Transactional Experiences of Existential Anxiety as a Barrier to Effective Humanistic Intervention

Abstract

There are some who criticize mainstream mental health approaches and point out that individuals in distress appear to be getting worse, as opposed to better, while in treatment. Ex-patients often advocate for a person-centered, humanistic approach to working with emotional distress, while clinicians tend to offer a disease-based, deficit-focused model. This article is an exploration of the dynamics between patients and professionals that may be contributing to conflicting perspectives on what constitutes helpful intervention. Specifically, concepts of terror management theory are used to explore how the existential anxieties experienced both by individuals with serious emotional difficulties as well as their treating clinicians, which are consciously or unconsciously avoided in treatment, can reciprocally trigger distressing anxiety in the other. Suggestions are offered as to what could help mitigate this existential stalemate in the psychotherapeutic context.

Keywords

psychotherapy consumer movement death anxiety terror management theory

As the mental health field has grown in its acceptance as a medical science, rates of diagnosed “mental illness” and related disabilities have skyrocketed (Deacon, 2013; Whitaker, 2010). Conversely, professionals continually tout breakthrough discoveries and promising, innovative advancements that are usually based in neurobiology (e.g., Insel, 2012; Ripke et al., 2013; State & Sestan, 2012). At the same time, many ex-patients and consumers have come together in an evergrowing movement that protests these very same “advancements” (Allsop, Jones, & Baggott, 2004; Bracken et al., 2012; Cohen, 2005; Jones, 2008; Read, 2005) while typically attributing their emotional difficulties to chronic stress and trauma (e.g., Dillon, 2012).

The consumer movement asserts that the mental health system has, for many individuals, contributed to the worsening of mental health through acts of abuse and oppression, inhumane treatments, coercion, infantilizing dependency, medicalization of emotional experience, and civil rights violations (Bassman, 2001; Cohen, 2005). This is particularly the case with individuals who have been diagnosed with a “serious mental illness,” and appears to be supported by recent research (e.g., Henderson et al., 2014; Whitaker, 2002, 2010). For instance, there are robust research findings providing evidence that the therapeutic relationship is one of the most important influences on outcomes in both psychotherapeutic and pharmacological interventions (Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012; Goldsmith, Lewis, Dunn, & Bentall, 2015; Krupnick et al., 2006). Yet many “experts” argue that a disease-oriented technique is more important (Tschacher, Junghan, & Pfammatter, 2012) and rigidly adhere to manualized and prescriptive formulas that are not designed for the typical person seeking services in the community (Morrison, Bradley, & Westen, 2010; Shedler, 2006; Thompson-Brenner & Westen, 2005). Furthermore, medicalized conceptualizations of emotional distress result in increased stigma and distancing of both professionals and the general public (Lebowitz, 2014; Pescosolido et al., 2010; Schomerus, Matschinger, & Angermeyer, 2014). In fact, distancing strategies are often recommended to help prevent burnout and “compassion fatigue” (Figley, 2002, 1998; Sansbury, Graves, & Scott, 2014). Last, many of the “gold-standard” approaches to treating emotional distress have been shown to be less tolerated (Markowitz et al., 2015; Tarrier, 2001) and associated with exacerbation of problems for some (e.g., Ogden, Pain, & Fisher, 2006), while standard medical interventions, in general, have been found to be directly associated with increased chronicity, violence, disability, cognitive deterioration, posttraumatic stress symptoms, and completed suicide (Breggin, 2008; Fazel, Wolf, Palm, & Lichtenstein, 2014; Foley et al., 2005; Greenfield, Stoneking, Humphreys, Sundby, & Bond, 2008; Harrow, Jobe, & Faull, 2012; Healy, 2012; Healy, Herxheimer, & Menkes, 2006; Hjorthoj, Madsen, Agerbo, & Nordentoft, 2014; Huxley, 2007; Jensen et al., 2007; Large & Ryan, 2014; Martin et al., 2004; Molina et al., 2009; Mueser, Lu, Rosenberg, & Wolfe, 2010; Nevo et al., 2014; Wunderink, Nieboer, Wiersma, Sytema, & Nienhuis, 2013).

The current undertaking of mainstream mental health practice is to “fix” something that is deficient, broken, or abnormal. Many consumers, on the other hand, desire a more humanistic approach emphasizing the discovery of an intrinsic life purpose, valuing uniqueness, and increasing quality of life. Humanistic psychology is a holistic approach affirming the basic principles of self-actualization, understanding distress in the context of life experiences, and focusing on long-term goals unique to each individual (e.g., Bühler, 1971). This framework is frequently marginalized and underutilized today in favor of more deficit-based, biological ones.

It is important to understand the numerous reasons for this divide, particularly when considering the lack of advancements in decreasing rates of disability and diagnosable mental health difficulties. Some reasons may include financial constraints of agencies, economic dependence on insurance companies, societal expectations of immediacy, and/or the vast surfeit of individuals seeking help for emotional distress. More specific to this article, however, is the suggestion that many professionals eschew the desires of their consumers because inherent to a humanistic approach is the idea that a position of authority and control must be conceded in order for the service user to realize his or her own potential and autonomous self. Additionally, the clinician must be open to a shared experience of distressing emotions. For many clinicians, this may produce uncomfortable feelings of anxiety, rage, and terror against which deficit-based approaches may protect them.

Concepts drawn from terror management theory (TMT; Greenberg, Pyszczynski, & Solomon, 1986) could be used to describe ways in which the profound terror and existential suffering that most individuals with serious emotional difficulties report trigger anxiety¹ in their clinicians. Simultaneously, clinicians’ worldviews and adaptations to their own life experiences may trigger equally profound existential anxiety in those individuals seeking their help. TMT broadly argues that most behavior is motivated by survival instincts and attempts to keep an awareness of death out of explicit consciousness. Although this basic premise has been theorized by many clinicians and researchers, most notably Ernest Becker, Greenberg and colleagues were the first to operationalize the idea into an empirically testable construct.

The following explores the ways in which TMT may help explain the challenges facing practitioners in providing the humanistic intervention desired by many consumers. Certainly, there are numerous complex factors that play into the dynamics of the therapeutic relationship, and not all patients or professionals cleanly fit this theory or exemplification. Additionally, this is not meant to be a comprehensive review of the robust literature supporting TMT,² nor is it designed to further marginalize individuals in distress by insinuating that their “pathology” causes therapists to behave in inhumane and unhelpful ways. Rather, the issues explored may be major factors in and help explain the disconnect that sometimes exists between consumers and mental health professionals as created by all parties involved.

Illustrative Vignette

A vignette is used throughout to depict a common dynamic played out between a “difficult” patient and a therapist frustrated in his efforts to help this patient. Because this article does not follow the standard of placing the sole focus on the “patient” but rather equally examines both individuals involved in the complex interplay of the therapeutic relationship, a vignette was contrived based on numerous clinical observations and first-person accounts from patients and ex-patients witnessed by both authors. Although a case study may prove valuable in its place, this would reinforce the sole focus on the patient as the “problem,” rather than examining the ways in which each person contributes to a dynamic that prevents humanistic and effective therapy for many. It is hoped that the following scenario can illustrate the points of view of each participant in a way that exemplifies the dynamic that is of concern to this theoretical exploration; namely, the conflict between disheartened ex-patients/psychiatric survivors and mainstream therapists doing their best to help those in distress. Neither case is based on any specific individual, but rather the aggregate clinical and personal experiences of the authors.

The Consumer Perspective

George Smith has been attending regular psychotherapy sessions with Dr. Brown for almost 2 years. He is frustrated by his continued feelings of distress, worthlessness, and hopelessness, and with the shame that he experiences around his belief that others (including his treatment team) are judging him. He has attempted to comply with the demands of this team by diligently taking his prescribed drugs and engaging in multiple skills training exercises in session and as homework. Yet he feels that his quality of life has significantly decreased since his initial period of crisis. He has been told that this is part of his “disease” and that he must learn how to cope with a lifetime of dependency on the mental health system in order to “function.” One day, Mr. Smith decides to confront his therapist once again and express his needs that he believes are not being met. He tells Dr. Brown that he wants somebody to listen to him without judgment, to accept him for who he is, to validate his experiences, and to help him believe that he has qualities that will allow him to thrive and move past the emotional difficulties he has experienced in the past several years. Furthermore, Mr. Smith tells the doctor that his fear of others and worries about things that Dr. Brown cannot understand are based on real experiences of pain and trauma from earlier in life. This attempt to speak up for himself and his needs appears to frustrate Dr. Brown, which leaves Mr. Smith feeling more ashamed, hopeless, helpless, defeated, and suicidal.

The Therapist’s Perspective

Dr. Brown began seeing Mr. Smith in a community mental health clinic after he was discharged from an inpatient facility with diagnoses of schizoaffective disorder and borderline personality disorder. Dr. Brown has become disillusioned and burned out working with this seemingly hopeless case. Sessions are often focused on teaching the patient skills to cope with irrational emotions, test reality, and decrease his chronic delusions, and to learn to interact more adaptively with others. In collaboration with a psychiatrist, Dr. Brown has witnessed multiple changes in Mr. Smith’s medication regimen to no avail; nothing seems to work and Mr. Smith continues to be delusional, paranoid, and angry! In the past 6 months or so, Mr. Smith has become increasingly noncompliant, argumentative, oppositional, and manipulative, to the point of threatening suicide. Dr. Brown’s view is that his patient has no desire to get better, prefers to play the victim, has no empathy for others, threatens to harm himself just to get attention, and talks about his delusions in a manner to purposely aggravate his providers. The treatment team has had to meet on several occasions to discuss this difficult case and it has become apparent that Mr. Smith was actively splitting the team. In this most recent session, it became clear that Mr. Smith had regressed further into a delusional state where he was making up traumatic events to increase his identification as a victim, was threatening further noncompliance by asserting that he was going to stop taking his medication against medical advice, and his paranoia, avolition, suicidality, and need to blame others had increased potentially to the point of possibly needing to be hospitalized.

Terror Management Theory and the Mental Health Field

Sigmund Freud (1961) was the first psychiatrist to discuss unconscious aspects of experiencing anxieties related to death. He argued that fears of death can arise in individuals who are overwhelmed by threats of annihilation, or when the individual experiences hostile feelings toward a loved one and fears a loss of protection from danger (Hurvich, 2000). Jung (1938) further argued that religious belief may provide emotional stability, and modern studies appear to support this assertion (Morris & McAdie, 2009).

Half a century later, anthropologist and existential philosopher Ernest Becker (1973) contended that paralyzing anxiety and terror may result from the existential dilemma that arises from an awareness of death in a species oriented toward survival. It is theorized that humans are distinct in their knowledge that they will one day die, and that this intolerable cognizance leads individuals to engage in various strategies to defend against the resultant distress. In fact, Becker asserted that most aspects of society are representative of a symbolic defense mechanism designed to ward off conscious awareness of human mortality. Mental distress is thought to arise when defenses against death awareness fail.

Greenberg et al. (1986) developed an empirically testable construct they named TMT, which was derived directly from Becker’s work. The developers of this theory designed this construct to help researchers understand the need for self-esteem, the rigidity with which people maintain their worldviews, and the difficulty that people from differing cultures and beliefs have in getting along with each other peacefully (Pyszczynski, Solomon, & Greenberg, 2015). TMT suggests that culture and societal worldview are aspects of civilization that provide protection from the terror resulting from mortality awareness and vulnerability to death. Humans appear to be unique in the animal world in their awareness that death is inevitable and that it can come at any time. In turn, according to TMT, human beings have developed intellectual and psychological mechanisms to keep this awareness out of consciousness to preserve contentment and peace of mind.

Indeed, it has been demonstrated that when a heightened awareness of death is experimentally manipulated, individuals experience a notable increase in anxiety and a decreased sense of well-being (Juhl & Routledge, 2015). Anxiety and terror associated with mortality have been shown to be increased when confronted with death-related issues and risky behavior (Hansen, Winzeler, & Topolinski, 2010), when facing one’s own self-awareness (Arndt, Greenberg, Simon, Pyszczynski, & Solomon, 1998), when confronted with questions regarding the meaning of life (Hayes, Schimel, Arndt, & Faucher, 2010), and when one’s strong beliefs are challenged or evidence is provide that refutes these beliefs (Schimel, Hayes, Williams, & Jahrig, 2007). Accordingly, people are driven to adhere to cultural prescriptions of reality and take great efforts to defend these values and beliefs so as not to become overwhelmed by existential terror. The greater certainty one has in these values and beliefs, the more effective it may be at buffering anxiety and low self-worth.

One way in which death anxiety may be defended against is through the development of and adherence to fundamental ideological worldviews (Pirutinsky, 2009). Religion and culture appear to assist individuals in coping with anxiety associated with death (Greenberg, Solomon, & Pyszczynski, 1997), through dictation of how life should be lived, and a personal sense of purpose, value, and meaning (Hayes et al., 2010). Ideologies of any kind, including mental health care paradigms, can provide people with a sense of control over seemingly random events (Kay & Eibach, 2013). The simple act of deriding an individual who has detracted from one’s ideology leads to decreased death anxiety (Arndt, Greenberg, Solomon, Pyszczynski, & Simon, 1997). Dr. Brown’s increased pathologizing and derision of Mr. Smith on being challenged and threatened with a sense of loss of control can be seen as an attempt to protect himself against terror and anxiety, or the projective identification of Mr. Smith’s anger and rage, rather than as conscious efforts to harm his patient.

When a patient presents for treatment in a state of terror or extreme distress brought on by terror-inducing circumstances, death-related issues, and questions about the meaning of life are highly salient. In the vignette, when Mr. Smith is perceived as challenging Dr. Brown’s treatment and the conceptual base on which his techniques lie, it may be surmised that the already present anxiety and terror become heightened to an unbearable level. It is not surprising, then, that Dr. Brown becomes frustrated, more likely to adhere to his theoretical worldview, and to overlook his role in Mr. Smith’s increased distress.

Additional factors mitigating the rise in death anxiety include close relationships (Hart, Shaver, & Goldenberg, 2005), self-esteem associated with adherence to a group’s rules and standards (Maxfield, John, & Pyszczynski, 2014), and the belief that progress is continuously occurring (Rutjens, van der Pligt, & van Harreveld, 2009). These findings may explain why communities of individuals with similarly held beliefs often remain exclusive, unitary, and blind to any failures of progress that may exist; descriptions that many in the consumer movement have used to describe the mental health field.

TMT and Child Development

Researchers in the area of developmental psychology have long hypothesized that the first contact with mortality occurs in early childhood, even at birth, with the inevitable experience of separation from the primary caregiver (Bowlby, 1969/1982; Seligman, 1975). If the caregiver impedes, or is experienced as impeding on, the child’s efforts to take steps toward independence and separation, he or she may come to associate these efforts with fears of harming or destroying the self and/or the caregiver. This kind of inconsistent caregiving results in an insecure attachment between infant and caregiver that prohibits the infant from acquiring a healthy capacity to manage anxiety through symbolic representation of the safe other (Hayes et al., 2010; Maxfield et al., 2014). This leaves the child unprotected from persistent existential fears and susceptible to the use of less adaptive coping strategies to try to mitigate them.

Repeated experiences of insecure attachments in childhood can lead to the development of long-standing insecure internal working models of attachment in adulthood (Dykas & Cassidy, 2011; Schore & Schore, 2011). These have significant, negative repercussions on the individual’s ability to function in the broader social environment, particularly in regard to the development and maintenance of intimate bonds with others and self-regulation of negative affective states (Bowlby, 1969/1982, 1988). Modern TMT research on childhood attachment styles has found that insecure attachment is indeed associated with atypical responses to existential threat, such as increased negativity and somatization (Goldenberg, 2005; Mikulincer, Florian, & Hirschberger, 2004). This research shows that a lack of an ability to self-regulate negative affective states leads individuals to cope with existential anxieties using strategies such as phobic avoidance, obsessive vigilance, or self-medication. In short, insecure attachments in childhood leave individuals vulnerable to existential anxieties.

Patient History

George Smith was born to an immigrant couple who came to the United States in order to make more money and support their respective families. This couple married young and quickly became disheartened, stressed, and bitter at the ongoing struggle of trying to feed a young child on little income and with little support. Although there was much love in this family, the marriage became cold and, in turn, George’s mother became despondent and dependent on him for emotional support. He was an energetic, sensitive, and creative child but was often confused and subdued by his mother’s alternating emotional distance and clinging behaviors that resulted from her increasing sense of helplessness and desperation in the face of discrimination and poverty. Additionally, George began to blame himself for his father’s intensely negative moods and emotional outbursts. By the time George entered school, he was terrified of the power he felt he had over his parents’ lives and he was desperate to save them by completely negating his internal experience and becoming a “loveable” child; however, George learned that no matter what he did, his parents remained intrusive, hostile, and rejecting as they continued to focus on survival, leaving him feeling chronically frightened, confused, helpless, and anxious. He became lost in a world of fantasy where he felt loved and nurtured, and where the world made sense. As he aged, his views of the world became more peculiar in an effort to soothe his overwhelming fear and anxiety. This led to odd behaviors that resulted in frequent instances of bullying and accusations of attentional difficulties from teachers.

This developmental history shows that George grew up in a family that became increasingly hostile and chronically stressed due to economic and discriminatory factors. He became the unwitting scapegoat of the family and internalized this guilt and blame. The disorganized attachment that developed between George and his parents created a chronic sense of fear and confusion that could only be quelled by retreating into a world of fantasy. He suppressed his terror by complying with his mother’s emotions and needs at the expense of his own and by creating fantastical explanations of a subjectively irrational world.

Therapist’s History

Jerry Brown was born to an upper middle-class family that prided itself on professional and material successes. His father was a lawyer, in a long lineage of litigators, and his mother was a doctor. The marriage was one that was emotionally distant and, in turn, Jerry’s father became despondent and aloof. His mother, on the other hand, was often absent, and when she was home, she avoided any conflict or acknowledgement of her husband’s distress. Jerry was an intelligent and energetic child, and he quickly learned that the only way to obtain the approval of his parents was to not be a nuisance, to speak like an adult, and to never misbehave. He became frightened of his own emotions and desires, particularly when they triggered his father’s withdrawal and depressed mood, and he avoided these feelings at all costs. Jerry began to believe that behaviors such as being too loud, crying, complaining of boredom, or running around as children do were signs of his badness; he learned to become subdued and to conform to the standardized education system and high expectations of his erudite parents. So long as Jerry performed at a superior level to that of his peers and “behaved,” he was rewarded by praise and approval. He became resentful toward his mother, but denied this to himself for he could not bear the guilt. Jerry negated his own needs and sacrificed his childhood to stand in for his increasingly absent mother and for his emotionally distant father.

Unlike George, Jerry grew up in a family of high socioeconomic status and a low level of expressed emotion. He was socialized into conformity in a society that values financial success, intellectualism, and suppression of emotions. Jerry’s parents were proud of his intellect and good behavior and Jerry found that he was able to quell the terror of losing his parental support by excelling academically and caring for his father. Both Jerry and George have developed insecure attachments; their methods of coping with the resultant existential anxieties will collide when the two come together in the intimate and emotionally salient psychotherapeutic relationship.

TMT and Mental Health

Research shows that individuals who have been diagnosed with a mental disorder display a high prevalence of insecure attachment styles (Lima, Mello, & de Jesus Mari, 2010; Maxfield et al., 2014), as well as serious emotional distress rooted in existential anxiety (Firestone, 1993, 1994; Goldenberg & Arndt, 2008; Pyszczynski & Kesebir, 2011; Vinogradov & Yalom, 1989; Yalom, 1995). More specifically, existential anxieties have been identified as a source of extreme states indicative of “serious mental illness,” such as psychosis (Geekie, 2012; Laing, 2010; A. Schwartz, 2013; Searles, 1965/1986), extreme mood lability (Havens & Ghaemi, 2005; Vijayan, 2014), and suicidality (Firestone & Firestone, 1998; Kastenbaum, 2000; Rogers, 2001; Rogers, Bromley, McNally, & Lester, 2007) among others. There is a growing literature that draws from TMT research to better understand the origins and maintenance of emotional distress. Much of this line of research focuses on the importance of terror management defenses—normal, unconscious means of avoiding death anxiety—in maintaining emotional equilibrium.

For instance, terror mismanagement research (e.g., Finch, Iverach, Menzies, & Jones, 2015; Strachan et al., 2007; Strachan, Pyszczynski, Greenberg, & Solomon, 2001) conceptualizes symptoms of emotional distress as the result of an inability to successfully cope with the anxieties that are brought on by reminders of one’s mortality. Anxiety buffer disruption theory (e.g., Abdollahi, Pyszczynski, Maxfield, & Luszczynska, 2011; Kesebir, Luszczynska, Pyszczynski, & Benight, 2011; Pyszczynski & Kesebir, 2011) posits that dissociation occurs as a result of one’s cultural worldview being shaken and rendered useless in protecting one from death anxiety after experiencing a traumatic life event. Furthermore, in a recent study, Hayes, Ward, and McGregor (2015) took a TMT-informed goal regulation perspective to show that death anxiety may provoke one to mentally disengage from fearful stimuli, sometimes to the point of distressing lack of motivation, depression, and suicidal ideation.

Interestingly, the literature on clinicians’ motivations for entering the therapeutic profession suggests that those working in the mental health field have strikingly similar backgrounds to those they seek to help. In their review of this topic, Farber, Manevich, Metzger, and Saypol (2005) noted a marked desire in clinicians to fulﬁll unmet needs for intimacy from childhoods marked by isolation and sadness as one of their prominent motivations. It has been suggested that all clinicians have some level of “woundedness” (Heron, 2001; Zerubavel & Wright, 2012) and that clinicians have experienced more childhood trauma and emotional neglect than other professionals (Fussell & Bonney, 1990; Marsh, 1988). Many experienced unstable and ungratifying caregiving environments in their childhood, and had taken on the lifetime role of caregiver to those closest to them (Farber et al., 2005).

As would be expected, it has been found that as a result of these early experiences, clinicians were more likely to employ maladaptive strategies to cope with this emotional distress in their personal lives (Elliott & Guy, 1993; Sussman, 1992). For instance, research on suicide among mental health professionals has shown that clinicians commit suicide at a rate exceeding that of the general population (Gilroy, Carroll, & Murra, 2002). Interestingly, having had a history of personal suicidality may predicate one to be less comfortable working with and more likely to pathogize suicidal individuals (Hunter, 2015). Hence, individuals diagnosed with “serious mental illnesses” and the clinicians who treat them appear to have had similar attachment experiences and are, as a result, more vulnerable to being triggered by existential anxieties experienced in similar others. This is exemplified in the histories of George Smith and Dr. Brown.

Divergent Paths

What, then, sets individuals with such similar backgrounds on such different life courses; with the first group’s distress diminishing their ability to live fulfilling lives, while the other’s serves as a key to a socially accepted career? Importantly, urbanicity, poverty, and minority group position have consistently been identified as key factors in the development of serious emotional distress (Draine, Salzer, Culhane, & Hadley, 2002; van Os, Kenis, & Rutten, 2010; Varese et al., 2012). Research has noted the large experiential gaps that exist between such individuals and clinicians, who generally are born into, and remain in, significantly higher socioeconomic classes (Beach, Duggan, Cassel, & Geller, 2007; Cooper, 2009; Rao, Anderson, Inui, & Frankel, 2007). Additionally, research has shown that individuals diagnosed with “serious mental illnesses” generally show a lifetime propensity toward interpreting meaning from sensations that are not part of the environmental reality and/or to experience dissociative phenomena in reaction to difficult experiences (Asarnow, Thompson, & Goldstein, 1994; Taylor, 1998).

Meanwhile, mental health professionals have been shown to utilize intellectualization and “psychologically minded” strategies, such as insight development and analyzing the mind states of others, to cope with these experiences (e.g., Farber et al., 2005). Laing (1985) famously explained this attitude of disengagement as “psychophobia”—a fear of one’s inner life that leads to frantic attempts to avoid engaging with it, and that of others. He dedicated much of his writing (Laing, 1967, 1985, 2010) to normalizing all manifestations of emotional distress, in large part to counteract the occurrence of these kinds of automatic, destructive, and fear-based reactions.

Although the similar backgrounds of patients and clinicians are rarely acknowledged in clinical research and education, it has led some to conceptualize clinicians as wounded healers, whose search for meaning, desire to assist others with their difficulties, and enormous need for connection is enacted in their professional lives (Hamman, 2001; Jung,1951/1967). It has been suggested that clinicians’ experiences of past or present emotional difficulties can facilitate an empathic connection with their patients, which constructively informs the healing process (Miller & Baldwin, 2000). However, existential anxieties and the traumatic experiences that engendered them tend to be unconsciously dissociated and established as a separate psychic state within the personality (Davies & Frawley, 1994). This is especially the case for clinicians, who often disavow their woundedness (H. J. Schwartz & Silver, 1990).

Becoming a Patient

As George entered adolescence, he became more organized; his grades were high, he appeared to have many friends, and he began to play football in an effort to make friends. Nevertheless, he continually felt isolated and invisible to others. He was known for his sensitivity and caring for women, though also for his possessiveness, jealousy, and propensity toward anger when he felt rejected. Internally, George was terrified, having become so distanced from the creative, introverted, energetic boy he once had been. When he left to attend college, he realized that he had no foundation on which to exist without his mother. Additionally, George had become exhausted and resentful for denying the reality of his impoverished and oppressive upbringing and the lies and false selfhood that he had created to succeed and stop the bullying. George’s existential fear of losing himself in moments of rejection and separation created a terror that he struggled to contain, and he began to hear the voices of his previous tormentors in moments of intense anxiety. His attempts to subdue this fear and confusion resulted in an ever increasingly complex and bizarre explanatory belief system that included the idea that he was God. This level of power he found in his grandiosity was the only way that George could explain his ability to make others behave in such abhorrent ways (i.e., the hostile behaviors of his parents, bullying) and his dissociated loss of self, while also suppressing the undercurrent of raw terror. Eventually, others began to notice and George was involuntarily hospitalized for “psychosis.”

Becoming a Therapist

As Jerry entered into adolescence, he was a straight-A student, excelled at many extracurricular activities, and had a few close friends. He was frightened of making mistakes or not succeeding, and the only source of pride or sense of self outside of academics was his role as caregiver to his depressed father. He was known as successful, intelligent, perfectionistic, and quick to care for others’ needs, even if it was not asked of him. Internally, Jerry was terrified of his “bad” desires and of his intense anger that he felt could literally kill his father from disappointment and grief. His intellect allowed him to remain distant from these internal experiences and fears and he believed strongly in the righteousness of the world and the authorities that run it. As Jerry entered college, his long-standing role as a caregiver and his intellectual qualities naturally led him to want to pursue a career in the helping field. This was, in part, due to the expectations of his parents, but also because he found the logic of science to be very helpful in making sense of a chaotic world and allowing him to feel safe. When Jerry was not excelling in school or caring for another person, he often became anxious and depressed as his purpose of existing felt ambiguous and empty. He had difficulty tolerating deep emotions, unplanned activity, or conflict of any sort. Eventually, Jerry found that his training as a psychologist and the rewarding experience of patients’ gratitude for him helping them gave him meaning in life and laid the foundation for both success and happiness. The sense of power he felt in his grandiose role of “helper” served to assuage the underlying fear that he so often felt throughout his earlier life.

Discussion

The mental health paradigm may serve as a powerful, protective ideological system that provides protection from existential anxieties, feelings of weakness, and a sense of helplessness. This ideology may offer a sense of self-regard (Piven, 2003), which, according to TMT, is protective against death anxieties (Hayes et al., 2010). Sarbin and Juhasz (1967) posited 60 years ago that the mental health field had replaced religion as the power structure responsible for maintaining social order and the status quo. They discussed the grandeur associated with being licensed to act in another’s “best interests” by using at times harmful treatments that often serve to ostracize an individual from society. These authors also describe the necessary faith-based belief system that sustains acceptance of theories that provide anxiety-repelling certainty.

Clinicians may also rely on their role as “helpers” to attain a fragile sense of self-esteem, identity, and empowerment. When a client challenges this sense of helping, whether through discussion of suicide, risk-taking behaviors, detachment from consensus reality, and/or simply expressing frustration or dissatisfaction with treatment, death awareness, or existential anxiety is likely increased in the clinician. As previously mentioned, when one has the opportunity to defend a worldview through reproaching a critic, the anxiety associated with this mortality salience is then decreased (Arndt et al., 1997). One way clinicians may engage in this process is through blaming the patient’s internal deficits or dysfunction and his or her “illness” for any negative outcomes of treatment. Indeed, when a victim is portrayed negatively, death anxiety remains hidden from awareness (Landau et al., 2004). Additionally, death anxiety appears to remain low when trauma is minimized and/or ignored (Hirschberger, 2006), perhaps explaining the long history of trauma denial within the mental health profession (e.g., van der Kolk, Brown, & van der Hart, 1989).

On the other hand, positive outcomes of treatment are usually associated with more humanistic methods that include positive meaning making and an increased sense of connectedness (Boyarz, Horne, & Saygert, 2012; Davis, Nolen-Hoeksama, & Larson, 1998). These humanistic principles that allow for autonomy, ambiguity, and egalitarianism require a level of secure attachment and/or a lack of reliance on current mental health ideologies for providing a sense of purpose and order in the world. For the many professionals who have grown up in chaotic and insecure families, engaging in such an approach may induce unbearable levels of existential anxiety. Additionally, those service users who do not improve according to the clinicians’ ideal of “recovery” may consistently threaten clinicians who rely on the role of “helper” to achieve a sense of self or purpose. Even for those with idyllic upbringings, a perfect sense of security, and a strong sense of purpose in life outside of the helping role, working with individuals in extreme distress can be a terrifying endeavor. Addressing this terror and resultant coping strategies is imperative to providing consumers with the highest quality of care.

Acknowledging and respecting the existential anxieties triggered by the interaction between patient and therapist allows for the development of specific solutions that may be incorporated into treatment planning. A sense of empowerment may develop simply from acknowledging one’s existential vulnerabilities while not defining oneself by them (Cristy, 2001). The works of Yalom (e.g., 2008) often contain intimate descriptions of his own “awakening experiences”—moments in which loss, illness, trauma, or aging brought him face to face with his own death anxiety, and may best exemplify this approach. Throughout his career, he has written about the ways in which these public confessions inspired him to rearrange his priorities, communicate more deeply with others, and increase his willingness to take the risks necessary for personal fulfillment.

Also employing this confessional, insight-oriented approach, Bryan Wittine (2005) wrote “The most meaningful issues of my life—my feelings of deficiency and frustration as a psychotherapist, my turbulent relationship with my fiancée, my conflict between spiritualist and wordiness, my fear of death—literally tumbled out” (p. 120), leading to an increased sense of meaningfulness in his personal and professional lives. Rollo May (1953/2009) also drew from his experiences as an existential psychotherapist to write:

On the basis of my own clinical practice [ . . . ] the chief problem of people in the middle decade of the twentieth century is emptiness [ . . . ] the pent-up potentialities turn into morbidity and despair, and eventually into destructive activities. (pp. 13, 24)

Psychiatrist Robert Jay Lifton (2003) brought this approach to sociology, drawing from his sense that his own personal feelings of absence of meaning had led him to experience apocalyptic thoughts, and suggested that America’s wars result partly from this very dynamic.

It also may prove valuable to foster the relationship while helping the distressed individual feel valued and get in touch with his or her experience of the present moment. Ernesto Spinelli (e.g., 1997) called for such an approach with his encouragement to maintain a relational in-the-moment participation of all parties involved in the relationship. This may encourage the formation of a close interpersonal relationship, as well as feeling valued by others to help one manage death anxiety.

At the same time, training and education of mental health professionals should encourage and focus on trainees engaging in self-reflection, forming close relationships with individuals other than patients, finding other avenues of feeling valued and worthwhile, and developing self-compassion. Furthermore, acknowledging and working with the therapist’s own history of mental distress may allow for the recognition and respect of the underlying fear associated with these experiences. With the common conceptualization of therapists as “wounded healers,” it may be paramount that mental health professionals engage in their own personal therapy so as to minimize their conscious or unconscious avoidance of intolerable feelings, such as anxiety, rage, and terror.

Although humanistic psychotherapy is broad and has been described as a “myth” that eludes definition (Mahrer, 2009), some of the basic assumptions often described in the clinical humanistic literature offer solutions to the above-described stalemate. First, highlighting the significant role of existential anxieties and other mystifying concepts in motivating human mental and cultural functioning could help provide service users and their providers with a sense of agency over them. Second, both parties’ reactions to their existential anxieties can be understood through a humanistic framework of expectations and explanations (Frank & Frank, 1993; Kirsch, 1985; as cited in Wampold, 2007). The development and acquisition of more functional explanations of existential anxieties in the therapeutic context can create new expectations by which related distress no longer feels inevitable and unresolvable. Third, another basic tenet of humanistic psychology and psychotherapy is the idea that self-actualization can only occur in individuals who accept the fact that they will one day die (Frankl, 1946; Maslow, 1968; Neimeyer, 1993). Working toward an acceptance of death in psychotherapy therefore could allow for explorations of these deeper issues, and with time, for an acceptance of the developmental experiences underlying them.

As previously mentioned, the dichotomy between “patient” and “therapist” is rarely so distinct, as evidenced by the increased disclosure of clinicians’ experiences with their own “serious mental illness” (Bassman, 2001; Carey, 2011; Fisher, 1994; May, 2000). This article does not intend to suggest that the conflicts discussed are generalizable to all clinicians in all circumstances. Certainly, further research needs to be conducted to understand how TMT may help inform clinical practice and possibly address the issues brought about by the consumer movement. It may be, however, if TMT is taken even further and the mental health field acknowledges humanity’s universal needs for secure relationship, community, meaning, and safety that “treatment” need not necessarily consist of specific techniques to “fix” a “broken brain.” Treatment could instead be an opportunity to provide one with relationship, hope, meaning, and positive self-regard so that terror and suffering may decrease.

Footnotes

Acknowledgements

The authors would like to thank Thomas Greening, PhD, for his assistance and feedback during the revision phase of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Noel Hunter is a doctoral candidate in clinical psychology at Long Island University–Post. Her work focuses on the link between childhood adversity and extreme states of distress, stigma and attitudes toward individuals labeled with a mental illness, and the need for recognition of emotional distress as meaningful responses to overwhelming life experiences. She recently completed her dissertation on helpful and harmful aspects of treatment for severe dissociative experiences and is currently finishing a chapter in the upcoming book Women & Psychosis.

Tristan V. Barsky is a doctoral candidate in clinical psychology in the Serious Mental Illness Specialty Concentration at Long Island University–Post. He is interested in conducting and researching psychodynamic and psychoanalytic treatments of individuals in institutional settings. He is presently working on his dissertation, which examines the psychological effects of publicly exposing art created in or about extreme states.

References

Abdollahi

Pyszczynski

Maxfield

Luszczynska

(2011). Posttraumatic stress reactions as a disruption in anxiety-buffer functioning: Dissociation and responses to mortality salience as predictors of severity of posttraumatic symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 329-341.

Allsop

Jones

Baggott

(2004). Health consumer groups in the UK: A new social movement? Sociology of Health & Illness, 26, 737-756.

Arndt

Greenberg

Simon

Pyszczynski

Solomon

(1998). Terror management and self-awareness: Evidence that mortality salience provokes avoidance of the self-focused state. Personality and Social Psychology Bulletin, 24, 1216-1227.

Arndt

Greenberg

Solomon

Pyszczynski

Simon

(1997). Suppression, accessibility of death-related thoughts, and cultural world-view defense: Exploring the psychodynamics of terror management. Journal of Personality and Social Psychology, 73, 5-18.

Asarnow

J. R.

Thompson

M. C.

Goldstein

M. J.

(1994). Childhood-onset schizophrenia: A followup study. Schizophrenia Bulletin, 20, 599-617.

Bassman

(2001). Whose reality is it anways? Consumers/survivors/ex-patients can speak for themselves. Journal of Humanistic Psychology, 41, 11-35.

Beach

M. C.

Duggan

P. S.

Cassel

C. K.

Geller

(2007). What does “respect” mean? Exploring the moral obligation of health professionals to respect patients. Journal of General Internal Medicine, 22, 692-695.

Becker

(1973). The denial of death. New York, NY: Free Press.

Bowlby

(1982). Attachment and loss: Attachment. New York, NY: Basic Books. (Original work published 1969)

10.

Bowlby

(1988). A secure base: Parent-child attachment and healthy human development. London, England: Routledge.

11.

Boyarz

Horne

S. G.

Saygert

T. V.

(2012). Finding meaning in loss: The mediating role of social support between personality and two construals of meaning. Death Studies, 36, 519-540.

12.

Bracken

Thomas

Timimi

Asen

Behr

Beuster

. . . Yeomans

(2012). Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430-434.

13.

Breggin

P. R.

(2008). Medication madness: A psychiatrist exposes the dangers of mood-altering drugs. New York, NY: St. Martin’s Press.

14.

Bühler

(1971). Basic theoretical concepts of humanistic psychology. American Psychologist, 26, 378-386.

15.

Carey

(2011, June 23). Expert on mental illness reveals her own fight. The New York Times. Retrieved from http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=all&_r=0

16.

Cohen

(2005). How do we recover? An analysis of psychiatric survivor oral histories. Journal of Humanistic Psychology, 45, 333-354.

17.

Cooper

L. A.

(2009). A 41-year-old African American man with poorly controlled hypertension: Review of patient and physician factors related to hypertension treatment adherence. Journal of the American Medical Association, 301, 1260-1272.

18.

Cristy

B. E.

(2001). Wounded healer: The impact of a therapist’s illness on the therapeutic situation. Journal of the American Academy of Psychoanalysis, 29, 33-42.

19.

Davies

J. M.

Frawley

M. G.

(1994). Treating the adult survivor of childhood sexual abuse. New York, NY: Basic Books.

20.

Davis

Nolen-Hoeksama

Larson

(1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75, 561-574.

21.

Deacon

B. J.

(2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33, 846-861. doi:10.1016/j.cpr.2012.09.007

22.

Diamond

S. A.

(1999). Anger, madness, and the daimonic. New York: SUNY Press.

23.

Dillon

(2012). Recovery from “psychosis.” In Geekie

Randal

Lampshire

Read

(Eds.), Experiencing psychosis (pp. 17-22). New York, NY: Routledge.

24.

Draine

Salzer

M. S.

Culhane

D. P.

Hadley

T. R.

(2002). Role of social disadvantage in crime, joblessness, and homelessness among persons with serious mental illness. Psychiatric Services, 53, 565-573.

25.

Dykas

M. J.

Cassidy

(2011). Attachment and the processing of social information across the life span: Theory and evidence. Psychological Bulletin, 137, 19-46.

26.

Elliott

D. M.

Guy

J. D.

(1993). Mental health professionals versus non-mental-health professionals: Childhood trauma and adult functioning. Professional Psychology: Research and Practice, 24, 83-90.

27.

Farber

B. A.

Manevich

Metzger

Saypol

(2005). Choosing psychotherapy as a career: Why did we cross that road? Journal of Clinical Psychology, 61, 1009-1031.

28.

Fazel

Wolf

Palm

Lichtenstein

(2014). Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: A 38-year total population study in Sweden. Lancet Psychiatry, 1, 44-54.

29.

Figley

C. R.

(2002). Compassion fatigue: Psychotherapists’ chronic lack of self-care. Journal of Clinical Psychology, 58, 1433-1441.

30.

Figley

C. R.

(Ed.). (1998). Burnout in families: The systemic costs of caring (Vol. 1). Boca Raton, FL: CRC Press.

31.

Finch

E. C.

Iverach

Menzies

R. G.

Jones

(2015). Terror mismanagement: Evidence that mortality salience exacerbates attentional bias in social anxiety. Cognition & Emotion, 24, 1-10.

32.

Firestone

R. W.

(1993). Individual defenses against death anxiety. Death Studies, 17, 497-515.

33.

Firestone

R. W.

(1994). Psychological defenses against death anxiety. In Neimeyer

R. A.

(Ed.), Death anxiety handbook: Research, instrumentation, and application (pp. 217-241). London, England: Taylor & Francis.

34.

Firestone

R. W.

Firestone

(1998). Voices in suicide: The relationship between self-destructive thought processes, maladaptive behavior, and self-destructive manifestations. Death Studies, 22, 411-443.

35.

Fisher

D. B.

(1994). A new vision of healing as constructed by people with psychiatric disabilities working as mental health providers. Psychosocial Rehabilitation Journal, 17, 67-81.

36.

Fluckiger

Del Re

A. C.

Wampold

B. E.

Symonds

Horvath

A. O.

(2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59, 10-17.

37.

Foley

Kelly

Clarke

McTigue

Gervin

Kamali

. . . Browne

(2005). Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis. Schizophrenia Research, 72, 161-168.

38.

Frank

(1993). Persuasion and healing: A comparative study of psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press.

39.

Frankl

(1946). Man’s search for meaning. Vienna, Austria: Verlag für Jugend und Volk.

40.

Freud

(1961). The Ego and the Id (J. Strachey, Trans.). In Strachey

(Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 19, pp. 339-625). London, England: Hogarth Press. (Original work published 1923)

41.

Fussell

F. W.

Bonney

W. C.

(1990). A comparative study of childhood experiences of psychotherapists and physicists: Implications for clinical practice. Psychotherapy, 27, 505-512.

42.

Geekie

(2012). The uncertainty of being: Existential aspects of the experience of psychosis. In Geekie

Randal

Lampshire

Read

(Eds.), Experiencing psychosis: Personal and professional perspectives (pp. 87-96). London, England: Routledge.

43.

Gilroy

Carroll

Murra

(2002). A preliminary survey of counseling psychologists’ personal experiences with depression and treatment. Professional Psychology: Research and Practice, 33, 402-407.

44.

Goldenberg

J. L.

(2005). The body stripped down: An existential account of the threat posed by the physical body. Current Directions in Psychological Science, 14, 224-228.

45.

Goldenberg

J. L.

Arndt

(2008). The implications of death for health: A terror management health model for behavioral health promotion. Psychological Review, 115, 1032-1053.

46.

Goldsmith

L. P.

Lewis

S. W.

Dunn

Bentall

R. P.

(2015). Psychological treatments for early psychosis can be beneficial or harmful depending on the therapeutic alliance: An instrumental variable analysis. Psychological Medicine, 45, 2365-2373.

47.

Greenberg

Pyszczynski

Solomon

(1986). The causes and consequences of a need for self-esteem: A terror management theory. In Baumeister

R. F.

(Ed.), Public self and private self (pp. 189-212). New York, NY: Springer-Verlag.

48.

Greenberg

Solomon

Pyszczynski

(1997). Terror management theory of self-esteem and cultural worldviews: Empirical assessments and conceptual refinements. Advances in Experimental Social Psychology, 29, 61-139.

49.

Greenfield

T. K.

Stoneking

B. C.

Humphreys

Sundby

Bond

(2008). A randomized trial of a mental health consumer-managed alternative to civil commitment for acute psychiatric crisis. American Journal of Community Psychology, 42, 135-144. doi:10.1007/s10464-008-9180-1

50.

Hamman

J. J.

(2001). The search to be real: Why psychotherapists become therapists. Journal of Religion and Health, 40, 343-357.

51.

Hansen

Winzeler

Topolinski

(2010). When the death makes you smoke: A terror management perspective on the effectiveness of cigarette on-pack warnings. Journal of Experimental Social Psychology, 46, 226-228.

52.

Harrow

Jobe

T. H.

Faull

R. N.

(2012). Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. Psychological Medicine, 42, 2145-2155.

53.

Hart

Shaver

P. R.

Goldenberg

J. L.

(2005). Attachment, self-esteem, worldviews, and terror management: Evidence for a tripartite security system. Journal of Personality and Social Psychology, 88, 999-1013.

54.

Havens

L. L.

Ghaemi

S. N.

(2005). Existential despair and bipolar disorder: The therapeutic alliance as a mood stabilizer. American Journal of Psychotherapy, 59, 137-147.

55.

Hayes

Schimel

Arndt

Faucher

E. H.

(2010). A theoretical and empirical review of the death-thought accessibility concept in terror management research. Psychological Bulletin, 136, 699-739.

56.

Hayes

Ward

C. L.

McGregor

(2015). Why bother? Death, failure, and fatalistic withdrawal from life. Journal of Personality and Social Psychology, 110, 96-115.

57.

Healy

(2012). Pharmageddon. Los Angeles: University of California Press.

58.

Healy

Herxheimer

Menkes

D. B.

(2006). Antidepressants and violence: Problems at the interface of medicine and law. Public Library of Science Medicine, 3(9), e372.

59.

Henderson

Noblett

Parke

Clement

Caffrey

Gale-Grant

. . . Thornicroft

(2014). Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry, 1, 467-482.

60.

Heron

(2001). Helping the patient. London, England: Sage.

61.

Hirschberger

(2006). Terror management and attributions of blame to innocent victims: Reconciling compassionate and defensive responses. Journal of Personality and Social Psychology, 91, 832-844.

62.

Hjorthoj

C. R.

Madsen

Agerbo

Nordentoft

(2014). Risk of suicide according to level of psychiatric treatment: A nationwide nested case-control study. Social Psychiatry and Psychiatric Epidemiology, 49, 1357-1365.

63.

Hunter

(2015). Clinical trainees’ personal history of suicidality and the effects on attitudes towards suicidal patients. New School Psychology Bulletin, 13, 38-46.

64.

Hurvich

(2000). Fear of being overwhelmed and psychoanalytic theories of anxiety. Psychoanalytic Review, 87, 615-649.

65.

Huxley

(2007). Disability and its treatment in bipolar disorders. Bipolar Disorders, 9, 183-196.

66.

Insel

(2012). Director’s blog: The top ten research advances of 2012 (National Institute of Mental Health). Retrieved from http://www.nimh.nih.gov/about/director/2012/the-top-ten-research-advances-of-2012.shtml#3

67.

Jensen

P. S.

Arnold

L. E.

Swanson

J. M.

Vitiello

Abikoff

H. B.

Greenhill

L. L.

. . . Hur

(2007). 3-Year follow-up of the NIMH MTA study. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 989-1002.

68.

Jones

(2008). In whose interest? Relationships between health consumer groups and the pharmaceutical industry in the UK. Sociology of Health & Illness, 30, 929-943.

69.

Juhl

Routledge

(2015). Putting the terror in terror management theory: Evidence that the awareness of death does cause anxiety and undermine psychological well-being. Current Directions in Psychological Science, 25, 99-103. Retrieved from http://eprints.soton.ac.uk/385875/

70.

Jung

(1938). Psychology and religion. New Haven, CT: Yale University Press.

71.

Jung

C. G.

(1951/1967). Fundamental questions of psychotherapy. In Read

Fordham

Adler

McGuire

(Eds.), The Collected Work of C.G. Jung (Vol. 16, pp. 116-25). Princeton, NJ: Princeton University Press.

72.

Kastenbaum

(2000). The psychology of death. New York, NY: Springer.

73.

Kay

A. C.

Eibach

R. P.

(2013). Compensatory control and its implications for ideological extremism. Journal of Social Issues, 69, 564-585.

74.

Kesebir

Luszczynska

Pyszczynski

Benight

(2011). Posttraumatic stress disorder involves disrupted anxiety-buffer mechanisms. Journal of Social and Clinical Psychology, 30, 819-841.

75.

Kirsch

(1985). Response expectancy as a determinant of experience and behavior. American Psychologist, 40, 1189-1202.

76.

Krupnick

J. L.

Sotsky

S. M.

Elkin

Simmens

Moyer

Watkins

Pilkonis

P. A.

(2006). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Focus, 4, 269-277.

77.

Laing

R. D.

(1967). The politics of experience and the bird of paradise. London, England: Routledge.

78.

Laing

R. D.

(1985). The use of existential phenomenology in psychotherapy. In Zeig

(Ed.), The evolution of psychotherapy (pp. 203-211). London, England: Routledge.

79.

Laing

R. D.

(2010). The divided self: An existential study in sanity and madness. London, England: Penguin Books.

80.

Landau

M. J.

Johns

Greenberg

Pyszczynski

Martens

Goldenberg

J. L.

Solomon

(2004). A function of form: Terror management and structuring the social world. Journal of Personality and Social Psychology, 87, 190-210.

81.

Large

Ryan

C. J.

(2014). Disturbing findings about the risk of suicide and psychiatric hospitals. Journal of Social Psychiatry and Psychiatric Epidemiology, 49, 1353-1355.

82.

Lebowitz

M. S.

(2014). Biological conceptualizations of mental disorders among affected individuals: A review of correlates and consequences. Clinical Psychology, 21, 67-83.

83.

Lifton

R. J.

(2003). Superpower syndrome: America’s apocalyptic confrontation with the world. New York, NY: Nation Books.

84.

Lima

A. R.

Mello

M. F.

de Jesus Mari

(2010). The role of early parental bonding in the development of psychiatric symptoms in adulthood. Current Opinion in Psychiatry, 23, 383-387.

85.

Mahrer

A. R.

(2009). What is psychotherapy for? An almost official answer. The Humanistic Psychologist, 37, 223-234.

86.

Markowitz

J. C.

Petkova

Neria

Van Meter

P. E.

Yihong

Hembree

. . . Marshall

R. D.

(2015). Is exposure necessary? A randomized clinical trial of interpersonal psychotherapy for PTSD. American Journal of Psychiatry, 172, 430-440.

87.

Marsh

S. R.

(1988). Antecedents to choice of a helping careerr: Social work vs. business majors. Smith College Studies in Social Work, 582, 85-100.

88.

Martin

Young

Leckman

J. F.

Mukonoweshuro

Rosenheck

R. A.

Leslie

(2004). Age effects on antidepressant-induced manic conversion. Archives of Pediatrics & Adolescent Medicine, 158, 773-780.

89.

Maslow

(1968). Toward a psychology of being. London, England: Wiley.

90.

Maxfield

John

Pyszczynski

(2014). A terror management perspective on the role of death-related anxiety in psychological dysfunction. The Humanistic Psychologist, 42, 35-53.

91.

May

(2000). Routes to recovery from psychosis: The roots of a clinical psychologist. Clinical Psychology Forum, 146, 6-10.

92.

May

(2009). Man’s search for himself. New York, NY: Norton (Original work published 1953)

93.

Mikulincer

Florian

Hirschberger

(2004). The terror of death and the quest for love: An existential perspective on close relationships. In Greenberg

Koole

S. L.

Pyszczynski

(Eds.), Handbook of experiemental existential psychology (pp. 287-304). New York, NY: Guilford.

94.

Miller

G. D.

Baldwin

D. C.

(2000). The implications of the wounded healer paradigm for the use of self in therapy. In Baldwin

(Ed.), The use of self in therapy (2nd ed., pp. 243-261). New York, NY: Hayworth Press.

95.

Molina

B. S.

Hinshaw

S. P.

Swanson

J. M.

Arnold

L. E.

Vitiello

Jensen

P. S.

. . . Group

M. C.

(2009). The MTA at 8 years: Prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 484-500.

96.

Morris

G. J.

McAdie

(2009). Are personality, well-being and death anxiety related to religious affiliation? Mental Health, Religion & Culture, 12, 115-120.

97.

Morrison

K. H.

Bradley

Westen

(2010). The external validity of controlled clinical trials of psychotherapy for depression and anxiety: A naturalistic study. Psychology and Psychotherapy: Theory, Research and Practice, 77, 109-132.

98.

Mueser

K. T.

Rosenberg

S. D.

Wolfe

(2010). The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis. Schizophrenia Research, 116, 217-227.

99.

Neimeyer

R. A.

(1993). Death anxiety handbook: Research, instrumentation, and application. London, England: Taylor & Francis.

100.

Nevo

G. W. A.

Avery

Fiksenbaum

Kiss

Mendlowitz

Monga

Manassis

(2014). Eight years later: Outcomes of CBT-treated versus untreated anxious children. Brain and Behavior, 4, 765-774.

101.

Ogden

Pain

Fisher

(2006). A sensorimotor approach to the treatment of trauma and dissociation. Psyciatric Clinics of North America, 29, 263-279.

102.

Pescosolido

B. A.

Martin

J. K.

Long

J. S.

Medina

T. R.

Phelan

J. C.

Link

B. G.

(2010). “A disease like any other?” A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry, 167, 1321-1330.

103.

Pirutinsky

(2009). The terror management function of Orthodox Jewish religiosity: A religious culture approach. Mental Health, Religion & Culture, 12, 247-256.

104.

Piven

J. S.

(2003). Death, repression, narcissism, misogyny. Psychoanalytic Review, 90, 225-261.

105.

Pyszczynski

Kesebir

(2011). Anxiety buffer disruption theory: A terror management account of posttraumatic stress disorder. Anxiety, Stress, & Coping, 24, 3-26.

106.

Pyszczynski

Solomon

Greenberg

(2015). Chapter one—Thirty years of terror management theory: From genesis to revelation. Advances in Experimental Social Psychology, 52, 1-70.

107.

Rao

J. K.

Anderson

L. A.

Inui

T. S.

Frankel

R. M.

(2007). Communication interventions make a difference in conversations between physicians and patients: A systematic review of the evidence. Medical Care, 45, 340-349.

108.

Read

(2005). The bio-bio-bio model of madness. The Psychologist, 18, 596-597.

109.

Ripke

O’Dushlaine

Chambert

Moran

J. L.

Kahler

A. K.

Akterin

. . . Sullivan

P. F.

(2013). Genome-wide association analysis identifies 13 new risk loci for schizophrenia. Nature Genetics, 45, 1150-1159.

110.

Rogers

J. R.

(2001). Theoretical grounding: The “missing link” in suicide research. Journal of Counseling & Development, 79, 16-25. doi:10.1002/j.1556-6676.2001.tb01939.x

111.

Rogers

J. R.

Bromley

J. L.

McNally

C. J.

Lester

(2007). Content analysis of suicide notes as a test of the motivational component of the existential-constructivist model of suicide. Journal of Counseling & Development, 85, 182-188. doi:10.1002/j.1556-6678.2007.tb00461.x

112.

Rutjens

B. T.

van der Pligt

van Harreveld

(2009). Things will get better: The anxiety-buffering qualities of progressive hope. Personality and Social Psychology Bulletin, 35, 535-543.

113.

Sansbury

B. S.

Graves

Scott

(2014). Managing traumatic stress responses among clinicians: Individual and organizational tools for self-care. Trauma, 17, 114-122.

114.

Sarbin

T. R.

Juhasz

J. B.

(1967). The historical background of the concept of hallucination. Journal of the History of the Behavioral Sciences, 3, 339-358.

115.

Schimel

Hayes

Williams

Jahrig

(2007). Is death really the worm at the core? Converging evidence that worldview threat increases death-thought accessibility. Journal of Personality and Social Psychology, 92, 789-803.

116.

Schomerus

Matschinger

Angermeyer

M. C.

(2014). Causal beliefs of the public and social acceptance of persons with mental illness: A comparative analysis of schizophrenia, depression and alcohol dependence. Psychological Medicine, 44, 303-314.

117.

Schore

J. R.

Schore

A. N.

(2011). Clinical social work and regulation theory: Implications of neurobiological models of attachment. In Bennett

Nelson

J. K.

(Eds.), Adult attachment in clinical social work (pp. 57-75). New York, NY: Springer.

118.

Schwartz

(2013, February 2). Drowned in a stream of prescriptions. The New York Times. Retrieved from http://www.nytimes.com/2013/02/03/us/concerns-about-adhd-practices-and-amphetamine-addiction.html

119.

Schwartz

H. J.

Silver

A.-L. S.

(1990). Illness in the analyst. New York, NY: International Universities Press.

120.

Searles

H. F.

(1986). Collected papers on schizophrenia and related subjects (Reprint ed.). London, England: Karnac Books (Original work published 1965)

121.

Seligman

(1975). Helplessness: On depression, development, and death. New York, NY: W. H. Freeman.

122.

Shedler

(2006). Why the scientist-practitioner schism won’t go away. The General Psychologist, 41(2), 9-10.

123.

Spinelli

(1997). Tales of un-knowing: Eight stories of existential therapy. New York: New York University Press.

124.

State

M. W.

Sestan

(2012). The emergin biology of autism spectrum disorders. Science, 337, 1301-1303.

125.

Strachan

Pyszczynski

Greenberg

Solomon

(2001). Coping with the inevitability of death: Terror management and mismanagement. In Snyder

C. R.

(Ed.), Coping with stress: Effective people and processes (pp. 114-136). New York, NY: Oxford University Press.

126.

Strachan

Schimel

Arndt

Williams

Solomon

Pyszczynski

Greenberg

(2007). Terror mismanagement: Evidence that mortality salience exacerbates phobic and compulsive behaviors. Personality and Social Psychology Bulletin, 33, 1137-1151.

127.

Sussman

M. B.

(1992). A curious calling: Unconscious motivations for practicing psychotherapy. New York, NY: Jason Aronson.

128.

Tarrier

(2001). What can be learned from clinical trials? Reply to Devilly and Foa (2001). Journal of Consulting and Clinical Psychology, 69, 117-118.

129.

Taylor

(1998). Advances in the diagnosis and treatment of children with serious mental illness. Child Welfare, 77, 311-332.

130.

Thompson-Brenner

Westen

(2005). A naturalistic study of psychotherapy for bulimia nervosa, part 1: Comorbidity and therapeutic outcome. Journal of Nervous & Mental Disease, 193, 573-584.

131.

Tschacher

Junghan

U. M.

Pfammatter

(2012). Towards a taxonomy of common factors in psychotherapy: Results of an expert survey. Clinical Psychology & Psychotherapy, 21, 82-96.

132.

van der Kolk

B. A.

Brown

van der Hart

. (1989). Pierre Janet on post-traumatic stress. Journal of Traumatic Stress, 2, 365-378.

133.

van Os

Kenis

Rutten

B. P.

(2010). The environment and schizophrenia. Nature, 468, 203-212.

134.

Varese

Smeets

Drukker

Lieverse

Lataster

Viechtbauer

Bentall

R. P.

(2012). Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661-671.

135.

Vijayan

(2014). Insight, death anxiety and social support in remitted patients with schizophrenia and bipolar affective disorder: A comparative study. Nepal Journal of Epidemiology, 4(2), 3.

136.

Vinogradov

Yalom

(1989). Concise guide to group psychotherapy. Arlington, VA: American Psychiatric Publishing.

137.

Wampold

B. E.

(2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62, 855-873.

138.

Whitaker

(2002). Mad in America. Cambridge, MA: Perseus.

139.

Whitaker

(2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York, NY: Crown.

140.

Wittine

(2005). The I and the self: Reminiscences of existential-humanistic psychotherapy. In Geller

J. D.

Norcross

J. C.

Orlinsky

D. E.

(Eds.), The psychotherapist’s own psychotherapy: Patient and clinician perspectives. Oxford, England: Oxford University Press.

141.

Wunderink

Nieboer

R. M.

Wiersma

Sytema

Nienhuis

F. J.

(2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: Long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry, 70, 913-920. doi:10.1001/jamapsychiatry.2013.19

142.

Yalom

(1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: Basic Books.

143.

Yalom

(2008). Staring at the sun. London, England: Piatkus Books.

144.

Zerubavel

Wright

(2012). The dilemma of the wounded healer. Psychotherapy, 49, 482-491.