Stephen D. became a Born-Again Christian his freshman year of college. His new faith quickly became the center of his life, and he began attending church several times a week and reading his Bible and praying daily. About six months into this journey he began to encounter some doubts. It felt to him as though a nagging voice in his mind kept asking how he knew that his faith was really true. These doubts frightened him, and in an attempt to fight them off he began to read one book of Christian apologetics after another, each book offering evidence that supposedly supported Christianity’s truth claims. This strategy seemed to work, and for several years he lived what he described as an “active, devout life.”
About a decade after his conversion Stephen’s uncle, a man whom he deeply admired, was diagnosed with cancer. Stephen prayed every day for his uncle’s healing, and when the cancer worsened, Stephen increased his efforts, praying more frequently and fervently than he had ever prayed for anything before. But after a relatively brief fight, the man died, leaving behind a shocked and bereft family. Stephen had begun to questions parts of his faith before his uncle’s death, but now his prayer life became nearly non-existent, as he no longer saw the point.
Stephen started to experience exercise-induced headaches, debilitating headaches which he had never before known. He finally went to his physician, who told him that he might have a brain aneurysm or tumor and that he immediately needed to have a CT scan. Stephen had the scan that afternoon and afterward sat alone in a little room, waiting for his test results, letting the possible imminence of his death sink in. He realized that deep down he doubted whether there would actually be an afterlife, and this realization seized him with terror.
The CT scan did not show anything on his brain, but Stephen was told that he needed to schedule an MRI to be sure. So for the next few weeks he continued to worry that his death might be imminent. He felt nauseated much of this time and ate very little. He knew this feeling might be the result of nervousness but that it also might be a symptom of brain cancer, and this caused him to grow even more nauseated. “I felt like some neurotic Woody Allen character,” he later told me. “I couldn’t even perform basic quotidian tasks. It’s like no matter what I was doing, these thoughts, the thought that I might be dead in a month, kept overwhelming my consciousness.”
Stephen’s health eventually checked out, and he started to eat more, but this proved to be just the beginning of what he described as as an existential crisis. Yalom (1980) defines an existential crisis as “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” (p. 207). Stephen said that his religious faith had mitigated his existential anxiety, for if God existed then there were metaphysical grounds for believing that life had a meaning and that humans had permanent, incorporeal souls. But now that his faith had eroded so too had his reasons for believing that life had meaning and that death was not the end. Put into the terms of basic crisis intervention, Stephen had lost his psychological equilibrium, as his “usual coping mechanisms and problem-solving methods” were no longer working to meet some of his deepest needs (James & Gilliland, 2012, p. 17).
Responses, Part One
Stephen told me his story a few months after his initial visit to the doctor. We sat at the Edgewater Inn, two old friends who’d studied philosophy together at the University of Colorado, sipping our respective beers and waiting to order a pizza. He told me that he went stretches, sometimes two or three days at a time, in which life seemed to have returned to normal. But then, as though being ripped from a pleasant dream, something would happen—e.g., he would read a news report about someone being killed—and he would experience that rush of terror. “Sometimes I get so freaked out I can’t even think straight,” he said. “Like the other day I was having a debate with this old friend, this guy I went to church with, and I normally cream him. It’s hardly a competition. But this time I couldn’t even keep a train of thought.”
It seemed that Stephen’s crisis had become a transcrisis. Even though the realization that he did not have a brain tumor had caused his life to mostly return to normal, seemingly minor “stressors” would often “tip the balance and send [him back] into crisis” (James & Gilliland, 2012, p. 12). Stephen said he had started to read books about death; I surmise he was intellectualizing the problem, the way philosophers often do, subconsciously hoping that by “thinking about [these existential issues] in a cerebral way” he could avoid “feeling them directly” (Cooper & Lesser, 2015, p. 50). Reading Ernest Becker’s The Denial of Death encouraged him to try to regain his psychological equilibrium by renewing his faith. He no longer believed that his faith could be supported by rational arguments, so he tried to follow Becker’s prescription and believe despite the evidence. After one sleepless night, he told me, he decided to take a Kierkegaardian “leap of faith” and resumed praying to God as though they were old friends reunited. But after a few weeks he found that he just could not keep leaping. “Remember what Camus wrote?” he asked me. “Remember his dictum that we should try to live without appealing to irrational ideas? Remember how he dismisses Kierkegaard and Jasper? Well that just seemed right to me. That just seemed like the only honest course of action.”
Cultural factors had probably worsened Stephen’s crisis. For several years he had been part of the Evangelical community, a subculture that teaches that doubting church creed is sinful, evidence that one cannot be counted among God’s elect. Since Stephen’s friends were part of this subculture, he had nobody with whom he felt he could share his struggle without being judged. On one occasion he began to share his doubts with a close friend, but the friend immediately began trying to evangelize Stephen. Stephen consequently shut down and kept his struggles to himself.
As we ate our pizza, Stephen told me he had finally concluded that the best course of action was to take Camus’ advice and try to live with what he knew to be true. “I spent all this time believing in this hoary old man in the sky, you know, basically because I couldn’t deal with reality. So what I’m trying to do now is just be honest with myself. There’s this Zen Buddhist teaching that asks you to meditate on your own death—imagining your body after it’s breathed its last breath, imaging the worms eating away at it, imagining the whole thing decomposing. I know it sounds macabre, but lately I’ve been trying to keep my own mortality in the forefront of my mind. I think the problem comes when you push things back. When you deal with them, when you stare death in the face, it starts to lose its power.”
Indeed some research supports Stephen’s contention that confronting death can yield powerful benefits. Martin, Campbell, and Henry (2005) found that near-death experiences often embolden people to be themselves and live according to their own values. They write:
Compared to individuals who have not had a close brush with death, those who have (1) Feel more able to refuse doing things they do not want to do, (2) Report less concern with social rejection and the opinions of others while also reporting more concern for the welfare of others, (3) Are less easily intimidated and display a greater willingness to take risks. (p. 223)
These authors posit two possible explanations for these changes. First, the posttraumatic growth model holds that near-death experiences often shatter people's basic assumptions about life and consequently open the door to new life choices that more closely align with reality and allow them to function better (p. 224). Second, near-death experiences sometimes encourage individuals to realize that some of their previous pursuits were based on cultural expectations that they did not really hold, and they now feel encouraged to reject some of these expectations and seek “more personally valid experiences” (p. 227). These authors note that there are ways, aside from having a near-death experience, to bring about these benefits. “We have found, for example, that merely asking individuals to write about their death can decrease their reliance on scripts and stereotypes and increase their reliance on bottom-up evaluation guided by self-reflection” (p. 228).
Responses, Part Two
Stephen and I again met for dinner two years later. He seemed different this time, quiet, maybe depressed. After dinner we took a walk around a little pond and eventually started talking about our respective dating lives. “I’ll tell you a secret,” he said. “This is so embarrassing, but what the hell.” He took a deep breath. “I’m heart-broken. I’m like some school kid. It’s like that first love, that first heartbreak, all over again.”
He said that before this heartbreak he had been doing well. He had gone back to school to get a masters degree in philosophy. He had been enjoying his classes and rarely felt hampered by those feelings of terror. “I’ll tell you what helped,” he said. “Distraction. That was the key. That’s what worked. I was so busy, so focused on my classes, that I didn’t have time to dwell on oblivion.” “And then?” I asked. “And then I dropped out of the program. I don’t know what I was thinking. It just wasn’t the right fit.”
Almost immediately after dropping out of school Stephen fell in love with a woman. For months he obsessed over her, trying desperately to win her love. “I knew at the time it was just another distraction. It’s like I needed something to do or I’d just obsess over things, over death, the evanescence of everything.” The woman, it turned out, did not share Stephen’s feelings, and once she broke things off, he went into a tailspin.
“I’d never thought about killing myself,” he said. “And don’t worry, I’m not saying I’m going to do it now. But, I don’t know, sometimes I think about it. Like the other day I was dog-sitting for my dad. And my stepmom, she has all these pain meds. So I was alone in the house, and I set all her bottles out, just lined them up on the couch. I just sat there and thought about it. I wondered what would happen if I took an entire bottle of Xanax. Would it kill me? Would I survive but have all this brain damage?”
Stephen said that he had not had any friends with whom he felt comfortable sharing his struggle. “It’s the culture,” he said. “We live in this culture that’s just terrified about having honest conversations about life and death. People will talk about weather, they’ll talk about sports, but once you start talking about the Big Things, once you tell someone you’re despondent because you fear that life has no meaning, they look at you like you’re completely unhinged. And, you know, they’ll mutter some little religious cliche, and then retreat back into chatter.”
Stephen again assured me that he was not considering suicide, but he feared he might get there one day. “I never used to get those people who were always whining the life had no meaning. I never understood why it was such a big deal, why they were so depressed all the time. But now I get it. Nietzsche was right. Once you do away with God, you do away with everything.” He paused as though still trying to process this heavy truth “Life,” he finally continued, “is meaningless. That’s just a statement of fact. Yeah, we can create our own subjective meanings, and for some people that’s enough. But when you get down to it, when you realize that we’re just ‘accidental byproducts of an uncaring universe,’ when you let that sink in, you realize that nothing matters. Nothing we do matters. Like I said, distraction is the key. But—and here’s what’s scary once life’s distractions cease to be interesting, amusing, once that happens, there’s nothing left.”
Interventions
I can see now that Stephen’s anxiety worsened whenever he lost his sense of purpose or meaning. For example, he maintained a psychological equilibrium when he believed in God but lost that equilibrium when he lost his faith and with it his belief that life in general and his life in particular had meaning. He again had a sense of equilibrium when he went back in school and again when he was pursuing his love, but he lost this equilibrium when he he stopped pursuing these goals. In retrospect, had Stephen been able to replace these losses with new sources of meaning, his latest crisis might have been averted or at least mitigated. Stephen’s existential anxieties would still exist on some level, but they would probably not be so debilitating.
Vos, Craig, and Cooper (2015) conducted a literature review of existential therapies and found that meaning-oriented therapies—that is, therapies that aim to “establish meaning and purpose in [clients’] lives” (p. 116)—were “promising as a means of addressing meaning-oriented and existential concerns in people with serious and life-threatening illnesses” (p. 124). Although these therapies have been evaluated on clients with life-threatening illnesses, I think there is good reason for believing they might help Stephen since his existential anxieties, his symptoms, seem essentially the same as those experienced by the individuals in the studies.
Meaning-orientated therapies are based on the teachings of Viktor Frankl, who taught that (1) a primary human motivation is “to search out the meaning and purpose of their lives” (and moreover that meaning is so important that humans will often forgo pleasure and even endure pain to attain it), (2) humans are “free to choose their responses within the limits of given possibilities,” and (3) humans can find meaning through “creative value” (i.e., through “what we give to the world, such as accomplishing a task, creating a work, doing a good deed”), “experiential value” (“what we take from the world, such as the experience of truth, beauty, and love toward another human being”), and “attitudinal value” (“the stand we choose to take toward unchangeable situations or unavoidable suffering”) (Ameli & Dattilio, 2013, p. 387). In what follows I will briefly review three meaning-orientated therapies that could benefit Stephen.
First, logotherapy is “a collaborative approach” that can be used in both individual and group settings and “combined with other psychotherapy orientations” (Ameli & Dattilio, 2013, p. 387). Robatmili et al. (2015) conducted a ten-session logotherapy group which encouraged participants to identify values that they found meaningful and to strategize ways to actualize these values (p. 56). Robatmili et al. (2015) found the program “to be effective in reducing depression levels and enhancing a sense of meaning in life” compared to a control group that received no treatment at all (p. 61). Ameli and Dattilio (2013) described different techniques that are often used in logotherapy: paradoxical intention, which uses humor to encourage clients to distance themselves from their problems; dereflection, which helps clients stop dwelling on their problems and focus instead on someone or something else; and attitude modification, which pushes clients to improve their attitudes and look for meaning in their situations (pp. 388-390).
Second, Meaning Centered Group Therapy (MCGP) consists of eight weekly courses and “utilizes a mixture of didactics, discussion and experiential exercises focused...on issues of meaning/peace and purpose in life” (Breitbart, 2002. p. 9). Breitbart et al. (2010) found that individuals who took MCGP experienced “significantly greater benefits from MCGP compared with supportive group psychotherapy”; most importantly, they experienced an enhanced sense of meaning as well as less “hopelessness, desire for death and anxiety” (p. 26). Breitbart et al. (201) further found that all of these benefits actually increased two months after the therapy had ended (p. 26).
Third, the Meaning-Making intervention (MMi) is an individualized, four-session intervention focusing “systematically on situational, global, and existential meaning” that is run by a therapist who “promotes self-exploration” (Henry et al., 2010, p. 1341). Henry et al. (2010) found that MMi “may have a specific effect on enhancing a sense of meaning in patients newly diagnosed with advanced ovarian cancer,” as their subjects, who received MMi along with their usual care, experienced an enhanced sense of meaning at one and three month follow-ups, compared to the control group which only received their usual care (p. 1345).
Stephen Today
I talked to Stephen recently, and he says he is doing better. He has moved into a new career, one he is excited about, and he says this makes all the difference, as this career has filled his life with enough (subjective) meaning to keep his existential anxieties at bay. He thinks he remains in a state of transcrisis, as life is filled with reminders that can easily send him back into crisis.
References
Ameli, M., & Dattilio, F.M. (2013). Enhancing cognitive behavior therapy with logotherapy: Techniques for clinical practice. Psychotherapy, 50(3), 387-391.
Breitbart, W. (2002). Spirituality and meaning in supportive care: Spirituality- and meaning-centered group psychotherapy interventions in advanced cancer. Supportive Care in Cancer, 10(4), 272-280.
Breitbart, W., Rosenfeld, B., Gibson, C., Pessin, H., Poppito, S. Nelson, C.,…Olden, M. (2010). Meaning-centered group psychotherapy for patients with advanced cancer: A pilot randomized controlled trial. Psycho-Oncology, 19(1), 21-28.
Henry, M., Cohen, S.R., Lee, V., Sauthier, P., Provencher, D., Drouin, P.,…Mayo, N. (2010). The Meaning-Making intervention (MMi) appears to increase meaning in life in advanced ovarian cancer: A randomized controlled pilot study. Psycho-Oncology, 19(12), 1340-1347.
James, R.K., Gilliland, B.E. (2013). Crisis intervention strategies (7th ed.). Belmont, CA: Brooks/Cole.
Martin, L.L., & Kleiber, D.A. (2005). Letting go of the negative: Psychological growth from a close brush with death. Traumatology, 11(4), 221-232.
Robatmili, S. Sohrabi, F., Shahrak, M.A., Talepasand, S., Nokani, M., & Hasani, M. (2015). The effect of group logotherapy on meaning in life and depression levels of Iranian students. International Journal for the Advancement of Counseling, 37(1), 54-62.
Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes, 83(1), 115-128.
Yalom, I.D. (1980). Existential psychotherapy. New York: Basic Books.
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