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Binswanger's disease

Binswanger's disease is a rare form of multi-infarct dementia caused by damage to deep white brain matter. It is characterized by loss of memory and intellectual function and by changes in mood. more...

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Binswanger's disease is one of the neurological syndromes associated with hypertension. It is uncommon, but obviously devastating. The histologic findings are diffuse, irregular loss of axons and myelin accompanied by widespread gliosis. Small infarcts may be seen in the frontal lobes. The pathologic mechanism may be damage caused by severe atherosclerosis.

A patient with long term severe hypertension develops progressive dementia. CT scans of the head demonstrate a diffuse loss of deep hemispheric white matter.

Binswanger's disease has no known treatment, let alone cure, although drugs used to treat high blood pressure, depression, arrhythmia and low blood pressure are used to treat the condition's symptoms.

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The existential approach in Heart-Centered therapies
From Journal of Heart Centered Therapies, 3/22/03 by David Hartman

Abstract: The amalgam of Heart-Centered therapies is highly eclectic, yet uniquely and specifically organized. Heart-Centered therapies are located within the traditions of deep experiential psychotherapy, and existential-humanistic psychology. The existential approach in psychotherapy is organized around life on earth itself and the social, cultural and spiritual ramifications of it, that is, the "human condition." People's existential issues are related to their mortality and impermanence, their experience of freedom of choice (or lack of it), their sense of worthiness, and their sense of separation/connection with others. We review the contributions of Kierkegaard, Nietzsche, Heidegger, Sartre, Bugental, Binswanger, Fromm, Laing, Sullivan, May, Frankl, and Yalom. We identify five themes that pervade existentialism: (1) meaning in life is found in the living of each moment; (2) passionate commitment to a way of life, to one's purpose and one's relationships, is the highest form of expression of one's humanity; (3) all human beings have freedom of choice and responsibility for our choices; (4) openness to experience allows for the greatest possible expansion of personal expression; and (5) in the ever-present face of death itself, we find the deepest commitment to life itself.

We also address the relationship between experiential psychotherapy, the existential approach, and Heart-Centered therapies. We summarize the historical roots of the experiential approach with Whitaker, and discuss the three basic principles that define it.

Primary topics

1. The Existential approach

2. The Experiential approach

Ego, Existential and Transpersonal Psychotherapy

Heart-Centered therapies work is clearly based on the premise that the process of therapy is not one of treating "a disease entity" in the medical model, but rather "reinstitutes a derailed, arrested, or distorted developmental process" (Engler, 1993, p. 121). The underlying developmental psychology must, of course, include the full developmental spectrum, i.e., transpersonal experience from conception through death. One way to observe these expanded developmental processes is to divide them into ego, existential and transpersonal (Zimberoff & Hartman, 2000).

The ego level is organized around the self-image of `I' as separate and unique from all that is `not I.' Work at the ego level builds boundaries, integrates polarizations, replaces nonfunctional concepts of self and others, and modifies character structure for more fulfillment. "Once individuals have developed a more cohesive egoic identity, they can embark on a process that takes them further on the journey of self-discovery, that of unfolding their existential self, or their true inner individuality" (Wittine, 1993, p. 167).

The existential level is organized around life on earth itself and the social, cultural and spiritual ramifications of it, that is, the "human condition." People's existential issues are related to their mortality and impermanence, their experience of freedom of choice (or lack of it), their sense of worthiness, and their sense of separation/connection with others. Work at this level is to loosen the rigidity of the self-image, to expand the relationship to the sacred, and to integrate one's relationship with death.

The transpersonal level is organized around the parts experienced as `not I,' including rejected and repressed parts, introjected and attached energies, and the unrealized potentials. The work at this level includes identifying and healing repressed shadow parts, often easily accessed through one's projections, and identifying and reclaiming the transcendent parts hitherto beyond reach (such as past life, preconception, prenatal, perinatal, and death experiences).

The Existential Approach

We offer the following five principles to be our understanding of the components of an existential approach to psychotherapy, healing and transformation. We will discuss these principles after first tracing the history of existential psychology and psychiatry. Our proposed five principles are:

1. Meaning in life is found in the living of each moment.

2. Passionate commitment to a way of life, to one's purpose and one's relationships, is the highest form of expression of one's humanity.

3. All human beings have freedom of choice and responsibility for our choices.

4. Openness to experience allows for the greatest possible expansion of personal expression.

5. In the ever-present face of death itself, we find the deepest commitment to life itself.

A brief history

The existential approach to therapy, healing and transformation is based on the discrete philosophy of existentialism. Existentialism is a sensibility, a perspective on life, not a set of doctrines. To try to define existentialism is to freeze it, in the words of Jean-Paul Sartre (1956), who gave the movement its name and identity.

Robert Solomon (1972) traces the sources of existentialist thought in the nineteenth and twentieth centuries primarily through Kierkegaard, Nietzsche, Heidegger, Camus, and Sartre, and identifies three themes that pervade existentialism. First is a strong emphasis on the individual, although that is variously defined and understood. For Neitzsche (1958), the goal in life, to really exist as opposed to so-called living, is to fully manifest your talents and virtues, thus "becoming the person you really are." Second is the central role of passionate commitment, as opposed to the usual philosophical emphasis on reason and rationality. Existentialism basically urges us to live our lives to the fullest, according to our own individual understanding. For the existentialist, to live is to live passionately. And third is the importance of human freedom to make choices, and the responsibility to do so consciously. "The message of existentialism, unlike many more obscure and academic philosophical movements, is about as simple as it can be. It is that every one of us, as an individual, is responsible--responsible for what we do, responsible for who we are, responsible for the way we face and deal with the world, responsible, ultimately, for the way the world is. It is, in a very short phrase, the philosophy of "no excuses!" (Solomon, 2000).

Heidegger (1962) dwelt on the concept of authenticity, and encourages us to be authentic, to "take hold of ourselves" and in the engagement with self to make the most appropriate choices in living in the world. Our existence carries possibilities, and offers us the opportunity to make choices among those possibilities. When we fail to face up to our existential condition, we fall back into doing tasks, into mundane inauthenticity, what he calls "fallenness." The primary drive to "take hold of ourselves," to live authentically, is the awareness of our own mortality. Heidegger refers to this as "Being-unto-death." This perspective of life as framed within birth and death, of living with death in mind, forces us to appreciate our limitations and immerse ourselves in our immediate context. Death individuates us.

A very different, but related concept is Nietzsche's "thought of eternal recurrence." Eternal recurrence provides an existential test for how one is living one's life, and what one is doing with one's life. Specifically, if offered the choice to repeat your life as it is, or to change it in some way in a future repetition, which would you choose? If you would choose to make changes in a future repetition, then Nietzsche urges you to choose to make those changes now. The alternative is to remain in bondage to the never-ending cycle of satisfying momentary desires at the expense of a more meaningful degree of satisfaction. As Goethe says in Faust, "From desire I rush to satisfaction, but from satisfaction I leap to desire."

These existential themes have become the genesis of existential psychotherapy. Soren Kierkegaard (1970) viewed existence as a conversation between life and death, observing that the most frequent human reaction to the inevitability of death is dread, or angst. One's reaction is often to flee the dreaded reality by creating an inauthentic life with self-sabotaging neurotic anxiety, defenses, resistance, repression, addictions, distractions and dissociation. The solution is engaged passionate commitment, crucial for authentic selfhood according to Kierkegaard.

Bugental (1965) asserts that neurosis is the avoidance of existential confrontation, and consists of the denial or distortion of authenticity, trying to create certainty where it does not exist, trying to invoke probability where there is only possibility, trying to disavow responsibility while we carry it always with us. Attempting the impossible creates neurotic anxiety. We then employ the myriad of neurotic defenses to armor ourselves against the threat. Research has tended to support that point of view (Thauberger & Sydiaha, 1975; Thauberger & Sydiaha-Symor, 1977; Thauberger et al., 1982).

Existential anxiety arises not just in relation to physical mortality, but also, and perhaps more so, to the threat of ego dissolution, the realization that the `I' is not solid and permanent but rather flimsy and fleeting, i.e., the threat of non-being. "Ego contains at its very core a panic about egolessness, an anxious reaction to the unconditional openness that underlies each moment of consciousness" (Welwood, 2000, p. 46).

Existential Psychiatry

The existential school of psychiatry, developed during the last half of the twentieth century, is based largely on Heidegger's work and has focused on the existential structure, or "world-design," of each individual's world and on authenticity and the dread of death (Ghaemi, 2001). These themes were emphasized by psychiatrists Ludwig Binswanger (1963), Erich Fromm (1947), and R. D. Laing (1969).

Binswanger interpreted Heidegger's conception of Being-in-the-World as an existential a priori whose job it is to ground an individual in the characteristics of his life and his world of relationships and roles. If this structure of one's existence was in some way altered, due to biological or psychological reasons, then it could lay the basis for varied manifestations of mental illnesses. This explains how a seemingly insignificant experience, when it openly challenges one's "world-design," can become a shattering experience. Binswanger's method was a highly original version of an "empathic" approach to psychosis when he developed it, emphasizing the need to "live in the world of the patient." Empathy is not a matter of understanding the psychotic person's ideas, it involves "being-together" with him, i.e., understanding the existential structures that function in his world design.

Binswanger also emphasized the importance of accepting personal responsibility for one's choices in life. He referred to Freud's injunction that a person's "I cannot" must always be understood as an "I will not." He saw the aim of psychotherapy to be assisting people to recognize and elaborate their distorted modes of relating to others and the world around them, to free themselves from habitual and arbitrary ways of being by taking responsibility for their choices in life.

Binswanger anticipated the interpersonal nature of Being-in-the-World later elaborated by Harry Stack Sullivan (1953) as interpersonal psychiatry. The conception of authenticity put forward by Kierkegaard and Heidegger was in the context of being true to oneself, that one becomes authentic when one "takes hold of oneself" and "takes a stand" on one's existence, i.e., embraces one's Being-in-the-World, or world design, in a vacuum, voluntarily separated from others, since relationships with others could only contaminate true authenticity. Binswanger extended the concept of authenticity to incorporate the possibility of authentic, positive Being-with-one-another relationships in a mutually loving We-self. He suggested that self-realization can be achieved through engagement in reciprocal, authentic relationships, i.e., relationships of reciprocal love. He found a theoretical ally in Martin Buber (1927/1970), who asserted the primacy of relationships in being truly human. Frie (2000, p. 118) summarizes Buber:

"Acknowledgment of the other person (not as a means to an end but in his or her totality) as a Thou is the condition of possibility for authentic existence. In contrast to Heidegger, Buber insists that authentic selfhood can only be comprehended in terms of the reciprocity of I and Thou." For Binswanger, the I-Thou relationship is characterized by mutuality, openness, and immediacy.

As important as relationship, or relatedness, is in Binswanger's view, its absence has an equally profound influence on the experience of being human. Frie (2000) discusses Binswanger's explanation of a relatedness scale, with the I-Thou relation on one end and individualized existence without relation to someone or something on the other end. Human nature finds its highest fulfillment in the I-Thou relationship, whereas its opposite at the other end of the scale is hopeless loneliness, frozen isolation, schizoid detachment, the nothingness of anxiety, or psychotic delusion. The loss of relatedness is central to the development of mental disorders; the more one experiences essential isolation, the deeper the descent into madness. Conversely, achieving intimate relatedness leads to mental health, personal growth and self-realization.

And, of course, Binswanger believed in particular that successful psychotherapy was dependent on the formation between therapist and patient of an I-Thou relationship based equally in care and love. This belief reflected a general shift from the Freudian intrapsychic dimension to the interpersonal realm. This emphasizes a basic distinction: whereas classical psychoanalysis stresses separation and autonomy from the other, an existential-interpersonal approach to psychotherapy relies on a deepening understanding of our continuing relationship to others. The aim in the I-Thou relationship is not for either one to dissolve the sense of individual self, but to enhance it through mutual interaction, respecting personal boundaries and recognizing individual differences.

The reality of the I-Thou experience in a therapeutic encounter between therapist and client is fundamental to the existential approach. It is an encounter in which "the deepest self of the therapist meets the deepest self of the client" (Rugala & Waldo, 1998, p. 68). It may be called "the intimate edge" of therapy (Ehrenberg, 1992), "the moment of real meeting" as a new transforming experience (Guntrip, 1969), "the existential moment" in which each person has dropped any facade (Bergantino, 1981). Rogers (1987) said that during a genuine "I-Thou" moment with a client, "the important thing is that two unique persons are in tune with each other in an astonishing moment of growth and change" (p. 39).

Also fundamental to the existential approach is the importance of death to every aspect of the experiencing of life. "Life and death are not opposites ... death too must be lived ... life is `encompassed' by death" (Binswanger, 1958). Neimeyer and Chapman (1980) suggest that for a person whose meaning and purpose remain unactualized, death threatens to destroy the expectation of fulfillment, of what gave life its significance. Death "aborts the development of a cherished identity still unborn. In contrast, to the individual whose major projects have been fulfilled, death is a source of less anxiety; it appropriately punctuates a meaningful life" (p. 234). Any unfinished business in life distracts one from a peaceful acceptance of death, just as it has preoccupied one from being fully present during the experiencing of daily life.

The interpersonal emphasis is crucially fundamental to Heart-Centered therapies in two ways. First, the etiology of clinical phenomena and psychopathology can only be understood in the context of the relationships within which they were originally formed. Thus we acknowledge the importance of early developmental interactions in our client's current experience. Secondly, therapeutic healing occurs within the context of an "interpersonal field of existence" (Atwood & Stolorow, 1984) between therapist and client, and the nature of that relationship determines the extent of the healing.

Existential Psychology

The existential approach in psychology developed during the same time period as it did in psychiatry. Rollo May in his work Existential Psychology (1969), suggests that our challenge arises in being able to open our vision to more of human experience, to free our clinical methodology to do justice to the richness and breadth of each individual's experience. The existential approach views the individual, not inductively, parts to a whole, but rather deductively; moving from whole to parts with the individual consisting of a whole person--composed of past, present and future--experiencing the conditions of existence that all people must face throughout their lifetimes, from birth through death. An existentialist viewpoint takes into account a "holistic" person (Hacker, 1994). When it was proposed, such an approach seemed refreshingly in contrast to the dominant approach in psychology of following the medical model of studying and addressing parts of the whole. May quotes Abraham Maslow, "It is extremely important for psychologists that the existentialists may supply psychology with the underlying philosophy which it now lacks. At any rate, the basic philosophical problems will surely be opened up for discussion again, and perhaps psychologists will stop relying on pseudosolutions or on unconscious unexamined philosophies they picked up as children" (p. 30).

Yalom (1989) identifies four "givens" of existence, particularly relevant to the existential psychotherapeutic experience. These "givens" are an inescapable part of human existence in the world: death, freedom, isolation, and meaninglessness. Death is inevitable, our own death and the death of those whom we love. Humankind devotes enormous energy to deny, elude and escape death's grasp. Freedom, the second given, is ours so that we may tailor life to our choosing. The given of isolation implies our day-to-day struggle with thoughts of our ultimate aloneness, and finally, the given of meaninglessness implies absence of any obvious meaning or sense to our life. Although these "givens" may seem grim, Yalom (1989) states that "they contain seeds of wisdom and redemption" (p. 5).

Recognizing a state of Being-beyond-the-world (Walters, 1998) in addition to Being-in-the-world, the existential position is that people can transcend the ground of human existence (Binswanger's term for the limits placed on freedom by the external environment and one's innate abilities and resources), i.e., their immediate situational existence. This transcendence allows people to deal effectively with their existential anxiety, fear and guilt through authenticity, integrity and fulfillment of meaning in their lives. Intentionality is the construct for that uniquely human quality of being capable of generating an unlimited number of options to choose from in any given moment (Slife & Barnard, 1988). It is in our teleological ability to consider and work toward a larger goal, meaning or purpose that we transcend the limitations imposed by human existence (Bakan, 1996).

Rugala and Waldo (1998, p. 67) succinctly state the simple underlying principle upon which so much of the existential approach is built: "the extent to which people are experiencing is the extent to which they are being fully alive. When people fail to experience, by denying awareness or avoiding opportunities, they waste their potential. Those who bypass experiencing carry the existential guilt of their unfulfilled potential." One of the great contributions of Laing (1969) was to differentiate between "false guilt" and "true guilt." Burston (1998, p. 83) provides a clear analysis:

How we live is our choice, whether the choice is made unconsciously and habitually or consciously. And our accountability to live with the consequences of our choices is unavoidable. "Existence cannot be postponed" (Yalom, 1980, p. 161).

Existential psychotherapy aims to help individuals to recognize and fulfill their highest potential, the highest expression of their world design. Meaning in life derives from achieving that self-expression, and striving to find meaning in one's life is the primary motivational force in human beings, their "will to meaning" (Frankl, 1984). When the will to meaning is frustrated, the individual experiences "existential frustration." Then the life energy is projected down into the lower dimension of a "will to power," or lower still into a dimension of the "will to pleasure." Without an existential sense of meaning, these dimensions are experienced as neurosis. Pleasure is not an end in itself but rather a by-product of having done something meaningful. Likewise, power is a means to an end that is attained by using power in a meaningful way. Frankl's Logotherapy assists clients to find meaning in their life through helping them to become aware of the hidden logos of their existence, i.e., the underlying patterns that facilitate or obstruct expressing one's meaningful purpose. The "existential analysis of logotherapy aims at nothing less than leading individuals to become more conscious and responsible" (Marseille, 1997, p. 3). Highly important in Frankl's view of the human condition is the difference between biologically rooted drives that push us and the spiritually rooted yearnings that pull us (Frankl, 1966). His theory holds that three capabilities express mankind's possibilities: self-detachment, self-transcendence, and the ability to "spiritually be in touch." We have the inner freedom of choice to transcend the narrow limits of self-interest by accepting a spiritual perspective that liberates us from self-serving attachments and identifications. Frankl (1955) says:

Fabry (1988) suggests that Frankl's perspective on meaning is that it occurs on two levels: ultimate meaning and the meaning of the moment. "If you are aware of ultimate meaning, in either a religious or a secular context, you will be able to respond meaningfully to the offerings of the moment because you have a built-in compass that points toward meaning."

The existential approach offers a phenomenological approach to the person, a holistic view of the entire being-in-the-now, rather than focusing on particular drives or instincts, separating id, ego and superego, emphasizing either biology or environment.

Cortright (1997) discerns five primary areas of focus in existential transpersonal therapy (and in most approaches to spiritual practice, coincidentally):

1. Present-centeredness

2. Awareness

3. Full sensory and bodily involvement

4. I and Thou

5. Morality

Most existential approaches view the present as the only reality; that is, all forces are seen to be acting now, in this immediate moment. The past exists here and now as memories, regrets, sources of shame or pride. The future exists here and now as anticipation, hope, rehearsing, dread. Effective therapy or healing involves seeing clearly how the past is alive in the present in the form of unfinished business and bleeding wounds. As the wounds heal and the business is finished, the person opens to the immediacy of the present moment. One of the reasons hypnotherapy is so powerful in helping people to change neurotic patterns is that the process involves experiencing the past (for example, age regression to a childhood trauma) or the future (for example, rehearsing an upcoming anxiety-provoking confrontation) as an experience in the present.

Awareness is viewed as the key to actual experiencing. Awareness liberates the person from inauthentic dissociated fantasy into his or her real and actual experience. Experience becomes more vivid and more real by attending to it, paying attention to it. It might be viewed as the process of waking up.

Attending to the moment requires fully inhabiting the physical and sensory realm of bodily existence. Grounded in sensitivity to the nuances of one's body's messages leads to greater immediacy of experience. As Fritz Peris said, "Lose your mind and come to your senses."

Reciprocal, mutual person-to-person relating with others follows from presence in the moment and grounding in one's own body. The I-Thou relationship suggested by Martin Buber contrasts with an I-It relationship, the everyday secular relating in which the other is seen as an object, a thing to be used or manipulated, a means to an end. Ultimately, the transpersonal existential perspective embraces the sacredness of human relationship.

Finally, the existential view of morality is that there exists a deep, intrinsic morality of the organism which, when liberated from the constrictions of conventional morality, is infallibly oriented to the highest good of all.

Bergantino (1981) suggests six principles of existentialism that relate well with psychotherapy:

The formulations by Cortright, Bergantino and others of the basis for existential psychotherapy have some notable resonance with the concepts of openness to experience, wisdom, and grace, to be discussed in a later section of this article.

Five principles of the existential approach

With this background, we offer the following to be our understanding of the components of existential approach to psychotherapy, healing and transformation:

1. Meaning in life is found in the living of each moment.

a. Nonattachment

b. Sacredness of each moment

c. Awakening from the "trance of ordinary life"

d. Completion (resolving unfinished business)

2. Passionate commitment to a way of life, to one's purpose and one's relationships, is the highest form of expression of one's humanity.

3. All human beings have freedom of choice and the responsibility for our choices.

4. Openness to experience allows for the greatest possible expansion of personal expression.

5. In the ever-present face of death itself, we find the deepest commitment to life itself.

a. The fear of death and the "death urge"

b. Everyday awareness of death

1. Meaning in life is found in the living of each moment.

Battista and Almond (1973) applied a meta-analysis of various approaches to the development of meaning in life (Bugental, 1965; Frankl, 1955, 1963; and Maslow, 1968, 1971). They argue that existing theories agree on four major points (Debats, 1999, p. 33): "When individuals state that their lives are meaningful, this implies that (a) they are positively committed to some concept of the meaning of life, (b) this concept provides them with some framework or goal from which to view their lives, (c) they perceive their lives as related to or fulfilling this concept, and (d) they experience this fulfillment as a feeling of significance."

Most people have experienced some of their most profoundly meaningful experiences in the most fleeting of moments. Consider the adage to "smell the roses along the path." Recall the inspiring experience of reveling in a momentary rainbow or sunrise. As people approach the reality of their own death, e.g., through a serious accident, a terminal illness, or the loss of an intimate friend, they tend to assign a profoundly higher value on each moment of their remaining life and significantly less importance to the accumulation of fame or fortune.

Being fully present in the experiencing of each moment also implies that the meaning and purpose to be found is in the engagement itself, not in some result that "I get out of it." Listen to this Zen saying: "Before enlightenment, chop wood and carry water. After enlightenment, chop wood and carry water." Frankl (1967, p. 8) observed, "Self-actualization occurs spontaneously; it is contravened when it is made an end in itself." He used this story to convey the message:

Implications for therapy

Bergantino (1981) reports that Wilfred Bion, the English psychoanalyst, felt the therapist's mind should always be in a state of chaos to create an openness to fresh experience instead of stereotypes of reality. Freud (1925) emphasized the importance of the therapist maintaining an unfixated attentional state that he called "evenly hovering awareness." When one is fully aware in a situation without rational judgment or emotional reaction, the individual is free to listen intuitively.

van der Kolk (1997) notes that "Our biggest challenge for traumatized people is to help them be here and not always there, and not to replay the same things over and over again." Traditional therapies too often keep people stuck in the "there," and don't help people find a way to get to "here." Traditional approaches to therapy are of limited effectiveness for severely traumatized people, especially for children, because they fail to reach the areas of the brain that were most impacted by early trauma (the midbrain, primarily the limbic system and amygdala). Cognitive and verbal therapies rely primarily on the areas of the brain least accessible in trauma. Traumatic memories allow the child access only to the right brain, while the left brain is responsible for organizing and making sense of information). The traumatized child's right brain is constantly subjected to the demands of stress hormones, and so is in a constant state of hyperarousal. Thus the midbrain comes to the (self-fulfilling) expectation that most life events will be traumatic. PET brain scans show that limbic system activation, particularly the amygdala, carries with it the felt sense of being out of control (Shapiro et al., 1995).

Now let's look at this presentness element of the existential approach in its manifestations of (a) nonattachment, (b) the sacredness of each moment, (c) the experience of awakening from the "trance of ordinary life," and (d) completion with the past (no unfinished business).

Nonattachment

Nonattachment is the freedom to "live with abandon" without fear of abandonment. It is living with an attitude of commitment to the path without attachment to the outcome. Nonattachment is learning to pay full attention to one's environment and one's reactions to it, but not to identify with either.

Some functions of the ego are self-organizing, grounded and centered. Some functions of the ego are our attempt to grasp and define ourselves, to neurotically defend ourselves against existential anxiety. Those functions of the ego are preoccupied with the past (the baggage of fears, beliefs, shame and guilt) or with the future (worries about what might or might not happen). One is grasping for then, ignoring now. The attempt to grasp the self and fixate it is doomed to endless frustration and disappointment because it comes out of fear, out of this core, chronic, anxious sense that we don't exist in the way we think we do (Engler).

"Acceptance of change is the essence of nonattachment" (Kyogen, 1995). From a Zen perspective, Kyogen likens a sense of nonattachment to drifting clouds and flowing water. Clouds attach to nothing, and so drift freely across the sky. Water twists and turns on its way downhill in complete accord with the path it must follow. The flowing of the water has the strength to move mountains, while the drifting of the clouds is utterly free. Whether we let go or not, things will slide away and we won't be able to prevent it. Better to let go and cooperate with the way things are than to try fruitlessly to resist the irresistible shape of reality.

Nonattachment is not carefree, however. While maintaining our responsibilities, we let go of the self-centeredness of personal preferences, opinions, and attachments. It is in commitment to selflessness that the practice of nonattachment has its deepest form. Nonattachment and commitment meet in willingness. "The willingness to accept things as they are, and the willingness to let things go; this is the essence of nonattachment. Stillness and activity, nonattachment and commitment, are the clouds and water," he writes. "A life of nonattachment without commitment is like a tree without its roots in the ground. It will grow progressively weaker, so how could this be true freedom? Nonattachment within commitment brings peace of mind when you know that you can bow no matter how things turn out" (Kyogen, 1995).

The Buddha said, "Nothing whatsoever is to be clung to as I or mine." Sheikh Muzaffer said, "Money--there should be a lot in your pocket, but none in your heart."

Implications for therapy

One of the primary injunctions for a therapist with an existential approach is to not have expectations, or an agenda, for the client's experience or therapeutic goals. This means being committed to the relationship with clients, working with clients diligently on their work as they choose it, and letting go of attachment to their outcome.

Sacredness of each moment

The sacred has been called "fullness of experience," and is glimpsed when we are savoring life, open to the timelessness of each moment (Schoen, 1991).

Satisfaction with life is one outcome of an individual's receptivity to experience. The tendency to find sacred meaning in daily experiences is positively associated with Satisfaction with Life and with Purpose in Life (Byrd et al., 2000). Emmons (2000) considers the ability to invest everyday activities, events, and relationships with a sense of the sacred or divine to be one of the core components of spiritual intelligence, the set of skills and abilities associated with spirituality that are relevant to everyday problem solving. Adams (1996) defines the core of experiencing the sacred as revelation and awareness of an essential, interpermeating communion between self and world.

Implications for therapy

Clients experience sacredness in themselves when counselors consider life sacred (Aspy & Aspy, 1985). Thus a counselor prepares for a session as an important event and reminds him/herself of the client's sacredness during the session. After the session, a counselor who considers life sacred will ask him/herself if the client is better prepared for life as a result. The concept of sacredness in a counseling role enables both client and counselor to experience growth.

Awakening from the "trance of ordinary life"

"Just as it is possible to awaken, to become lucid, in a dream, so it is possible to attain moments or periods of heightened awareness--`wakefulness'--in waking life" (Metzner, 1998, p. 28).

Awakening from the "trance of ordinary life" (Deikman, 1982) is to disidentify from role, image, or identity. When an individual identifies with an image or an identity, he/she "takes on" the accoutrements associated with it. For example, identification with an addiction may lead to increased involvement in the addictive activity, whereas identification with behaviors incompatible with an addiction may lead to reduced involvement in the addictive activity (Walters, 1996).

In psychosynthesis, the part of oneself fixated at an incomplete developmental stage is a subpersonality, functioning mechanically, unconsciously. If an individual becomes totally identified with a subpersonality, he/she places its needs and perspectives above all else, "repetition compulsion" in psychoanalytic terms. By recognizing and naming subpersonalities, disidentifying from them and dialoguing with them, their underlying (unresolved) needs and as yet unclaimed higher qualities become apparent. Their distorted behaviors can be transformed and energies released for the benefit of the total person. Thus in a psychosynthesis perspective, the growth process is seen as a series of awakenings (Crampton, 1974). New awarenesses require a reordering of personality-elements to accommodate a broader self-concept, an expanded identity. The goal of personal psychosynthesis is to promote growth and to integrate the personality: to coordinate one's various personality aspects, to resolve inner conflicts, and to create a sense of ease and harmony. Psychosynthesis recognizes that at each level of integration, the personality has the potential to transcend itself once again, temporarily dis-integrating on the way toward a more inclusive and comprehensive sense of wholeness. Hypnosis is especially helpful in accessing ego states and clarifying one's identity as being greater than any one of them.

Disidentifying from role, image, or identity can mean loosening the strictures of social pressure. We will use the eastern term samsara for the cultural consensus reality, the set of explicit and implicit beliefs and myths about the nature of reality and the society's place in it, that makes the activities of the people in that society meaningful. Each of us needs to feel that he belongs and that his life has meaning in terms of some valued, larger scheme of things. One way to begin to escape from the samsaric condition, the "trance of ordinary life," is to pay enough directed attention to your mental processes so that you can distinguish between primary perception coming in from the external world and your particular associational reactions to it. In other words, distinguish the stimulus from your response and short-circuit habitual reflexes. If you can keep your primary perception and your reactions to it clearly distinguished in your consciousness, you are less likely to project your reactions onto others, or to distort incoming perceptions to make your perceptions consistent with habitual internal reactions. Reactions and perceptions do not become indiscriminately fused together. We call this way of experiencing mindfulness. Discover the "early conclusions" that became deeply embedded in unconscious belief, the "internal working model" or "life script," and you reclaim the possibility of conscious and free choice rather than unconscious reflex reaction.

This self-awareness also allows you to maintain an attentive watchfulness on your primary perception, to establish a watchman at the gate (DeRopp, 1968). When you realize that an incoming stimulus is the sort that will trigger an undesirable reaction, you can inhibit the reaction. It is easier to become self-conscious, and thus remove some of the energy from incoming stimuli before they have activated associational chain reactions, than to stop the reactions once they have been activated. The watchman robs the reaction of its power early enough to prevent it from gaining any momentum, i.e., the continuous observation of the tendency to react lessens one's identification with the reaction and so takes away some of its power.

Brain researchers now document frequent lapses of consciousness in most people's daily existence, unknown to the individuals themselves.

Carl Jung (1996) spoke of the need to "wake up."

Implications for therapy

Self-observation and mindfulness techniques do not always work to bring change. Some of our patterns are so deeply ingrained and thoroughly defended that they are not only highly resistant to change by insight, but may be incapable of being perceived at all. Individual or group psychotherapy becomes exceptionally valuable for expanding one's "field of (mindfulness) vision." One's intentions in therapy, healing and transformation must be clearly identified. Waking up to one's dysfunctional defenses and patterns is one thing. Transcending the samsaric limitations of the "trance of ordinary life" is quite another. How far one might go in therapy, i.e., the extent to which assumptions of the consensus reality (samsara) are questioned in it, should be determined by the client's intentions, but is in fact also limited by the power and implicitness of the therapist's own enculturation.

Completion with the past (resolving unfinished business)

For most people, the past is alive in the present in the form of unfinished business and uncompleted developmental tasks. As one resolves and completes what was left unfinished, the person opens to the immediacy of the present moment, reducing reactivity and increasing self-esteem. The healthy person asks, "Is there anything that I need to say or do or clear up that I haven't?" and then sets out to establish completion where it is needed, to make amends with the past. Completion allows one to live fully, prepared to meet the uncertainty of each moment without regrets.

Implications for therapy

The actual component steps in the therapeutic process of resolving unfinished business are analyzed by Greenberg and Malcolm (2002). The resolution model begins generally with bringing to awareness one's sense of blame toward another, complaints about another's behavior, or expressing a sense of hurt over perceived damage done by another. The next step is to enact or anticipate the negative behavior of the other as he/she imagines the other to be (e.g., rejecting, hostile, critical or uncaring). Next, the individual expresses intense primary emotions, shifting from a defensive reaction to an internal exploration of the personal consequences of the other's wrongful behavior, what was lost or taken away (e.g., anger, sadness or shame). Next, the wished-for aspects of the relationship are focused on to identify the unmet interpersonal needs or the incomplete developmental milestone. These needs are expressed to the imagined other with an increasing sense of entitlement and empowerment. The empowerment leads to a shift in the view of the other toward a more complex, multifaceted understanding. One might begin to experience empathy for the other, softening the previous judgments; alternatively, one might begin to experience the other as less threatening, but still blameworthy, as the individual feels more empowered. Finally, individuals who reach resolution do so by focusing on affirmation of the self as worthwhile, and finding it possible either to gain an increased understanding of the other or to hold the other accountable for the violations experienced. Understanding the other leads to compassion, and perhaps forgiveness. Holding the other accountable leads to de-blaming the self and affirming one's worthiness. In either event, the individual experiences a sense of resolution and completion, empowerment and optimism about the future.

This model describes the process of resolving unfinished business that is integrally interwoven into the regression experiences in Heart-Centered therapies.

2. Passionate commitment is the highest form of expression of one's humanity

Rollo May said, "Joy is the zest that you get out of using your talents, your understanding, the totality of your being, for great aims" (1998). Bergantino (1981) speaks of the power of "existential moments" in life, and specifically in therapy. In such moments, two or more people share raw emotion and a momentarily coinciding world-view. These moments are "the capturing and expression of one's being at precisely the moment such passion becomes one with consciousness" (p. 12). Such intimately shared moments can only occur within the framework of a mutual commitment (to each other and/or to a mutually identified "other").

Recent research (Debats, 1999) supports the assertion that an individual's sense of meaning in life is significantly determined by his/her degree of commitment to personal meanings (Battista & Almond, 1973), and likewise that a significant commitment to some goal or goals for living provides a sense of order and purpose (Thompson & Janigian, 1988). In other words, meaning in life is not determined by specific orientations or content of beliefs, but by the degree of devotion employed to realize these meanings. A terrorist suicide bomber may subjectively feel his life to be as meaningful as Mother Theresa did hers. Debats' research (1999) also verifies earlier findings (Reker & Cousins, 1979) that experiencing meaning and purpose in life in the here and now is associated with satisfactory life experiences and positive future expectations, in other words, hope. Passionately living today, "engagement in life" (Yalom, 1980), is the answer to meaninglessness, and is a reflection of perceiving the future as open or calling with opportunity, and that one's experience in the future will predictably be a reflection of one's choices today.

Although the centrality of commitment in creating meaning is universal throughout the lifespan, the context of the source of meaning follows a developmental track. Adolescents and young adults predominantly refer to personal meanings that are essentially self-centered and need-based (Hedlund, 1987), whereas through adulthood there is a gradual shift from self-centered to other-centered personal meanings (Erikson, 1963). Therefore, while Frankl's (1955, 1963) assertion that the core of each person's search for meaning in life involves a process of self-transcendence (other-directed mission or purpose) is true for middle and later adulthood, it is not for adolescence and young adulthood (Debats, 1999).

Many researchers have consistently found that relationships are the most important source of meaning for all age groups and both genders (Ebersole & De Paola, 1987; Hedlund, 1987; De Vogler & Ebersole, 1980, 1983). Females identify significantly more relationship meanings than males, however (Debats, 1999), confirming the emerging understanding in the field of identity development that there is a relatively greater significance of relatedness in female development, and of self-definition in male development (Guisinger & Blatt, 1994).

Implications for therapy

Effective psychotherapy must engage the passions of both client and therapist: the passion for growth and for health; the passion that provides the motivation to persevere in the face of great challenge; and the passion of the heart that "leads the way" for the mind to follow. And the commitment of both client and therapist are essential: the commitment to the relationship itself that provides continuity; the commitment to integrity and ethical practices that insures safety; the commitment to deep interpersonal honesty and openness that creates a window of opportunity for change.

3. All human beings have freedom of choice and responsibility for our choices

Sartre said, "Our existences precede our essences." We don't know what we're here for until we have lived life. Who I am in life is not determined by God, or by genetics, or by my family. How I choose to live makes me what I am. I create myself. You could say that the essence of humanity--the thing that we all share, and makes us distinct from anything else in the world--is our lack of essence until we manifest it, our freedom to become. We all share the task of making ourselves through personal choices every day throughout the lifespan.

That task may be, for many, a burden. People so often shrink away from their freedom to choose and from the vast scope of the range of possibilities from which to choose. Such people "lie to themselves about the degrees of freedom that they have with which to choose their lives, thereby creating much of the technology for their own misery by establishing a false set of limitations" (Bergantino, 1981, p. 27).

The neurotic defenses can be viewed as the tendency to reject what is painful (denial and avoidance); the tendency to grasp onto something that appears to be solid, offering comfort and security (fixation, obsession and compulsion); and the tendency to desensitize ourselves so that we aren't faced with feeling the chaos (numbing and dissociation). In other words, defenses selectively focus, or become absorbed in, some partial aspect of the whole to avoid dealing with the whole. Grasping, rejecting, and desensitizing strategies are actually determined by developmental deficiencies; the selected area of absorption is the relevant unresolved developmental stage(s). The neurotic defenses can be viewed as attempts to control the eight worldly concerns that, by Buddhist teachings, keep us chained to the wheel of suffering: praise and blame, loss and gain, pleasure and pain, success and failure.

Any of these ways of dealing with trauma, untenable choices and the resulting anxiety, begin as brilliantly creative survival strategies, constructed out of the individual's inner resources. But due to incomplete maturation the resource is disfigured into a contorted replica of itself, and becomes both compulsive and covert. Ultimately, the defense becomes an obstacle to access to the original unperverted resource, and therefore an obstacle to further growth. For example, one may become judgmental toward others as a protection against the fear of vulnerability, based on experiencing the pain and anxiety of a harshly critical parent. The judgmentalism keeps the individual from opportunities to develop intimacy with others and experience the satisfaction of loving vulnerability.

"Growing up" through those unresolved developmental stages is to release the fixation, or absorption. Growing up might be viewed as the process of resolving the tendency to react reflexively, automatically, to a momentary stimulus as "the straw that broke the camel's back" (i.e., a drop in a reservoir of unresolved energies), and allowing instead the capacity to respond directly to it as simply a drop. We aim to interrupt the unconscious, automatic reflex reaction to a conditioned stimulus, thereby returning real, conscious choice.

Faced with existential anxiety, avoidance through neurotic defense is not the only option, of course. A second existential choice is self-rejection, to judge, attack or punish oneself for being the person he/she has become. One of the most heart-rending experiences as therapist can be to observe an adult in an age regression experience confronting the child they once were with blame, revulsion, rejection and hatred. A third existential choice is to remain open and non-defensive in the face of our deepest anxieties. Bugental (1965, p. 286) refers to these choices as between dread or courage. "The crossroads of life, existentially speaking, lie at the point of the confrontation of existential anxiety." "How man responds to that anxiety--whether with dread or with courage--tells the story of his nonbeing or his being."

Implications for therapy

The effective therapist must empower the client to make clear choices, and then acknowledge and honor those choices, setting aside his/her own agenda for that client's therapeutic experience or outcome.

4. Openness to experience

The concept of openness is central to the existential perspective. Heidegger referred to human existence (Dasein) itself as an openness (Lichtung), such as a meadow or an openness in the forest, suggesting that it is human existence that permits the world to reveal itself. Openness to experience may be operationalized as non-defensiveness, willingness to share experiences, openness to the unknown and unknowable, to emotions, ideas and spirituality, and to seeming incompatibilities. Operating in such a space, one finds understanding. "Understanding is not an act of the will. It is an event. Understanding happens to man in the openness of the existential encounter" (Hora, 1960, p. 498).

The existential approach requires a fundamental reframing of unhappiness, pain, suffering, and anguish, of the symptoms of mental disease. In the existential approach, these symptoms are the inevitable consequence of trying to distance or cut oneself off from one's deep inner self. If the person ultimately succeeds in cutting off, distancing, and sealing off, the payoff may be reduced anxiety, fear, and depression, but relief comes at the cost of emotional numbness and existential death, i.e., of becoming an adjusted, normal automaton. Confronting these symptoms provides a window into existential becoming and into the inner existential possibilities. This window occurs when some emerging possibility faces the individual, a possibility of fulfilling his existence, but this possibility requires abandoning one's present security. The open field of possibilities can bring overwhelming fear to that part of a person that wants to settle for being an adjusted, normal automaton, anxiety to that part that spurns the openness of freedom of choice. The existential approach sees these painful states not as targets of therapy, to be reduced or healed, but rather as points of entry into the deeper self where resides the very real opportunity to choose from among the vast possibilities, as a gateway for exploration into the meaning of life.

Faced with existential anxiety, avoidance through neurotic defense is one option; to remain open and non-defensive in the face of our deepest anxieties is the path to wisdom (Zimberoff & Hartman, 2001). Recent research (Kramer, 2000) documents the correlation between openness and wisdom. Indeed, "openness to experience is the most frequent predictor of wisdom" (p. 83). See Figure 1.

[FIGURE 1 OMITTED]

Kramer's research (2000) documents that people who are generally considered wise share the following attributes:

* openness to experience;

* promotion of their own personal development and enjoyment of learning;

* enrichment of relationships;

* critical awareness and tolerance of ambiguity and complexity;

* self-clarity including a critical stance toward oneself;

* capability of finding purpose and meaning in life's turbulence and using their negative emotional experiences as catalysts for emotional growth, enriched understanding, and exploration of deeper meanings of human experience;

* ability to see patterns in their experience and life choices, and to use the insights gained to help themselves and others;

* concern for others' welfare and a lack of self-absorption;

* acceptance of, indeed embracing of their own negative and positive characteristics for greater wholeness in the self.

Erik Erikson (1979) suggests that wisdom is the ego strength of the final developmental stage. He defined wisdom as "the detached and yet active concern with life itself in the face of death itself, and that it maintains and conveys the integrity of experience in spite of the disdain over human failing and the dread of ultimate nonbeing" (p. 60). He believed that an individual fulfilled his/her life cycle "finding terminal clarity," and that a final "existential identity" emerges from the culmination of one's psychosocial development (Hall, 1983).

The description of a wise person bears a marked resemblance to the concept of existential identity. The resolution for inauthentic life patterns is to openly face the basic life issues, awakening in each experienced moment to the spontaneous, the magical, the real. Indeed, "awareness of existential issues is a prerequisite for personal adjustment and authentic existence" (Stevens, 1992, p. 32).

The experience of feeling grace while in selfless service to others has a long history in the Christian tradition as well as Hindu and Buddhist traditions. Research has documented seven themes associated with the experience of grace (Gowack, 1998):

* feeling present in the moment, often with heightened awareness

* feeling oneness or connection, often without fear

* feeling blessed and/or loved

* feeling energized

* feeling guided

* feeling peace

* feeling joy

The experience of feeling grace is characterized as a transpersonal, transcendent, and mystical experience that dissolves the boundaries of one's ego-self, expanding the context of life to incorporate the ever-presence of grace.

Implications for therapy

Cognitive flexibility is closely associated with existential openness, and resourceful coping is another factor positively linked to existential openness (Stevens, 1992). Specifically, the coping strategy of interpreting existential issues as promising rather than threatening leads obviously to greater openness to them.

5. The imperative of death

Existential issues are the ones so deeply embedded and so fundamentally threatening that they motivate avoidance at any cost through neurotic defenses (Zimberoff & Hartman, 2001). What can be so fundamentally threatening? "All threat ... ultimately is the threat of nonbeing, is the existential threat" (Bugental, 1965, p. 93). The individual perceives his/her very existence to be at stake. How I define myself determines what I interpret as threatening, of course. If I define myself by my job, then losing the job is a threat to my being. If I define myself as "not the kind of person who would do that," then when I do it I feel threatened with non-being. I protect myself from the threat of annihilation with all manner of defenses.

Regret over the things we have done--or left undone--comes most sharply into focus within the context of mortality and the inevitability of death. We may feel regret over past decisions in which we have chosen the easy way out, or chosen not to commit ourselves or not to get involved, or have chosen to do less rather than more, when we have lost our nerve.

The great existential paradox is that the problem of death is the problem of modern life. Becker (1993) quotes Gestalt therapist Laura Perls: "Speaking strictly for myself, I am deeply convinced that the basic problem, not only of therapy, but of life, is how to make life livable for a being whose dominant characteristic is his awareness of himself as a unique individual, on the one hand, and of his mortality on the other hand. The first feeling, that is, feeling that we are individuals that are unique, gives us a feeling of overwhelming importance. The other feeling, that we will die, gives us a feeling of fear and frustration. Suspended between these two poles, man vibrates in a state of inevitable tension and anxiety." Where do we get the equanimity to face our own death? To get it from psychotherapy, we must expand the rightful realm of exploration in therapy to include death and mortality.

Transformation usually follows a predictable pattern of transitions: an ending, then an intermediate zone, then a new beginning. At times of new beginnings, we often feel uncertain or anxious about choice and commitment. In the intermediate zone, we feel confused and ungrounded. When something ends, we are afraid of loss, separation and death (Bridges, 1980). The intermediate, transitional moments provide unique opportunities for immediate dramatic change. We draw here an analogy between the bardos of The Tibetan Book of the Dead or Bardo Thodol (Sogyal Rinpoche, 1993), and moments of transcendence. "These are borderline states; they are times of crisis, when the tension is at its peak, but which are also most pregnant psychologically, since they are times when change can most readily occur. Inherent in such states is the opportunity for transformation. In the crack between two worlds--of the living and the dead, of death and rebirth--lies the supreme opportunity" (Moacanin, 1986, p. 67). This crack appears whenever we expand our experience of who we are, embracing parts previously suppressed, or disidentifying from limited self-definitions. These moments occur in experiential transpersonal psychotherapy, in shamanic work, in soul retrievals, in meditative states, in ritual rites and other spiritual ecstacies. And the most pregnant of all is the moment of death, so perennial wisdom has it, when the mind is capable of attaining ultimate liberation.

Sogyal Rinpoche (1993) discusses the inclusion of death in this lifetime:

The fear of death and the "death urge"

Death is a common theme in many transpersonal altered state experiences, and this is the case with existential therapies (Zimberoff & Hartman, 1999). The context of death may express the fear of existential annihilation, taking one of several forms:

(1) It may be that of ego death, the surrender of the limited self-concept in the service of transformation and integration. This is the context that accompanies a near-death experience, and carries the transformational acceptance of death. It is the profoundly spiritual transformation that deep existential therapy can bring.

(2) It may be that of the necessary death that must precede rebirth, the initiation required for successful return of the hero discussed by Joseph Campbell.

(3) It may be that of the profound impact on one's life of the inevitability of death, the ever-presence of death. The threat of death may be seen as "a dark, unsettling presence at the rim of consciousness" (Yalom, 1980, p. 27), or everyday awareness of death may provide the motivation to live life more immediately.

(4) The context of death may be that of the depressed lack of psychical energy we call malaise, symptomatic of soul loss in shamanic traditions and Jungian psychology.

Alternately, the context of death encountered in existential therapies may reflect a "death urge," taking one of several forms:

(1) It may be that of an existential resistance to life, to being incarnate on earth, the deep sense of "I don't want to be here." This is not a suicidal condition, not even an unconscious one, but rather a lack of commitment to life. It may be at its root a homesickness for the existence that preceded this earthly life.

(2) The form of death urge may be that of someone who gets to a particular stage of development and has a mortal fear of moving on to the next stage, preferring instead to end it prematurely, either figuratively or literally.

(3) It may be that of fulfilling a pre- or perinatal imprint on one's encounter with death prior to or in birth, e.g. re-enacting the traumatic suffocation created in a prolapsed umbilical cord birth or an overterm birth. In one study (Salk et al., 1985), respiratory distress lasting one hour or more in infancy was correlated with a high risk of teenage suicide. The study showed that 60% of 52 adolescents with suicide attempts had 3 or more of the following risk factors at birth: respiratory distress, chronic disease in the pregnant mother, lack of prenatal care, tobacco or drug use by the pregnant mother, or alcohol use by the pregnant mother.

(4) The "death urge" may be fulfilling one's perception of the parent's desire for the child's death, e.g. parental rejection in the form of contemplated or actual adoption or contemplated or attempted abortion. Such an unborn child is aware of being an "unwelcome child," and reacts with shame and overpowering anxiety over its right to exist. The existential angst and death urge become deep, unconscious forces at work throughout the individual's life. Research by Southgate and others suggests that many child accidents are in fact unconscious attempts at suicide (Southgate & Whiting, 1987). Feldmar (1979) studied a number of adolescent patients with a history of more than five suicide attempts each, always at the same time of year. He eventually determined that the suicide dates of four patients corresponded to the month in which their mothers had tried to abort them. The adolescents had no conscious knowledge of the abortion attempts that they were unconsciously acting out. Feldmar discovered that they had even used a method of suicide similar to the method of the abortion, for example, chemicals or instruments. After discovering that their suicide attempts were seasonal intrusions of prenatal memory, the patients were free of the suicidal compulsion. They never attempted suicide again, even when their `anniversaries' returned.

Death anxiety is a core anxiety, and a widespread, mostly unconscious fixation on the unsettling presence of death awareness in our peripheral consciousness. Freud (1917/1966) posited the death instinct (Thanatos) as a counterbalance to the self-preservation instinct (Eros). The threat of death is experienced as overwhelming, against which we erect psychological defenses, such as denial, neurotic obsessions, escape through addictions, or total absorption in the mundane details of day to day existence. Facing death without defense invites a deep existential crisis, and ultimately it also leads to resolution of death anxiety through transpersonal experience. The way out of the deep existential crisis, in the words of Mahrer (1996),

Fear of death begins at birth, and the imprint of it is stronger when the trauma of birth is greater. Death anxiety is birth anxiety. We anticipate the end of worldly life based on the suffocation that we all experienced to some degree, and any other traumas, at the end of womb life and the beginning of worldly life. It may have been, "There's no way out" or perhaps, "This is unbearable," or "I'd rather die than cause so much pain to others," or "It is all just too much. I'm overwhelmed." Death and birth are interchangeable symbols in the unconscious (Feher, 1980). Exploring one's birth prepares one to explore death, and ultimately prepares one to "live one's death."

The Jungian context for this death urge relates to a general malaise, the lack of conscious relation to the "central integrative force of the psyche, the `doctor within,' which Jung calls the archetypal Self" (Smith, 1997, p. 133). "Failure to face death, to accept life, and to live in accord with one's deeper self results, Jung believed, in a pathological condition. This pathological condition could be considered a form of soul loss" (Smith, 1997, p. 118). Jung described the condition "loss of soul" as "a slackening of the tensity of consciousness, which might be compared to a low barometric reading, presaging bad weather. The tonus has given way, and this is felt subjectively as listlessness, moroseness, and depression. One no longer has any wish or courage to face the tasks of the day. One feels like lead, because no part of one's body seems willing to move, and this is due to the fact that one no longer has any disposable energy" (Jung, 1958, p. 119). The condition can go so far that the individual parts of the personality become independent and thus escape from the control of the conscious mind, a phenomenon known as hysterical loss of function. The condition results from physical and mental fatigue, bodily illness, violent emotions, traumatic shock (p. 120), and dissociation and suppression of consciousness (p. 281). The source of these underlying causes is usually prenatal and perinatal, and they result in profound existential conflict. Experiential transpersonal therapy is a powerfully effective way to retrieve and integrate the "lost soul" and affirm life over death. For the individual to face death and accept life is for the ego to face its own death to promote the life of the greater Self, the individuated life.

There are certain people who are labeled by the psychiatric community as having "suicidal tendencies." What makes these people prone to suicide? These are often people who have a history of suicide attempts that may date back to their early childhood. Some of these attempts may have been very serious where they nearly died or they may have been superficial "cries for help." There are some people who seem to be preoccupied with suicide, while others talk about it only from time to time. Certainly depression underlies most suicidal ideation. But where does that depression come from and where do those thoughts of killing oneself come from?

Research and years of experience indicate that suicidal thoughts often come from pre- and perinatal experiences. When a baby is conceived and that conception is unwanted, the mother herself may begin thinking about having an abortion. Even though the mother has never told the child about these thoughts or feelings, experiential therapy can bring this knowledge to one's conscious awareness. Thought is stored in the cells of each individual as deeply embedded semantic and implicit memories. In this way thoughts of abortion, transmitted by the mother to the child, become a death urge which may plague this person his/her whole life. This can be quite baffling to a psychotherapist, especially if there is no other obvious trauma in the person's history to explain suicidal ideation.

This death urge can be brought to consciousness through deep experiential therapy, especially through somatic techniques such as conscious connected breathing, and can also be released in the same way. The breath is the healing mechanism which allows these negative thoughts to flow out of the consciousness in the same way that they flowed in. The breath carries the negative energies out and brings in balance. The breath is the vehicle for transformation, the vehicle that removes this unconscious death urge and transforms it into the drive for life.

If the mother has thoughts of not wanting the baby, of wanting a boy instead of a girl, or fears about giving birth, these are all transmitted to the baby through the breath. When the baby is inside the womb, it is connected to the mother through three main sources: the nourishment of the umbilical cord, the constant beat of the heart and the rhythmic ebb and flow of the breath. The heartbeat and the breath are the main sounds and vibrations which the baby is aware of for nine months. It is what keeps the baby totally connected to its mother in a very visceral way. When we begin conscious connected breathing, all of those experiences during the nine months of breath-connection to the mother are almost instantly brought back to consciousness. It is a "body memory." The sound and vibration of the individual's own breath triggers the memory of the mother's breath in the womb. The cells, nerves and muscles all remember the experience of breathing. Graham Farrant (1986) referred to recollections of prenatal events as cellular memory. Frank Lake (1980) found that prenatal memories stemmed from viral cells, that viruses were primitive prenatal cells that formed during trauma and carried traumatic memories. He, too, referred to prenatal memories in terms of cellular memory.

Everyday awareness of death

The humanistic-existential psychological perspective, in general, accepts the precept that people's attitudes toward death, their realization of their own mortality, contribute to their personal development, level of self-actualization and their search for meaning in life. Existential death awareness experience is understood to be the collection of feelings, thoughts, perceptions and bodily sensations that express the person's attitudes toward the finiteness of his or her own life or that of a closely related person. It is the quality of one's present-moment experiencing of the certainty of a future experience of death.

Yalom and Lieberman (1991) describe existential death awareness, or existential awareness, to be people's active exploration of existential issues in life, with honesty and authenticity, not self-deception; consciously dealing with the issues of finitude, the inevitability of death, life's brevity and, hence, preciousness, the fragility, capriciousness and contingency of being, one's personal responsibility for one's life and one's choices, one's ultimate isolation as an inherent quality of being human, and the significance or meaning of one's life. Existentially aware individuals look into, rather than away from, death.

Recent research (Widera-Wysoczanska, 1999) sheds light on everyday awareness of death and its impact on deepening one's appreciation for life, search for meaning in life, and self-actualization. Based on her qualitative clinical investigation of the awareness of death, she has created a model of the death awareness experience. The first of three elements of the model is the context of people's death awareness experience, composed of both internal (e.g., fear of separation, depression) and external (e.g., absence or death of a parent in childhood, lack of sensitivity to need for appropriate discussion about death in childhood). A second element of the model is the psychic phenomena related to death of self or closely related other, including grief, desire, fear and anger. The grief may be for the anticipated loss of one's own life and the uncertainty of whether "I'll be ready when the time comes." The grief may be for the anticipated loss of a close other, resulting in loneliness, emptiness, and powerlessness. The grief may be for the loss of "what might have been," i.e., regrets over relationships that never were possible or were interrupted due to another's untimely death. People may experience a death wish, either for themselves (e.g., suicide for emancipation or to punish relatives) or others (e.g., the ultimate expression of anger, "I wish you were dead!"). Fear of death may be prompted by the unknown (e.g., "What will happen to my body and my soul when I die?") or by the preoccupation over the ever-present possibility that it may happen any minute. Anger or rage about death can either be paralyzing or motivating (intensifying the energy to attain success, today before it is too late).

The third element of Widera-Wysoczanska's model of the death awareness experience is the (positive or negative) impact of the death experience on one's life, including the means of protection against death, and the meaning given to the self and surrounding reality. People use various behaviors intended to protect the ego against debilitating feelings or thoughts about death. A passive form of protection against death requires a resignation from one's personal needs or acceptance of compromises in meeting needs in life; for example, relying on beliefs in reincarnation or in promises of a rewarding afterlife to cope with unacceptable conditions in this life. An active form of coping with death utilizes creativity and agency in one's life; for example, finding safety in relationships, or using "magical" beliefs about being able to control the timing or effects of death. An individual's defenses against death may be maladaptive, leading to psychopathology, or they may be positive, leading to courage and initiative in life choices.

The meaning given to the self and surrounding reality consists of feelings, thoughts and relationships directed toward developing a personal life and creating the surrounding reality. Those feelings and thoughts may be helplessness and powerlessness due to anxiety over death, or shame about one's defenselessness or neediness in the face of death anxiety, or they may be fulfillment and confidence in oneself as a proactive agent of choice in life. Widera-Wysoczanska has observed two general lifestyle responses to people's created meaning of death. One is a "personalizing" process directed toward life, in which people focus on their faith in themselves and recognize internal opportunities to develop and grow. This lifestyle choice establishes importance in enjoying one's life, creating distance from negative events and influences, living more fully in the moment, more intensively, and giving more serious attention to their psychological health. The other primary lifestyle is a "depersonalizing" process directed away from life, in which people withdraw from relationships in order to avoid the ultimate loss of that important person to death. These people attempt to establish safety from death by maintaining proper but distant relations, stopping being spontaneous and freely expressing their feelings, and giving up even trying to satisfy their needs for intimacy and connectedness. This lifestyle sacrifices living life creatively in an effort to guarantee safety in a risk-free life. This person, afraid of death, is actually terrified of life. A line in the popular song "The Rose" captures this approach to life:

Widera-Wysoczanska offers three categories of death awareness experience, based on the childhood experience of the people in her research: death creates life, death limits life, and death is loneliness. Death creates life: People who were supported in childhood with open discussions about death and about the grief, fear, anger and shame that often accompany the death of another, developed a sense of personal freedom, fulfillment and integrity in relation to death as an adult. Their lifestyle is directed toward internal growth and acceptance. Death limits life: People who lacked such supportive openness about death from caregivers in childhood developed an unconscious fear of death, feelings of powerlessness against death, and passive coping behaviors. Their lifestyle is directed by external influences and attempts to insulate themselves from the anxiety about death. Death is loneliness: Lack of support while experiencing a fear of death in childhood, a lack of discussion or any meaningful communication about death during childhood, and a feeling or sense of rejection by relatives cause deep self-criticism and a lack of real trust in others. Such an individual attempts to purchase safety from death through relationships devoid of intimacy, or through avoiding relationships, choosing to live alone and lonely. This individual becomes alienated from the self as well as from others. Widera-Wysoczanska (1999) concludes:

Villoldo discusses the awareness and relationship with death in the context of shamanic healing. The first step is the work of the south, associated with the spirit of the serpent. You learn how to shed your past as the serpent sheds its skin, to erase your personal history, in the sense that your present is no longer created by the momentum of your personal past identity and limitations. The second step is the work of the west, the work of the jaguar, and it's the place where you come to lose fear through some ceremony or experience of symbolic death. You come to meet your death in a place of power. To grow in enlightenment, we must surrender to the separation of our energy essence from the material body. That can only happen when you lose your fear of death, because death is the glue that binds these two together. Fear is the greatest enemy of the shaman. Once you let go of fear, you can begin to truly receive those lessons of immortality; living our lives more fully, more powerfully, and in closer communion to nature and to the divine. The work of the north, which can only come after conquering fear of death, is coming to a direct communion with the divine, coming to direct communion with the masters, not following anybody else's footsteps, following your own, settling for nothing short of that direct experience of the divine. Then follows the work of the east, of being able to be a visionary, to hold that image of the possible, for yourself, for your community, for the planet. In Villoldo's words:

Implications for therapy

The significance of everyday awareness of death is observed in many specific situations in Heart-Centered therapy. For example, once an individual has experienced an age regression to a past life, and experienced the death in that life, his/her relationship with death is forever changed, in much the same manner as when an individual returns from a near-death experience. Their fear of the unknown is replaced by the comfort of familiarity. Another example is that when an individual goes back in age regression to a fearful or devastating loss due to death, he/she is able to bring current but then-unavailable resources to the experience. An adult returns to her struggle with her mother's death as a ten-year-old, and with the lack of any discussion about the meaning of death or her feelings of grief, guilt, shame, fear and remorse. In the therapeutic age regression, however, she brings the experience and wisdom of an adult and the compassionate understanding of what the ten-year-old needs. This new experience brings with it healing and resolution, and a newfound peace with the inevitability of death.

Yalom (1980) reports on the positive effects of a confrontation with one's own impending death in terminally ill patients who have an existential awareness. In general, they communicate more openly with family and close friends, they experience fewer fears, they rearrange their life priorities, they are less preoccupied with the trivialities of life, they live life more immediately rather than postpone experience and pleasure into the future. Those with an outlook on life that is less existentially aware tend to experience these positive shifts to a lesser degree.

Yalom and Lieberman (1991) also document the same potentially positive psychological shifts toward personal growth in the bereavement process of an existentially aware individual who has lost a close relation to death such as a spouse. In general, they (existentially aware widows and widowers) are obviously stretching (doing new things, developing new interests, learning new skills or hobbies, etc.), are more aware of being an `I' rather than a `we' (struggling to find his/her own identity and roots), are willing to explore new relationships, are more self-sufficient (taking care of finances or home maintenance, etc.), are taking better care of their own physical health, and are engaged in new or renewed forms of creative expression (painting or writing, etc.). Bereaved surviving spouses who are less existentially aware are less likely to transform their confrontation with death experience into one of personal growth and liberation. While Yalom and Lieberman found their widow and widower subjects to have revised their self-image to about the same extent during the months following the loss of their spouse, the existentially aware individuals did so by grafting on new elements of the self rather than rejecting old ones for replacement. In short, "existentially aware individuals possess a certain type of internal strength--a sureness about oneself, a relative freedom from neurotic or distorting defenses that enables them to fix their gaze on their existential situation" (1991, p. 344).

The techniques and skills to facilitate existentially-oriented therapy

Corey (1991) suggests two central tasks of an existential therapist. One is to invite clients to recognize how they have allowed others to make decisions for them, abdicating their freedom to choose. Second is to encourage them to take steps to accept accountability for their lives, moving toward greater autonomy.

King and Citrenbaum (1993) discuss what it takes to be a good existentially oriented therapist. They say, "wimps cannot be very good existential therapists" (p. 74) because to be effective with clients one must walk the talk, speaking from personal experience about freedom, responsibility, courage and change. They identify three common pitfalls for existential therapists to avoid. One is the widespread misperception that clients are fragile and can easily shatter if the therapist makes a mistake in challenging their defenses. Second, having a high need to be liked, which most people in the helping professions do, can skew therapeutic choices toward being a "nice guy" at the expense of being a powerful change agent. And third, "therapists, in our opinion, rank low when it comes to one issue that we, as existentialists, value highly: therapeutic risk taking," (p. 75) and instead tend to be mundane, predictable, and inflexible in doing psychotherapy.

Mahrer (1996) suggests a more profound requirement: "understanding and knowing consists of sharing the other person's existential being, and this means jettisoning virtually the whole world of psychiatry's and psychology's predetermined categories, dimensions, nomenclatures, tests, inventories, scales, and measures. It abandons the whole tradition of assessment and evaluation and of mental illnesses and disorders." Also, he states:

The Experiential Approach

Experiential psychotherapy is a term commonly used in the field of humanistic, existential and transpersonal therapies. It applies as a general description to Heart-Centered therapies. We will summarize the historical roots of the term and its meaning in order to better appreciate the contribution of experiential psychotherapy to current practice.

Carl Whitaker was head of the Department of Psychiatry at Emory University in the 1950s, and with a number of other gifted clinicians began experimenting with therapeutic techniques. In the 1960s the group wrote many articles on what eventually was termed experiential therapy, including "Rational and Nonrational Psychotherapy" (Malone et al., 1961), "The Usefulness of Craziness" (Warkentin et al., 1961), and "Experiential Psychotherapy: Evaluation of Relatedness" (Whitaker et al., 1963). Dick Felder (Felder & Weiss, 1991) tells the story of how the term experiential therapy originated. Carl Whitaker was leading a psychotherapy group and a patient asked him, "What am I doing here?" Whitaker responded, "You're here for the experience of being here." When the patient continued, "And what are you doing here?" Whitaker answered, "I'm the most experienced patient here."

Three basic principles have been identified as defining experiential psychotherapy (Felder & Weiss, 1991). The first is that the unconscious is naturally oriented toward growth and wellness rather than pathology. People are self-healing organisms, and the unconscious mind carries an ultimate personal wisdom par excellence of what each person needs to grow and heal. The unconscious rather than the ego is considered the wellspring of health and vitality. Thus, regression is a means of access to and expression of the unconscious, and is welcomed in experiential psychotherapy. In general, regression experience releases personal power and insight by allowing corrective experience in the original traumatized state. "When you find yourself lacking, you don't need to look further, only deeper" (p. 3).

The second principle is that all pathology and healing exist in the context of relationship. The dysfunctions in a client's life developed within their closest relationships, the nuclear family. And the corrective experiences that lead to healing those dysfunctions occur within the therapeutic relationship. A fundamental tenet of experiential therapy is that the therapist, unlike other relationships in the client's life, is able to tolerate and respect anxiety. The therapist does not derail the development of growthful anxiety by providing reassurance or solutions to the client, by focusing on symptoms, by having an agenda for the course of therapy, or by medicating. Anxiety is seen as an opportunity to change and grow, the fuel for potential therapeutic success. To opt for comfort and solace rather than moving into the anxiety is to lose that opportunity.

The third principle of experiential psychotherapy is that the therapist is deeply, personally, and inexorably a part of the therapeutic relationship, to the extent that the primary dynamics of the relationship reside in the therapist. This principle is best explained by Felder (Felder & Weiss, 1991, pp. 23-24):

A difference between experiential therapy and traditional psychotherapy is the underlying theory of the meaning of symptoms. Traditionally, in the medical model of verbal therapy, symptoms are the clues to the diagnostic category of disorder, and treatment consists of suppressing them. The symptoms are the problem, and relief of symptoms equals cure. In experiential therapy, symptoms are accepted as the emergence into consciousness of previously unconscious intrapsychic forces. Treatment consists of exaggerating symptoms, which provides conscious access to and cathartic expression of their underlying dynamics, which in turn allows for their resolution and ultimately the release of the symptoms. This parallels the principles of the healing system called homeopathy. Rather than defining symptoms as the problem to be eliminated, homeopathy sees symptoms as manifestations of the healing process (Grof, 1993).

Experiential techniques decrease psychological resistance by sidestepping the everyday ego state which implements all the defense mechanisms created in the unconscious. It is relatively easy for a client in talk therapy to censor thoughts, suppress emotions, avoid painful material, deny the obvious, and skirt the issues. Directly accessing the body's memories and associations, re-experiencing early prenatal, perinatal and childhood trauma, the collective unconscious, and the transpersonal component make it very difficult to censor, suppress, avoid and deny. Chronic psychological resistance becomes blocked energy. Therapy requires bringing that blocked energy to consciousness, experiencing it and mobilizing it into action. We use specific techniques to assist the client to experience and release their fear, experience and release their anger, experience and release their powerlessness. Expressing the inner state helps one to experience and change it. The change comes when the client moves from the individual unconscious level to the transpersonal level of clarity and awareness.

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David Hartman, MSW and Diane Zimberoff, M.A. *

* The Wellness Institute, 3716-274th Avenue SE, Issaquah, WA 98029 USA 425-391-9716

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