved in a severe conflict with her 13-year-old daughter and with two older children who, because of her alcoholism and unpredictable behavior, had elected to live with their father. Her previous therapy, individual, group, and family formats, had effected little improvement. A year and a half of therapy in a specialized group for alcoholics had helped Sylvia gain some control over her drinking. In most other ways, though, she remained on a plateau of stress, and therapy was merely a holding operation.

Charles's entrance into the therapy group, where she had been a member for several months, radically altered the course of her therapy. It forcibly confronted her with the idea of death, and some important themes hitherto overlooked emerged in her clinical picture. Sylvia's first reaction when Charles informed the group that he had incurable cancer was irrational. Earlier, I described her strong anger at him for passively giving into cancer and not seeking other than conventional medical modes of help. A couple of weeks after Charles had informed the group about his cancer, Sylvia had a panic reaction. She had bought a new leather sofa for her home but was strangely distressed by its smell. Furthermore, she had a house guest who was an artist, and she became convinced that the fumes from the oil paints were toxic. That evening, she developed a slight rash on her face and, in the middle of the night, woke up in severe panic, convinced that she was going to die as a result of respiratory failure caused by an allergic reaction to the sofa and to the paint fumes. She grew more and more frightened and finally called an ambulance in the middle of the night. She began drinking again and, 3 weeks after Charles's entrance, was arrested for drunken driving. She stated that her driving was a form of suicide. She felt that suicide was a mode of achieving some mastery over death because it gives one an active control of one's fate rather than waiting for something horrible to engulf you.

Her anxiety level continued high for several weeks, and she was so uncomfortable that she raised the question of leaving the therapy group. At the same time, she developed the conviction that her number was up in the group and that I was trying to get rid of her. When, because of her continued headaches, I referred her to an internist for a physical examination, she went into an acute depression and interpreted this referral as my saying to her that I refused to take care of her anymore and was sending her to someone else. When new people were introduced into the group, she was convinced that they were being brought in to replace her.

After her initial anxiety subsided, Sylvia stopped avoiding Charles and began to make contact with him, at first tentatively and then in a much more positive manner. There were meetings in which Charles was depressed or anxious, and it was Sylvia who, of all the members, found the courage to wonder aloud whether Charles was concerned about his cancer or about time running out. Gradually, Sylvia began thinking and talking more about some of her central concerns: aging, her fear of getting cancer, her dread of loneliness. She became preoccupied with her mother's death and began thinking about the events around it with greater detail and more intensity than she had for the last 15 years. These themes had always been present, yet they had never been formally worked on in her therapy.

Sylvia's case provides wonderful proof of how the therapist's frame of reference controls the content of the material provided by the patient. For example, Sylvia had had severe insomnia for 15 years and had been treated by many clinicians with a variety of approaches and a vast number of sedatives. A few weeks after Charles entered the group, she again described her intractable insomnia. But this time, because the therapist was tuned to a different channel, she added the information that for years she had awakened virtually every night between 2 and 4:00 a.m. in a sweat, saying to herself, "I don't want to die. I don't want to die." In her previous 10 years of therapy, including two years with me, she had never told that to a therapist.

When I invoked death anxiety as a central organizing principle, many disparate symptoms and events fell into a coherent pattern. Sylvia's panic attacks, which often initiated eating and drinking binges, were almost invariably precipitated by some type of insult to her body, some suggestion of physical illness or deterioration. Sylvia's death anxiety was always greatest when she was alone. The implicit message she delivered to her 13-year-old daughter was, "Don't grow up and leave me. I can't bear to be alone. I need you to stay as young as you are and to remain with me. If you don't grow up, I won't grow older." This message seriously affected her daughter, who displayed severe delinquent behavior.

Sylvia's chief mechanism of defense against her anxiety was her belief in the existence of an ultimate rescuer. A belief that lay at the root of her pervasive orality, manifested in part by her alcoholism and obesity, and was particularly evident in her relationship toward therapy and her therapists. She was perpetually obsequious and deferential to them. She feared nothing more than the possibility of being rejected or abandoned by them. To this end, she exaggerated her needfulness, concealed any positive gains that she made, and often presented herself as exaggeratedly confused and helpless. Her task in therapy was, it seemed, to present herself through a number of strategies as so enfeebled that the therapist would be forced to take her in hand and give her succor.

The more Sylvia confronted these issues, the higher her anxiety mounted. Soon she was so uncomfortable that she needed to be seen more frequently than once a week in the group meeting. I saw her for a series of individual sessions in which we did a focal analysis of her death concerns. The death of her mother had been the most painful event of Sylvia's life, and she couldn't think about it without horror. Her mother had developed cancer of the cervix, and at the age of 25, Sylvia left her family, flew to her mother's bedside, and nursed her for the last month of her life. Her mother at this point was either unconscious or in a highly irrational state of consciousness where she was hallucinatory and very paranoid. Without bladder or bowel control, her mother needed Sylvia's continual nursing. Finally, in the midst of excrement and overwhelming stench, with gurgling sounds in her throat and with blood and mucus running out of her mouth, her mother died. Sylvia remembers feeling at that time that her head was disconnected from her body, that it was swelling and would split apart, similar to the headache she experienced after Charles entered the group.

Sylvia has many frightening childhood memories about death. Her grandfather had died when she was seven, and her grandmother 6 months later. She remembers seeing her grandmother in the casket and remembers her conviction that they had cut her grandmother's throat. In retrospect, she thinks her grandmother had had thyroid surgery. When she was 12, a schoolmate drowned, and she went to his funeral, also a very frightening experience for her. Sylvia herself had been a sickly child and was told on many occasions by her mother, and recalls her mother telling friends and relatives how close she had come to dying when young. She had several bouts with pneumonia in the first 5 years of her life. At the age of six, she had a broken arm and chronic osteomyelitis. She required surgery at that time and remembers with great dread the suffocating ether cone. Ever since then, she had had severe anxiety with anesthesia. During the birth of each of her children, the anesthesia evoked so much death anxiety that she had brief psychotic episodes.

Her earliest memory is of being dead as a very young child and of an aunt massaging her legs, perhaps trying to bring her back to life. She thinks she may have been in a coma and remembers that her aunt was crying. She also remembers that every time her body was touched, she felt intense pain but could not speak or communicate in any other way to ask her aunt to stop massaging her. A second early memory is a recollection of being dead and floating out of her body and trying desperately but in vain to rejoin it.

In addition to these early sensitizing experiences, which exposed her to death too much and too soon, several other important factors in Sylvia's life prevented her from building traditional defenses against death terror. She had no sense of reliance on either her mother or her father. Her father deserted the family when she was a young child, and her recollection of her mother is that she was undependable and irresponsible. Her mother panicked at any sickness or physical injury and called in some other member of the family to do the necessary nursing if anyone was ill. Her mother had not been available to her emotionally or physically. Even when Sylvia was a pre-adolescent, her mother left home, presumably with a man, for days on end, leaving the family entirely in Sylvia's care. Her mother faced her own death with unrelenting terror and provided Sylvia with a model that sensitized her even more to a fear of death. Many patients report that their parents' mode of facing death is extremely important in shaping their own attitudes toward death. There are in this observation some obvious implications for the treatment of the dying patient. One way to maintain meaning in life until the very end is to consider the model one sets for others.

Sylvia's death anxiety was obviously overdetermined. Not only had she had too many, too soon, early life-threatening experiences and frequent reminders of her close brush with death by her mother, but she also was not able to develop traditional denial-based defenses against death anxiety. She could not expect protection or rescue from her parents. Her father had, in effect, died, and her mother was herself overwhelmed by life. She could neither exile death to a distant realm nor develop credence in her own invincibility. Death was an imminent presence. It had almost snared her on more than one occasion, and she viewed herself as very vulnerable and very fragile.

Sylvia remembers trying to take solace in religious doctrine and pleading with her grandmother to prove to her that there was a God because if there were, he would prevent her from dying or take care of her when she died. She was raised a Southern Baptist with all that religion's hell-and-brimstone accoutrements. On several occasions when she was ill as a child, she had made a bargain with God: spare my life, and I will become a nun and devote my life to you. Now, decades later, Sylvia still brooded over her betrayal of that contract.

Our individual sessions devoted to death and anesthesia were productive, and Sylvia became much more aware of the extent of her fear of death and of the role this fear played in her life. As she proceeded in the therapy group, she became aware of her terror of growing old and of her exceedingly maladaptive defense, which consisted of a freeze-and-camouflage maneuver. In other words, she suspended living and growing in the magical hope that death might simply overlook her. She neglected her physical appearance and spent evenings and weekends vegetating. She had become increasingly obese because of some magical belief that if she could avoid becoming thin and emaciated like her mother, then she could avoid death. Hatty Rosenberg describes identical dynamics in one of her patients. Her suspension of living was brought home to her in the group when one of the men brought her flowers on her birthday. She caught her breath as she became aware of how much she wanted a lover and of how much she had missed over the last several years by straddling the fence between living and not living.

Sylvia also became aware of the fact that she treated herself like a dying person and made certain demands on others to treat her accordingly. Once, when she was attacked for her hypochondriacal rumination in the group, she blurted out, "How can you treat me like this when I'm dying?" She realized the absurdity of the statement, but also that it was a phrase she had muttered sotto voce for many years.

Much of Sylvia's work in the group centered about her relationship with Charles and with me. Her relationship with Charles became much more real. She stopped denying his illness, stopped urging him to seek a healer's help, and stopped competing with him for the title of the individual in the group most close to death. Week by week, she slowly began to relinquish her belief in my omnipotence. While she tried to hold on to her image of me as a figure larger than life, she also became aware of her impatience with me for my fallibility. Accordingly, I was careful not to assume a posture of omniscience but was as open and transparent as possible.

Sylvia's improvement became noticeable and solid. She began facing death rather than being paralyzed by it. She realized that to escape death anxiety, she had attempted in the past to merge with her therapist or friends. Even television served that purpose. And when she was very much afraid of death, she would watch television for long periods of time because, "Simply hearing a voice makes me realize I'm still alive." She stopped being afraid of loneliness and began to feel that it would be possible for her to live a satisfying life even without a comforting, dependent relationship with a child or a man. There is an old saying, "He who carries his own light need not fear the dark." She began to groom herself, to lose weight, and to build up a social life outside the group. The group had for 2 years constituted her entire social world, and we realized that she was approaching termination when, in one meeting, she announced that she had to leave 30 minutes early because of a dinner date.

The most striking occurrence, however, was her announcement to the group that for several weeks she had been meditating daily on her mother's death—not an obsessive rumination, as had often been the case in the past, but a conscious meditation on all the horrible aspects of her mother's death, with a deliberate plan for mastering it through total familiarity. This decision was especially important since it was a plan she had conceived herself rather than one suggested by the therapist. For years, she had been obsessed with the idea that she would die at the same age as her mother. The group observed that she no longer spoke of this obsession, and she replied, "I haven't thought about that for a long time. It simply isn't part of my experience anymore. I'm into living now."

She made a firm decision to terminate the group and, expectedly, suffered recurrences of many of her symptoms. She experienced some nightmares, some death panics in the middle of the night, and fleeting desires to petition some superior figure for relief. This exacerbation of symptomatology, however, was brief, perhaps in part because the therapist had predicted that it would occur in the face of the pain of termination. At her last session, she brought this dream: "I was in a large cave, and there was a guide there who promised, I thought, to show me some dazzling exhibition. However, there was nothing at all in the cave, no paintings or artwork of any sort. He then took me into another room which was a rectangular room, perhaps the size of the group therapy room here, and once again there were no paintings or any kind of exhibition. Finally, the only thing I could see were a couple of windows overlooking some drab gray skies and oak trees. Then, on the way going out, the guide suddenly changed. He had red hair and incredible magnetism so that I thought he was absolutely electric. There was something very, very strong going on between the two of us. A very short time later, I saw him again, and he had seemed to have lost all of the magnetism and become a normal man in blue jeans again."

This dream is a splendid and poignant depiction of the relinquishment of magic. It portrays Sylvia's coming to terms with the illusory quality of her belief in the ultimate rescuer. In the dream, I cannot show her a dazzling exhibition. Instead of enchanting paintings, I offer only windows looking out at the drab reality of the world. Toward the end of the dream, Sylvia makes one final attempt to enclose me in magic. I suddenly become a figure with superhuman qualities, but the old self-deceptive spell has lost its staying power, and I soon revert back into what I really am: a guide. No more, no less.

In her previous therapies, Sylvia had always made sporadic terminations. She so dreaded the separation, the saying goodbye, and the realization that the therapist's powers were limited that she avoided the final sessions and broke off contact abruptly. Now she directly confronted the separation process and the underlying reminders of death in the same way she confronted death anxiety. Rather than being overcome by it, she took it into herself and moved through the anxiety to experience a richer life than she had ever known before.

Chapter 5: Problems of Psychotherapy: Denial by Patient and Therapist

Despite the omnipresence of death and the vast number of rich opportunities available for exploring it, most therapists will find extraordinarily difficult the tasks of increasing the patient's death awareness and working through death anxiety. Denial confounds the process every step of the way. Fear of death exists at every level of awareness, from the most conscious, superficial, intellectualized levels to the realm of deepest unconsciousness. Often, a patient's receptivity at superficial levels to the therapist's interpretation acts in the service of denial at deeper layers. A patient may be responsive to the therapist's suggestion that the patient examine his or her feelings about his or her finiteness, but gradually the session becomes unproductive. The material runs dry, and the discourse moves into an intellectualized discussion. It is important at these times that the therapist not leap to the erroneous conclusion that he or she is drilling a dry well. The blocking, the lack of associations, the splitting off of affect are all manifestations of resistance and should be treated accordingly.

One of Freud's first discoveries in the practice of dynamic therapy was that the therapist repeatedly comes up against a psychological force in the patient that opposes the therapeutic work. He wrote, "Through my psychic work, I had to oppose a psychic force in the patient which opposed the pathogenic idea from becoming conscious." The therapist must persevere. The therapist must continue to collect evidence, to work with dreams, to persist in his or her observations, to make the same points, albeit with different emphasis, over and over again. Observations about the existence of death may seem so banal, so overly obvious, that the therapist feels fatuous in persisting to make them. Yet, simplicity and persistence are necessary to overcome denial.

One patient, a depressed, masochistic, suicidal individual, in a debriefing session some months after termination of therapy, described the most important comment I had made to her during therapy. She had frequently described her yearning for death and, at other times, the various things she would like to do in life. I had made, more than once, the embarrassingly simple observation that there is only one possible sequence for these events: experience first, and death last.

The patient is not the only source of denial. Of course, frequently the denial of the therapist silently colludes with that of the patient. The therapist, no less than the patient, must confront death and be anxious in the face of it. Much preparation is required of the therapist, who must, in everyday work, be aware of death. My co-therapist and I became acutely aware of this necessity while leading a group of patients with metastatic cancer. During the first months of the group, the discussion remained superficial, much talk about doctors, medicines, treatment regimens, pain, fatigue, physical limitations, and so forth. We considered this superficiality to be defensive in nature, a signal of the depth of the patients' fear and despair. Accordingly, we respected the defense and led the group in a highly cautious manner. Only much later did we learn that we therapists had played an active role in keeping the group superficial. When we could tolerate our anxiety and follow the patients' leads, then there was no subject too frightening for the group to deal with explicitly and constructively. The discussion was often extraordinarily painful for the therapists. The group was observed through a one-way mirror by a number of student mental health professionals, and on several occasions, some had to leave the observation room to compose themselves. The experience of working with dying patients has propelled many therapists back for another course of personal therapy, often highly profitable for them, since many had not dealt with concerns about death in their first traditional therapy experiences. If a therapist is to help patients confront and incorporate death into life, he or she must have personally worked through these issues.

An interesting parallel is to be found in the initiation rites of healers in primitive cultures, many of which have a tradition requiring that a shaman pass through some ecstatic experience that entails suffering, death, and resurrection. Sometimes the initiation is a true sickness, and the individual who hovers long between life and death is selected for shamanism. Generally, the experience is a mystical vision. To take one not atypical example, a Tongus, a Siberian tribe shaman, described his initiation as consisting of a confrontation with shaman ancestors who surrounded him, pierced him with arrows, cut off his flesh, tore out his bones, drank his blood, and then reassembled him. Several cultures require that the novice shaman sleep on a grave or remain bound for several nights in a cemetery.

Why stir up a hornet's nest? Many therapists avoid discussions of death with a patient, not because of denial, but because of a deliberate decision based on the belief that the thought of death would aggravate that patient's condition. Why stir up a hornet's nest? Why plunge the patient deeply into a theme that can only increase anxiety, and about which one can do nothing? Everyone must face death. Does not the neurotic patient have quite enough troubles without being burdened with reminders of the bitter qua awaiting all humans? It is one thing, these therapists feel, to excavate and examine neurotic problems. There, at least, they can be of some help. But to explore the real reality, the bitter, immutable facts of life, seems not only folly but anti-therapeutic. The patient dealing with unreconciled Oedipal conflicts, for example, is hamstrung by fantasmal torments. Some constellation of internal and external events that occurred long ago persists in the timeless unconscious and haunts the patient. The patient responds to current situations in distorted fashion, to the present as though it were the past. The therapist's mandate is clear: to illuminate the present, to expose and scatter the demons of the past, to help the patient detoxify events that are intrinsically benign but irrationally experienced as noxious. But death. Death is not a ghost from the past, and it is not intrinsically benign. What can be done with it?

Increased Anxiety in Therapy

First, it is true that the thought of our finitude has a force field of anxiety about it. To enter the field is to heighten anxiety. The therapeutic approach I describe here is dynamic and uncovering. It is not supportive or repressive. Existential therapy does increase the patient's discomfort. It is not possible to plunge into the roots of one's anxiety without, for a period of time, experiencing heightened anxiousness and depression.

The case of Sylvia is clearly illustrative. After Charles told the group about his cancer, she experienced a violent eruption of anxiety and a recrudescence of many primitive defenses against this anxiety. Earlier, I described two patients reported by Stern who were in long-term individual analysis and who successfully terminated therapy only after an explicit and exhaustive working through of the mortal terror emanating from the fear of death. Once the therapy of each of these two patients entered the realm of death anxiety, each experienced a dramatic recrudescence of dysphoria. When one patient worked through his fantasy of the analyst protecting him against death and realized that there was to be no deliverer, he was plunged into a deep depression. "His hyperactivity in his work and in his hobbies turned into feelings of being utterly helpless, of living in a haze, of dissolution of his identity. This induced a regression to ambivalent symbiotic wishes, wishes for oral incorporation of his wife, of the analyst, and tremendous rage against both." The other patient too realized that his neurotic defenses would not protect him against death, and his analysis took a similar course. "He became depressed, felt constantly in a haze, and experienced the recrudescence of many infantile patterns which attempted a last-ditch defense against death." Each of the four other cases that Stern reported also experienced a temporary dysphoria and depression as they confronted the future trauma of death. Buggen, in his excellent discussion of the subject, refers to this phase of treatment as the existential crisis: an inevitable crisis which occurs when the defenses used to forestall existential anxiety are breached, allowing one to become truly aware of one's basic situation in life.

Life Satisfaction and Death Anxiety: A Therapeutic Foothold

From a conceptual standpoint, the therapist does well to keep in mind that the anxiety surrounding death is both neurotic and normal. All human beings experience death anxiety, but some experience such excessive amounts of it that it spills into many realms of their experience and results in heightened dysphoria and/or a series of defenses against anxiety which constrict growth and often themselves generate secondary anxiety. Why some individuals are brought down by the conditions that all must face is a question I've already addressed. The individual, because of a series of unusual life experiences, is both unduly traumatized by death anxiety and fails to erect the normal defenses against existential anxiety. What the therapist encounters is a failure of the homeostatic regulation of death anxiety.

One approach available to the therapist is to focus on the patient's current dynamics that alter that regulation. I believe that one particularly useful equation for the clinician is: death anxiety is inversely proportional to life satisfaction. John Hinton reports some interesting and relevant research findings. He studied 60 patients with terminal cancer and correlated their attitudes, including sense of satisfaction or fulfillment in life, with their feelings and reactions during terminal illness. The sense of satisfaction in life was rated from interviews with the patient and the patient's spouse. The feelings and reactions during the terminal illness were measured by interviews with the patients and by rating scales completed by nurses and spouses. The data revealed that, to a highly significant degree, "When life had appeared satisfying, dying was less troublesome. Lesser satisfaction with past life went with a more troubled view of the illness and its outcome." The lesser the life satisfaction, the greater was the depression, anxiety, anger, and overall concern about the illness and levels of satisfaction with the medical care. These results seem counterintuitive because, on a superficial level, one might conclude that the unsatisfied and disillusioned might welcome the respite of death. But the opposite is true. A sense of fulfillment, a feeling that life has been well-lived, mitigates against the terror of death.

Nietzsche, in his characteristic hyperbole, stated, "What has become perfect, all that is ripe, wants to die. All that is unripe wants to live. All that suffers wants to live that it may become ripe and joyous and longing. Longing for what is further, higher, brighter." Surely this insight gives the therapist a foothold. If he can help the patient experience an increased satisfaction in life, he can allay excessive anxiety. Of course, there is a circularity about this equation since it is because of an excessive death anxiety that the individual lives a constricted life, a life dedicated more to safety, survival, and relief from pain than to growth and fulfillment. Surls poses the same dilemma. "The patient cannot face death unless he is a whole person. Yet, he can become a truly whole person only by facing death." The problem, and it is especially critical with schizophrenic patients, Surls believes, is that "The anxiety concerning life's finitude is too great to face unless one has the strengthening knowledge that one is a whole person. A person cannot bear to face the prospect of inevitable death unless he has had the experience of fully living, and the schizophrenic has not yet fully lived." Yet still there is a foothold. The therapist must not be overawed by the past. It is not necessary that one experience 40 years of whole, integrated living to compensate for the previous 40 years of shadow life. Tolstoy's Ivan Ilyich, through his confrontation with death, arrived at an existential crisis and, with only a few days of life remaining, transformed himself and was able to flood retrospectively his entire life with meaning.

The less the life satisfaction, the greater the death anxiety. This principle is clearly illustrated by one of my patients, Philip, a 53-year-old, highly successful business executive. Philip had always been a severe workaholic. He worked 60 to 70 hours a week, always lugged a briefcase brimming with work home every evening, and during one recent 2-year period, worked on the East Coast and commuted weekends to his home on the West Coast. He had little life satisfaction. His work afforded safety, not pleasure. He worked not because he wanted to, but because he had to, to assuage anxiety. He hardly knew his wife and children. Years ago, his wife had had a brief extramarital affair, and he had never forgiven her, not so much for the actual act, but because the affair and its attendant pain had been a major source of distraction from his work. His wife and children had suffered from the estrangement, and he had never dipped into this potential reservoir of love, life, satisfaction, and meaning.

Then a disaster occurred that stripped Philip of all his defenses. Because of severe setbacks in the aerospace industry, his company failed and was absorbed by another corporation. Philip suddenly found himself unemployed and, possibly because of his age and high executive position, unemployable. He developed severe anxiety, and at this point sought psychotherapy. At first, his anxiety was entirely centered on his work. He ruminated endlessly about his job. Waking regularly at 4:00 a.m., he lay awake for hours thinking of work, how to break the news to his employees, how best to phase out his department, how to express his anger at the way he had been handled. Philip could not find a new position, and as his last day of work approached, he became frantic.

Gradually, in therapy, we pried loose his anxiety from the work concerns to which it adhered like barnacles to appear. It became apparent that Philip had considerable death anxiety. Nightly he was tormented by a dream in which he circled the very edge of a black pit. Another frightening recurrent dream consisted of his walking on the narrow crest of a steep dune on the beach and losing his balance. He repeatedly awoke from the dream, mumbling, "I'm not going to make it." His father was a sailor who drowned before Philip was born. Philip had no pressing financial concerns. He had a generous severance settlement, and a recent large inheritance provided considerable security. But the time—how was he going to use the time? Nothing meant very much to Philip, and he sank into despair.

Then one night, an important incident occurred. He had been unable to go to sleep, and at approximately 3:00 a.m., went downstairs to read and drink a cup of tea. He heard a noise at the window, went over to it, and found himself face to face with a huge, stocking-masked man. After his startle and the alarm had subsided, after the police had left and the search was called off, Philip's real panic began. A thought occurred to him, a jarring thought that sent a powerful shudder through his frame: Something might have happened to Mary and the children. When, during our therapy hour, he described this incident, his reaction, and his thought, I, rather than comfort him, reminded him that something will happen to Mary, to the children, and to himself as well.

Philip passed through a period of feeling wobbly and dazed. All of his customary denial structures no longer functioned: his job, his specialness, his climb to glory, his sense of invulnerability. Just as he had faced the masked burglar, he now faced, at first flinchingly and then more steadily, some fundamental facts of life: groundlessness, the inexorable passage of time, and the inevitability of death. This confrontation provided Philip with a sense of urgency, and he worked hard in therapy to reclaim some satisfaction and meaning in his life. We focused especially on intimacy, an important source of life satisfaction that he had never enjoyed. Philip had invested so much in his belief in specialness that he dreaded facing and sharing with others his feelings of helplessness. I urged him to tell all inquirers the truth, that he was out of a job and having trouble finding another, and to monitor his feelings. He shrank away from the task at first, but gradually learned that the sharing of vulnerability opened the door to intimacy. At one session, I offered to send his resume to a friend of mine, the president of a company in a related field, who might have a position for him. Philip thanked me in a polite, formal manner, but when he went to his car, he cried like a baby for the first time in 35 years. We talked about that cry a great deal, what it meant, how it felt, and why he could not cry in front of me. As he learned to accept his vulnerability, his sense of communion, at first with me and then with his family, deepened. He achieved an intimacy with others he had never previously attained. His orientation to time changed dramatically. No longer did he see time as an enemy to be concealed or killed. Now, with day after day of free time, he began to savor time and to luxuriate in it. He also became acquainted with other long-dormant parts of himself and for the first time in decades allowed some of his creative urges expression in both painting and writing.

After 8 months of unemployment, Philip obtained a new and challenging position in another city. In our last session, he said, "I've gone through hell in the last few months, but you know, as horrible as this has been, I'm glad I couldn't get a job immediately. I'm thankful I was forced to go through this." What Philip learned was that a life dedicated to the concealment of reality, to the denial of death, restricts experience and will ultimately cave in upon itself.

Death Desensitization

Another concept that offers a therapeutic foothold against death anxiety is desensitization. Desensitization to death—a vulgar phrase which is demeaning because it juxtaposes the deepest human concerns with mechanistic techniques. Yet, it is difficult to avoid the phrase in a discussion of the therapist's techniques for dealing with death anxiety. It seems that with repeated contact, one can get used to anything, even to dying. The therapist may help the patient deal with death terror in ways similar to the techniques that he uses to conquer any other form of dread. He exposes the patient over and over to the fear in attenuated doses. He helps the patient handle the dreaded object and to inspect it from all sides. Montaigne was aware of this principle and wrote, "It seems to me, however, that there is a certain way of familiarizing ourselves with death and trying it out to some extent. We can have an experience of it that is, if not entire and perfect, at least not useless, and that makes us more fortified and assured. If we cannot reach it, we can approach it. We can reconnoiter it, and if we do not penetrate as far as its fort, at least we shall see and become acquainted with the approaches to it."

In several years of working with groups of cancer patients, I have seen desensitization many times. Over and over, a patient approaches his or her dread until gradually it diminishes through sheer familiarity. The model set by other patients and by the therapist, whether it be resoluteness, uneasy stoic acceptance, or equanimity, helps to detoxify death for many patients. A basic principle of a behavioral approach to anxiety reduction is that the individual be exposed to the feared stimulus in carefully calibrated amounts in a psychological state and setting designed for the development of anxiety. The group approach employed this strategy. The group often began and ended with some anxiety-reducing meditational or muscle-relaxing exercise. Each patient was surrounded by others with the same illness. They trusted each other and felt completely understood. The exposure was graduated in that one of the operating norms of the group was that each member be allowed to proceed at his or her own speed and that no pressure be placed on anyone to confront more than he or she wished to.

Another useful principle in anxiety management is dissection and analysis. One's feeling of organismic catastrophic dread generally includes many fearful components that can yield to rational analysis. It may be helpful to encourage the patient, both the everyday psychotherapy patient and the dying one, to examine his or her death and sort out all the various component fears. Many individuals are overwhelmed by a sense of helplessness in the face of death. And indeed, the groups of dying patients I have worked with devoted much time to counteracting this source of dread. The major strategy is to separate ancillary feelings of helplessness from the true helplessness that issues from facing one's unalterable existential situation. I have seen dying patients regain a sense of potency and control by electing to control those aspects of their lives that were amenable to control. A patient may change his mode of interacting with his physician. He may insist on being informed fully about his illness or on being included in important treatment decisions. Or he may change to another physician if he is dissatisfied with the current one. Other patients involve themselves in social action. Others develop a sense of choicefulness. They discover with exhilaration that they can elect not to do the things they do not wish to do. Others who believe that developing new ways to manage psychological stress will influence the course of their cancer engage actively in psychotherapy. And when all else seems beyond one's control, one even then has the power to control one's attitude toward one's fate, to reconstruct what one cannot deny.

There are other component fears: the pain of dying, afterlife, the fear of the unknown, concern for one's family, fear for one's body, loneliness, regression. In achievement-oriented Western countries, death is curiously equated with failure. Each of these component fears, examined separately and rationally, is less frightening than the entire gestalt. Each is an obviously disagreeable aspect of dying. Yet neither separately nor in concert do these fears need to elicit a cataclysmic reaction. It is significant, however, that many patients, when asked to analyze their death terrors, find that they correspond to none of these, but to something primitive and ineffable. In the adult unconscious dwells the young child's irrational terror; death is experienced as an evil, cruel, mutilating force. Recall the terrifying children's fantasies of death described in chapter 3. Views of death far more horrible than those of the mature adult. These fantasies, no less than Oedipal or castration fears, are atavistic unconscious tags that disrupt the adult's ability to recognize reality and to respond appropriately. The therapist works with such fears. As with any other distortions of reality, he attempts to identify, to illuminate, and to scatter these ghosts of the past.

Death Desensitization: Empirical Evidence

Several reports in the literature, all psychology doctoral dissertations, describe workshops on death awareness that employ many of these approaches to death desensitization and measure quantitative changes in death anxiety. One 8-hour marathon workshop, which consisted of discussions of death, the viewing of a movie about death, guided fantasies in a state of deep muscle relaxation of each member's own terminal illness, death, and funeral, reported that the eight experimental subjects, in contrast to a control no-group sample, reorganized their ideas about death, used less denial in confronting their own deaths, and after an 8-week follow-up, had lower death anxiety scores. In postgroup interviews, some of the subjects gratuitously averred that the workshop catalyzed significant other life changes. One alcoholic, for example, reported that the laboratory had had an enormous impact on him. He had decided that he did not wish to die the demeaning death of an alcoholic and had become totally abstinent. Another similar death desensitization program, SYATD (Shaping Your Attitudes Toward Death), reduced death fears as measured by two manifest death anxiety scales. A death and self-discovery workshop laboratory resulted in decreased death anxiety but also in an increase in a sense of purpose in life. Other programs have shown an immediate post-workshop reduction in anxiety with

A return to pre-workshop levels in four weeks. Finally, a six-week death education class for nurses did not affect death anxiety immediately, but resulted in a significant reduction 4 weeks later.

Death is only one component of the human being's existential situation, and a consideration of death awareness illuminates only one facet of existential therapy. To arrive at a fully balanced therapeutic approach, we must examine the therapeutic implications of each of the other ultimate concerns. Death helps us understand anxiety, offers a dynamic structure upon which to base interpretation, and serves as a boundary experience that is capable of instigating a massive shift in perspective. Each of the other ultimate concerns to which I now turn contributes another segment of a comprehensive psychotherapy system. Freedom helps us to understand responsibility assumption, commitment to change, decision and action. Isolation eliminates the role of relationship whereas meaninglessness turns our attention to the principle of engagement.

Part two, freedom. In the section on the concept of death in psychotherapy, I suggested that the clinician would find the discussion strange yet oddly familiar. Strange because the existential approach cuts across traditional categories and clusters clinical observations differently, but familiar because in his or her bones, the experienced clinician apprehends the importance and the omnipresence of the concept of death. Strange yet familiar will apply to this section as well. Though the term freedom is not found in the psychotherapist's lexicon, the concept of freedom plays an indispensable role in both theory and practice of all traditional and innovative therapies.

To illustrate, consider these incidents in therapy that have come to my attention over the past several years.

One, to a patient who insists that her behavior is controlled by her unconscious, a therapist says, "Whose unconscious is it?"

Two, a group leader has a "can't bell" which he rings whenever a patient in his group says, "I can't." The patient is asked to recant and then to restate the phrase as, "I won't."

Three, a patient caught up in a highly self-destructive relationship stated, "I cannot decide what to do. I can't bring myself to end the relationship, but I pray that I could catch him in bed with another woman so I would be able to leave him."

Four, my first supervisor, an orthodox Freudian analyst who firmly believed in Freud's deterministic view of behavior, said to me 20 years ago in our first meeting, "The goal of psychotherapy is to bring the patient to the point where he can make a free choice." Yet though we had over 50 more supervisory sessions, I don't recall his ever having said another word about choosing, which he pronounced as the goal of therapy.

Five. Many therapists repeatedly ask patients to change their speech and own what happens to them. Not, "He bugs me," but, "I let him bug me." Not, "I have a mind that skips," but, "When I get hurt and feel like crying, I defend myself by being confused."

Six. A therapist asked a 45-year-old patient to have a dialogue with his dead mother and to repeat this sentence several times: "I will not change until you treat me differently when I was 10 years old."

Seven. Otto Will, a legendary therapist, is reported to have periodically interrupted the interminable ruminations of a highly restricted obsessive patient with such suggestions as, "Say, why don't you change your name and move to California?"

Eight. At 5:00 p.m., a sexually compulsive man arrived by plane in a city where he had a professional commitment the following morning. While still at the airport, he hurriedly began phoning a series of women acquaintances to arrange for a sexual liaison on that evening. No luck. They all had previous engagements. Of course, he could easily have phoned them days or indeed weeks earlier. His response was relief. "Thank God. Now I can read and get a good night's sleep, which is what I really wanted to do all along."

These incidents may appear to be a potpourri of patients' thoughtless utterances and of smug, gimmicky therapists' ploys, yet as I shall demonstrate, they are all of a piece, bound together by the conceptual thread of freedom. Furthermore, though these incidents are frocked in insubstantial garb, insubstantial concerns, each properly considered will be seen to have implications that stretch down into the socket of existence. Each incident offers a perspective on the theme of freedom, and each will serve as a springboard for the discussion of some therapeutically relevant aspect of freedom.

To the philosopher, freedom has broad personal, social, moral, and political implications and consequently encompasses a wide terrain. Moreover, the issue is intensely controversial. The philosophical debate concerning freedom and causality has not ceased for 2,000 years. Throughout the centuries, the concept of absolute freedom has always engendered bitter opposition because it has clashed with prevailing world views: first with the belief in divine providence, later with the laws of scientific causality, still later with a Hegelian view of history as a meaningful progression, or with Marxist or Freudian deterministic theories. However, in this section, as elsewhere in this book, I shall examine only those aspects of freedom that have important everyday relevance to the clinician. Specifically, in chapter 6, the individual's freedom to create his or her own life. And in chapter 7, the individual's freedom to desire, to choose, to act, and, more important for the purposes of psychotherapy, to change.

Chapter 6, responsibility. Responsibility has many connotations. We label a trustworthy, dependable person responsible. Responsibility also implies accountability, legal, financial, or moral. In the mental health field, responsibility refers to the patient's capability for rational conduct as well as to the therapist's moral commitment to the patient. Although none of these connotations is entirely irrelevant to this discussion, I use responsibility here in a specific sense, in the same sense as did Jean-Paul Sartre when he wrote that to be responsible is to be the uncontested author of an event or a thing. Responsibility means authorship. To be aware of responsibility is to be aware of creating one's own self, destiny, life predicament, feelings, and, if such be the case, one's own suffering. For the patient who will not accept such responsibility, who persists in blaming others, either other individuals or other forces, for his or her dysphoria, no real therapy is possible.

Responsibility as an existential concern. But how is responsibility existential? That death is an existential issue is self-evident. Mortality and finitude are obvious givens of existence. But when we speak of responsibility, or as in the following chapter of willing, then the existential reference is not immediately evident. At the deepest level, responsibility accounts for existence. This was brought home to me many years ago by a simple experience so potent that it has remained vividly with me.

I was snorkeling alone in the warm, sunny, clear waters of a tropical lagoon and experienced, as I often do while in the water, a deep sense of pleasure and coziness. I felt at home. The warmth of the water, the beauty of the coral bottom, the sparkling silver minnows, the neon-bright coral fish, the regal angel fish, the fleshy anemone fingers, the aesthetic pleasure of gliding and carving through the water, all in concert created an underwater elysium. And then, for reasons I have never understood, I had a sudden, radical shift in perspective. I suddenly realized that none of my watery companions shared my cozy experience. The regal angel fish didn't know that it was beautiful. The minnows that they sparkled, the coral fish that they were brilliant, nor, for that matter, did the black needle urchins or the bottom debris, which I tried not to see, know of their ugliness. The at-homeness, the coziness, the smiling hour, the beauty, the beckoning, the comfort—none of these really existed. I had created the entire experience. I could, by the same token, glide through oil-slicked waters bobbing with empty plastic Clorox containers and choose to consider it either beautiful or disgusting. At the deepest level, the choice and the creation were mine. In Hurrell's terms, my noa or meaning had exploded, and I had become aware of my constitutive function. It was as though I peered through a rent in the curtain of daily reality to a more fundamental and deeply unsettling reality.

In his novel *Nausea*, in one of the great passages of modern literature, Sartre describes this moment of illumination, the discovery of responsibility. He wrote: "The roots of the chestnut tree were sunk in the ground just under my bench. I couldn't remember it was a root anymore. The words had vanished, and with them the significance of things, their methods of use, and the feeble points of reference which men have traced on their surface. I was sitting, stooping forward, head bowed, alone in front of this black, naughty mass, entirely beastly, which frightened me. Then I had this vision. It left me breathless. Never until these last few days had I understood the meaning of existence. I was like the others, like the ones walking along the seashore, all dressed in their spring finery. I said like them, 'The ocean is green. That white speck up there is a seagull,' but I didn't feel that it existed, or that the seagull was an existing seagull. And then all of a sudden, there it was, clear as day. Existence had suddenly unveiled itself. It had lost the harmless look of an abstract category. It was the very paste of things. The root was sunk into existence. Or rather, the root, the park gates, the bench, the sparse grass, all that had vanished. The diversity of things, their individuality, were only an appearance, a veneer. This veneer had melted, leaving soft, monstrous masses all in disorder, naked in a frightful, obscene nakedness. This root, on the other hand, existed in such a way that I could not explain it. Naughty, inert, nameless. It fascinated me, filled my eyes, brought me back unceasingly to its own existence. In vain, to repeat this is a root, it didn't work anymore."

Sartre's protagonist confronts the raw, monstrous masses—the very paste of things, stuff that has no form, no meaning until he supplies it. The knowledge of his true situation crashes in on him as he discovers his responsibility for the world. The world acquired significance only through the way it is constituted by the human being—in Sartre's terms, the "for-itself." There is not meaning in the world outside of or independent of the "for-itself."

Western and Eastern philosophers alike have pondered the problem of man's responsibility for the nature of reality. The heart of Kant's revolution in philosophy was his position that it is human consciousness, the nature of the human being's mental structures, that provides the external form of reality. Space itself, according to Kant, "is not something objective and real but something subjective and ideal. It is, as it were, a schema issuing by a constant law from the nature of the mind for the coordinating of all outer sense of whatever end."

What are the implications of this worldview for the psychology of the individual? It was Heidegger and then Sartre who explored the meaning of responsibility for the individual being. Heidegger referred to the individual as *Dasein*, not as "I" or "one" or "ego" or "a human being," for a specific reason. He wished always to emphasize the dual nature of human existence. The individual is there—the *Da* in *Dasein*—but also he or she constitutes what is there. The ego is two in one: it is an empirical ego, an objective ego, something that is there, an object in the world, and a transcendental, constituting ego which constitutes—that is, is responsible for—itself and the world.

Responsibility, viewed in this manner, is inextricably linked to freedom. Unless the individual is free to constitute the world in any of a number of ways, then the concept of responsibility has no meaning. The universe is contingent. Everything that is could have been created differently. Sartre's view of freedom is far-reaching. The human being is not only free but is "doomed to freedom." Furthermore, freedom extends beyond being responsible for the world, that is, for imbuing the world with significance. One is also entirely responsible for one's life, not only for one's actions, but for one's failure to act. There is, as I write, mass starvation in another part of the world. Sartre would state that I bear responsibility for this starvation. I, of course, protest. I know little of what happens there, and I feel I can do little to alter the tragic state of affairs. But Sartre would point out that I choose to keep myself uninformed and that I decide at this very instant to write these words instead of engaging myself in the tragic situation. I could, after all, organize a rally to raise funds or publicize the situation through my contacts in publishing, but I choose to ignore it. I bear responsibility for what I do and for what I choose to ignore. Sartre's point in this regard is not moral. He doesn't say that I should be doing something different, but he says that what I do do is my responsibility.

Both of these levels of responsibility—significance attribution and responsibility for life conduct—have, as we shall see, enormous implications for psychotherapy. Both to constitute, to be responsible for oneself and one's world, and to be aware of one's responsibility is a deeply frightening insight. Consider its implication: nothing in the world has significance except by virtue of one's own creation. There are no rules, no ethical systems, no values. There is no external reference whatsoever. There is no grand design in the universe. In Sartre's view, the individual alone is the creator. This is what he means by "man is the being whose project is to be God."

To experience existence in this manner is a dizzying sensation. Nothing is as it seemed. The very ground beneath one seems to open up. Indeed, "groundlessness" is a commonly used term for a subjective experience of responsibility awareness. Many existential philosophers have described the anxiety of groundlessness as anxiety, the most fundamental anxiety, an anxiety that cuts deeper even than the anxiety associated with death. In fact, many consider death anxiety as a symbol for the anxiety of groundlessness. Philosophers often make the distinction between "my death" and "death" or "the death of another." What is truly terrifying about my death is that it implies the dissolution of my world. With my death, the meaning-giver and spectator of the world dies too and is truly confronted with nothingness.

The concerns of nothingness and of self-creation have another deep and unsettling implication: loneliness, an existential loneliness, which, as I shall discuss in chapter 8, extends far beyond ordinary social loneliness. It is the loneliness of being separated not only from people but from the world as one ordinarily experiences it as well. As Sartre put it, "the responsibility of the for-itself (that is, the individual consciousness) is overwhelming since it is thanks to the for-itself that it happens. There is a world."

We respond to the anxiety of groundlessness as we do when confronted with anxiety: we seek relief. There are many ways to shield ourselves. First, unlike death anxiety, the anxiety of groundlessness is not evident in everyday experience. It is not easily intuited by the adult and probably not experienced at all by the child. Some individuals, like Sartre's Roquentin in *Nausea*, have flashes of their constitutive activity on several occasions in life, but generally it remains far from awareness. One avoids situations, for example, making decisions, isolation, autonomous action, that if deeply considered would make one aware of one's fundamental groundlessness. Thus, one seeks structure, authority, grand designs, magic—something that is bigger than oneself. Even a tyrant, as Fromm reminds us in *Escape from Freedom*, is better than no leader at all. Thus it is that children are upset by freedom and demand limit-setting. Panicky psychotic patients exhibit the same need for structure and limits. The same dynamic underlies the development of transference in the course of psychotherapy.

Other defenses against the anxiety of groundlessness include the common ones used against full awareness of my death, because death denial is an ally of groundlessness denial. Perhaps the most potent defense of all, however, is simply reality as it is experienced—that is, the appearance of things. To view ourselves as primal constitu ordinarily experience it. Our sense data tell us that the world is there and that we enter and leave it. Yet, as Heidegger and Sartre suggest, appearances enter the service of denial. We constitute the world in such a way that it appears independent of our constitution. To constitute the world as an empirical world means to constitute it as something independent of ourselves. Heidegger said, "to be taken in by any of these devices that allow us to flee from our freedom is to live inauthentically," or as Sartre said, "in bad faith." Sartre considered it his project to liberate individuals from bad faith and to help them assume responsibility. It is the psychotherapist's project as well. In much of the remainder of this chapter, I shall explore the clinical ramifications of responsibility avoidance and the techniques available to the therapist to facilitate the process of assumption of responsibility.

Responsibility avoidance: clinical manifestations. Even the most casual historical review of the field of psychotherapy reveals radical changes in the modes whereby therapists offer help to patients. The riotous proliferation of new, competing therapies appears to defy any coherent pattern and consequently has at times undermined the general public's confidence in the field. But a careful look at these new therapies, as well as at new developments in traditional therapies, reveals that they have one outstanding feature in common: an emphasis on the assumption of personal responsibility. That this is so, that modern approaches focus heavily on responsibility, is no accident. Therapies reflect and are shaped by the pathology that they must treat.

Fandi Vienna, incubator and cradle of Freudian psychology, had all the characteristics of late Victorian culture: instinctual, especially sexual, repression; heavily structured and clearly defined rules of behaviors and manners; separate spheres for men and women; an emphasis on willpower and moral strength; and an intoxicating optimism springing from a scientific positivism that promised to explain all aspects of the natural order, not excluding human behavior. Freud realized quite correctly that such rigid suppression of natural inclinations was detrimental to the psyche. Libidinal energy that could not be permitted to surface nakedly begat restrictive defenses and indirect means of expression. The defenses and the oblique mode of libidinal expression together comprised the clinical picture of the classical psychoneurosis.

But what would Freud emphasize were he to examine contemporary American culture, especially in California, which has been the birthplace of so many of the newer therapeutic approaches? Natural instinctual strivings are given considerable free expression. Sexual permissiveness, beginning in early adolescence, is, as many surveys have demonstrated, a reality. A generation of young adults have been nursed and spoon-fed, according to a compulsively permissive regimen. Structure, ritual, boundaries of every type are being relentlessly dismantled. In the religious orders, Catholic sisters defy the Pope. Priests refuse to remain celibate. Women and gay men divide the Episcopal Church on their right to be ordained. And women rabbis lead services in many synagogues. Students address professors by their first names. Where are the forbidden dirty words, the professional titles, the manuals of manners, the dress codes?

A friend of mine, an art critic, characterized the new California culture by describing an incident that occurred on his first visit to Southern California. He stopped at a fast-food drive-in and was given, with his hamburger, a small plastic container of ketchup. Elsewhere, these containers have a dotted line and the notation "to tear here." The California container has no dotted lines, only the simple inscription, "Tear anywhere."

The picture of psychopathology has changed accordingly. The classical psychoneurotic syndromes have become a rarity. Even a decade ago, an individual with a true psychoneurotic clinical picture was a treasure eagerly vied for by both young trainees and senior staff. Today's patient has to cope more with freedom than with suppressed drives. No longer pushed from within by what he or she has to do, or pulled from without by what he or she must or ought to do, the patient has to cope with the problem of choice, with what he or she wants to do. With increasing frequency, patients seek therapy with vague, ill-defined complaints. Indeed, I often finish my first consultative session with no clear picture of a patient's problem. I consider the fact that the patient cannot define the problem as the problem. The patient complains of something missing from life, of being cut off from feelings, of emptiness, of zestlessness, or of a sense of being cast adrift. The course of therapy of such patients is similarly diffuse. The word "cure" has been banished from the vocabulary of therapy. Instead, the therapist speaks of "growth" or "progress." Since the goals are indistinct, the end point of therapy is similarly blurred, and courses of therapy often continue aimlessly year after year.

The atrophy of structure-providing social and psychological institutions in our lives has served to confront us with our freedom. If there are no rules, no grand designs, nothing we must do, then we are free to do as we choose. Our basic nature hasn't changed. One might say that with the stripping away of freedom-concealing diversions, with the deconstruction of externally imposed structure, we are today closer than ever to experiencing the existential facts of life. But we are unprepared. It is too much to bear. Anxiety clamors for release, and at both individual and social levels, we engage in a frenetic search to shield ourselves from freedom.

Let me turn now to an examination of the specific psychic defenses that protect the individual from responsibility awareness. No therapist goes through a day of clinical work without encountering several examples of responsibility-avoiding defenses. I shall discuss some of the more common ones: compulsivity, displacement of responsibility to another, denial of responsibility (innocent victim), losing control, avoidance of autonomous behavior, and decisional pathology.

Compulsivity. One of the more common dynamic defenses against responsibility awareness is the creation of a psychic world in which one does not experience freedom but exists under the sway of some irresistible, ego-alien, "not me" force. We call this defense compulsivity. A clinical illustration of it is provided by Bernard, a 25-year-old salesman whose major problems centered on guilt and drivenness. He was driven in his sexual behavior, in his work, and even in his leisure. He was the man who, in the example in the introduction to part two, upon failing to arrange a sexual liaison (he had deliberately phoned too late), breathed a sigh of relief: "Now I can read and get a good night's rest, which is what I really wanted all along." In that remarkable phrase, "which is what I really wanted all along," lies the crux of Bernard's problem. The obvious question is, "Why, Bernard, if this is what you really want, did you simply not do that directly?" Bernard answered that query in several ways. "I didn't know that was what I really wanted until I felt the wave of relief that came over me when the last woman refused me." At another time, he stated, in effect, that he was unaware there was a choice involved. "Making a woman is what it's all about." The drive was so compelling that it was unthinkable for him not to bed an available woman, even though it was perfectly clear that the brief sexual exhilaration was heavily outweighed by the associated dysphoria, anticipatory anxiety, feelings of self-dissatisfaction (because his sexual ruminations reduced his effectiveness at work), guilt, and fear that his sexual promiscuity would be discovered by his wife; self-contempt because of his awareness that he acted in bad faith by using women as one would use a machine. Bernard then avoided the problem of responsibility and choice by a compulsivity that obliterated choice. His subjective experience was similar to hanging on for dear life to a frenzied, uncontrollable bronco. He sought therapy to find relief from his dysphoria but was blind to the fact that at some level he was responsible for having created his dysphoria, his compulsivity—in short, for having created every aspect of his life predicament.

Displacement of responsibility. Many individuals avoid personal responsibility by displacing it to another. This maneuver is exceptionally common in the psychotherapy situation. One of the major themes in my work with Bernard was his effort to shift the burden of responsibility from himself to me. He didn't think about his problem from one session to the other. Instead, he merely stored up the material and dumped it in my lap. He countered this observation with the cunning rejoinder that if he processed the material beforehand, spontaneity would be stripped from the sessions. He rarely produced dreams because he couldn't will himself to write down the dreams during brief awakenings in the night, and by morning he had forgotten them. On the rare occasions when he did write down a dream, he never once looked at the dream between the time of writing it and his session. Consequently, he often could no longer decipher his own script. During a summer break, when I was away on vacation, he marked time waiting for my return and dreamed the night before we resumed that he was at a football game and watching himself perched upon my shoulders, catching a touchdown pass. His behavior during that first session was a symbolic reenactment of the dream. He deluged me with detailed accounts of his summer anxieties, guilt, sexual behavior, and self-deprecation. He had, for four weeks, given in to his compulsivity and anxiety, waiting for me to return to show him how to take a stand against them. Though he had often used brainstorming exercises in his work, he seemed dismayed when I suggested a simple exercise for him: reflecting on himself for 20 minutes and then writing down his observations. After a few fruitful attempts, he couldn't find the time for the exercise. After a session in which I persisted in pointing out how he dumped his problems on me, he dreamed: "A man X, an individual who resembled Bernard, obviously a double, called me for an appointment. He said I had known his mother and that he himself now wanted to see me. I felt I didn't want to see him. I then thought that since he was in public relations, maybe I ought to think of what I can get from him. But then we couldn't work out a meeting time. Our schedules were incompatible. I said to him, 'Perhaps we ought to schedule a meeting to talk about your schedule.'" I woke up laughing. Bernard drove 50 miles to see me and never once felt burdened by the long commute. Yet, as the dream clearly illustrates, he could not and would not find the time for a session with himself. Obviously, for Bernard, and for every patient who will not work in the absence of the therapist, it's not a matter of time or convenience. What is at stake is the facing of one's own personal responsibility for one's life and one's process of change. And always lurking beyond that awareness of responsibility is the dread of groundlessness. The assumption of responsibility is a precondition of therapeutic change. As long as one believes that one's situation and dysphoria are produced by someone else or by some external force, then what sense is there in committing oneself to personal change? People show indomitable ingenuity in finding ways to avoid awareness of responsibility. One patient, for example, complained of severe, long-standing sexual problems in his marriage. I believe that by facing his responsibility for his situation, he would have had a frightening confrontation with freedom and discovered that he was locked up in a prison of his own creation. In fact, he was free if sex were important enough to leave his wife or find another woman or to consider leaving his wife. The mere thought of separation was sufficient to propel him into paroxysms of anxiety. He was free to change any aspect of his sexual life. And that fact too was momentous because it meant that he would have to assume the responsibility of a lifelong stifling of his sexual feelings and many other aspects of his affective life as well. Consequently, he doggedly avoided facing responsibility and attributed the sexual problems to a number of factors outside of himself: that is, to his wife's sexual lack of interest and her disinclination to change; to squeaky bedsprings so noisy that the children would overhear the sounds of coitus and for many absurd reasons the bed could not be replaced; to his aging (he was 45); an innate libidinal deficit; to his unresolved problems with his mother, which, as is so often true for genetic explanations, served more as apologia for responsibility avoidance than as catalyst for change.

Other modes of displacing responsibility are commonly seen in clinical practice. Paranoid patients obviously displace responsibility to other individuals and forces. They disown and attribute to others their own feelings and desires and invariably explain their dysphoria and failures as the result of external influence. The major and often impossible therapeutic task with paranoid patients is to help them accept authorship of their projected feelings. The avoidance of responsibility is also the major obstacle in the psychotherapy of the patient with a psychophysiological illness. The assumption of responsibility in these patients is twice removed. They experience somatic rather than psychological distress, and even when they recognize the psychological substrate to their somatic distress, they still characteristically employ externalization defenses, attributing their psychological dysphoria to "bad nerves" or to adverse work or environmental conditions.

Denial of responsibility, innocent victim. A particular type of responsibility avoidance is often seen in individuals generally thought of as hysterical personalities who deny responsibility by experiencing themselves as innocent victims of events that they themselves have unwittingly set into motion. For example, Clarissa, a 40-year-old practicing psychotherapist, entered a therapy group to work on her long-standing difficulties in developing intimate relationships. She had particularly severe problems in relating to men who, beginning with a brutal, punitive father, characteristically rejected and punished her. During our initial intake session, she told me that several months previously, she had terminated a lengthy psychoanalysis and that she now felt that her problems would be better dealt with in a group setting. After several months in the group, she informed us that she had re-entered analysis shortly after beginning the group, but had not considered it of sufficient import to report to the group. At this point, however, her analyst, who strongly disapproved of group therapy, interpreted her membership in a therapy group as "acting out." It is obvious that a patient cannot work in a therapy group if his or her individual therapist opposes and undermines the work. I attempted, at Clarissa's suggestion, to communicate with her analyst, but he elected to maintain a psychoanalytic posture of total confidentiality and, somewhat huffily, I thought, refused even to converse with me about the matter. I felt betrayed by Clarissa, irritated with her analyst, and dazed by the turn of events. Throughout, Clarissa remained ingenuous and slightly bewildered at the confusing events occurring to her. The group members viewed her as playing dumb, and in an effort to help her see her role in these events, they became increasingly forceful, almost punitive, in their comments. Clarissa felt once again victimized, especially by men, and, as she put it, due to circumstances beyond her control, was forced to leave the group. This incident was a miniature version of Clarissa's core problem: an avoidance of responsibility, which she accomplished by playing the role of innocent victim. Though she was not yet prepared to see it, the incident held the key to her difficulties in establishing intimate relationships. Two important men in her life, her analyst and her group therapist, felt manipulated and, speaking for myself, annoyed with her. The other group members felt similarly used. She did not relate to them in good faith, but instead, they felt they were mere pawns in a drama she was enacting with her therapists. Recall that Clarissa entered therapy because of her problems in developing intimate relationships. Her responsibility for these difficulties was crystal clear in the group. She was never with a person. While next to the group members, she was with me. While next to me, she was with her analyst. And no doubt, when next to him, she was with her father. Clarissa's dynamics of innocent victimhood were especially obvious because she was herself an experienced psychotherapist, had led therapy groups, and well knew the importance of communication between individual and group therapists.

Denial of responsibility, losing control. Another mode of shirking responsibility is to be temporarily out of one's mind. Some patients enter a temporary irrational state in which they may act irresponsibly, for they are not accountable even to themselves for their behavior. It was this problem that, in one of the examples at the beginning of part two, the therapist addressed when he asked a patient who was lamenting that her behavior was not deliberate, "Whose unconscious is it?" It is important to note that careful examination of such patients will reveal to a therapist that the "losing control" behavior is by no means disorderly. It is purposeful and offers the patient both secondary gains (payoffs) and a self-deceptive avoidance of responsibility. A patient who was brutalized and then rejected by an insensitive, sadistic lover lost control and by going crazy radically changed the balance of control in the relationship. She followed him around for weeks, repeatedly broke into and vandalized his apartment, created scenes by screaming and throwing dishes when he was dining in restaurants with friends. Her crazy, unpredictable behavior defeated him utterly. He panicked, sought protection from the police, and eventually required emergency psychiatric care. At this point, her goal accomplished, she morbidly, *dictu*, regained control and behaved thenceforth in an entirely rational manner. In muted form, this dynamic is by no means uncommon. Many an individual is tyrannized by the potential irrationality of a partner. Losing control offers another common payoff: nurturance. Some patients so deeply crave to be nursed, to be fed, to be cared for in the most intimate ways by their therapist that to gain those ends, they lose control, even to the point of deep regression requiring hospitalization.

Avoidance of autonomous behavior. Therapists are often baffled by patients who know very well what they can do to help themselves feel better, but inexplicably refuse to take that step. Paul, a patient who was depressed and in the process of changing jobs, went to New York for job interviews. He felt desperately lonely. The interviews themselves filled only 6 hours of a 3-day period, and the rest of the time was spent in lonely, frenzied waiting. Having in the past lived many years in New York, Paul had many friends there whose presence would have no doubt heartened him. He spent two lonely nights looking at the telephone, wishing they would call—an impossibility, since they had no way of knowing he was in town. Yet he could not pick up the telephone to call them. Why? We analyzed this at length, beginning with such explanations as "no energy," "too humiliated to ask for company," "they'd feel I only call them when I need them." Only gradually did we understand that his behavior was a reflection of his unwillingness to recognize that his well-being and his comfort rested in his own hands and that help would not come unless he acted to create that help. At one point I commented that it was frightening to be one's own father. That phrase reverberated powerfully for Paul, and during subsequent therapy he often referred back to it. The paradox for him, as for Sam in chapter 4 who after his wife left him would not go out and search for friends lest he miss an incoming phone call, was that to alter his social loneliness he had to encounter a deeper existential loneliness. In these examples, we see the confluence of two frames of reference. The assumption of responsibility results also in the relinquishment of one's belief in the existence of the ultimate rescuer—an exceedingly difficult task for an individual who has constructed his belief system around that belief. These two frames of reference, acting in concert, constitute the basic dynamics of dependency and provide the therapist with a coherent and powerful explanatory system by which to understand the pathologically dependent character.

Disorders of wishing and deciding. The next chapter will discuss in depth the relationship between responsibility assumption and willing—that is, wishing and deciding. And I need pause only briefly here to note that when one in full awareness wishes and decides, one is confronted with responsibility. The central thesis of this chapter is that one creates oneself. The central thesis of the next is that wishing and deciding are the building blocks of creation. As Sartre has often told us, an individual's life is constituted by his or her choices. An individual wills himself into being what he is. If one is terrified by self-constitution and by the groundlessness inherent in such knowledge, then one may avoid willing by, for example, deadening oneself to wishing or feeling, by abdicating choice, or by transferring one's choice to other individuals, institutions, or external events. In chapter 7, I shall consider these mechanisms of responsibility avoidance through willing denial.

Responsibility assumption and psychotherapy. To assist the patient in assuming responsibility, the therapist's first step is not a technique, but the adoption of an attitude upon which subsequent technique will rest. The therapist must continually operate within the frame of reference that a patient has created his or her own distress. It is not chance or bad luck or bad genes that has caused a patient to be lonely, isolated, chronically abused, or insomniac. The therapist must determine what role a particular patient plays in his or her own dilemma and find ways to communicate this insight to the patient. Until one realizes that one has created one's own dysphoria, there can be no motivation to change. If one continues to believe that distress is caused by others, by bad luck, by an unsatisfying job—in short, by something outside oneself—why invest energy in personal change? In the face of such a belief system, the obvious strategy is not therapeutic but activist: to change one's environment.

Readiness to accept responsibility varies considerably from patient to patient. For some patients, it is extraordinarily difficult and constitutes the bulk of the therapeutic task. Once they assume responsibility, therapeutic change almost automatically and effortlessly transpires. There are others who recognize responsibility more quickly but boggle repeatedly at other stages of treatment. Generally, responsibility awareness does not proceed evenly on a unified front. Individuals may accept responsibility on some issues and deny it on others.

Identification and labeling. The first task of the therapist is to be attentive to the issue, to identify instances and methods of responsibility avoidance, and to make these known to the patient. Therapists, depending on stylistic preference, use a vast variety of techniques to focus a patient's attention on responsibility. Take several of the examples at the beginning of part two. A therapist who counters a patient's excuse for behavior—"It was not deliberate, I did it unconsciously"—with the question, "Whose unconscious is it?" is encouraging responsibility awareness, as is the therapist who asks a patient to own what happens to him or her: "Not, 'He bugs me,' but, 'I let him bug me.'" The "can't bell," which summons individuals to change "can't" into "won't," is a ploy designed to enhance the awakening of responsibility. As long as one believes in "can't," one remains unaware of one's active contribution to one's situation. The patient instructed to say, "I will not change, mother, until you treat me differently when I was 10 years old," is in effect being asked to ponder her refusal rather than her inability to change. Furthermore, she is confronted with the absurdity of her situation and with her tragic and futile sacrifice of a life upon the altar of spitefulness.

Vera Gatch and Maurice Tamerlin studied audio tapes of psychotherapy sessions and report a potpourri of confrontative—at times insensitive so—interventions designed to enhance responsibility awareness. Quote: "When one man complained bitterly and passively that his wife would not have sexual intercourse with him, a therapist clarified the implicit choice with the remark, 'You must like her that way. You've been married to her a long time.'" A housewife complained, "I cannot manage my child. All he does is sit and watch TV all day." The therapist explicated the implicit choice with, "And you're too little and helpless to turn off the TV." An impulsive, obsessional man cried, "Stop me! I'm afraid I'm going to kill myself." The therapist said, "I should stop you. If you really want to kill yourself, to actually die, nobody can stop you except you." Interacting with a passive, oral-dependent man who felt that life held nothing for him because he suffered from the unrequited love of an older woman, one therapist began singing, "Poor little lamb that has lost its way." End quote.

The general principle is obvious. Whenever the patient laments about his or her life situation, the therapist inquires how the patient has created this situation. It is often helpful if the therapist keeps the patient's initial complaints in mind and at appropriate points in therapy juxtaposes these complaints with the latter's in-therapy attitudes and behavior. For example, consider a patient who sought therapy because of feelings of isolation and loneliness. During therapy, he discussed his sense of superiority and his scorn and disdain of others. His resistance to changing these attitudes was significant. They were ego-syntonic and doggedly maintained. The therapist helped the patient understand his responsibility for his uncomfortable predicament by commenting whenever the patient discussed his scorn of others: "And you are lonely." A patient who resents the restriction in his or her life must be helped to appreciate how he or she has contributed to that situation—for example, by choosing to stay married, to hold two jobs, to keep three dogs, to maintain a formal garden, and so forth. Generally, one's life becomes so structured that one begins to consider it as a given, as a concrete structure that one must inhabit rather than as a web spun by oneself, which could be spun again in any number of ways. This is why I am sure that Otto Will said to his constricted obsessive patient, "Why don't you change your name and move to California?" He confronted the patient forcefully with his freedom, with the fact that he really was free to change the structure of his life, to constitute it in an entirely different way.

Of course, there is a ready rejoinder: "There are many things that cannot be changed. One must earn a living. One must be father or mother to one's children. One must fulfill one's moral obligations. One must accept one's limitations." A paraplegic has no freedom to walk. A poor man no freedom to retire. An aging widow may have little possibility to marry, and so on. This objection, a fundamental objection to the concept of human freedom, may arise at any stage of therapy and is so important that I shall consider it at length in a separate section.

Though there is a place for these techniques of labeling and underscoring responsibility, there is a limit to their therapeutic effectiveness. "Can't bells" or slogans like "Take charge of your life" or "Own your feelings" are often arresting. But most patients require more than exhortation, and therapists must employ methods that have a deeper impact. The most potent methods available to therapists involve analyzing the patient's current here-and-now in-therapy behavior and demonstrating that the patient recreates microcosmically in the therapy situation the same situation that he or she faces in life. Indeed, as I shall discuss, psychotherapy may be structured specifically for the purpose of illuminating the patient's awareness of responsibility.

Responsibility and the here and now. The therapist who attempts to analyze a patient's narrative in an effort to demonstrate the latter's responsibility for a life situation often wanders into quicksand. The patient says, *stovoce*, "This is all very well. He can sit there in his comfortable office and tell me I got myself into this, but he doesn't really know what a sadistic bully my husband is, or what an impossible boss I have, or how really overwhelming my compulsion is, or what it's really like in the business world, or any other of an unlimited number of insurmountable obstacles." There are no limits to this resistance because, as every experienced therapist knows, the patient is not an objective observer of his or her own life predicament. The patient may use externalizing mechanisms of defense or, in a number of other ways, distort the data to fit his or her assumptive world. Thus, it is only on rare occasions that the therapist can facilitate responsibility assumption by working solely with secondhand data. Leverage is vastly increased if the therapist works with firsthand material that manifests itself in the here and now of treatment. By focusing on experiences that have transpired in the therapy situation, experiences in which he or she has participated, the therapist may help the patient examine the latter's own responsibility for nascent behavior before it becomes encrusted and obscured by mechanisms of defense. The therapeutic impact is considerably increased if the therapist selects an incident or an aspect of behavior with obvious similarities to the problem that brought the patient to therapy.

A patient, Doris, provides a clinical illustration. She sought therapy because of severe anxiety centering largely upon her relationship with males. Her major problem, as she described it, was to involve herself in relationships with abusive men, from which she was unable to extricate herself. Her father had abused her, as had her first husband, her current husband, and a long string of employers. Her account of her difficulty was persuasive, and my inclination was to empathize with Doris for having been so ill-fated as to be thrown time and time again into the clutches of tyrannical bastards. She had been in a therapy group for several months when she had a severe anxiety storm. Unable to wait until the next group meeting, she called me one morning for an emergency individual appointment. With considerable difficulty, I rearranged my schedule and agreed to see her at 3 p.m. that afternoon. At 20 minutes to 3, she called and left a message cancelling the appointment. A few days later, in the group meeting, I inquired what had happened. She replied that she had felt slightly better that afternoon, and since my rule was that I would see a group member for an individual hour only once during the entire course of therapy, she had decided to save her hour for a time when she might need it even more. Now, I never made such a rule. I would never refuse to see a patient in an emergency, nor had any of the group members heard me make any statement to that effect. But Doris was convinced I had told it to her. She chose to recall other incidents of our relationship in a highly selective fashion. For example, she remembered with astonishing clarity a single impatient comment that I had once made to her months before about her monopolistic tendencies, and she frequently repeated it in the group. However, she had forgotten many positive, supportive statements I had made to her in subsequent months. Doris's interaction with me in the microcosm of the here and now.

was representative of her relationship with men and illuminated her role, that is, her responsibility in her life situation. She distorted her perception of me in the same way that she distorted her perception of other men. That is by seeing us all as authoritarian and uncaring.

But there was still more to be learned from the incident. I felt annoyed with Doris for cancelling the appointment at the last moment after I had made such an effort to clear the time for her. I felt irritated too at her insistence, even though seven other members disagreed with her, that I had voiced a rule about only one individual session. With some effort, I tempered my irritation and maintained my therapeutic objectivity. But I could easily imagine how difficult it would be to relate to Doris in a non-therapeutic, real-life situation.

In essence, then, what happened was that Doris had certain beliefs about men, certain expectancies about how they would behave toward her. These expectancies distorted her perception, and perceptual distortion resulted in her behaving in ways that elicited the very behavior she dreaded. This maneuver, the self-fulfilling prophecy, is common. The individual first expects a certain event to occur, then behaves in such a way as to bring the prophecy to pass, and finally relegates awareness of his or her behavior to the unconscious.

This incident was crucial in Doris's therapy because it had such far-reaching implications for her basic problem. If she could understand and accept her responsibility for the way she related to me, then it was only a short step, requiring minimal generalization, for her to become aware of her responsibility for her mode of relating to other men in her life. The therapist should, I believe, see such an incident and hang on to it with tenacity. I label it explicitly and underscore its importance, saying, "Doris, I believe what just happened between you and me is exceedingly important because it gives us an important clue to some of the problems that exist between you and men in your life." If the patient is not yet prepared to accept the interpretation, repeat it in the future when there is additional corroborative evidence or when the therapist-patient relationship is more solid.

Awareness of one's own feelings constitutes a therapist's most important instrument for identifying a patient's contribution to his or her life predicament. For example, a depressed 48-year-old woman complained bitterly about the way her children treated her. They dismissed her opinions, dealt with her in cavalier fashion, and when some serious issue was at stake, addressed their comments to their father. I tuned into my feelings about her and became aware of a whining quality in her voice which tempted me not to take her seriously and to treat her as a child. Sharing my feeling with the patient was enormously useful to her. It helped her become aware of her childlike behavior in many areas. The analysis of the here and now, her whining, was extremely important in helping her to solve the puzzle of her children's treatment of her. After all, they merely followed her instructions. They treated her precisely as she asked to be treated, that is, asked nonverbally through whining, through her excuses based on weakness, and through her helpless depression.

Not only is the patient's responsibility avoidance recapitulated in the patient-therapist relationship, but it is also reenacted in the patient's basic posture toward therapy. Patients, often with the silent collusion of the therapist, may settle comfortably, passively, and permanently into therapy, expecting little to happen, or if anything is to happen, that it will come from the therapist. A therapist who has a sense of being heavily burdened by a patient who is convinced that nothing useful will transpire in the hour unless he or she brings it to pass has allowed that patient to shift the burden of responsibility from his or her own shoulders to those of the therapist.

Therapists may deal with this process in a number of ways. Most therapists choose to reflect upon it. The therapist may comment that the patient seems to dump everything in his or her, the therapist's lap, or that he or she, the therapist, does not experience the patient as actively collaborating in therapy. Or the therapist may comment upon his or her sense of having to carry the entire load of therapy. Or the therapist may find that there is no more potent mode of galvanizing a sluggish patient into action than by simply asking, "Why do you come?"

There are several typical resistances on the part of patients to these interventions, and they center on the theme of "I don't know what to do," or "If I knew what to do, I wouldn't need to be here," or "That's why I'm coming to see you," or "Tell me what I have to do." The patient feigns helplessness, though insisting that he or she doesn't know what to do. The patient has, in fact, received many explicit and implicit guidelines from the therapist. But the patient does not disclose his or her feelings. The patient cannot remember dreams or is too tired to write them down or forgets to put paper and pencil by the bed. The patient prefers to discuss intellectual issues or to engage the therapist in a never-ending discussion of how therapy works. The problem, as every experienced therapist knows, is not that the patient doesn't know what to do. Each of these gamuts reflects the same issue. The patient refuses to accept responsibility for change, just as outside the therapy hour, he or she refuses to accept responsibility for an uncomfortable life predicament.

Ruth, a patient in a therapy group, illustrates this point. She avoided responsibility in every sphere of her life. She was desperately lonely. She had no close women friends, and all of her relationships with males had failed because her dependency needs were too great for her partners. More than 3 years of individual therapy had proved ineffective. Her individual therapist reported that Ruth seemed like a lead weight in therapy. She produced no material aside from circular rumination about her dilemmas with men, no fantasies, no transference material, and over a three-year span, not a single dream. In desperation, her individual therapist had referred her to a therapy group.

But in the group, Ruth merely recapitulated her posture of helplessness and passivity. After 6 months, she had done no work in the group and made no progress. In one crucial meeting, she bemoaned the fact that she had not been helped by the group and announced that she was wondering whether this was the right group or the right therapy for her.

Therapist: Ruth, you do hear what you do outside the group. You wait for something to happen. How can the group possibly be useful to you if you don't use the group?

Ruth: I don't know what to do. I come here every week and nothing happens. I get nothing out of therapy.

Therapist: Of course you get nothing out of it. How can something happen until you make it happen?

Ruth: I feel blanked out now. I can't think of what to say.

Therapist: It seems important for you never to know what to say or do.

Ruth (crying): Tell me what you want me to do. I don't want to be like this all my life. I went camping this weekend. All the other campers were in seventh heaven. Everything was in bloom. And I spent the whole time in complete misery.

Therapist: You want me to tell you what to do? Even though you have a good idea of how you can work better in the group.

Ruth: If I knew, I'd do it.

Therapist: On the contrary, it seems very frightening for you to do what you can do for yourself.

Ruth (sobbing): Here I am again in the same shitty place. My mind is scrambled eggs. You're irritated with me. I feel worse, not better, in this group. I don't know what to do.

At this point, the rest of the group joined in. One of the members resonated with Ruth, saying he was in the same situation. Two others expressed their annoyance at her eternal helplessness. Another commented accurately that there had been endless discussions in the group about how members could participate more effectively. In fact, a long segment of the previous meeting had been devoted to that very issue. She had innumerable options. Another told her she could talk about her tears, her sadness, or about how hurt she was, or about what a stern bastard the therapist was, or about her feelings toward any of the other members. She knew, and everyone knew that she knew, these options. Why, the group wondered, did she need to maintain her posture of helplessness and pseudo-dementia?

Thus galvanized, Ruth said that for the last 3 weeks, during her commuting to the group, she had made a resolution to discuss her feelings toward others in the group, but always reagended any of the postgroup coffee clutches. She had wanted to participate but had not done so because she was reluctant to get any closer to Cynthia, another member of the group, lest Cynthia, whom she saw as exceptionally needy, would begin phoning her in the middle of the night for help. Following an intense interaction with Cynthia, Ruth openly showed her feelings about two other members of the group, and by the end of the session had done more work than in the six previous months combined.

What is worth underlining in this illustration is that Ruth's lament, "Tell me what to do," was a statement of responsibility avoidance. When sufficient leverage was placed upon her, she knew very well what to do in therapy. But she did not want to know what to do. She wanted help and change to come from outside. To help herself, to be her own mother, was frightening. It brought her too close to the frightening knowledge that she was free, responsible, and fundamentally alone.

Responsibility assumption in group therapy. The concept that therapy is a social microcosm, a setting in which the patient not only recites but displays his or her psychopathology in the here and now, pertains to all therapy settings: individual, couples, families, or groups. It is particularly relevant to the group situation. First, the large number of individuals, 8 to 10, including the therapist or therapists, provides the opportunity for most of the patients' conflict areas to be ignited. In the individual setting, the patient often encounters, in interaction with the therapist, his or her conflicted problems surrounding authority or problems relating to parents or to parental surrogates. But in the group setting, the patient encounters so many others who activate so many different interpersonal issues: sibling rivalry, heterosexuality, homosexuality, competition with peers, intimacy, self-disclosure, generosity, giving and receiving, and so forth, that we are justified in considering the therapy group as a miniaturized social universe for each of its members.

The here and now of the small interactional therapy group provides especially optimal conditions for therapeutic work on responsibility awareness. One of the most fascinating aspects of group therapy is that the members are all born simultaneously. Each starts out in the group on an equal footing, each in a way that is visible to the other members and, if the therapist does his job, apparent to himself, gradually scoops out and shapes a particular life space in the group. Thus, one is responsible for the interpersonal position one scoops out for oneself in the group and, by analogy, in life as well, and for the sequence of events that will occur to one. The group has many eyes. Members do not need to accept another's description of how he or she is victimized by external persons or events. If the group functions at a here-and-now level, that is, the primary focus is upon experiencing and analyzing intermember relationships, then the members will observe how each creates his own self-victimization, and they will eventually feed these observations back to each member in turn.

Though we therapists do not often think of the group process in this manner, I believe that the major activities of the group, especially in the initial stages of therapy, are directed toward each member's becoming aware of personal responsibility. Why do we encourage members to be direct and honest in the group, that is, to be themselves? Why do we encourage feedback? Why do we encourage members to share their impressions and feelings for the other members? I believe that the group therapist, often without necessarily being aware of doing so, attempts to escort each patient through the following sequence:

One, patients learn how their behavior is viewed by others. Through feedback and later through self-observation, patients learn to see themselves through others' eyes.

Two, patients learn how their behavior makes others feel.

Three, patients learn how their behavior creates the opinions others have of them. Members learn that as a result of their behavior, others value them, dislike them, find them unpleasant, respect them, avoid them, exploit them, fear them, and so on.

Four, patients learn how their behavior influences their opinion of themselves. Building on the information gathered in the first three steps, patients formulate self-evaluations. They make judgments about their self-worth and lovability, and they learn how their behavior leads to these judgments.

Each step begins with the patient's own behavior and attempts to demonstrate the repercussions of that behavior. The end point of this sequence is that the group member apprehends that one is oneself responsible for how others see one, treat one, and regard one. Furthermore, one is also responsible for the manner in which one regards oneself. That one's group experience is a microcosm of one's life experience is an obvious and compelling fact. And in my experience, patients have no difficulty generalizing assumption of individual responsibility from in-group situations to life situations. Once having reached this point, a patient has entered the vestibule of change, and the therapist then embarks on the venture of facilitating the process of willing, as I shall discuss in the next chapter.

The interactional therapy group enhances responsibility assumption not only by making members aware of their personal contribution to their unsatisfying life situations but also by accentuating each member's role in the conduct of the group. The underlying principle is that if members assume responsibility for the functioning of the group, then they become aware that they have the ability and the obligation to assume responsibility in all spheres of life. The effective therapy group is one in which the members themselves are the primary agents of help. As patients look back over a successful therapy group experience, they rarely attribute their improvement directly to the therapist, either to specific comments by the therapist or to their overall relationship with the therapist. Instead, patients generally cite some aspect of their relationships with other members, either support, conflict and resolution, acceptance, or often the experience of having been helpful to others.

The leader-centered group fails to foster such events, and in it, often all hope and all help are seen as emanating from the leader. Such leader-centered approaches as Gestalt therapy groups and transactional analytic groups fail, in my opinion, to take full advantage of the therapeutic potential inherent in the group format. It is important, therefore, that the group leader be aware that his or her task is to create a social system. A system in which the group and the members themselves are the agents of change. The leader must be acutely sensitive to the location of responsibility in the group. If he or she looks forward with dismay to the therapy group meetings and ends each one feeling drained and fatigued, then it's clear that something has gone seriously wrong in the shaping of an optimal therapeutic culture. If the leader has the sense that everything depends on him or her, that if he or she doesn't work, nothing will happen in the group, that the members are moviegoers coming to see what's playing that week, then the members of the therapy group have successfully transferred the burden of responsibility onto the shoulders of the therapist.

How does the group therapist help to shape a group that assumes responsibility for its own functioning? First, the leader must be aware of being generally the only person in the group who, on the basis of past experience, has a relatively clear definition in mind of what constitutes a good work meeting versus a non-work meeting. The leader must help the members acquire such a definition and then encourage them to act accordingly. A number of techniques are available. The leader may use process checks, breaking into the meeting from time to time and asking the members to evaluate how the meeting has been going for them over the past 30 minutes or so. If the meeting has been painfully lumbering along, the leader may ask them to compare it with a previous dynamic session so that they gradually begin to differentiate work meetings from non-work ones. If everyone is in accord that the meeting has been fruitful and compelling, the leader encourages the members to fix that session in their minds as a standard with which to compare subsequent meetings.

If, in response to the leader's question about members' evaluation of the meeting, a member comments that he or she was involved only for the first 15 minutes, but then tuned out for the next 30 minutes after Joe or Mary started talking, the leader may, in a variety of ways, question why that particular member let the meeting go on in a manner that was personally unrewarding. How could that person have rechanneled the meeting? The leader may pull the group and, finding that there was a general consensus that the meeting was unrewarding, ask, "All of you seem to have known this. Why did you not stop the meeting and redirect it? Why is it left to me to do what everyone here is capable of doing?" Many variations in technique are possible, of course, depending on the stylistic preferences of the therapist. What is important is the underlying strategy of encouraging patients to take responsibility for their lives through the process of taking responsibility for their therapy.

Chapter 6B: Large Group Therapy

The same principle operates in the larger therapeutic groups. Facilitation of the patients' assumption of personal responsibility has been a major impetus in the creation of the therapeutic community. Confinement in a psychiatric hospital has always been an autonomy-stripping experience. Patients are deprived of power, of decision-making, of freedom, of privacy, and of dignity. Maxwell Jones designed the therapeutic community so that the hospital experience would augment rather than diminish the patients' autonomy. The hospital ward was restructured so that patients had broad responsibility for their own treatment and their own environment. The patient government assumed the rights to decide upon ward rules, furloughs, ward personnel decisions, and even discharges and medication regimens. A synonym for responsibility assumption is life management. Many therapeutic approaches emphasize the teaching of life management skills. Inpatient units commonly conduct life management or contract groups in which each patient's contract, an agreement to take over the management of his or her life, is reviewed and various contractual issues are discussed. The group may then systematically focus on what each person can do to take charge of such specific issues as personal finances, physical health, or social companionship.

Responsibility assumption and the therapist's style, activity, and passivity.

The facilitation of responsibility assumption often poses a dilemma for the therapist. A too-active therapist takes over for the patient. A passive therapist conveys a sense of powerlessness to the patient. The problem is especially pronounced in psychoanalytic technique when the analyst's narrow range of behavior and relative inactivity may foster prolonged dependency. Milton Mer, an analyst concerned with this problem, warns that excessive therapist passivity may discourage the patient's assumption of responsibility. He wrote, "The analyst's passivity in the presence of the patient's expression of helplessness confirms what he chooses to believe, namely that he is not responsible for his actions, and therefore may simply follow his impulses." Hearing no word of warning and no definition of the possible consequences, may he not, with some justice, conclude that he cannot help himself, particularly when the conclusion permits him to fulfill the aim of his drives. Mer warns also that the alternative excessive activity, either in the form of guidance or limit setting, may also interfere with the assumption of responsibility. Quote, "It is not suggested that the analyst attempt to forbid the contemplated act, for this would also indicate that the patient is not to be held responsible and can be curbed only by an outside force, the authority of the analyst." End quote.

How to steer a middle course? What facilitative posture can the therapist assume? Maer suggests that the therapist should attempt to help the patient recognize this process of choosing. As he said, it is the analyst's job to point out that the patient is in the process of deciding whether or not to engage in a particular act. For in so doing, he clearly outlines the responsibility of the patient for his future. By this means, the patient is given the opportunity to make a choice between neurotic necessity and responsible freedom. If he is able to choose responsible freedom, he makes his first cleavage in his neurotic structure. In other words, the therapist concentrates upon increasing the patient's awareness that, like it or not, he or she is faced with choice and cannot escape this freedom.

Other therapists have sought for more active ways of encouraging responsibility assumption. Transactional analysts, for example, place heavy emphasis upon the therapeutic contract. They devote the initial sessions not toward establishing a diagnosis, which would merely accentuate the definition of the therapist-patient relationship as healer-supplicant, but toward developing a contract. The contract must emanate from the individual rather than from the wishes of others which have been internalized in the parent ego state as shoulds or oughts. Furthermore, the contract must be action-oriented, not "to understand myself better," but "I want to lose 30 lbs" or "I want to be able to get an erection with my wife at least once a week." By setting concrete, attainable goals, goals that the patient has defined, and by continuing to call the patient's attention to the relationship between work in therapy and these goals, transactional therapists hope to increase the patient's sense of responsibility for individual change.

Active suggestions on the part of the therapist may properly employed be used to increase awareness. I do not mean here that the therapist take over for the patient, making decisions and, in short, telling him or her how to live. However, there are times when the therapist may make a suggestion that seems an obvious behavioral option, but that the patient, because of a restricted perspective, has never considered. Thus, the question "Why not?" may be far more useful than the question "Why?" It's not even important that the patient follow this suggestion. The most important message of the procedure may be precisely that the patient's attention is called to the fact that he or she has never considered obvious options. Therapy may then proceed to consider the possibility of choice, the myth of choicelessness, and the feelings evoked by a confrontation with freedom.

The following clinical vignette is illustrative. George was a 30-year-old successful dentist whose major problem centered about responsibility avoidance. He had been married once, but the marriage had failed, in general, because of his dependent posture toward his wife, and specifically because, as he said, he had found himself involved with another woman. Since then, he had experienced considerable torment in regard to his efforts to decide upon remarriage. He was faced with a decision among several women, all of whom were interested in him, and went to great lengths to induce others—his friends, his therapist, and the women themselves—to make the decision for him.

An episode that illuminated for him his difficulties in assuming responsibility involved a visit to his parents, whom he saw approximately once a year. His father had always been viewed as the family villain, and George's relationship to him had always been highly conflicted and dissatisfying for both. For over a decade, their fighting had revolved around automobiles. Whenever George returned home, he wanted to use one of the family cars, and his father, an automobile mechanic, consistently objected, claiming that he needed the car or that the car was mechanically malfunctioning. George described his mother as a powerful woman who controlled every aspect of the family life aside from the automobiles, the one province where she allowed her husband dominion.

George anticipated his upcoming visit to his parents with considerable trepidation. He anticipated what would happen. He would want to use the car. His father would object, claiming that the brakes or the tires were bad and would then insult him and ask him why couldn't he be a mench and rent a car. "What kind of family is that?" George asked. "I come to see them once a year and they don't care enough even to pick me up at the airport."

"Why not rent a car?" I asked him. "Is the idea so outlandish? Why have you never considered it? After all, you make four times as much money as your father, are unmarried, and have no outstanding expenses. What would the extra few dollars a day mean to you?"

George seemed startled at my suggestion. As obvious as it was, it was clear that he had never seriously considered it before. He thought about it and called his family the next day to tell them when he would be arriving. George suggested to his mother that he would rent a car, and his mother instantly assured him that the car was fixed now, that his father would pick him up at the airport, that they much looked forward to seeing him, and there would be no question about other forms of transportation.

The inevitable scene at the airport came to pass. His father greeted him with, "Why didn't you rent a car? Look at that car rental counter. For $8.95, you could have rented a car." They had a loud, embarrassing quarrel. George ran over to the car rental stall, rented a car, and angrily and self-righteously spurned his father's offer to pay for it. He and his father went home in separate cars. His father immediately went into the bedroom and left for work early in the morning. Since George was there for only a day, he didn't see his father again.

We discussed this incident at great length in therapy. George considered it a prototypical example of his family interaction and as apologia for his current state. He said, "As much as this disturbed me now, think of what it must have been like to grow up in a family like that." It was, George thought, especially illustrative of why he had such doubts about his masculinity. Consider the model his father constituted, and consider also how impossible it was for him to talk to his father.

I provided an entirely different perspective. How much effort had he made to speak to his father? Consider his father's position. George's mother had offered his father services without consulting him, as though he were the family butler. His father felt controlled and angry, and attempted to exert himself in his only domain of power, the use of the car. But what efforts had George made to speak to his father? Could he not have spoken to his father as well as to his mother on the phone? What stopped him from simply phoning his father and saying, "Dad, I'll rent a car at the airport since I need one the next day. I won't be in until 10:00, but please wait up for me so we'll have a chance to talk."

George seemed flabbergasted. "That's impossible," he exclaimed. "Why? I can't talk to my father on the phone. You just don't know my family, that's all."

But George continued to feel a vague sense of guilt about his father, about that gay-headed, stubborn old man who had survived a concentration camp, and who for 30 years had gone to work every day at 6:00 a.m. to put four children through college and graduate school.

"Write him a letter and tell him just how you feel," I suggested. George once again seemed stunned at my suggestion, as well as annoyed with my naivete. "That's impossible."

"Why?" I asked. "We don't write letters. I've never written my father a letter in my life. And yet you complain about being alienated from him, about not being able to communicate with him. If you really want to communicate with him, then do so. Write him. No one prevents you from doing so. You can't pass this buck."

This simple interchange profoundly unsettled George, and that evening he tremulously and tearfully began to compose a letter to his father, a letter that would begin, "Dear Dad," and not, "Dear Mom and Dad," or "Dear folks!" As fate would have it, the spirit of freedom and responsibility stalked his father that same night, and before he had finished the letter, his father telephoned him to apologize. The first time that his father had ever phoned him, George told his father about the letter he was writing, and was so moved that he sobbed like a child. Suffice it to say that things were never the same again between George and his father, and that an analysis of George's immediate disclaimer that it was impossible to phone his father or to write a letter opened up rich vistas in therapy.

Fritz Pearls, Gestalt therapy, and responsibility assumption.

Of the proponents of an active therapist style in the approach to responsibility, none have been more vigorous or inventive than Fritz Pearls. Pearls's approach rests on the basic concept that responsibility avoidance must be recognized and discouraged. He explained, "As long as you fight a symptom, it will become worse. If you take responsibility for what you are doing to yourself, how you produce your symptoms, how you produce your illness, how you produce your existence, the very moment you get in touch with yourself, growth begins, integration begins." Pearls was acutely sensitive to the patient's use or avoidance of the first-person pronoun and to any switch from active to passive voice. He wrote, "We hear the patient first depersonalize himself into 'it' and then become the passive recipient of the vicissitudes of a capricious world. 'I did this' becomes 'it happened.' I find that I must interrupt people repeatedly asking that they own themselves." We cannot work with what occurs somewhere else and happens to one. And so I ask that they find their way from "it's a busy day" to "I keep myself busy." From "gets to be a long conversation" to "I talk a lot," and so on.

Once Pearls had identified the modes of responsibility avoidance, he then urged the patient to translate helplessness back into unwillingness. The patient was urged to take responsibility for every gesture, every feeling, every thought. Pearls sometimes used an "I take responsibility" structured exercise. With each statement, he said, we ask patients to use the phrase "and I take responsibility for it." For example, "I am aware that I move my leg, and I take responsibility for it. My voice is very quiet, and I take responsibility for it. Now I don't know what to say, and I take responsibility for not knowing."

Pearls asked patients to take responsibility for all of their internal conflicting forces. If a patient was caught in an agonizing dilemma and while discussing it experienced a knot in his stomach, Pearls asked the patient to have a conversation with the knot. Place the knot in the other chair and talk to it. You play the role of you and the role of the knot. Give it a voice. What does it say to you? Thus, he asked the patient to take responsibility for both sides of a conflict in order to be aware that nothing happens to one, that one is the author of everything, of every gesture, every movement, every thought.

Therapist: Are you aware of what your eyes are doing?

Patient: Well, now I realize that my eyes keep looking away.

Therapist: Can you take responsibility for that?

Patient: That I keep looking away from you.

Therapist: Can you be your eyes now? Write the dialogue for them.

Patient: I am Mary's eyes. I find it hard to gaze steadily. I keep jumping and darting about.

We choose each of our symptoms. Pearls felt unfinished or unexpressed feelings find their way to the surface in self-destructive, unsatisfying expressions. This is the source of the term Gestalt therapy. Pearls attempted to help patients to complete their gestalts, their unfinished business, their blocked-out awareness, their avoided responsibilities.

A description of a therapeutic encounter illustrates Pearls's approach to responsibility. He wrote, "Two weeks ago, I had a wonderful experience. Not that it was a cure, but at least it was an opening up. This man was a stammerer, and I asked him to increase his stammer." As he stammered, I asked him what he feels in his throat, and he said, "I feel like choking myself." So, I gave him my arm and said, "Now choke me." "Goddamn, I could kill you," he said. He got really in touch with his anger and spoke loudly without any difficulties. So I showed him he had an existential choice to be an angry man or to be a stutterer. And you know how a stutterer can torture you and keep you on tender hooks. Any anger that is not coming out flowing freely will turn into sadism, power drive, and other means of torture."

This approach to symptoms, asking the patient to produce or augment a symptom, is often an effective mode of facilitating responsibility awareness. By deliberately producing the symptom, in this instance, a stammer, the individual becomes aware that the symptom is his. It is of his own creation. Though they have not conceptualized it in terms of responsibility assumption, several other therapists have simultaneously arrived at the same technique. Victor Frankl, for example, describes a technique of paradoxical intention in which a patient is asked deliberately to increase a symptom, be it an anxiety attack, compulsive gambling, fear of a heart attack, or binge eating. Don Jackson, Jay Haley, Milton Ericson, and Paul Watlavic have all written on the same approach, which they label symptom prescription.

Pearls developed a unique method of working with dreams, a method ingeniously designed to facilitate the individual's assumption of responsibility for all his or her mental processes. Throughout most of history, human beings have considered dreaming as a phenomenon beyond the realm of personal responsibility. This viewpoint is reflected in the common idiom, if a person wishes to disclaim an act or thought, he says, "I wouldn't even dream of it." Before the advent of Freudian dynamic psychology, dreams were generally considered to be divine visitations from without or chance occurrences. For example, one theory suggested that the cells of the cortex slept and that as the toxic metabolites of the day were cleaned away, clusters of cells awoke in strictly random patterns. The dream, according to this theory, is comprised by the output of the cells as they awaken. The nonsensical quality of most dreams is therefore a function of the adventitious sequence in which cells are aroused. And an intelligible dream is formed serendipitously in much the same way that a horde of monkeys punching at typewriters by chance compose a comprehensible paragraph.

Freud argued persuasively that dreams were products of neither chance nor outside visitation, but instead of the conflicting, interacting components of the personality: the id impulses, the manifest days residue of the subconscious, the dream censor, an unconscious machinist of the ego, the conscious ego, secondary revision. Though Freud discovered that the individual, or at least the interplay of these parts of the individual, was the sole author of the dream, his compartmentalization of the psyche resulted, Pearls insisted, and quite correctly, I believe, in personal responsibilities being lost in the component crevices.

Pearls, who termed the dream the existential messenger, aimed to maximize the individual's appreciation of his or her own authorship of the dream. First, Pearls attempted to bring the dream to life by changing its tense. He asked the patient to repeat the dream in the present tense and then to reenact the dream by turning it into a play in which the patient becomes the director, the props, and the actors. The patient is asked to play the parts of all the objects in the dream drama. For example, I observed Pearls working with a patient who dreamed of driving his car, which began to sputter and finally died altogether. Under Pearls's instruction, the patient played multiple parts: the driver, the car, the empty gas tank, the sluggish spark plugs, and so on. By this strategy, Pearls hoped the patient could begin to reassemble into a whole the scattered bits of his personality, that is, to complete the individual gestalt.

Responsibility assumption meant to Pearls that the individual has to take responsibility for all his or her feelings, including unpleasant ones that are often projected upon others. As he said, "We are not willing to take the responsibility that we are critical. So we project criticism onto others. We don't want to take the responsibility for being discriminating. So we project it outside. And then we live in fear of being rejected. And one of the most important responsibilities is to take responsibility for our projections and become what we project." By reclaiming all previously disowned parts of oneself, the individual's experience becomes richer. One is at home within oneself and within one's world. Of course, Pearls added, "taking responsibility for your life and being rich in experience and ability is identical. And what I hope to do is to make you understand how much you gain by taking responsibility for every emotion, every movement you make, every thought you have, and shed responsibility for anybody else."

Shedding responsibility for anybody else is vitally important for the psychotherapist. Pearls was acutely aware of the patient's effort to manipulate others, especially the therapist, into taking care of him or her. He said, "The therapist has three immediate tasks: To recognize how the patient tries to get support from others rather than to provide his own. To avoid getting sucked in and taking care of the patient. And to know what to do with the patient's manipulative behavior." Not getting sucked in is not easy, and the therapist must be accustomed to recognizing and resisting a patient's many and varied means of persuasion. Again, Pearls gives the example of a patient who says, "I can't cope in this situation, and you can. I need you to show me the way so that I can go on with my life." This is sometimes not much of a life at all, but rather an existence which includes a succession of propositions submitted by the patient to people who like to take over the management of others. The therapist is merely the latest try. Hopefully, the buck stops here.

In order to resist being manipulated, Pearls took an extreme position on stopping the buck. He began his workshops in this manner: "So if you want to go crazy, commit suicide, improve, get turned on, or get an experience that will change your life. That's up to you. I do my thing and you do your thing. Anybody who doesn't want to take responsibility for this, please do not attend this seminar. You came here out of your own free will. I don't know how grown up you are, but the essence of a grownup person is to be able to take responsibility for himself, his thoughts, feelings, and so on." Pearl's position here is extraordinarily severe and may, especially with severely disturbed patients, require modification. Many patients require months of work to become able to assume responsibility, and it is often unrealistic to make full responsibility assumption a prerequisite for therapy. Occasional situations arise, however, where the therapist is well advised to require some degree of responsibility assumption at the onset of therapy. Many therapists insist that highly suicidal patients make a no-suicide pact, in which they agree not to attempt suicide for a specified period of time. Properly used, such an approach can significantly diminish suicide risk.

Though Pearls's words leave no doubt that he was highly sensitive to the issue of responsibility and cognizant of the fact that the therapist must not accept the burden of the patient's responsibility, he was never able to solve, or for that matter, I believe, to recognize fully, the paradox of his approach to therapy. "Assume responsibility," the patient is told. But what is the rest of the patient's experience? An encounter with an enormously powerful, charismatic, wise old man who pronounces nonverbally, "And I'll tell you precisely how, when, and why to do it." Pearls's active personal style, his aura of power and omniscience contradicted his words. To receive two simultaneous, conflicting messages, one explicit and the other implicit, is to be placed in a classical double bind.

Let me describe another therapeutic approach that attempts to avoid that pitfall.

Helmut Kaiser and responsibility assumption.

Of the many therapists who have confronted the dilemma of how to increase responsibility assumption without at the same time taking over for the patient, Helmut Kaiser's contributions stand out for thoughtfulness and consistency. Though both Kaiser and Pearls built their approaches to therapy around the axis of responsibility, the style and the structure of their approaches were diametrically opposed. Kaiser, who died in 1961, was a highly inventive therapist who, because he wrote little, has never enjoyed wide recognition. A book of his collected works was issued in 1965 under the title Effective Psychotherapy. Kaiser believed that patients have a universal conflict which he described as "a condition of the mind common to all neurotics which issues from the fact that quote mature adulthood entails a complete, a fundamental and eternal and insurmountable isolation end quote."

Kaiser tells the story of a medical school chum, Walter, who in the midst of his studies accepted a role in an amateur dramatic production and became impassioned with the theater. He was clearly talented and deliberated abandoning his medical studies and throwing his whole life into the career of an actor. But how talented was he? Would he become a great actor? Walter agonized over his decision and sought the opinion of expert after expert. Kaiser observed the torments of his friend and suddenly it dawned upon him that Walter was expecting the impossible. He didn't merely want an opinion. He wanted much more. He wanted someone else to take the responsibility of his decision. Quote, "In the time that followed, G [that is, Kaiser] could observe how Walter slowly, step by step, discovered that no judgment, no advice from any other person could contribute anything to the decision he had to make. Feeling compassionate towards Walter's struggle, he was always willing to discuss with his friend all the innumerable pros and cons which could possibly have a bearing on the step considered. Yet, when they had gone through all the possible consequences, had estimated chances, weighed indications, sifted information, and only the ultimate conclusion was missing, they regularly fell into a deep, painful silence. G then sensed Walter's unspoken question: 'Now, what do you think?'" End quote.

What Walter faced and recoiled from is a profound human paradox. We yearn for autonomy but recoil from autonomy's inevitable consequence: isolation. Kaiser called this paradox "mankind's congenital Achilles heel" and said that we would suffer enormously from it if we did not cover it over with "some magician's trick, some device to deny isolation." That magician's trick is what Kaiser called the universal symptom: a mechanism of defense which denies isolation by softening one's ego boundaries and fusing with another. Earlier I discussed fusion or merger as a defense against death anxiety in the description of man's yearning for an ultimate rescuer. Kaiser reminds us that isolation—and though he does not explicitly make this point, the groundlessness beneath isolation—is a powerful instigator of one's efforts to fuse with another.

What events hurl us into a confrontation with isolation? According to Kaiser, those events that most make one aware that one is entirely responsible for one's own life, especially the confrontation with a life-altering decision or the development of a conviction that is not supported by authority. At these times, we strive, as did Kaiser's friend Walter, to find others who will assume responsibility for us.

Kaiser was exquisitely sensitive to the efforts of the patient to avoid the isolation of responsibility by transferring executive powers to the therapist. How can the therapist thwart these efforts of the patient? Kaiser pondered this question and posited several approaches but finally decided that the issue was so important that it must be dealt with by a modification in the very structure of therapy. To discourage responsibility transfer, therapy should be entirely unstructured. The therapist entirely nondirective, the patient entirely responsible not only for the content but for the procedure of therapy. Kaiser declared that there should be no rules for the therapist.

His description of a therapist-patient interaction is illustrative.

Patient: May I ask what the therapy will consist of? I mean, what is the procedure?

Therapist: The procedure? I'm not sure that I understand you fully, but if I do, I would say there is no procedure.

Patient (smiling politely): Oh, of course. I meant only, what do you want me to do?

Therapist: That is exactly what I thought you meant by procedure.

Patient: I don't understand.

(20 seconds silence)

Patient: I mean, of course, there must be something I'm supposed to do, isn't there?

Therapist: You seem certain that there is something you are supposed to do here.

Patient: Well, isn't that so?

Therapist: As far as I'm concerned, no.

Patient: Well, uh, I um I I I don't understand.

Therapist (smiling): I think you understand what I said, but you can't quite believe it.

Patient: You're right. I really don't think that you mean it literally.

Therapist: (After 10 seconds pause) I meant it literally.

Patient: (After an uneasy silence of 60 seconds with some effort) Is it all right if I say something about my anxiety attacks?

Therapist: It seems impossible for you to believe that I meant what I said.

Patient: I'm sorry. I didn't mean to, but indeed I'm not sure at all that I really—Excuse me. What did you say?

Therapist: I said it seems impossible for you to believe that I meant what I said.

Patient (shaking his head slightly as if irritated): No, I mean, is it all right for me? He looks up, and when his eyes meet those of the therapist, he starts laughing.

Kaiser believed that anything that increases the patient's feeling of responsibility for his own words must tend to cure him. And as this illustration indicates, he refused even to accept the responsibility of instructing the patient how to operate in therapy. There are obvious limitations to such extreme technique. I believe that Pearls erred in the direction of supplying too much structure and energy to the patient, and that Kaiser erred in precisely the opposite direction. No therapist can help a patient who, because of bewilderment, lack of structure, or lack of confidence, prematurely drops out of therapy. Because the therapist ultimately hopes to assist the patient assume responsibility, it doesn't follow that the therapist must demand that the patient do so at each step, even in the onset of therapy. The therapeutic situation usually requires flexibility. Often, to keep patients in therapy, therapists must be active and supportive in initial sessions. Later, once the therapist alliance is welded fast, the therapist may accent those therapeutic conditions.

That enhance acceptance of responsibility. Elsewhere, Kaiser stresses the importance of the therapeutic relationship and of communicational directness. And no doubt in actual therapy situations, he made the necessary adjustments. He wrote an intriguing play, emergency, which in fact illustrates therapeutic flexibility paralants.

The protagonist of emergency, a psychiatrist, Dr. Terwin, is consulted by Mrs. Porfiri, the wife of a psychiatrist, who states that her husband is deeply disturbed but refuses to seek help. Dr. Turwin pretends to be a patient and consults Dr. Perfairi. Gradually, almost imperceptibly, he then proceeds under the rubric of patient to treat the therapist. Obviously, Dr. Perfairy was not able to assume responsibility, not even the responsibility of requesting therapy. And the therapist didn't demand it of him, but instead did what all good therapists must do. He modified the therapy to fit the patient.

Responsibility awareness American style or how to take charge of your own life, pull your own strings, take care of number one and get it. Responsibility awareness has come of age in America. What once was the discourse often obscure of the professional philosopher and later the bone mo of the left bank avantgard has become a major consumer item in the new world today. Many nationwide bestsellers have as their central theme responsibility assumption. Your erroneous zones to take one example has these chapter headings. Taking charge of yourself choice your ultimate freedom. You don't need their approval. Breaking free from the past. Breaking the barrier of convention. Declare your independence. The central message of the book is clearly stated. Begin to examine your life in the light of choices you have made or failed to make. This puts all responsibility for what you are and how you feel on you. Similar books, for example, Pulling Your Own Strings and Self-Creation, have also zoomed quickly to the top of the bestseller lists.

Mass consumerism requires that a product be attractive, well packaged, and most important of all, easily and quickly consumed. Unfortunately, these requirements are generally incompatible with the effort and the thoughtfulness that are needed if one is truly to examine and alter one's life and world perspective. Thus, a leveling down occurs. We are subjected to exhortation and bestsellers such as your erroneous zones tells us how to put an end to procrastination. Quote, sit down and get started on something you've been postponing. Begin a letter or a book. Simply beginning will help you to eliminate anxiety about the whole project. Give yourself a designated time slot, say Wednesday from 10 to 10:15 p.m., which you will devote exclusively to the task you've been putting off. Quit smoking now. Begin your diet this moment. Give up booze this second. Put this book down and do one push-up as your beginning exercise project. That's how you tackle problems with action. Now, do it. Decide not to be tired until the moment before you get into bed. Don't allow yourself to use fatigue or illness as an escape or to put off doing anything. End quote. Or rid yourself of dependency. Quote, "Give yourself five minute goals for how you're going to deal with dominant people in your life. Try a oneshot, no, I don't want to." and test the reaction of your reaction in the other person. Stop taking orders." End quote.

Responsibility has caught the public eye and professional workshops with a responsibility theme have burgeoned across the country. For example, a large workshop called taking charge of your own life and subtitled the psychology of healthcare, the role of individual responsibility was offered at several locations in 1977 and 78. It included on its program RO in a keynote address on the existential struggle toward personal and spiritual freedom. Albert Ellis on his rational emotive approach to the individual's responsibility for growth and change in the area of sexuality and intimacy and Arnold Lazarus on multimodel therapy an approach to self-healing described in his book I can if I want to. Other topics in the workshop included behavioral stress management approach to helping the hard driving type A patient change behavioral patterns, stress and bof feedback, overcoming shyness, Eastern meditational approaches to self-control and changing no change habit patterns. Of particular interest is the great diversity of clinical approaches clustered on the same program. In the past, one would not have perceived the common theme of these various approaches. Currently, they are grouped together under the rubric of responsibility.

EST. The mass merchandising of responsibility assumption is nowhere more evident than in EST, the most publicized and commercially successful of the growth workshops of the 1970s. Owing to this success and to its concern with the concept of responsibility, EST warrants a particularly close examination. A slickly packaged, mass- prodduced, enormously profitable, large group approach to personal change, founded by Verer Hehart, EST has spiraled in a few short years from a one-man operation to a massive organization. By 1978, it had over 170,000 graduates. And in 1978, it grossed over $9 million with a paid staff of 300 and a volunteer unpaid staff of 7,000. And it includes on its advisory boards prominent business executives, attorneys, university presidents, the former chancellor of the University of California Medical School, eminent psychiatrists, government officials, and popular entertainers.

The EST format consists of a large group of individuals, approximately 250, who spend two weekends listening to a trainer who instructs them, interacts with them, insults them, shocks them, and guides them through a number of structured exercises. Though the EST packet is a pop of techniques borrowed from such personal growth technologies as Scientology, mind dynamics, encounter groups, gestalt therapy, and Zen meditation. Its primary thrust is assumption of responsibility. Participants and EST leader statements make that crystal clear. Quote, the leader explained, "Each of us is different because each of us makes different choices. It is the inability to choose that keeps us stuck in our lives. When you make a choice, your life moves forward. The choice usually boils down to a simple yes or no. I don't know is also a choice, the choice to evade responsibility. End quote. One participant describes her recollections of the workshop in this manner. Quote, "When you are responsible," Stuart the trainer thundered, "you find out you just didn't happen to be lying there on the tracks when the train passed through. You are the who put yourself there." The theme of responsibility pervades every aspect of the training. In fact, if I were to sum up in a few words what I got from the training data, it would be that we are each the cause of our own experience and responsible for everything that happens in our experience. end quote.

The theme of responsibility assumption is an explicit part of the EST catechism. In this interaction, an EST trainer argues and argues effectively that one is responsible for being mugged. Quote, "You are each the sole source of your own experience and thus totally responsible for everything you experience. When you get that, you're going to have to give up 90% of the that's running your lives. Yes, Hank. Look, says Burly Hank, looking quite irritated. I get that I'm responsible for everything I do. I see that. But when I get mugged, there's no way I'm going to accept responsibility for getting mugged. Who's the source of your experience, Hank? In this case, it would be the mugger. The mugger would take over your mind. My mind and my wallet. Do you take responsibility for getting out of bed that morning? Sure. For being on that street? Yes. For seeing a man with a gun in his hand? For seeing him? Yes. Seeing the mugger. Take responsibility for seeing him. Yes. Well, says Hank, I would certainly see him. If you had at that moment no eyes, no ears, nose, or sensations in the skin, you wouldn't experience this mugger, would you? Okay, I get that. Then you are responsible for being at that street at that hour with money that might be stolen. Okay, I get that. That you chose not to risk your life by resisting this man and that you chose to give up your wallet. When a guy says, "Give me your money with a gun in his hand," there's no choice. Did you choose to be at that place at that time? Yeah, but I didn't choose to have that guy show up. You saw him, didn't you? Sure. You take responsibility for seeing him, don't you? For seeing him. Yeah. Then get it. Everything that you experience doesn't exist unless you experience it. Everything a living creature experiences is created uniquely by that living creature who is the sole source of that experience. Wake up, Hank.

Most EST graduates, when discussing their gains, emphasize above all the assumption of responsibility. One EST graduate stated that people realized they created their own backachches, migraines, asthma, ulcers, and other ailments. Illness doesn't just happen to us. It was remarkable to watch person after person get up and admit that they and they alone were responsible for their physical ailments. Once these people faced the experiences of their life honestly, their ailments vanished. In the following interaction, an EST trainer goes even further and argues that a man is responsible for his wife's having cancer. How the hell am I responsible for my wife's getting cancer? You're responsible for creating the experience of your wife's manifesting behavior, which you choose to call, by agreement with others, a disease called cancer. But I didn't cause the cancer. Look, Fred, I get that what I'm saying is hard for you to fit into your belief system. You've worked hard for 40 years to create your belief system. And though I get that right now you're being as open-minded as you can be. For 40 years, you believed that things happen out there and that you passive innocent bystander keep getting run over by cars, buses, stock market crashes, neurotic friends, and cancer. I get that everyone in this room has lived with that same belief system. Me innocent reality out there guilty. But that belief system doesn't work. It's one reason why your life doesn't work. The reality that counts is your experience. And you are the sole creator of your experience. You are the sole creator of your experience. This statement is strikingly similar to many of Sartra's statements about freedom and responsibility. The core of EST, the it of getting it, is responsibility assumption. It would appear then that EST works with some important but obscure concepts and rephrases them into a resting language, an accessible Californian pop sarter. If this ingenious application of philosophical thought works, then professional therapists may have a great deal to learn from ESD methodology. But does it work? Unfortunately, we have no definitive answers to that question. No controlled outcome research on EST has been done. And though EST graduate testimonials are legion, they may not be relied upon as a measure of effectiveness. A similar enthusiastic chorus of testimonials has surrounded every new personal growth technology from tea groupoups and counter groups, nude encounters and marathons to eelin body awareness, psycho drama, raling, ta, gestalt, lifepring, cinon. Yet, the natural history of so many of these approaches, which will most likely be the history of EST as well, includes a period of bright pulsation, then a gradual dimming and ultimate replacement by the next technology. Indeed, many of the participants in each of these have had a history of prior attendance and allegiance to some other approach. What is behind this history? Does it raise doubts about whether the approach has a truly substantial, enduring effect?

Follow-up studies have shown that an extremely high percentage of EST graduates rated their experiences as highly positive and constructive. Yet, one must be cautious in evaluating research whose design does not include adequate controls. Much empirical research suggests that there is no outcome assessment more susceptible to error than a simple follow-up, which is in essence a compilation of testimonials. To examine only one aspect of research design, consider the problem of self- selection. Who chooses to go to EST? Is it possible that those who elect to attend to part with a large sum of money to put up with a grueling weekend are going to change or to say they change regardless of the content of the program? The answer is most assuredly yes. Research on placebo reactors, on subject expectational sets, and on the psychological attitudes of volunteers strongly indicates that the outcome to the individual is heavily influenced by factors that exist before the workshop. This tendency of course makes research very difficult. The common design of recruiting volunteers for a personal growth procedure such as an encounter group and contrasting their outcomes with those of a similar number of nonvolunteer control subjects is highly flawed. In fact, a growth group or workshop composed of dedicated individuals who have committed themselves to the experience, who are desirous of personal growth, and who have high expectational sets created in part by an effective pregroup hype, will always be deemed successful by the great majority of participants. To deny benefit would create significant cognitive dissonance. The postgroup high, the glowing testimonials are ubiquitous. Only a particularly inept leader could fail under these circumstances.

If there is no reliable outcome evidence, on what can we rely? I suggest that if we examine the internal evidence available on EST, we shall discover a serious and alarming inconsistency. While avowing the goal of responsibility assumption, EST is at the same time extraordinarily heavily structured. In the EST weekend, there are numerous heavily enforced ground rules. No alcohol, drugs, tranquilizers, or watches. No one is permitted to go to the bathroom except at the 4-hour bathroom breaks. Name tags are to be worn at all times. Chairs are not to be moved. Punctuality is stressed. Late comers are punished by not being permitted entry or by public humiliation. Members are not permitted to eat except at widely spaced meal breaks and are required to turn over snacks hidden in their pockets. Many EST graduates volunteer to be non-paid assistants and judging from their description of their experiences are enormously exhilarated by the act of giving up their autonomy and basking in the powerful rays of authority.

Consider these comments made by an EST volunteer, a clinical psychologist. My next task was to arrange the name tags. They had to be 10 in a vertical row, not touching, in perfect parallel columns. Now, I was to become aware of EST's meticulous attention to detail. The instructions for each chore were exact, deliberate, with the precision one would expect from an excellent instruction manual. I was expected to carry out the task with the same precision. From name tags, I went to tablecloths. Each tablecloth was to be pinned with a square corner and should almost but not quite touch the floor. I looked up to see the person supervising the assistants standing alongside me. It touches the floor. I redid the tablecloth with full attention. My square corners were perfect, and the cloth hung to precisely the right length. I had completed the job, which in EST terms meant that I had finished it with nothing left out of the experience. Perfect parallel columns, meticulous attention to detail, the precision one would expect from an instruction manual, tablecloths hung to precisely the right length. Where amid this lust for conformity and structure is one defined freedom and responsibility? I became even more troubled when at a workshop I noted a cadre of EST assistants, all of whom dressed like Verer Heart, blue blazer, white open collar shirt, gray slacks, and had their hair cut like Verer Heart and like Verer Heheart began their sentences with and spoke about EST in hushed almost religious tones.

Consider other reports of volunteers which I have drawn without much selective effort from EST books endorsed by Verer Heheart and sent to me by EST to inform me about the organization. A young woman who had volunteered to clean the San Francisco townhouse where Verer had his office told me that she had been instructed in detail about how to do the job. I had to clean under each object such as those found on a coffee table and then replace it precisely where I found it. not a half inch away. The person assigned to clean toilets at headquarters reported that there was one and only one EST way to do the job. He shared that he had been astonished to discover how much thought and effort could go into cleaning toilets the EST way, that is completely. We were instructed to smile in the role of greeter. At other times, we were to remain pokerfaced. When I remarked on this to my supervisor, he said simply, "The purpose of assisting is to assist. Do what you're doing now. Do your humor at humor time." A practicing psychologist describes her volunteer work. The high point of the weekend came when the man in charge of logistics said to me after I had mapped the shortest and most efficient route to the bathrooms, "Thank you, Adelaide. You've done an excellent job in writing these instructions." Wow, I was high for hours. Doing things the right way. Cleaning toilets the EST way. Replacing coffee table objects precisely, not a half inch away. Doing humor at humor time. Hi for hours after being complimented for mapping the most efficient route to the bathroom. These words reflect an obvious satisfaction in the losing of one's freedom, in the joy of surrendering autonomy and dawning the blinders of a beast of burden. Many EST graduate statements reflect not a sense of personal power, but a giving up oneself to a higher being. Judgment and decision-making are seated. Nothing is more important than being smiled on by a divine providence. An ESD volunteer states ingeniously, "Verer can become very loud when a job isn't completed." "I quake, but I know he loves me." Does that sound really crazy? That's the way it is. So, you go about your job the way Verer wants the job done. Heard becomes a figure larger than life. His blemishes are touched up, his shortcomings turned into virtues, his talents turned into superhuman qualities. A clinical psychologist gives her impressions of her first exposure to Verer Heart. At that time I had not yet met Verer. A friend had told me that he makes you feel as though you are the whole world, as though nothing else exists. The lights dimmed promptly at 8, and Verer emerged, looking much younger than his 40 years. his skin and eyes incredibly clear. Dressed in an impeccably tailored beige jacket, open- necked white shirt, and dark slacks, the audience rose and applauded. Verer had come to be with them. The audience had settled in and was intensely focused on this magnetic and attractive, but not quite handsome man with the body of a tennis player and the eyes of a prophet. Incredibly clear eyes. the eyes of a prophet. Verer had come to be with them. It was such pronouncements, pronouncements that signal the end of personal judgment and freedom, that prompted another EST graduate, also a clinical psychologist, to write, "The more I envision the gooststepping core at the center of the EST organization, the more virtue I see in anarchy." Thus, the major critique that may be levied against EST is not that it is simplistic. There may be a virtue in that, not that it is mass production. Every great system of thought demands a popularizer, but that it is fundamentally inconsistent. Authoritarianism will not breed personal autonomy, but on the contrary always stifles freedom. It is sophistry to claim as EST presumably does that a product of personal responsibility may emerge from a procedure of authoritarianism which after all is the product and which the procedure the wish to escape from freedom as from has taught us is rooted deep. We will go to any length to avoid responsibility and to embrace authority even if necessary if it requires us to pretend to accept responsibility. Is it possible that the authoritarian procedure has become the product? Perhaps it was from the onset. We shall never know.

Responsibility and psychotherapy research evidence. The connection between responsibility and psychotherapy rests on two related propositions. Responsibility avoidance is not conducive to mental health and responsibility acceptance in psychotherapy leads to therapeutic success. Let me examine the available research to determine what empirical evidence exists to support these propositions. First, it is important to recognize that these propositions oversimplify the matter. Consider, for example, the nature of defense mechanisms, some of which result in responsibility avoidance, such as innocent victim, externalization, or losing control, and are maladaptive, while others, such as those with considerable social reinforcement, like belief in grace, or divine providence, may stand one in goodstead. Some individuals may on the other hand face responsibility too fully, too openly and without the internal resources to face the ensuing anxiety. A certain amount of ego strength is necessary if one is to face one's existential situation and the anxiety inherent therein.

Is responsibility avoidance bad for mental health? It is no easy matter to find evidence that responsibility avoidance is bad for mental health since neither responsibility nor freedom nor willing has been explicitly studied by researchers. A computerized search yielded no empirical studies whatsoever. The term responsibility is not to be found in the formal nosological categories. Nor is the concept of responsibility avoidance or acceptance to be found in studies of psychotherapy. Consequently, I approached the literature obliquely and inquired whether there were studies that bore even a possible relevance to responsibility. The most relevant construct discussed in chapter 4 was locus of control. Recall that locus of control measures at a superficial level whether an individual accepts personal responsibility for his or her behavior and life experiences or whether the individual believes that what happens to him or her is unrelated to personal behavior and is therefore beyond personal control. Individuals who accept responsibility are considered to have an internal locus of control and those who reject it have an external locus of control. External locus of control may be considered as lack of responsibility acceptance. If responsibility avoidance is bad for one's health, then I expected external locus of control to be positively correlated with abnormal personal functioning. I found research that has demonstrated that externals, when contrasted with internals, have greater feelings of inadequacy, have more mood disturbances, and are more tense, anxious, hostile, and confused, are lower achievers, less politically active, and more suggestible, are less imaginative, more frustrated, and more apprehensive. Schizophrenic patients are far more likely to score in an external direction. Severely impaired psychiatric patients are more likely to be externals than our mildly impaired patients. Depression is the disorder that has been most researched with the locus of control construct since the clearly evident hopelessness and fatalism of the depressed patient suggests even to the untrained observer that such patients have lost the belief that they have the power to act in their own behalf and to influence their own experiential worlds. Many have demonstrated that depressed individuals have an external locus of control and as a result of the breakdown of a perceived correction between behavior and outcome develop a deep sense of helplessness and hopelessness. A major theory of depression is the learned helplessness model formulated by Martin Seligman which postulates that the various components of depression effective cognitive and behavioral are consequences of one's learning early in life that outcomes that is rewards and punishments are out of one's control. A person who learns that there is no causal relationship between his or her behavior and outcome not only ceases to act in an effective manner but also begins to events aspects of depression. Translated into existential terms, this model postulates simply that those who believe that they are not responsible for what happens to them in the world may pay a heavy penalty. Though they avoid paying the price of existential anxiety associated with awareness of responsibility, they may, as Saligman claims, develop a fatalism and depression.

The learned helplessness model of depression is rooted in the experimental laboratory and is based on observations that experimental animals exposed to unavoidable stress become less adaptive at avoiding subsequent escapable stress. For example, dogs given inescapable shock were subsequently poorer at escaping from avoidable shock than where dogs given prior escapable shock or no shock at all. There have been many attempts to design comparable laboratory studies with humans. For example, subjects have been exposed to inescapable noise and on subsequent testing exhibit more failures to escape an escapable noise when placed in a human analog of an animal shuttle box or show debilitated performance on certain problem-solving tests. These results demonstrate then that if individuals are taught in the laboratory that their behavior cannot extricate them from situations, then subsequent coping behavior is impaired. Furthermore, David Klene and Martin Celigman found that depressed individuals who did not receive pre-treatment of inescapable noise performed in a comparable manner with those non-depressed subjects who did receive inescapable noise. William Miller and Seligman found comparable findings with problem-solving experiments. In other experiments, it has been found that depressed subjects, unlike non-depressed subjects, have low expectancies for future successes on laboratory tasks and that these expecties are not influenced by reinforcement. An interesting conceptual paradox exists between the learned helplessness model of depression and the cognitive model of depression described by Aaron Beck which posits that a depressive patient is characterized by negative expectations and a powerful tendency to assume personal responsibility for outcome. Thus, depressed patients blame themselves for events clearly out of their control. For example, psychotically depressed patients may blame themselves for starting war or for a natural catastrophe. Lynn Abramson and Harold Sackim discussed this still unreconciled paradox in an excellent review. To summarize, the locus of control, a widely used psychological instrument which can be conceptually compared to responsibility, acceptance, and avoidance, offers some evidence that responsibility avoidance, external locus of control, is associated with some forms of psychopathology, especially depression. The learned helplessness laboratory paradigm of depression offers further corroborative evidence.

What does research tell us about the origins of the individual's posture toward control or responsibility? There is some evidence that the antecedance of internality and externality lie in early family environment. A consistent, warm, attentive, and responsive millu is a precursor of the development of an internal locus of control. While an inconsistent, unpredictable, and relatively uncongenial millu, much more frequently found in lower socioeconomic classes, begets a sense of personal helplessness and an external locus of control. Ordinal position, too, makes a difference. Firstborns are more likely to be internals, possibly because they are more often placed in positions of responsibility for household affairs and for their own conduct and are often put in charge of younger siblings as well.

Does psychotherapy increase responsibility awareness? Is that helpful? Several research projects have investigated the relationship between therapeutic outcome and shifts in the locus of control. John Gillis and Richard Jesser demonstrated that hospitalized patients who improved shifted from externality to internality on locus of control. PS Dua reported that a behavioral therapy program with a population of delinquent adolescents resulted in increased internality of locus of control. Steven Noick and Jarvis Burns demonstrated a rise in internality by using effectance training in a summer camp of deprived inner city adolescence. Several studies of members of encounter experiential groups found that the group experience shifted members toward internality. Unfortunately, these studies are slender contributions, not rigorously designed, and use either no control groups at all or a no treatment control, which fails to control for Hawthorne effects. Furthermore, the results are correlational and do not tell whether a patient improves because of a shift in locus of control or whether a patient shifts locus of control because of improvement.

Another research approach has been to study the subjective reports of patients who have completed therapy. If patients are asked about the aspects of therapy which they found particularly useful, they often cite the discovery and assumption of personal responsibility. In a study of 20 successful group therapy patients, my colleagues and I administered a 60 item Q sort reflecting mechanisms of change in therapy. Patients were presented with the 60 items each on a separate card and asked to force sort them into seven categories from most helpful to least helpful. These 60 items were developed from 12 curative factor categories each consisting of five items. Catharsis, self-standing, identification, that is with other members than the therapist, family reenactment, installation of hope, universality, that is learning that others have similar problems. Group cohesiveness, acceptance by others. Altruism, being helpful to others. Suggestions and advice. Interpersonal learning input, learning about how others perceive one. Interpersonal learning output, improving skills and interpersonal relationships, and existential factors. The existential category consisted of these five items. One, recognizing that life is at times unfair and unjust. Two, recognizing that ultimately there is no escape from some of life's pain and from death. Three, recognizing that no matter how close I get to other people, I must still face life alone. Four, facing the basic issues of my life and death and thus living my life more honestly and being less caught up in trivialities. And five, learning that I must take ultimate responsibility for the way I live my life. No matter how much guidance and support I get from others, the therapists in this study were not existentially oriented but instead led traditional interactionally based groups and the existential factor category was inserted almost as an afterthought. Hence, when the results were tabulated, it was with much surprise that we learned that many patients attributed considerable importance to these throw-in items which are not part of a traditional therapeutic program. The entire category of existential factors was ranked sixth in importance of the 12 categories arrived at by summing and averaging the rank order of the individual items. One item number five learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others was especially highly valued of the 60 items. It was ranked fifth most important by the patients. D. York and C. Iceman repeated this experiment with 18 drug and alcohol addicts who received six months of intensive six days a week psychotherapy with heavy emphasis on group methods and 14 parents of drug addicts also in an intensive treatment program. These researchers found too that this responsibility item was often chosen. It ranked first of the 60 items in one group and second in the other. Jay Drier administered a curative factor instrument to patients entering a psychiatric hospital and again 8 days later. He demonstrated that the majority of patients entering an acute psychiatric hospital expected that the chief mode of help would be that others would give them concrete advice or suggestions to help them deal with their major life problems. By the eighth day of treatment, the majority had altered that belief. Rather than believe that help would come from a source outside of themselves, they now stated that they knew they must assume greater personal responsibility. In an extensive study of the effects of women's consciousness raising groups, Morton Lieberman at all reports that quote interviews with group members repeatedly revealed a thematic concern that I alone am responsible for my own happiness. End quote. Leonard Horowitz studied three videotaped interviews with 40 patients. The first tape was before therapy, the second after eight months of therapy, and the third after 12 months of therapy. He did a systematic count of the number of statements made by a patient beginning with I can't or I have to or close synonyms thereof. I am not able to, I must, I need to, and so on and reported a significant decrease of such statements, less of a sense of powerlessness and gradual assumption of personal responsibility as therapy progressed. These data all suggest that the successful psychotherapy patient becomes more aware of personal responsibility for life. It seems that one of the results of effective therapy is that one not only learns about relatedness and intimacy, that is about what one can obtain from relating to others, but also that one discovers the limits of relatedness, that is what one cannot get from others in therapy and in life as well.

Chapter 6C. Therapist style research evidence. Patients, especially those who seek to avoid responsibility, prefer therapists who are active and directive and who structure the therapy sessions, just as after all what good guides are supposed to do. Three projects using the locus of control instrument provide research evidence of this preference. GC Hellwe asked psychiatric patients and college students to view films of two therapists conducting an interview. Carl Rogers, a non-directive interviewer, and Albert Ellis, an extremely active directive interviewer, and then to select the therapist each would most prefer. The subjects who had an external locus of control, that is avoided responsibility awareness, much preferred the active directive therapist. RA Jacobson asked therapists of behavioristic and of analytic orientations to construct profiles of their therapeutic approaches. She then asked subjects to select the therapist they would prefer and found that individuals with an external locus of control preferred directive behavioral therapists while those with an internal locus of control preferred nondirective analytic therapists. KG Wilson using similar techniques found that the critical variable was the therapist's position as perceived by the patient toward control and participation. Internals will select therapists who they the patients perceive will permit them full participation and control in the therapy process. The problem for patients with responsibility avoidance that is with external locus of control is that the choice of an active directive therapist may be self-defeating. The control requested is not the control required. The more active and forceful the therapist even if ostensibly in the service of helping the patient assume responsibility, the more is the patient infantilized. An outcome project my colleagues and I conducted demonstrates this point. We studied 18 encounter groups which met for 30 hours over a 10-week period led by leaders from a wide variety of ideological schools. Observers rated every aspect of a leader's behavior. Total level of activity, content of comments, the degree of executive function, setting limits, rules, norms and goals, managing time, pacing, stopping, interceding, and the number of structured exercises that is some specific task or exercise which the therapist asked the group to perform such as feedback exercises, hot seat or psycho drama. All leaders used structured exercises. Some used many structured exercises each session, some very few. When we analyzed the relationship between leader behavior and outcome, self-esteem, coping mechanisms, interpersonal style, peer evaluations, life values, and so forth. Some interesting correlations emerged. One, a curve linear relationship existed between amount of executive function and outcome. In other words, the rule of the golden mean prevailed. Too much or too little correlated with poor outcome. Too much executive function resulted in a highly structured authoritarian group in which members failed to develop a sense of autonomy. Too little a lazy fair style resulted in a bewildered floundering group. Two, the more structured exercises used by the leader, the more competent did the members deem him to be immediately at the end of the group, but the less successful was the outcome of his group members measured 6 months later. The moral of this latter finding is obvious. If you want patients to think you know what you're doing, be an active, vigorous structuring guide. However, be prepared to accept the fact that such a strategy gets in the way of the growth of the patient and probably impedes responsibility assumption.

Limits of responsibility. The concept of responsibility is crucial to psychotherapy and it is pragmatically true. It works. Acceptance of it enables the individual to achieve autonomy and his or her full potential. But how far does this truth go? Many therapists are professional advocates of responsibility but secretly in their own hearts and in their own belief systems are environmental determinists. I have for many years treated psychotherapists both in individual therapy and in a therapy group for psychotherapists and have discovered how frequently psychotherapists and I do not exclude myself maintain a double standard. Patients constitute and are responsible for their worlds, while therapists themselves live in a nononsense, objective, structured world and do their best to adjust to what really is. Both therapists and patients pay a penalty for their inconsistent belief systems. The therapists advocate responsibility assumption, but their secret doubt leaks out. They cannot convince patients of something they themselves do not believe. They are unconsciously sympathetic to and consequently are soon ins snared by a patients resistance. For example, in the treatment of a divorced, depressed woman who is desperate in her search for another mate, the therapist may begin to waver in his or her efforts to help the patient assume responsibility. Her resistance strikes a responsive chord in the therapist who begins to think, "The patient seems like an engaging, attractive person. The culture is rough for a single 48-year-old woman. The singles scene is in many ways uninviting. There are very few attractive single straight men in San Francisco. Her job, which she needs for survival, doesn't provide opportunities to meet other people. Perhaps she's right. If only Mr. Wright would come along, 90% of her problems would vaporize. This patient is a casualty of destiny. And so the therapist enters into collusion with the patients resistance and is soon reduced to suggesting strategies for meeting men, singles clubs, computer dating, parents without partners, and so on, as though the patient were incapable of such planning on her own. The real education of the therapist occurs when Mr. Wright does come along and somehow happily ever after never transpires. Mr. Wright is not quite smart enough or he is too dependent or too independent or too poor or too rich or too cold. Or she doesn't want to give up her freedom or she clasps him with such desperation that he is frightened away or she is so anxious that her spontaneity is stifled and he finds her empty and uninteresting. In fact, the therapist will in time find that there is no end to the number of ways that an individual who is conflicted about intimacy can manage to unhinge a relationship. Obviously, double standards in the therapeutic as well as in any other relationship will not do. The therapist must examine his or her own beliefs about responsibility and arrive at a consistent position.

The relationship between environment and personal freedom is extraordinarily complex. Do individuals carve their own destinies or are they, as environmental determinists like BF Skinner claim, entirely determined by environmental contingencies. As Skinner said, a person does not act upon the world. The world acts upon him. Generally in a debate between a determinist and a libertarian, one who believes in freedom of the will, logic and reality seem to be on the side of the determinist. The libertarian is softer and appeals to unmeasurable emotional argument. Psychotherapists are thus in a dilemma. To work effectively, they must be libertarian. Yet many with extensive backgrounds in science, in either experimental or social psychology, or in the biological or medical sciences, find themselves wishing that they could manage a leap of faith into a free choice perspective, but believe secretly that the determinist argument is unassailable. Yet there are substantial arguments for the position of personal responsibility, some of which have the backing of empirical research and may offer therapists a way out of this dilemma.

First, one must recognize that an exceptionless environmental determinism is an extreme position which no longer can claim exclusive support of hard empirical research. Skinner contends that since we are determined by our environment, each of us may manipulate behavior by manipulating environment. But this contention is internally inconsistent. Who is it after all who is manipulating the environment? Not even the most fanatical determinist can contend that we are determined by our environment to alter our environment. Such a position obviously leads to an infinite regress. If we manipulate our environment, then we are no longer environmentally determined. On the contrary, the environment is determined. Binswanganger in a 1936 essay commemorating Freud's 80th birthday makes this point by noting that Freud's personal stature and contributions were a marvelous example of the limitations of his deterministic theory. He wrote, "The fact that our lives are determined by the forces of life is only one side of the truth. The other is that we determine these forces as our fate. Only the two sides together can take in the full problem of sanity and insanity. Those who, like Freud, have forged their fates with the hammer, the work of art he has created in the medium of language is sufficient evidence of this, can dispute this fact, least of all."

In his presidential address to the American Psychological Association in 1974, Albert Bandura referred to this viewpoint as reciprocal determinism and distinguished between the potential and the actual environments. Though all individuals may have the same potential environment, each actually regulates his or her environment. As Bura put it, a researcher once studied schizophrenic and normal children in a setting containing an extraordinary variety of attractive devices, including television sets, photographs, pinball machines, electric trains, picture viewers, and electric organs. To activate these play things, children had simply to deposit available coins, but only when a light on the device was turned on. Coins deposited when the light was off increased the period that the device would remain inoperative. Normal children rapidly learned how to take advantage of what the environment had to offer and created unusually rewarding conditions for themselves. By contrast, schizophrenic children who failed to master the simple controlling skill experienced the same potentially rewarding environment as a depriving unpleasant place. Thus, there is a reciprocal relationship between behavior and environment. One's behavior can influence one's environment. Andura pointed out, quote, "We are all acquainted with problemrone individuals who through their obnoxious conduct predictably breed negative social climates wherever they go. Others are equally skilled at bringing out the best in those with whom they interact." End quote. The environment that each individual creates in turn influences future behavior. Environment and behavior are interdependent. Environments are not given but like behavior have causes. Bura claimed that quote in the regress of prior causes for every chicken discovered by an undirectional environmentalist a social learning theorist can identify a prior egg. End quote. A vast body of empirical research supports the position of reciprocal determinism. This material has been aly reviewed elsewhere and I shall not cite it except to note that it is substantial and rigorous and stems from such areas as human communicational interaction, expectational set, reciprocal relationships between personal preferences and mass media content, cognition and perception, self-regulatory functions of the self system that is a psychoscybernetic model of self and bio feedback.

Though many libertarians are pleased with the unexpected empirical support offered by the theory of reciprocal determinism, many will say it doesn't go far enough. They will argue that a fatal flaw exists in social psychological and behavioral experimental methods. The flaw is that the dependent variable is behavior. In discussing the relationship between freedom and determinism, Bura began with this self-evident argument from the behaviorists standpoint. Quote, "In deciding which movie to attend from many alternatives in a large city, there are few constraints on the individual so that personal preferences emerge as the predominant determinants. In contrast, if people are immersed in a deep pool of water, their behavior will be remarkably similar. However uniquely varied they might be in their cognitive and behavioral makeup, the phrase that creates vast problems for the libertarian is that the behavior of people immersed in water will be remarkably similar. The issue of course is behavior. How is it determined that behavior should be the criterion by which choice or freedom is measured? If one measures limb thrashing, bodily activity or physiological indices, then certainly it is true that the human's physical range or behavioral options like that of any other creature will be drastically curtailed. But even immersed to the neck, a human being has freedom. He or she chooses how to feel about the situation, what attitudes to adopt, whether to be courageous, stoic, fatalistic, cunning, or panicked. There is no limit to the range of psychological options available. Almost 2,000 years ago, Epictitus said, "I must die. I must be imprisoned. I must suffer exile. But must I die groaning? Must I whine as well? Can anyone hinder me from going into exile with a smile?" The master threatens to chain me. What say you? Chain me? My leg you will chain? Yes, but not my will. No, not even Zeus can conquer that. This is no minor quibble. Even though the image of a drowning man's possessing freedom may appear ludicrous, the principle behind the image is of great significance. One's attitude toward one's situation is the very crux of being human, and conclusions about human nature based solely on measurable behavior are distortions of that nature.

It cannot be denied that environment, genetics or chance plays a role in one's life. The limiting circumstances are obvious. Sardra speaks of a coefficient of adversity. All of us face natural adversities that influence our lives. For example, contingencies may hinder any one of us from finding a job or a mate, physical handicaps, inadequate education, poor health, and so forth. But that does not mean that we have no responsibility or choice in the situation. We are responsible still for what we make out of our handicaps, for our attitudes toward them, for the bitterness, anger or depression that act synergistically with the original coefficient of adversity to ensure that a handicap will defeat the individual. Despite, for example, the high market value on physical attractiveness, many people have a style and charm that transcend unattractive physical features. It was Abraham Lincoln, I believe, who said that after 40, everyone is responsible for his face. When all else fails, when the coefficient of adversity is formidable, still one is responsible for the attitude one adopts toward the adversity, whether to live a life of bitter regret or to find a way to transcend the handicap and to fashion a meaningful life despite it. A patient of mine, the likelihood of whose finding a desirable mate was severely jeopardized by a serious physical deformity, tormented herself by choosing to believe that life without a love sexual relationship with a man was without value. She closed off many options for herself, including the deep pleasure of an intimate friendship with another woman or a nonsexual friendship with a man. The bulk of the therapeutic work with this patient consisted of challenging this basic assumption that one was either coupled or one was nothing. A view that has always had strong social reinforcement, especially for women. Eventually, she arrived at the realization that though she bore no responsibility for her deformity, she bore complete responsibility for her attitude toward it and for her decision to adhere to a belief system that resulted in severe self-deprecation. Recognition and acceptance of the external given, the coefficient of adversity, do not involve a passive stance toward one's external environment. Indeed, neo-Marxists and proponents of radical psychiatry have often levied this very charge toward the mental health movement. That is, that it neglects the adverse material circumstances of the individual whom it urges to accept unquestioningly his or her capitalist imposed lot in life. But a full acceptance of responsibility implies not only that one imbuss the world with significance but also that one has the freedom and the responsibility to change one's external environment whenever possible. The important task is to identify one's true coefficient of adversity. The ultimate task of therapy in this regard is to help patients reconstrue that which they cannot alter. physical disease.

Personal responsibility extends farther than responsibility for one's psychological state. Considerable medical evidence demonstrates that bodily ailments are influenced by an individual's psychological state. The field of body mind interdependence in physical disease is so vast that space prevents more than a quick obesence in the proper direction and a brief discussion of recent developments about responsibility for one particular illness cancer. Freud adam braided the field of stress disease linkage in 1901 in the psychopathology of everyday life where he suggested