Ross 

G. Menzies
Rachel E. Menzies
Genevieve A. Dingle   Editors

Existential
Concerns and
Cognitive-Behavioral
Procedures
An Integrative Approach to Mental
Health
Existential Concerns and Cognitive-Behavioral
Procedures
Ross G. Menzies
Rachel E. Menzies  •  Genevieve A. Dingle
Editors

Existential Concerns
and Cognitive-Behavioral
Procedures
An Integrative Approach to Mental Health
Editors
Ross G. Menzies Rachel E. Menzies
University of Technology Sydney University of Sydney
Ultimo, NSW, Australia Camperdown, NSW, Australia

Genevieve A. Dingle
University of Queensland
St Lucia, QLD, Australia

ISBN 978-3-031-06931-4    ISBN 978-3-031-06932-1 (eBook)

https://doi.org/10.1007/978-3-031-06932-1

© Springer Nature Switzerland AG 2022

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For Helen and Colin, my mother and father,
who gave me the finest chance to build a
life. – RGM
For Lachlan, who has filled my life with
joy. – REM
For my parents Nan and John who taught me
the value of education and about difficult
choices in life. – GAD
About This Book

Clients enter therapy with a range of problems of living. They don’t speak in diag-
nostic terms, but instead focus on the everyday difficulties that confront them. These
difficulties may include isolation, loneliness, anxiety and sadness, guilt and regret,
and problems making decisions in a world that offers seemingly endless choice. In
contrast, the cognitive-behavior therapist is trained in the language of conditioning
and extinction, avoidance and safety behaviors, behavioral activation, and atten-
tional biases. This book explores the ideas of the existentialist philosophers as a
bridge between the suffering client and technically trained clinician. The volume is
not a rejection of cognitive behavior therapy (CBT) but seeks to place CBT in the
broader context of the most popular philosophic tradition of the nineteenth and
twentieth centuries.
The existentialists argued that the individual's starting point in confronting life is
characterized by a sense of disorientation in the face of an apparently meaningless
and absurd world. Further, they proposed that each individual must become solely
responsible for giving meaning to life and living it passionately and authentically.
Each of us must confront the existential issues of death, isolation, identity, freedom,
and meaning and find our solutions to these problems.
The present volume explores each of these existential themes in turn. Each sec-
tion opens with a theoretical chapter describing the relevant existential dilemma and
its impact on human experience. The second chapter in each section explores its
relationship to mental health disorders and psychopathology. The third chapter in
each section explores the evidence for treating the existential issue from a CBT
framework.

Editors

vii
Contents

Part I Introductory Issues


Existentialism and the Problems of Being ����������������������������������������������������    3
Gerard Kuperus
Existentialism and Its Place in Contemporary Cognitive
Behaviour Therapy������������������������������������������������������������������������������������������   13
Michael Worrell

Part II Death
Death Awareness and Terror Management Theory��������������������������������������   35
Ilan Dar-Nimrod

Fears of Death and Their Relationship to Mental Health����������������������������   57
Matteo Zuccala and Rachel E. Menzies

Creative Approaches to Treating the Dread of Death����������������������������������   75
Rachel E. Menzies and David Veale

Part III Isolation

Existential Isolation: Theory, Empirical Findings, and Clinical
Considerations��������������������������������������������������������������������������������������������������   95
Peter J. Helm, Ronald F. Chau, and Jeff Greenberg

Isolation, Loneliness and Mental Health ������������������������������������������������������  115
Isabella Ingram and Peter J. Kelly

Social Prescribing: A Review of the Literature��������������������������������������������  135
Genevieve A. Dingle and Leah S. Sharman

ix
x Contents

Part IV Identity

Identity and the Courage to Be: From Kierkegaard to Covid-19 ��������������  153
Paul Rhodes
Yet You May See the Meaning of Within: The Role of Identity
Concerns and the Self in Psychopathology����������������������������������������������������  167
Ayoub Bouguettaya, Tess Jaeger, and Richard Moulding

Clarifying Identity and the Self in a CBT Context ��������������������������������������  185
Michael Kyrios, Kathina Ali, and Daniel B. Fassnacht

Section IV  Freedom


Freedom, Responsibility and Guilt����������������������������������������������������������������  207
Thomas Heidenreich and Alexander Noyon
Failed Potentialities, Regret and Their Link to Depression
and Related Disorders ������������������������������������������������������������������������������������  223
Ross G. Menzies
Reframing the Past and the Treatment of Existential
Guilt and Regret����������������������������������������������������������������������������������������������  235
Ross G. Menzies

Part VI Meaning
 the Need for Meaning��������������������������������������������������������������������������������  249
On
Gerard Kuperus
Meaninglessness, Depression and Suicidality: A Review
of the Evidence ������������������������������������������������������������������������������������������������  261
Adrian R. Allen
Letting Go, Creating Meaning: The Role of Acceptance
and Commitment Therapy in Helping People Confront
Existential Concerns and Lead a Vital Life ��������������������������������������������������  283
Joseph Ciarrochi, Louise Hayes, Gareth Quinlen, Baljinder Sahdra,
Madeleine Ferrari, and Keong Yap

Index������������������������������������������������������������������������������������������������������������������  303
About the Editors and Contributors

Editors

Ross G. Menzies  completed his undergraduate, master’s, and doctoral degrees in

psychology at the University of NSW. He is currently Professor of Psychology in
the Graduate School of Health, University of Technology Sydney (UTS). In 1991,
he was appointed founding director of the Anxiety Disorders Clinic at the University
of Sydney, a post which he held for over 20 years. He is the past president of the
University of NSW and twice national president of the Australian Association for
Cognitive Behaviour Therapy (AACBT). He is the previous editor of Australia's
national CBT journal, Behaviour Change, and has trained psychologists, psychia-
trists, and allied health workers in CBT around the globe. Professor Menzies is an
active researcher with nearly three decades of continuous funding from national
competitive sources. He currently holds over $AUS7 million in research funding.
He has produced 10 books and more than 200 journal papers and book chapters and
was the president and convenor of the 8th World Congress of Behavioural and
Cognitive Therapies (WCBCT) in Melbourne in 2016. He has recently been
appointed a founding director and treasurer of the newly formed World Confederation
of Cognitive and Behavioural Therapies (WCCBT). Ross lives with his wife and
three youngest children in the inner west of Sydney.

Rachel E. Menzies  is a postdoctoral fellow at the University of Sydney, where she

completed her honors, master’s, and doctoral degrees in psychology. She published
her first paper on death fears in Clinical Psychology Review as an undergraduate
student, and followed this by convening a symposium on the topic at the 8th World
Congress of Behavioural and Cognitive Therapies in Melbourne in 2016. Her
experimental work on fear of death and psychopathology has been published in
several leading journals, and she can regularly be heard on national and interna-
tional radio, popular podcasts, and at relevant public events (e.g., The Festival of
Death and Dying, Adelaide Writers Week). In 2017, she gave her first invited ple-
nary address on death anxiety, and an invited workshop, at the 47th Congress of the

xi
xii Editors

European Association of Behavioural and Cognitive Therapies (EABCT). Since

then, she has published five books on existential issues and completed an invited
workshop tour on the dread of death across seven cities for the Australian Association
for Cognitive Behaviour Therapy (AACBT). In 2021, she won the national PhD
Prize from the Australian Psychological Society for her work of death anxiety and
its relationship with mental health. Rachel lives with her husband and runs a private
practice in the inner city of Sydney.

Genevieve A. Dingle  is an associate professor and director of clinical psychology

programs at the University of Queensland with a research interest in how groups
and communities can influence mental health and well-being. This includes both
formal groups (such as cognitive behavior therapy groups, and therapeutic commu-
nities for alcohol and other drug treatment) as well as arts-based groups such as
choirs and creative writing groups. Genevieve worked for over a decade as a clinical
psychologist in hospitals and private practice. She is the editor of the jour-
nal  Behaviour Change  and serves on the executive of the  Australian Music and
Psychology Society and the Arts Health Network (QLD), and convenes the interdis-
ciplinary UQ Music, Dance & Health research group. She is one of five authors of
Routledge’s text, The New Psychology of Health: Unlocking the Social Cure, that
was awarded the British Psychological Society Book of the Year Award in
2020. Genevieve lives in Brisbane with her husband and two daughters.
Contributors

Kathina Ali  Flinders University, Adelaide, SA, Australia

Adrian Allen  University of New South Wales, Sydney, NSW, Australia
Ayoub Bouguettaya  University of Birmingham, Birmingham, UK
Ronald F. Chau  The University of Arizona, Tucson, AZ, USA
Joseph Ciarrochi  Australian Catholic University, Sydney, Australia
Ilan Dar-Nimrod  The University of Sydney, Sydney, NSW, Australia
Genevieve A. Dingle  The University of Queensland, Brisbane, QLD, Australia
Dan Fassnacht  Flinders University, Adelaide, SA, Australia
Madeleine Ferrari  Australian Catholic University, Sydney, Australia
Jeff Greenberg  The University of Arizona, Tucson, AZ, USA
Louise Hayes  University of Melbourne, Melbourne, VIC, Australia
Thomas Heidenreich  Esslingen am Neckar, Germany
Peter J. Helm  The University of Arizona, Tuscon, AZ, USA
Isabella Ingram  University of Wollongong, Wollongong, NSW, Australia
Tess Jaeger  Deakin University, Melbourne, VIC, Australia
Peter J. Kelly  University of Wollongong, Wollongong, NSW, Australia
Gerard Kuperis  University of San Francisco, San Francisco, CA, USA
Michael Kyrios  Flinders University, Adelaide, SA, Australia
Rachel E. Menzies  The University of Sydney, Sydney, NSW, Australia
Ross G. Menzies  University of Technology Sydney, Sydney, NSW, Australia
Richard Moulding  The Cairnmillar Institute, Melbourne, VIC, Australia
Alexander Noyon  Hochschule Mannheim, Mannheim, Germany

xiii
xiv Contributors

Gareth Quinlen  Australian Catholic University, Sydney, NSW, Australia

Paul Rhodes  The University of Sydney, Sydney, NSW, Australia
Baljinder K. Sahdra  Australian Catholic University, Sydney, NSW, Australia
Leah S. Sharman  The University of Queensland, Brisbane, QLD, Australia
David Veale  Kings College London, London, UK
Michael Worrell  NHS Trust, London, UK
Keong Yap  Australian Catholic University, Sydney, NSW, Australia
Matteo Zuccala  The University of Sydney, Sydney, NSW, Australia
 Part I
Introductory Issues
Existentialism and the Problems of Being

Gerard Kuperus

Abstract  This introductory chapter discusses the philosophical movement of exis-

tentialism particularly by looking at the issue of human existence or being. The fact
that nothing is given beyond our being, that everything is up to us, is not merely a
situation of freedom but in fact, as Sartre (Essays in existentialism. Carol Publication
Group, Secaucus, 1999) points out, quite distressing. The chapter discusses mainly
Nietzsche, Sartre, Heidegger, and Jaspers while also taking up some important
reflection from Tolstoy. Our being is marked by what lies at the peripheries of our
existence, such as death as well as others. We are then determined by what we are
not, and it is the challenge of existentialism for us to relate to the world in an
authentic way.

Keywords  Nietzsche · Sartre · Heidegger · Jaspers · Tolstoy · Existentialism ·

Death · Authenticity · Atheism · Truth

1 Introduction

This introductory chapter to this volume takes up some of the main theoretical
approaches in the philosophical movement that is known as existentialism. Needless
to say, this is a selection of thinkers and by no means a complete summary. The
purpose of this chapter is to indeed introduce existentialism as it is most relevant for
this volume. The focus is existential thinking about the problems around our exis-
tence – the problems of being – and how different existentialists have dealt with the
ethical, social, and ontological issues around the idea that we are thrown into a
world without any absolute meaning, value, or truth besides the one’s we humans
have created. I take up in particular Nietzsche, Sartre, Heidegger, and Jaspers, sup-
plemented by some reflections on Tolstoy’s The Death of Ivan Ilyich. In particular,

G. Kuperus (*)
Philosophy Department, University of San Francisco, San Francisco, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 3

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_1
4 G. Kuperus

I take up the issues around the strong sense of freedom and responsibility our being
brings with it, as well as issues at the border of our being, both the limits or our
existence and others. Both Heidegger (1962) and Jaspers (1963, 1971) discuss this
as being in the world in which the self – as being (or “being there,” Dasein) – is
determined through its relationship to what it is (seemingly) not. In order to grasp
this move to understand ourselves through the borders or limits of our being, I will
first discuss Nietzsche’s discussion of truth and his challenge of dualistic thinking
that has determined the tradition of Western philosophy.

2 Truth as an Illness

The history of existentialism can arguably start with Arthur Schopenhauer

(1788–1860), who had a tremendous influence on Friedrich Nietzsche (1844–1900),
most of all through his claim that life has no meaning. To grasp the importance and
radical nature of the insight of nihilism, it has to be located historically, both within
society and the philosophical tradition of the West. Indeed, that these ideas were
radical might be missed if we fail to consider that the history of Western philosophy
is one that emphasized and searched for objective truth. From Plato (who famously
suggested that the shadows that we take to be reality are cast by a true reality, a
divine absolute truth consisting of forms) to Descartes (who found the true founda-
tion for all the sciences in the form of cogito, ergo sum), there has been a dominant
story that truth exists and that reason and the control of the intellect can guide us to
truth. With both Plato and Descartes, we also find the dualism of mind and body. For
Plato, it was the soul (psyche) that continues to live after the body dies, while for
Descartes, it is the mind that is absolutely independent of the body (see further
Lawhead, 2005, and Skirbekk, 2001). With his famous cogito, ergo sum, he first and
foremost determined us as a thinking thing. Existentialists were not the first philoso-
phers to challenge this history running roughly from Plato to Descartes. Already in
ancient Greece, we can find different voices, such as Heraclitus (see Curd &
McKirahan, 2011) who thinks in non-dualistic and often contradictory thoughts:
Famously, we find that we can and cannot step in the same river twice. In fact,
Nietzsche (1994) argues that the history of philosophy has often suppressed these
theories that do not fit into Plato’s narrative (see also Swift, 2005). He mentions in
this regard in particular the philosophy of Democritus. Dominant philosophers such
as Plato ordered his books to be burned, Nietzsche suggests. While his theory in this
regard often sounds like a conspiracy, the more important point is that the history of
Western philosophy is one that has been seeking truth and does so on the strict basis
of dualistic thinking. Dualistic thinking is limited insofar as it creates oppositions
such as truth and falsity, good and bad, good and evil, mind and body, and human
and animal that are always used in conjunction, one providing meaning to the other.
Against this backdrop of a search for truth and certainty, it is indeed a radical
break when Nietzsche (following Schopenhauer) exclaims that there is no truth and
that this search for truth is a sign of our weakness and illness. These claims emerge
Existentialism and the Problems of Being 5

in a time that can be characterized through a loss of power (political, philosophical,

scientific, and ethical) of the church. Nietzsche (2001) writes about “the madman”
who still believes in God. Of course, his society was still largely Christian, but at
that time, the church had already lost its political power. The church had mostly lost
the battle with science (although Darwin in the Origins of Species never explicitly
mentions humans as descending from apes), while the philosophical and, in particu-
lar, the ethical powers were still strong. It is, it turns out then, easier to revolt against
political systems and scientific beliefs than it is to revolt against philosophical ideas
and moral values. It is the latter two that are utterly personal as they get to the core
of who we are and what we should and should not do.
Yet Nietzsche (2001) wanted to dismantle these last strongholds of the church.
We are living a herdlike existence, he argued, failing to think for ourselves, failing
to think about values, let alone create our own values. This is not easy since we feel
that we need purpose and meaning in the world. Thus, he argues, we utilize truth
and values as a crutch. And that is exactly our problem. Within this context,
Nietzsche makes this remarkable statement about philosophy: “all philosophizing
up to now was not about ‘truth’ but about something else, let us say about health,
future, growth, power, life” (Nietzsche, 2001, p. 2). Philosophers may have seemed
to have argued and written about truth, but in fact, it was all about them. They
expressed themselves and used their writing as a means to generate some truth to
support themselves, as some medication against their inability to accept there is no
truth. Nietzsche explicitly does not want to create truths, and instead, he writes in a
personal way to express the idea that all truth is a personal perspective, a meaning.
What is particularly interesting is that while for many the discovery of a loss of
purpose and meaning can present a crisis, Nietzsche argues that the believe in a God
and in purpose, value, and truth is the true crisis. Nietzsche writes from a perspec-
tive in which he regards himself as a philosophical doctor examining the human
race. His self-imposed nickname, “the philosopher with the hammer,” does in that
regard not only refer to a destructive move but also to the medical instrument.
Nietzsche, however, does not provide a cure but rather a diagnosis of the problem
that plagues humanity. By confronting the issue of depending upon objective truths,
Nietzsche directs us to separate from the herd and famously “to become who you
are” (cp. Nietzsche, 2001).
In short, Nietzsche (2001) tells us we are sick, he provides us with a diagnosis,
and then he tells us to cure ourselves by becoming who we are. With the latter, he
indicates the need to escape from the herd mentality, in which we are not ourselves.
Nevertheless, as mentioned above, Nietzsche’s thought emerges in a period of time
when religion was challenged. Today, we can relate the herd mentality to our mass
behavior in terms of consumption, fashion, politics, and mass culture. For Nietzsche,
it mostly relates to the Christian morality, a morality that is not our own, but pro-
vided to us through a long history in which concepts such as good and evil were
generated in reactionary processes. As argued in On the Genealogy of Morality, the
term “bad” was initially used for the poor, unschooled, and uncultured (Nietzsche,
1968). To be “good” meant to be wealthy, educated, cultured, “clean,” and powerful.
The term “evil” was introduced by the Jews who used the term for their oppressors.
6 G. Kuperus

To be “good” as opposed to evil was now determined as being oppressed and not
having power.
It is certainly easy to misinterpret Nietzsche (1968) here, as it has invited anti-­
Semitic readings, but his point is really that what it means to be good has changed
historically and is by no means absolute. Moreover, he wants us to question the very
idea that being good is associated with being in a position of oppression and power-
lessness. Both the morals of “good and bad” and “good and evil” lack authenticity.
What it means to be good is in both cases determined through its opposite. Both are
reactionary. Although one might argue that Nietzsche here appears to emphasize
power and thus open the door to tyranny and oppression, such interpretations would
again miss the point. Seeing weakness itself as an indication of one’s goodness
leads to subordination while we should overcome oppression. We can only do so by
overcoming ourselves, i.e., the selves that are not truly selves.
There is, Nietzsche (1968) implies, something very comforting about being in a
position of oppression. In a sense, we seem to be afraid of our power. This is exactly
the point Jean-Paul Sartre makes when he suggests that we are afraid of our own
freedom. Everything we do and who we become is entirely up to us, he argues
(Sartre, 1999). The only thing we did not choose is the fact that we exist. Sartre’s
partner, Simone de Beauvoir, provides a somewhat critical note to this as women (or
woman) find themselves in a situation that is not as free as that of their male coun-
terparts. She is already determined as “the other” and her place, especially in 1949
when she published the Second Sex, is that of the housewife and mother. Nevertheless,
De Beauvoir (1968) embraces Sartre’s existentialist ethics that suggests we are
responsible for who we are. She herself lived this ethics by not following the norms
already given by society. She did become herself by not marrying, by not having
children, and by pursuing a career as a writer. With that, she not only created herself,
but she also challenged the gender norms that constrained women during this time
and created a new model that others could follow.
Sartre (1999) emphasizes that freedom is not necessarily a gift. We are actually
constantly afraid of our own freedom and the need to make choices. We do, gener-
ally speaking, not like to make choices since each time we do, we are responsible
for the consequences. Many of my students experience anxiety over their careers
and the multiple choices they are faced with. Especially in their senior year, students
are confronted with this as the choices seem unlimited. In the university, they could
choose from a limited number of majors and courses offered that had to fit their
schedule. After college, anything seems possible.
Sartre not only emphasizes that we are responsible for ourselves but also for
everyone else as he writes, “If I want to marry, to have children; even if this mar-
riage depends solely on my own circumstances or passion or wish, I am involving
all of humanity in monogamy and not merely myself” (Sartre, 1999, p. 294). If I
choose to marry, I am choosing the institution of marriage and am responsible for
the implications that are part of that institution. Sartre continues: “I am responsible
for myself and everyone else. I am creating a certain image of man of my own
choosing. In choosing myself, I chose man” (ibid). I am not just making a personal
choice; I am choosing what humanity should look like. This might sound rather
Existentialism and the Problems of Being 7

radical in today’s world in which freedom is often determined as having virtually no

limitations, with the only exception that one’s actions should not harm others, at
least directly. The language of “rights” addresses this. Sartre chooses a very differ-
ent approach, largely influenced by Immanuel Kant, in suggesting that in choosing
myself, I choose everyone else. My course of action should be the most desirable
action in this particular situation. If I as a heterosexual male fall in love with a
woman and I decide to marry, I should wish everyone else did exactly the same.
Here, we find the power of Sartre’s philosophy: I am free, and thus I can choose not
to marry for a variety of reasons. Maybe I don’t want to reinforce certain structures,
such as those that limit marriage to heterosexual couples. Maybe I take issue with
marriage creating certain expectations, such as reproduction or gender roles. Or
maybe I wish to seek other forms of living that are not determined by forces exter-
nal to me.
Here, we thus see the difficulties and the pressure that existentialist freedom cre-
ates. As Sartre states, it is “very distressing that God does not exist” (ibid. 296).
Following a pattern that already lays out what man is – or should be – is comforting.
Instead, as commanded by Nietzsche (2001), we are told to not follow the herd and
to create our own existence. Thus, we are “condemned to be free” (ibid.). Even
more, Sartre’s notion of freedom as responsibility is a reaction to the violence that
occurred in the Second World War. It is also within this context that he states that I
am responsible for the actions of others, including the violence that occurs around
me. While there was some resistance, people in France and the rest of Europe were
largely standing by as violence occurred around them. In a world without absolute
values, anything is possible, yet that does not mean we should let it happen. In
today’s society, that means that if we do not stop the deportation of undocumented
people, the separation of children from their parents at the border, the lack of health
care, or even homes for people, we are also responsible. There is an obvious truth to
this also in a democracy: We should not blame so much the right-wing xenophobic
politicians but rather those who vote for these leaders and those that enable them to
perpetuate unjust structures. Yet Sartre’s claim lies beyond that: We should not let
violence and injustice occur around us. We have a responsibility to stop it and pro-
tect the victims even if it means we would have to pay with our own lives.
If we think we are powerless, Sartre (1999) would accuse us of bad faith and
quietism. The latter is “the attitude of people who say ‘let others do what I can’t do.’
The doctrine I am presenting is the very opposite of quietism since it declares ‘there
is no reality except in action’” (ibid. 300). Indeed, Sartre’s philosophy can be seen
as a philosophy of action in which I should act instead of making up excuses. As De
Beauvoir points out, our situation might seem as one that lacks power, yet that does
not release us from the duty to fight that very situation. Thus, our existence, or
being, is determined entirely by ourselves: Power lies in how we choose to live our
lives. There is no blueprint, no design, except for what I make of myself. Thus,
Sartre argues that the human being is entirely what one makes of oneself. In order
to do so, we need to lead a life of involvement and not just let things happen.
8 G. Kuperus

3 Being-in-the-World

As Sartre (1999) notes, the only thing we did not choose about our existence is the
very fact that we exist. Martin Heidegger (1962) phrases this as being thrown into
the world or, in “Heideggerian,” “thrownness.” Different than Sartre, he emphasizes
time or temporality. The meaning of being, for Heidegger, is time, i.e., we are tem-
porarily here. Based on Kierkegaard’s description of dread, he provides a descrip-
tion of the experience of anxiety (Angst), which is, as he writes, not a fear for
something in particular but rather the confrontation with nothing or the nothingness
that lies beyond our existence.1 We are born, we live, and then we die. Without the
promise of an afterlife, this “being-toward-death” is a confrontation with our fini-
tude and an experience of anxiety. It is, even more, a fundamental experience or
rather a “fundamental attunement” (Grundstimmung). We are, so to speak, getting
in tune here with our ground, and that ground is nothing. In other words, the con-
frontation with the lack of a beyond attunes us to our being as temporal.
Human beings engage in all kinds of ways that keep us from this confrontation.
We are entertained or entertain ourselves with our gadgets, television, adventures,
travel, and so forth. Heidegger describes, in fact, how the experience of boredom
can lead us to a fundamental attunement similar to the experience of our mortality.
In 1992, the Disposable Heroes of Hiphoprisy sang “Television, The Drug of the
Nation.” Today, our smartphones and computers connected to streams of social
media and (mis)information have become part of our being and body. We have
become a hybrid of human and technology. The latter is, indeed, increasingly deter-
mining our being. If these are indeed drugs, we have to ask the question: What ill-
ness are these drugs used against? Of course, drugs and relying on them can
themselves become a disease, but why are we attracted to drugs in the first place?
We all know that a walk through a city or a hike in the forest is going to be a much
more positive experience than flipping through screen after screen on Facebook,
Instagram, or Twitter. Yet the fact that we chose the latter is an indication of a prob-
lem. In fact, almost a century ago, Heidegger (1962) saw similar issues in the way
urban lives, driven by technology, constituted a new form of living in which gossip-
ing and a general business are determining our relationship to the world. We are not
ourselves; we are inauthentic beings, Heidegger suggests. Only in certain moments,
such as in the attunement of being-toward-death and boredom, do we experience
ourselves, our being. Technology, one could say, assures that we never find a
moment of boredom in which we are forced to reflect on our being. The choices we
have to make are easy ones and often binary: watching show x or y, clicking “like”

1
 It might seem that Søren Kierkegaard (1813–1855) would also have influenced Nietzsche, but no
evidence exists that Nietzsche read his work (which was not translated into German at the time).
Because of this language barrier, the influence of Kierkegaard is only occurring much later through
thinkers such as Heidegger. Kierkegaard also represents a break with many of the other existential-
ists since he still held on to a Christian faith.
Existentialism and the Problems of Being 9

or “dislike,” and “thumps up” or “thumps down.” In fact, it keeps us from becoming
who we are.
Fundamental attunements can be intimidating. The realization that I am going to
die is not a fact I want to think about nonstop. It seems that today, as in Heidegger’s
time, we are entertained nonstop in order to distract ourselves from ourselves, i.e.,
from our being. We are fleeing away from ourselves, from boredom or the anxiety
over our finitude, in which we are confronted with our very being as a being that is
free. This is, thus, a way to think about the attraction to television, social media,
gossip about celebrities (or our neighbors), and endless streams of (mis)information.
Yet ultimately, it is not death but living that provides the biggest challenge. As
we have already seen, Jean-Paul Sartre (1999) emphasizes responsibility as the ulti-
mate consequence of freedom and the idea that anything is possible. For Sartre,
following Nietzsche, no absolute values exist. We can and have to create our own
values, Nietzsche tells, followed by Sartre’s exclamation that we are fully respon-
sible for ourselves and everyone else. Now, that is more intimidating than the
knowledge that I am going to die. We like to blame others, the government, men or
women, millennials, etc. When it comes to ourselves, we blame our circumstances
and situation. Although it is important to recognize that we do not all have equal
opportunities, it is a tricky issue since we can easily fall into bad faith. Not falling
into bad faith is a true challenge; however, since without anything or anyone to
blame now, everything is our own responsibility. Thus, when Nietzsche (2001) tells
us to live our life as if we want to live it over and over again, or when Heidegger
(1962) says that through a fundamental attunement we can recognize the signifi-
cance of our being and thus make the most out of it, or when Sartre says you are
fully responsible, this is where we find the true demand of existentialism. There is
no greater meaning to being than what we make of it.
For existentialism, the challenge becomes to live a life that is authentic or one’s
own. It would, however, be a mistake to exclude external forces. According to
Heidegger, we are “being-in-the-world.” The dashes have a significant meaning
here: for a human being to be means to be in the world. “World” is my world insofar
as it is constituted by all the entities that I encounter. Yet those entities and the others
I encounter in the world also constitute an otherness or something alien.
This encounter with an alien part of my being is provided particular attention by
Karl Jaspers, an existential thinker who started out as a psychiatrist and turned to
philosophy. As such, he provides an existential understanding of psychotherapy (see
Schlimme, 2013, p. 150). As a philosopher, I will stay away from any clinical impli-
cations and focus on the philosophical concepts. Nevertheless, as should be clear
throughout this chapter, the implications of existentialism can have severe impacts
on mental health, both in a positive and negative way.
One thought that is consistently expressed by Jaspers is that while psychiatry as
a science works with larger structures, it is important to see the patient as a person,
a unique individual, formed by a certain constitution (Anlage) and one’s environ-
ment or milieu (cp. Jaspers, 1963). Yet he also emphasizes that we are free beings:
When speaking about one’s worldview (Weltanschauung), he is particularly think-
ing about our religious and/or philosophical ideas. Even while we often think those
10 G. Kuperus

are fixed, it can be in constant flux (cp. Schlimme, 2013, p. 157). Indeed, as such,
we are much more free than we assume, or as Sartre would say, we are much more
free than we are willing to accept.
About truth, Jaspers writes that “even the existence of truth in itself can become
doubtful” (Jaspers, 1963, p. 42). We encounter different conflicting truths, we have
rejected absolute truths and possibly even all truth, and we can even speak of
“pseudo truths.” Thus, “the question of truth is one of the dizzying questions of
philosophizing” (Jaspers, 1963, p. 43). Specifically within the context of existential-
ism, Jaspers defines the issue of truth then in terms of boundaries (a “border situa-
tion” or Grenzsituation), where my existence and some other existence can come
into conflict. One of those potential conflicts is our relationship to death – a conflict
between our existence and nonexistence. Death is a part or our being, yet it is diffi-
cult to accept it as such. The same is true for other aspects of our own being that we
tend to place at the border of our existence, for example, suffering, fight, contin-
gency, and guilt. As all existentialists, Jaspers (1971) emphasizes the limit of our
existence as a defining moment of it. Accepting these situations at the limits as part
of our being is one of the major challenges we are facing as individuals.
In Philosophy of Existence, Jaspers defines the central issue of existentialism,
paraphrasing Kierkegaard, as follows: “everything essentially real is for me only by
virtue of the fact that I am I myself. We do not merely exist; rather, our existence is
entrusted to us as the arena and the body for the realization of our origin” (Jaspers,
1971, p. 22). Existence is a given and that is not the issue, to realize it in the best
possible way, in a world that provides no absolute truths; this is indeed the chal-
lenge. For Jaspers, one can either fall into nothingness, “the bottomlessness of the
infinite (Jaspers, 1963, p. 39), or I can give myself to myself and “sense the fullness
of the encompassing” (ibid. 40). The term “the encompassing” refers to being itself,
this eluding entity that “always seems to recede from us, in the very manifestation
of all the appearances we encounter […] it is the source from which all new hori-
zons emerge, without itself ever being visible, even as a horizon” (ibid. 1963, p. 40).
Being or “the encompassing” is what has to accompany all that exists, including us.
It is our origin yet invisible and ungraspable. Thus, what I am “always remains a
question” (Ibid. 45).
Although the influence between Heidegger and Jaspers is a lot more complex
than I can even start to discuss in these pages, we can find similarities in the sense
that both thinkers emphasize being as elusive and both regard mortality as a consti-
tutive aspect of our being. Heidegger (1962) ultimately suggests that the meaning of
being is temporality. We have a beginning and end, and it is that end, death, which
is essential to our being. Both Jaspers (1963, 1971) and Heidegger (1962) empha-
size the difficulty to accept death as a part of ourselves. Heidegger describes how we
are fleeing away in “the they” and describes the experience of our finitude in terms
of anxiety. Jaspers discusses the difficulty to accept death as part of our being within
the context of psychiatry. As one of the “border situations,” death is at the limit of
my being, some other existence, or rather nonexistence.
Existentialism and the Problems of Being 11

4 Conclusion

Our existence, or to be as a human being, is full of challenges and relationships with

otherness and alien forces. One of the central ways in which I have approached that
issue has been through an engagement with the question, What death means in an
existential way? A good illustration can be found in Tolstoy’s novella The Death of
Ivan Ilyich. After falling while hanging curtains in his new home, the main character
first experiences some discomfort, then falls ill, and eventually dies. The process is
an extended and painful one. Ilyich cannot tolerate his family or other people,
except for Gerasim, the family’s young butler, who shows compassion and does not
fear death. As it becomes clear that he is dying and Ilyich is confronted with his
mortality, the pain and agony eventually subside.
With, on the one hand, the agony of Ilyich and, on the other hand, the calmness
of Gerasim, it becomes clear to the reader that it is not a physical illness that is tor-
menting Ilyich. It is regret about his life: the psychological burden of not having
lived the life that he would have wanted. His death is a confrontation with the fact
that he has not truly lived: He has waisted away his life in a loveless marriage, and
he has worked his way up the social ladder. He has not lived his own life; he has
lived a life determined by external forces. Life and work might be without meaning,
but he has failed to create a life of his own, an authentic life. A famous line from the
book sums it up perfectly: Ilyich’s life has been “most simple and most ordinary and
therefore most terrible” (Tolstoy, 2004, p. 43). When one is facing death, the most
terrifying aspect is not death but life. The realization that one has not lived an
extraordinary life comes when it is too late, when he cannot do anything about it.
Tolstoy, Nietzsche, Heidegger, Jaspers, and Sartre all provide important insight
regarding the responsibility we face as humans to create our own lives. It is easy to
not choose, to let things happen, as is the case with Ilyich. Heidegger (1962) and
Jaspers (1963) suggest that we have to let a confrontation with our mortality occur,
not at the end but earlier in life. This can guide us in living our lives fully. In a
slightly different way, Sartre (1999) emphasizes that we are fully responsible for all
our choices. We cannot blame others or find other excuses to not act. Nietzsche
(2001) even sees our whole society as a construction in which we are herd animals
and in which a slave morality actually encourages us to be in a position of the
oppressed, a victim of powerful circumstances. In the ethics of “good and evil,”
good is determined exactly as being subordinate, and this kind of ethics has, accord-
ing to Nietzsche, let to the demise and sickness of our society.
What Nietzsche, as an atheist, saw coming is that with the death of God, people
will have to confront the reality that this life is all there. By giving up on the promise
of a reward in the afterlife, all attention turns to living or life itself.
When the attention turns to life itself in which anything is possible, we are pre-
sented with absolute freedom. This is what we should want, yet we flee away from
it. We try to be like someone else, perhaps some celebrity, and we all end up being
like everyone else. Nietzsche (2001) describes this as the herd mentality and
Heidegger (1962) as “the they” (das Man), and Sartre (1999) emphasizes that we
12 G. Kuperus

are afraid of our own freedom as we fall into patterns of “bad faith.” We try to con-
vince ourselves that things are not up to us even while we deep down know better.
We can change our lives but, as Ivan Ilyich discovers, not at the very end when it is
too late.
To be, to exist in an existential sense means to be free and thus to be responsible
for my being as well as that of others. We exist as “being-in-the-world,” and we
constantly encounter border situations in which some apparent alien force turns out
to be a part of our existence. It is in these encounters with other human beings, the
world, or death that we have to find a way toward an authentic existence. This is the
challenge existentialism presents to us.

References

Curd, P., & McKirahan, R. D. (2011). A Presocratics reader: Selected fragments and testimonia.
Hackett.
De Beauvoir, S. (1968). The second sex. Modern Library.
Heidegger, M. (1962). Being and time. Harper Collins.
Jaspers, K. (1963). General psychopathology. University of Chicago Press.
Jaspers, K. (1971). Philosophy of existence. University of Pennsylvania Press.
Lawhead, W. F. (2005). The philosophical journey: An interactive approach. McGraw-Hill.
Nietzsche, F. W. (1968). On the genealogy of morals. Modern Library.
Nietzsche, F. W. (1994). Frühe Schriften. Deutscher Taschenbuch Verlag.
Nietzsche, F. W. (2001). The gay science. Cambridge University Press.
Sartre, J.-P. (1999). Essays in existentialism. Carol Publication Group.
Schlimme, J. E. (2013). An existential understanding of psychotherapy and psychiatric practice.
Psychopathology, 46(5), 355–362.
Skirbekk, G. (2001). A history of Western thought: From ancient Greece to the twentieth century.
Routledge.
Swift, P. (2005). Becoming Nietzsche: Early reflections on Democritus, Schopenhauer, and Kant.
Lexington Books.
Tolstoy, L. (2004). The death of Ivan Ilych. Bantam.
Existentialism and Its Place
in Contemporary Cognitive Behaviour
Therapy

Michael Worrell

Abstract  This chapter explores the place that ‘existential thinking’ may hold in
contemporary Cognitive Behaviour Therapy (CBT). It is proposed that a wide range
of CBT models can usefully explore a range of existential themes such as death,
meaninglessness, isolation and freedom. At the same time, it is suggested that a
more in-depth consideration of central propositions of existential phenomenology
challenges many of the assumptions and therapeutic practices of CBT. Central to
this is the existential-phenomenological emphasis on ‘relatedness’, which puts into
question the unclarified Cartesian philosophy implicit in much CBT. The chapter
also discusses how key insights of existential phenomenology may be explored in
the training of CBT therapists via phenomenologically based experiential exercises.

Keywords  Existential phenomenology · Existential givens · Phenomenology ·

CBT · ‘Relatedness’

In anxiety one feels ‘uncanny’ Here the peculiar indefiniteness of that which Dasein finds
itself alongside in anxiety, comes proximally to expression ‘the nothing and the nowhere’.
But here ‘uncanniness’ also means ‘not-being-at-home’. (Heidegger, 1962, p. 233)

1 CBT and Existentialism: An Uncanny Relationship?

Can existentialism, or existential thinking (a broader term I use to encompass exis-

tential philosophy as well as existential therapy), be said to have a ‘home’ in con-
temporary CBT? Or is it more accurate to suggest that CBT has, as one of its original
homes, existential philosophy? For some, the juxtaposition of CBT and existential
thinking may itself appear ‘uncanny’ and disorienting as they represent fundamen-
tally different and opposed ways of understanding human experience and psycho-
logical distress. Much of course depends upon how one defines and delineates the
nature of ‘existentialism’ and ‘CBT’. Both of these terms are in their own ways

M. Worrell (*)
Central and North West London Foundation NHS Trust, London, UK
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 13

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_2
14 M. Worrell

contested and unclear. Can it be said that CBT exists? It is often noted that CBT is
in fact not a unitary school unless a stance is taken to limit the definition of CBT to
include only a set range of perspectives, research projects, commitments and
practices.
Salkovskis (2002), surveying the development of the field, defined CBT as ‘a set
of empirically grounded interventions’. This definition would initially seem to
imply that CBT is essentially a set of ‘tools’ that are ready to hand and are primarily
to be thought about in terms of whether they are good tools, appropriate for some
tasks and not others, depending also on the skilfulness of the person wielding the
tool. This would also seem to indicate that the foundation stone for CBT therapists
is the empirical method itself (which is of course also in need of clarification and by
no means anywhere a settled issue). So, for example, even if CBT therapists may
adopt different positions regarding the direct causal role of cognition in psychopa-
thology, they would nevertheless agree on how such questions should be approached
through the experimental method. However, CBT as a whole does not endorse the
idea that it can be defined principally in terms of techniques and the extent to which
they are empirically supported. Beck et  al. (1979), Clark (1995) and Salkovskis
(2002) have strongly argued that it is not possible to define Cognitive Behavioural
Therapy simply in terms of its technical interventions. Rather, a wide range of inter-
ventions can be employed to the extent that these interventions make sense in terms
of the CBT model. That is, it is the conceptual and theoretical aspects of the cogni-
tive behavioural model, which remain contested and subject to debate, that define it.
It follows from this that any consideration of the relationship between existentialism
and CBT cannot simply be at the level of techniques, as in ‘are there technical pro-
cedures that may be employed to address existential issues in CBT’ (although this
is of course not irrelevant). The relationship between CBT and existentialism must
also be explored at a conceptual, theoretical and indeed philosophical level.
And what of existential philosophy and existential psychotherapy? As the previ-
ous chapter demonstrated, while ‘existentialism’ is clearly identifiable as one of the
most important and influential philosophical movements of the twentieth century,
its defining features and key arguments have always been subject to heated division,
debate and revision (Cooper, 1999). Indeed, if one were to imagine all the key exis-
tential thinkers were able to meet together in one place, a café perhaps, to discuss
their thinking, most likely, the one thing that they would each agree on is that all the
others present in the room have substantially misunderstood and misrepresented the
views being presented.
CBT therapists, seeking to gain inspiration or guidance from existential philoso-
phy, also need to contend with the fact that there are already a substantial number of
‘existential psychotherapies’ (Cooper, 2003). These have ranged from approaches
that have worked out the therapeutic implications arising from the work of a single
philosopher, such as the work of Medard Boss who developed ‘Daseinsanalysis’
with the direct collaboration of Martin Heidegger (Boss, 1963) to those approaches
that draw inspiration from a diverse range of existential philosophers (see, for
example, van Deurzen et al., 2019). It is also the case that existential philosophy has
had considerable impact across a diverse range of psychotherapies. This includes a
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 15

wide range of humanistic psychotherapies and existential-humanistic psychothera-

pies (Schneider, 2008), as well as forms of psychoanalysis that have attempted to
rework fundamental psychoanalytic ideas such as the unconscious and transference
through the lens of existential philosophy (Stolorow et al., 2002). All of these forms
of inspiration and integration are themselves subject to controversy and critique.
Currently, there exists no widely held agreement as to what constitutes an appropri-
ate or indeed ‘authentic’ application, or thinking through of the implications, of
existential philosophy for therapeutic practice.

2 Existential Issues Versus

Existential-Phenomenological Thinking

The most straightforward and accessible discussion of existential philosophy and its
relevance to and place in CBT would be one that highlights a range of ‘existential
issues’ and topics and explores how CBT therapists, and CBT as a model, might
incorporate or address these issues. In this regard, the work of Yalom (1980) is
highly useful in that he has identified four such ‘fundamental existential concerns’
and clearly demonstrates how a wide range of clinical and experimental evidence
supports the role of these concerns in different forms of psychological distress as
well as the practice of therapy. The four existential issues that Yalom identifies are
death, meaninglessness, isolation and freedom. Each of these themes and concerns
can indeed be found in a range of existential philosophies. Equally, as potential
‘transdiagnostic’ issues, each of these themes lends themselves quite readily to a
range of CBT conceptualisations and interventions. ‘Death’, for example, or at least
‘fear of death’ and ‘death anxiety’ can be a legitimate focus for CBT and may sub-
stantially enrich CBT practice. There is in fact a very substantial range of empirical
literature to support the notion that concerns around death feature very heavily in
differing forms of psychopathology and that there may be CBT-specific forms of
intervention that can usefully address this (see Menzies et al., 2018, as well as chap-
ters in the present volume). Equally of course, these concerns lend themselves to
forms of analysis and interventions arising from a wide range of different theoreti-
cal perspectives including the humanistic and psychoanalytic. Issues around death,
and indeed the hypothesis of a ‘death drive’, are featured prominently in
Psychoanalysis (Freud, 1920/2003).
Arguably, taking such a ‘thematic’ focus to existential issues, while legitimate
and potentially highly productive, constitutes only the most superficial engagement
with existential thinking. Why might this be so? While Yalom’s (1980) discussion is
original, engaging and useful, it remains the case that there are a wide range of other
existential issues and concerns that can be presented as equally primary but have
somehow not made it onto this list of ‘the big four’. To identify an issue or concern
as being ‘existential’ is to suggest that this issue is in some way rooted in, and an
expression of, some fundamental ‘given’ aspect of what it means to be human. The
16 M. Worrell

issue is somehow essential, unavoidable and constitutive of human existence itself.

Without it, human existence would not be what it is. Additionally, and unfashion-
ably, to identify an issue or factor as existential is to argue that this is in some way
universal and that it finds expression and can be discerned cross-culturally and
across time.

3 Identifying the ‘Existentials’

The range of relevant existential ‘givens’ can in fact be seen to be quite wide, and
what should and should not be included in any such description is a subject for
debate. Medard Boss (1963), for example, based upon the work of Martin Heidegger,
has argued that our ‘dreaming existence’ is a fundamental aspect of what it is to be
a human being. In a manner that CBT therapists may initially find difficult to appre-
ciate, Boss describes our experience of dreaming as in a sense ‘equal’ to, although
different from, our waking existence. To be human, for Boss, is to live in dreaming
and to be in the world through and as dreaming. Additionally, Boss (1963) discusses
how human existence is always fundamentally an embodied existence. Embodiment,
existence through ‘being-a-body’, is so fundamental that it is difficult to appreciate
the emphasis on death awareness and death anxiety other than through an apprecia-
tion of the fundamentally embodied nature of human existence. In addition, drawing
on Heidegger, Boss argues that human existence is always characterised by some
‘mood’. Human beings are said to be ‘attuned’ to the world via mood as an ‘atmo-
sphere’ that, rather than being seen as simply the outcome of cognitive processing,
is fundamental to the way human existence reveals the world itself. The most fun-
damental of moods for existential philosophers is that of anxiety. Existential anxiety
is in this sense basic to human existence, and we are anxiety. Existential anxiety
reveals human existence as always ‘open’, ‘unfinished’ and as always a being-­
towards-­death (Heidegger, 1962). Additionally, human existence is seen as inevita-
bly always ‘guilty’. Rather than this indicating some form of moral lapse or sin,
existential guilt refers to the fact that, as limited beings, we are always already
‘behind’ our possibilities for being. Any choice we make, and we are always inevi-
tably making such choices, involves an implicit or explicit ‘no’ and letting go of
other known and unknown possibilities for being.
A further addition to this list of ‘existential givens’ is suggested by the existen-
tial therapist Hans Cohn (2002) who has convincingly argued that sexuality is
fundamental to human existence. Sexuality is existential in the sense that each
human being responds to and takes up a stance towards the ‘possibilities of being
sexual’ and that this stance is an expression of their manner of relating to self, oth-
ers and world. Existential sexuality is a primary means of relating to and revealing
a world.
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 17

4 Existential Uncertainty

Spinelli (2015), in his original take on existential psychotherapy, has suggested that
one of the most central existential concerns, or rather ‘principles’ to arise from
existential-phenomenological philosophy, is that of ‘uncertainty’. This emphasis on
‘principles’ is important as it suggests that many of the themes and dimensions
discussed above will also be seen to be expressions of and to include a ‘reference
to’ such principles. Existential guilt, for example, can only be fully understood to
the extent that this expresses a response to, and is revealing of, existential uncer-
tainty. According to Spinelli (2015), the principle of existential uncertainty
asserts that:
I can never fully determine with complete and final certainty or control not only what will
present itself as a stimulus to my experience, but also how I will experience and respond to
stimuli. An immediate consequence of this stance is that even how I will experience myself
under differing stimulus conditions cannot be predetermined. (2015, p.  22, emphasis in
original)

At the same time, the principle of uncertainty is also contextualised by the fact that
human existence is always, using Heidegger’s language ‘thrown’, that is, that human
beings ‘always already’ find themselves in a context and situations over which they
exert little control and yet must in some way respond to. Such contextual givens
such as racism, inequality and the vagaries of a global pandemic provide the back-
ground conditions from within which the principle of uncertainty arises. The prin-
ciple of uncertainty in existential phenomenology also reveals itself to be paradoxical
in that any statement such as ‘all is uncertain’ reveals itself as a statement of cer-
tainty (Spinelli, 2015). Thus, rather than a fixed position of the certainty of uncer-
tainty, existential phenomenology challenges us to consider the uncertainty of
certainty and the uncertainty of uncertainty. In regard to the latter possibility, this
would, for example, encourage a CBT therapist to consider each new instance of ‘a
client presenting with panic attacks and thus appropriate for treatment X with man-
ual Y’ as potentially novel, unpredictable and uncertain. The manual need not nec-
essarily be thrown away as an inauthentic expression of certainty, but rather, the
question becomes, What new uncertainties may be revealed by the attempt to under-
stand how the manual and model both throws light upon and obscures the client’s
experience of problems in living that have been described as ‘panic attacks’?
Recently, CBT therapists who have turned their attention to the task of identify-
ing ‘transdiagnostic factors’ have argued that ‘intolerance for uncertainty’ is poten-
tially one of the most significant factors implicated in a range of different forms of
psychological distress. McEvoy and Erceg-Hurn (2016) have argued that intoler-
ance for uncertainty may constitute both an important transdiagnostic factor and a
‘trans-therapy’ factor. That is, intolerance for uncertainty may be a key factor that is
altered by a range of differing therapies even when this is not an explicit target of
those therapies. As such, they consider it to be a potential ‘universal process’.
18 M. Worrell

5 Existential Relatedness

As Spinelli (2015) has argued, possibly the most foundational principle of existen-
tial phenomenology is the principle of ‘existential relatedness’. This is also, unfor-
tunately, the principle that is the most difficult to grasp and keep hold of due to the
extent to which it challenges typical Western assumptions that can most certainly be
seen to be present in most forms of psychological practice including CBT. Martin
Heidegger’s (1962) expression ‘being-in-the-world’ attempted to express this fun-
damental relational nature of human existence. This is also elaborated as ‘Dasein’,
which describes the nature of human being as ‘being-there’ or alternatively ‘the
“there” where being reveals itself’. Unfortunately, despite the use of hyphens that
are intended to express the extent to which being and world are a unitary phenom-
enon, it can be so easy to read this expression as indicating the existence of two
separate aspects ‘being’ and ‘world’ that somehow enter into or create a
relationship.
In much psychology, based as it is on a ‘Cartesian’ perspective that separates
subject from object and ‘inner’ from ‘outer’, and certainly in much CBT, there are
a range of apparent ‘splits’. Consider the distinctions between cognition and behav-
iour or cognition and emotion or indeed between ‘situation’ and ‘response’. Related
distinctions can be identified in terms of body and mind, self and other, and ‘cogni-
tive representation’ and ‘outer reality’. The existential-phenomenological principle
of relatedness can be seen to challenge each of these apparent separatist distinctions
and to instead propose that while we may indeed experience and report upon seem-
ingly more isolated phenomena such as ‘my self’, ‘my freedom’, ‘my body’ and so
forth, each of these more subjectively grounded descriptions in fact emerge from a
more foundational relatedness. It is more existentially adequate to speak of ‘body-­
mind’ and ‘lifeworld’. Thus, issues and dilemmas such as ‘freedom’ and ‘choice’
cannot be adequately considered from the more typical individualistic and separatist
position or must at least be considered as highly limiting.
A typical misunderstanding of existential thinking is that it emphasises the pri-
macy of the ‘lone individual’, isolated in their own inner emotional experience,
condemned to create their own individual and unique life project in the face of the
absurdities of existence. Such a view can of course be found but must be contextu-
alised within a more thoroughly relational perspective. In such a perspective, the
experience of an individual unique self is seen as an outcome of relatedness, and
each existential choice can be seen as implicating others and the world and as hav-
ing unpredictable and uncertain consequences for others and the world. Thus
Yalom’s (1980) emphasis on isolation could be more adequately understood as a
polarity with ‘being-with-others’ on one end and ‘isolation’ on the other. The fol-
lowing quote from Merleau-Ponty serves well to express this central principle of
relatedness:
True reflection presents me to myself not as idle and inaccessible subjectivity, but as iden-
tical with my presence in the world as to others, as I am now realising it: I am all that I
see, I am an intersubjective field, not despite my body and historical situation, but, on the
contrary, by being this body and this situation, and through them, all the rest. (As quoted in
Friedman, 1964, p. 201)
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 19

The principle of existential relatedness can be seen as having many radical conse-
quences for the practice of therapy, and any consideration of the place of existential
thinking in CBT needs to grapple with such consequences. Existential thinking,
therefore, is not identifiable by its specific focus on themes such as death, meaning,
isolation and freedom, but rather, that such concerns are explored in terms of their
grounding in relatedness.

6 The ‘Way’ of Existential Thinking: Phenomenology

In the sections above, I have attempted to show that while it is a valid undertaking
to identify and explore a range of existential issues such as death, meaninglessness,
isolation and freedom, there is nothing uniquely existential about any exploration
that considers these themes. I have also briefly shown that each of these themes
needs to be more thoroughly contextualised within the existential-­phenomenological
notions of relatedness and uncertainty. Prior to considering what place such ideas
might have in CBT, it is also necessary to briefly consider the particular method and
stance that existential thinkers such as Heidegger, Sartre and Merleau-Ponty adopted
in order to approach such issues. This concerns the philosophy and method of
‘phenomenology’.
Phenomenology can be considered primarily as a way of doing philosophy rather
than a set and agreed-upon philosophical system. It is a practice and a way of explor-
ing and describing experience. The term ‘phenomena’ is understood as ‘that which
appears’, and as such, phenomenology becomes the exploration and description of
‘what appears in the way that it appears’ (Moran, 2000).
Spinelli (2015) has described the phenomenological method in terms of three
overlapping and interdependent phases or steps. A phenomenological investigation
of any phenomena, such as the experience of ‘being anxious’, or ‘being depressed
about the economy’, involves the following interdependent overlapping steps:
1. The phenomenological reduction: Here, the researcher, philosopher or thera-
pist is required to identify and to make an attempt to set aside any p­ reconceptions,
personal biases or theoretically based views regarding the nature of the phenom-
ena under investigation. This includes hypotheses about causal factors involved
in its generation or maintenance. This step is often regarded as the most chal-
lenging aspect of the method as frequently, assumptions and preconceptions
remain unreflected upon. The task of the reduction remains an attempt at intro-
ducing an unusual degree of experiential openness to whatever arises, not unlike
some descriptions of mindfulness. In therapy, this step requires of the therapist a
willingness to set aside any notions of being a ‘change agent’ or ‘educator’ in
favour of a stance that attempts to ‘stay with’ the lived experience of the client as
it reveals itself in the immediacy of the therapeutic conversation. If there is
something that can be said to express a degree of ‘competence’ here, it is this
very willingness and ability to stay present and open to the client’s experience as
20 M. Worrell

well as the experience of the therapist as they attempt this unusual form of
intense listening, seeing and sensing.
2. The rule of description: The second step can be summarised as ‘describe don’t
explain’. The therapist or investigator is encouraged to attempt a descriptive
clarification of the phenomena under investigation: How is ‘being anxious’ expe-
rienced? What does it entail? How is this experienced bodily and within the
world? Again, these descriptions should be as free of ‘causal scientific hypothe-
ses’ as possible.
3 . The rule of ‘equalisation’: In this final step, the investigator or therapist is
required to avoid placing any ‘hierarchies of significance’ on the descriptions
that were obtained. Thus, a client’s reports of a sense of ‘feeling small and insig-
nificant’ or ‘like my heart will explode’ or that ‘the space between my door and
the stairs seems infinite and uncrossable’ are each regarded as potentially equal
in their meaningfulness and relationship to the phenomena of being anxious.
The descriptive phenomenological method presents itself as a clear alternative to
the typical hypothesis testing approach of CBT whose intent is often to construct a
causal model to explain the development and maintenance of a psychological prob-
lem. Nevertheless, a number of CBT-oriented researchers have seen in the phenom-
enological method a useful tool that has potential in the training of CBT therapists,
particularly in regard to all frequent temptation to ‘jump to conclusions’ regarding
the nature of a client’s difficulties (O’Conner, 2015).
In summary, it has been argued above that existential thinking and existential
phenomenology present CBT therapists with a significantly expanded and deepened
description of ‘what it means to be human’. It raises issues such as death, meaning-
lessness, isolation and freedom but does so in a novel way that seeks to highlight the
irreducibly relational and contextual basis of human experience and existence.
Existential thinkers have argued that such issues are best approached from a phe-
nomenological perspective, and this perspective is one that makes unique demands
on the therapist or investigator, which in large part rest upon the willingness to ‘let
go of’ much of the theoretically derived assumptions regarding ‘what it means to be
a therapist’. In what way can these ideas and perspectives have any place within a
CBT that presents itself as the project of developing a scientific understanding of
human distress and the practice of therapy? In the sections that follow, I outline a
variety of ways in which different versions of CBT have both points of contact as
well as points of divergence with some of the existential principles and methods
described above.

7 Standard ‘Beckian’ CBT and Existential Thinking

One does not need to dig too deep in order to find clear evidence of a place for exis-
tential thinking in what might be regarded as ‘standard’ Beckian CBT. In what
might be regarded as the foundational CBT text, Beck and his colleagues
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 21

acknowledge the influence of the existential and phenomenological philosophies of

Heidegger and Husserl as well as the contributions of the phenomenological studies
of Jaspers, Binswanger and Strauss (Beck et al., 1979). More recently, Clark et al.
(1999) have stated that the philosophical perspective that most clearly is in tune
with and captures the central concerns of CBT is existential phenomenology. Moss
(1992), writing from a more traditional existential therapy perspective, has argued
that Beck and other cognitive therapists have effectively given a greater degree of
respectability and legitimacy to existential ideas and have succeeded in ‘smuggling’
insights from existential phenomenology into the respectable halls of academia via
the ‘back door’.
A strong case can be made that Beck and his colleagues are correct when they
seek to characterise CBT as being consistent with existential phenomenology. The
focus on forms of meaning that are in principle directly accessible by the therapist
and client alike, as opposed to an emphasis upon the role of the therapist as ‘inter-
preter’ of the client’s statements in terms of hypothesised ‘underlying’ or ‘uncon-
scious’ factors, provides a clear point of contact between CBT and existential
psychology. Beck’s description of a cognitive triad of self-world-future also seems
consistent with a range of existentially derived analyses regarding the centrality of
meaning. Beck’s description of the process of ‘guided discovery’ could also be
interpreted as a form of structured phenomenological exploration. Therapist ques-
tions that arise from a guided discovery standpoint are those that ‘stay close’ to the
client’s experience but may direct their attention to aspects of this experience that
they are not currently attending to in order to widen the client’s perspective. If
Beck’s cognitive therapy is presented as a framework for the therapeutic exploration
of meaning, it could also be easily argued that many of the thematic focus points of
existential phenomenology, death, isolation, freedom, choice and meaning, are a
legitimate topic for CBT therapists to the extent that these themes present them-
selves in clinical work. Indeed, the recent contributions of ‘experimental existential
psychology’ (Greenberg et al., 2004) that have presented quantitative data that sup-
port the hypothesised role of ‘death anxiety and defences’, for example, may pro-
vide substantial support for CBT therapists to consider the role of these
existential themes.
In addition, the so-called ‘disorder-specific’ models of CBT that have focussed
on identifying the specific cognitive content and processes maintaining specific dif-
ficulties can also be read as highly informative, phenomenologically rich and clini-
cally helpful analyses of the manner in which the clients presenting problems are in
fact best thought of as their ‘attempted solutions’ to universally experienced aspects
of existence such as anxiety.
The work of Robert Leahy (2015), which represents a further elaboration of an
essentially Beckian CBT perspective, has drawn explicitly on existential philosophy
and has sought to highlight the more ‘tragic’ aspects of existence as well as the need
for competent CBT therapists to develop the capacity to ‘stay with’ expressions of
distress that arise from encounters with inevitable aspects of existence, such as
death and loss, rather than attempting to ‘reconstruct’ the client’s cognitions.
22 M. Worrell

Drawing directly on the philosophies of Heidegger and Sartre, Leahy sug-

gests that:
individuals struggle with their freedom of choice, often having difficulty with the “given”
that is arbitrarily part of their everyday lives, while recognising that the choices people face
often involve dilemmas or tradeoffs that are emotionally difficult. Choice, freedom, regret,
and even dread, are viewed as essential components of life in this model, and these “reali-
ties” cannot simply be eliminated by cost-benefit analysis, rationalization, or pragmatism.
(2015, p. 10)

At the same time, however, there remain significant points of difference and poten-
tial conflict. Most significant is the reliance of standard Beckian CBT that can be
described as a ‘correspondence theory of truth’ based upon assumptions of the sep-
arateness of cognition, emotion, behaviour and world (no matter how closely
entwined and interactional these elements are regarded as being). The correspon-
dence theory of truth holds that the truth of a client’s cognitive representations,
which are in some way ‘internal’ and separate from the world, can be evaluated in
terms of the degree to which they correspond with the way the world ‘really is’.
That CBT, in its standard version, can be seen to embrace both a ‘rationalist’ stance,
and a correspondence theory of truth can be clearly seen in the following quote that
is from an article whose explicit purpose is to clarify perceived misconceptions
regarding the CBT model:
Standard cognitive therapy is a structured, time-limited, problem-oriented psychotherapy
aimed at modifying the faulty information processing activities evident in psychological
disorders like depression... The therapist and patient collaborate to identify distorted
cognitions, which are derived from maladaptive beliefs or assumptions. These cognitions
and beliefs are subjected to logical analysis and empirical hypothesis testing which leads
individuals to realign their thinking with reality. (Clark, 1995, p. 155)

Existential phenomenology, with its emphasis on the inherently relational nature of

human existence, challenges the model of truth implicit in the above quotation.
With it, the possibility of a therapist identifying and challenging distortions or errors
in thinking is challenged as is the assumption that therapeutic encounters are pri-
marily to be seen as forms of ‘treatment’ for identified psychological ‘disorders’. As
noted above, the phenomenologically based perspective of existential thought sug-
gests that therapists are more likely to gain a more adequate understanding of a
client’s experience to the extent that they are able, initially at least, to ‘set aside’
notions of treatment or psychoeducation.

8 Schema Therapy: Working with the ‘Depths’ of Meaning

While the concept of ‘schema’ features clearly in standard CBT, the use of this
concept has been considerably expanded by Young et  al. (2003) and others who
have developed ‘schema-focussed’ approaches that seek to understand client dis-
tress and change in terms of ‘deep’ cognitive structures that are often, in their con-
tent, clearly related to and expressive of fundamental existential issues.
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 23

Young et al. (2003) argues that traditional CBT assumes that clients will be able
to directly change distorted cognitions and unhelpful behaviour through rational-­
logical strategies such as empirical analysis, logical discourse, gradual behavioural
exposure tasks and experimentation. Young et al. (2003) argue that for many clients,
this is not the case and that their distorted cognitions and behavioural patterns are
highly resistant to change even after months of sustained intervention. Young et al.
argue that for many such clients, their distorted cognitions and unhelpful behaviours
are ego-syntonic, that is, they are experienced as central to the client’s identity and
that ‘to give them up can seem like a form of death- a death of part of the self’
(2003, p. 4). This understanding of the uncertainty and potential losses associated
with meaningful cognitive change is very much in tune with the perspective of exis-
tential phenomenology where individual’s ‘world views’, their beliefs, explicit and
implicit are seen as in many ways expressive of efforts to cope with the given exis-
tence and to provide a degree of predictability and certainty in the face of inevitable
uncertainty.
Young et al. (2003) has also suggested that the origin of schemas lies in the frus-
tration of a number of core emotional needs in childhood. Such needs are seen by
Young et al. (2003) as ‘universal’ aspects of human experience and development.
These needs include:
1. Secure relationship attachments that provide safety, stability, nurturance and
acceptance
2. Autonomy and sense of competence and individual identity
3. Freedom to express valid needs and emotions
4. Spontaneity and play
5. Realistic limits and self-control
Young et al. (2003) regard ‘schema healing’ as the ultimate goal of schema therapy.
The process of schema healing, however, is seen as long and often arduous. They
argue that individual will often resist the process of schema change as:
Patients resist giving up schemas because the schemas are central to their sense of identity.
It is disruptive to give up a schema. The whole world tilts. In this light, resistance to therapy
is a form of self-presentation, an attempt to hold onto a sense of control and inner c­ oherence.
To give up a schema is to relinquish knowledge of who one is and what the world is like.
(2003, p. 32)

A number of features of the schema approaches seem to allow for a greater degree
of appreciation for existential issues in a broadly CBT perspective. The focus on
‘deeper’ levels of meaning would appear to open up the possibility of working with
more existential aspects of meaning and experience. Ottens and Hanna (1998) have
argued for an integration of cognitive and existential perspectives on the basis of
this shared, focused-upon meaning at a schematic level. These authors argue that
many of the schemas identified by CBT theorists are inherently ‘existentially con-
stituted’ as they refer to basic fundamental aspects of a client’s identity, essence and
validity in the world. Indeed, it may be possible to identify explicitly existential
schemas such as ‘my existence is wrong or should not be’, ‘my existence is a burden
24 M. Worrell

and is damaging to others’ and ‘my existence is vulnerable and not real’. Schema
therapy also seems to express a greater appreciation for the dilemmas and chal-
lenges of change that is in tune with existential thinking. Any potential movement
towards changing a schema, while it may open up greater and more positive possi-
bilities, is also unpredictable in its implications. This perspective on change, that
change is often a question of trade-offs and ‘workability’ rather than ‘rational
correspondence with reality’, is also of central concern to those versions of CBT
that have described themselves as ‘constructivist’.

9 Constructivist and ‘Post-rational’ CBT

A key concern for a range of ‘constructivist’ approaches is the question of ‘episte-

mology’ that is ‘how we come to know what we know’. These approaches have
tended to contrast themselves with what they regard as the more ‘objectivist’ and
‘rationalist’ approach of standard CBT. In the so-called objectivist approach, knowl-
edge is regarded as ‘representation’ of an external world and where such representa-
tions can be tested as to their degree of accuracy. By contrast, the constructivist sees
knowledge as a product of social construction, negotiation and co-construction.
Lincoln and Hoffman (2018) have suggested that existential phenomenology and
constructivism converge on taking seriously the philosophical and epistemological
basis of therapy and psychological theory. Additionally, they can both be under-
stood as challenges to the limits of modernism in psychological theory and practice
and emphasise multiple ‘ways of knowing’ and the extent to which personal and
cultural assumptions may condition and constrain knowing and action.
A diverse range of ‘narrative’, ‘constructivist’ and postmodern approaches to
CBT have been proposed that on the whole have not greatly influenced the main-
stream of CBT practitioners but that nevertheless represent important developments.
Social constructivism as a philosophy has had a wide-ranging influence over differ-
ing psychotherapies and academic disciplines. In some respects, it represents a
development of certain strands of existential phenomenology. Important theorists
who have attempted to develop a more constructivist version of CBT include
Guidano (1991) and Mahoney (2003).
Guidano (1991) explicitly contrasts what he regards as a ‘post-rationalist’ cognitive
therapy with rationalist (standard) CBT that he positions as inevitably being
focussed upon ‘control’:
the therapeutic relationship established in rationalist and objectivist psychotherapy cannot
become other than an instrument- a more or less authoritarian instrument- for the reestab-
lishment of a rational, realistic, and otherwise socially dictated order. (Guidano,
1991, p. 100)

Guidano argues that for the constructivist, rationality is inherently relativistic. There
is no ‘God’s-eye view’ from which a therapist is in a position to judge the irrational-
ity or otherwise of a client’s thoughts. Guidano’s post-rationalist cognitive therapy
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 25

focusses upon the gaps and incongruities that inevitably exist between the individu-
al’s ongoing, embedded, acting, experiencing ‘I’ and their sense of self that continu-
ally emerges from abstractly self-referencing this ongoing experience—the
observing and appraising ‘me’ (alternatively phrased as the self as subject ‘I’ versus
the self as object ‘me’). Guidano emphasises that the experiencing I is always ahead
of and not equivalent to the reflecting Me. Guidano draws upon attachment theory
as a resource to help theorise the difficulties and distortions that arise in the ability
of the reflecting Me to adequately capture the experiencing I. ‘Normal functioning’
is regarded as being equivalent to a personal meaning organisation that is capable of
evolving towards greater complexity via assimilation of contradictions in experi-
ence and construction. In psychotherapy, the experience of emotion is regarded as
central in promoting reorganisation of self-constructs and emotion schemas.
Key to Guidano’s (1991) constructivist perspective is an understanding of the
nature of resistance to change as being essentially about the inherent need for indi-
viduals to maintain the coherence and stability of their current meaning construc-
tions. Those constructions that are more ‘core’ to the sense of self are highly
resistant to change, and as such, resistance is seen as essentially expressive, self-­
protective efforts at maintaining coherence and identity rather than expressing poor
motivation or non-compliance.
Mahoney’s (2003) version of constructivist psychotherapy also focusses on
‘deep’ tacit core-organising principles and uses a wide range of strategies to assist
clients in increasing their awareness of these. He describes strategies such as the
‘life review’ that focuses on the elaboration of a life narrative as well as ‘mirror
time’, which is a mindfulness-based intervention involving the client being able to
become aware of and stay with emotions, memories and thoughts that arise as they
view their own face in a mirror for a specified period of time.
Key to the therapeutic application of these constructivist principles is a prefer-
ence for a more unstructured therapeutic process, a lessened focus on highly speci-
fied treatment targets and a focus on the therapeutic relationship and the accessing
and exploration of emotional embodied experience as key processes of change
(Mahoney, 2003). Additionally, in contrast to an attempt at the identification and
‘correction’ of cognitive distortions, these approaches advance what they refer to as
an ‘almost reverential’ appreciation for clients’ meaning-making processes.
As with many apparent polarities, the contrast between so-called objectivist and
rationalist CBT and constructivist CBT may be much less stark as many have pro-
posed. In fact, standard CBT appears to contain many elements that fit more easily
within a constructivist perspective than a rationalist one. Consider, for example,
strategies to alter ‘rules for living’. Seldom is this done via appeal to logic alone.
Most often, this is addressed through an open dialogue regarding the possibilities
and limitations of any change in such ways of being. This consideration of the pros
and cons of change and the recognition that change may at times lead to unexpected,
unpredicted consequences is a feature embraced by both standard CBT as well as
existential and constructivist thinking. The constructivist strand of CBT has on the
whole had a limited impact, and the most recent elaboration of the standard CBT
model by Beck and Haigh (2014) has incorporated a much greater focus on
26 M. Worrell

constructivist aspects while still maintaining an overall rationalist perspectives. It

appears that the pragmatic and clinically focussed CBT is capable of embracing and
living with the apparent contradiction between these two philosophical polarities.
By far the most interesting development, in terms of potential for contact with exis-
tential themes, within the family of CBT therapies has been the development of a
range of ‘third-wave’ CBT therapies. These approaches are often characterised by a
renewed interest in the philosophical underpinnings of the approach. Possibly the
most important of these approaches, in terms of existential issues, is Acceptance
and Commitment Therapy or ACT, to which we now turn.

10 Acceptance and Commitment Therapy:

An Existential CBT?

Of all approaches, ACT possibly comes closest to constituting an ‘existential CBT’.

At the same time, as will be discussed below, there remain significant points of
disagreement and difference that should not be glossed over or ignored.
According to Yalom (1980), existential psychotherapy may not constitute a spe-
cific school of therapy at all and that what it represents is more of an attitude or
position towards the nature of psychological suffering and the process of therapy.
This basic existential attitude contends that human difficulties are expressions of
individuals attempt at responding to the nature of existence itself. Hence, psycho-
logical disturbance and distress is to some degree inevitable and unavoidable. Most
human difficulties are thus issues ‘to be lived’ as opposed to ‘problems to be solved’
in any final sense. Existential thinking can be said to embrace what the philosopher
Miguel De Unamuno (1954) has referred to as a ‘tragic sense of life’. This contrasts
clearly with the apparent optimism of much CBT that sees the possibility of ‘a
CBT’ for most human difficulties. ACT, on the other hand, appears to embrace a
much more existentially attuned tragic sense of life. Hayes et al. (1999), in their
original presentation of ACT, distinguish between what they refer to as the ‘assump-
tion of healthy normality’ and the assumption of ‘destructive normality’. Hayes
et al. (1999) argue that the ‘psychological mainstream’ (including CBT) has adopted
the assumption that the natural state of human existence is one of health and that, by
corollary, the experience of abnormality, in the form of psychological distress, is a
form of disease. That is, the common assumption amongst clients as well as thera-
pists is ‘I am meant to be happy, and if not, there is something wrong that can and
should be fixed’. ACT, by contrast, asserts that psychological distress and difficulty
are inevitable aspects of human existence principally due to the manner in which
language works and the extent to which we become ‘entangled’ with language.
While the connection between ACT and existential phenomenology may seem to
be most obvious in regard to the ACT emphasis on issues of mindful acceptance and
‘values’, the connection actually runs much deeper and ultimately arises from the
fact that ACT represents an evolution of a radical behavioural approach that can be
traced to the work of Skinner.
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 27

Numerous authors have highlighted points of convergence between Skinner’s

version of behaviourism and existential phenomenology. Principally, this is due to
the fact that Skinner proposed a more contextual and less mechanistic science of
behaviour. Kvale and Greness (1990), for example, have pointed to some surprising
points of convergence between the psychology of Skinner and the existential phi-
losophy of Sartre. This convergence rests upon the rejection of the Cartesian notion
of the a ‘dual world’—an inner world of thoughts and emotions versus an outer
world consisting of environmental stimuli. Two quotes from the respective authors
seem to point towards an essential agreement on the notion that behaviour should be
understood only in terms of acting-within-context and without recourse to notions
of ‘inner states’ or cognitive representations:
Our “perception” of the world- our “knowledge” of it- is our behaviour with respect to the
world. (Skinner, 1953, p. 90)

The point of view of pure knowledge is contradictory; there is only the point of view of
engaged knowledge. This amounts to saying that knowledge and action are only two
abstract aspects of an original, concrete relation. (Sartre, 1956, p. 30)

Hayes et al. (1999) describe the philosophy of functional contextualism as deriving

from the pragmatism of William James as well as other influences. In contextual-
ism, the basic unit of analysis becomes the ‘act-in-context’ with the hyphens serv-
ing to emphasise that this must be understood in terms of a ‘whole event’ including
its historical and situational context. Parts or elements (such as a specific behaviour
of an individual) are only abstracted in accord with a specific purpose or goal of
analysis. Thus, contextual analyses are viewed as being inherently relational.
Within ACT, ‘truth’ is a matter of pragmatism, and a psychotherapeutic theory is
true to the extent that it is effective in supporting the attainment of its specified
goals. Hayes (2016) asserts that the goals that are chosen by a researcher or a thera-
pist and client together can only be stated and ‘owned’ and that the results of any
particular analysis or therapeutic intervention do not in themselves justify the choice
of that goal. Following Skinner, the stated goal of contextual behavioural science, of
which ACT is an expression, is ‘the prediction and influence of behaviour with pre-
cision scope and depth’ (2016, p. 20). Hayes (2016) acknowledges that ACT, as a
form of functional contextualism, overlaps with other forms of contextualism that
he labels as ‘descriptive contextualisms’. Existential phenomenology is a clear
example of a descriptive contextualism. Descriptive contextualism, while sharing
many core assumptions of functional contextualism, starts from a different goal.
The goal of descriptive contextualism has been stated in terms of the search for
‘understanding’ as opposed to the search for the means to exert influence or achieve
predictive precision.
In the application of a contextual behavioural science approach to psychological
therapy, many further points of contact with existential approaches to therapy can be
seen. ACT proposes that therapy should not principally be focussed on the attempt
at controlling or eliminating unwanted psychological phenomena such as anxiety or
depression. Rather, such efforts at control are seen as themselves as constituting the
28 M. Worrell

main difficulty. ACT suggests that therapy can more effectively be reconfigured to
support clients in clarifying for themselves key values, that is, ‘What do you want
to stand for? What do you want your life to “be about” regardless of whether or not
you continue to experience these distressing phenomena?’ The central aim of ACT
is also described as the effort to support ‘psychological flexibility’, which has been
defined as contacting the present moment fully as a conscious human being and,
based on what the situation affords, changing or persisting in behaviour in the ser-
vice of chosen values (Hayes et al., 1999).
ACT has the potential to renew an interest within CBT regarding issues that are
in essence philosophical. Hayes et al. (1999) argue strongly that it is important for
therapists to be clear on the philosophical assumptions that they are embracing. As
noted above, Hayes (2016) has suggested that such assumptions can be clarified and
owned. Existential phenomenologists, on the other hand, might present the chal-
lenge that such assumptions can also be questioned. From an existential perspective,
the chosen value of moving towards the possibility of ‘prediction and control’
remains problematic to the extent that this value may serve to introduce a significant
degree of bias and distortion in terms of a therapist’s ability to ‘stay with’ phenom-
ena as they reveal themselves. In the conduct of therapy, this may express itself in
terms of a therapists’ attempt to ‘shape’ a client, even if this is done in a flexible and
paradoxical manner, towards a predefined ideal of psychological flexibility. Contrast
the emphasis on prediction and control, in essence a desire to move towards cer-
tainty, with the existential-phenomenological embrace of uncertain certainties and
uncertain uncertainties. The ACT therapist’s frequent use of experiential techniques
of defusion, mindfulness and committed action may run the risk, from an existential-­
phenomenological point of view, of detracting from the therapist’s and client’s abil-
ity and willingness to ‘stay with’ phenomena as and how they reveal themselves in
the therapeutic conversation.

11 Summary: Finding a Place for Existential

Thinking in CBT

The above, admittedly superficial and incomplete, exploration of where existential

thinking may have points of contact and divergence with various forms of CBT has
hopefully demonstrated that there may be interesting and productive points of dia-
logue and debate between these differing perspectives. From an existential perspec-
tive, committed as it is to the embracing of a phenomenological stance, there is a
grave risk that CBT therapists may seek to ‘technologise’ existential issues. Thus,
‘death anxiety’, ‘meaninglessness’, ‘existential choice and responsibility’ and, even
worse, ‘relatedness’ could become just additional variables or factors in an increas-
ing ‘set’ of ‘transdiagnostic issues’ that will attract researchers into devising spe-
cific interventions for their ‘overcoming’, resulting in that most despair and angst
inducing eventuality of the development of ‘yet another manual’. There is of course
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 29

nothing inherently wrong with attempting to explore such existential issues from a
more empirical standpoint. However, the risk is that in doing so, some of the more
disturbing, challenging and demanding aspects of existential thinking is lost.
Cohn (2002) has emphasised a very useful distinction that CBT therapists could
keep in mind. This is the difference and relationship between what has been referred
to as the ‘ontological’ and the ‘ontic’. The ontological refers to aspects of being
itself, essential and fundamental givens of existence. The ontic, on the other hand,
refers to our everyday experience of existing. Cohn, drawing off the work of
Heidegger, emphasises that the ontological can be seen as being included in the
ontic. It does not need to be seen as somehow behind the ontic or causal of the ontic.
Thus, a client who presents with a phobia of snakes, for example, need not be prin-
cipally approached in terms of this ‘all being about the fear of death’. Similarly, a
client presenting with OCD that expresses great difficulties with the issue of respon-
sibility need not be seen as principally struggling with a case of ‘excessive existen-
tial responsibility and guilt’. These clinical presentations should not be seen as
being principally caused by these existential concerns with the notion that delineat-
ing, formulating and designing interventions to more effectively target these exis-
tential dimensions will lead to a better therapeutic result. Instead, if these existential
dimensions are in fact ontological, aspects of existence itself, then they are present
at all times and in all situations. Thus, my writing this paper is itself expressive of
my attempts at responding to both my ‘being-towards-death’—there is a ‘deadline’
for its completion, which I have now missed, and my choice to attempt its comple-
tion also contains within it my stance towards ‘existential responsibility and guilt’;
my choice necessarily entails saying no to other possibilities of being. My award-­
winning novel remains, alas, unwritten.
Existential dimensions of existence cannot be seen as being either pathological
or healthy, and therapists are encouraged instead to remain at an ontic level but with
the possibility of developing ears that are able to discern the presence of existential
dimensions in many clinical presentations, as well as in their own experience as a
thread that at times may be useful to clarify and explore. How might this ‘existential
competence’ be developed? I would suggest that in the training of CBT therapists,
other than didactic explorations of existential literature, principally, this can be sup-
ported by experiential practice exercises that focus on the capacity for ‘deep listen-
ing’ and ‘staying with phenomena as and how they reveal themselves’. Below, I
have outlined several of these exercises in the hope that some may prove enticing
and productive for reflection.

12 Exercises in Phenomenological Listening

The following exercises are offered as possibilities for CBT therapists in training
regardless of their preferred version of CBT. The intention is not to practice these
exercises as forms of ‘skill’ that relate directly to CBT interventions. They are not
opportunities for ‘role play’, and they are not intended as practice runs for how CBT
30 M. Worrell

therapists should work with their clients. Rather, they are designed to allow the pos-
sibility of the therapist in training to ‘gain a sense’ of what phenomenological lis-
tening might be like and what it might be like to allow ‘existential issues’ to present
themselves in the way they present themselves without the need for these to be
‘assessed’, ‘formulated’ or ‘intervened’ with.
In each exercise, there are three ‘positions’, that of therapist, client and observer.
Ideally, each participant takes a time in each role. There is no set time limit for these
exercises, but in general, between 10 and 15  minutes per interaction should be
sufficient.
Exercise 1: ‘Just’ Listening
In this exercise, the ‘client’ is asked to describe a recent experience where they had
some form of emotional experience, be it positive or negative. The client is simply
asked to describe, ‘What was this experience like for you?’ The task of the ‘thera-
pist’ is to remain completely silent throughout and to attempt to listen in a way that
allows them as full a sense as possible of what this experience was like for the client.
No questions or redirections are allowed. At the end of the exercise, each participant
is asked to describe what this experience was like—was it interesting, frustrating,
enjoyable, anxiety provoking, etc.
Exercise 2: Listening to Myself Listening to You
In this exercise, the ‘client’ is again asked to describe in detail a recent experience
where they felt a strong emotion. The ‘therapist’ is again asked to remain silent and
to focus on listening in depth to the client. However, on this occasion, the therapist
is also asked to listen intently to their own experience of attempting to listen to the
client: ‘What is it like to attempt to enter into the experience of the client in the man-
ner that the client has this experience. What images, memories, emotions, body
sensations, etc., arise when this attempt is made?’ Again, after each exercise, each
participant is asked to describe what occurred for them and their reflections
about this.
Exercise 3: Clarification of Embodied Emotional Experience
In this exercise, the therapist is at last allowed to speak! However, their task is to
remain one of attempting to gain as adequate as possible understanding of the cli-
ent’s experience as and how it presents itself. In this exercise, the therapist is permit-
ted to ask for clarifications and further description; however, such clarificatory
questions should be limited to questions that are attempts to gain further descrip-
tions of the clients’ ‘embodied emotional experience’. There should be no attempts
made to identify and separate ‘key cognitions’, nor should there be any attempts to
steer the conversation towards problem solving or towards alternatives that the cli-
ent has not already engaged with. Again, reflection and discussion are invited after
each exercise.
Exercise 4: Existential Observations
This exercise is principally focussed upon the ‘observer’ position. In this exercise,
the therapist and client proceed as above for Exercise 3 (there is a second run of
Exercise 3 with these additional instructions). The observer is asked to listen intently
Existentialism and Its Place in Contemporary Cognitive Behaviour Therapy 31

to both the therapist and client as they are engaged with each other and to also note
their own experience while doing so. In addition, the observer is asked to see if they
can discern the presence of any ‘existential dimensions’ that arise within the dia-
logue. What is it like to simply note the presence of these dimensions in the manner
in which they present without these necessarily being ‘targeted’? Again, reflection
and discussion are invited following the completion of the exercise.

13 Conclusion

This chapter has endeavoured to show how existential thinking and existential
issues ‘show up’ in a variety of forms of CBT. There is no doubt that existential
thinking is fundamentally a different form of human enquiry than the scientific,
evidence-based methodologies favoured by CBT theorists and therapists.
Nevertheless, there are significant points of contact and convergence that are worthy
of further dialogue and debate. It is possible that for CBT to maintain its commit-
ment to an empirical hypothesis testing, problem-solving perspective, the existen-
tial thinking will remain primarily at the level of suggesting a range of themes that
may lead to the identification of important ‘transdiagnostic factors’. Where existen-
tial thinking is engaged with more fully, including an engagement with phenomeno-
logical methods as well as the conclusions and findings of phenomenological
investigations, it remains the case that CBT therapists and theorists are presented
with a rage of highly significant challenges that again raise the old as yet still open
and unresolved question regarding the best way to understand the relationships
between cognition, emotion, behaviour, other ‘selves’ and world.

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Part II
Death
Death Awareness and Terror Management
Theory

Ilan Dar-Nimrod

Abstract  Terror Management Theory (TMT) is the dominant social psychologi-

cal theory examining the relationship between death awareness and human
behaviour. According to TMT, cultural worldviews and self-esteem are thought
to serve an important anxiety-buffering function in order to manage (or ‘tran-
quilise’) existential fear of death. This chapter reviews the evidence for TMT in
a wide array of settings, evaluating empirical support of the fundamental princi-
ples of the theory and for more recent theoretical extensions of the original
account. These review addresses empirical findings that examine cognitive, atti-
tudinal, affective, and behavioural consequences of the awareness of our own
death. It also examines moderators proposed and the potential role of death anxi-
ety in psychopathology. Lastly, competing theoretical accounts offering alterna-
tive explanations for the empirical findings of the role of death awareness on
human behaviour are briefly introduced.

Keywords  Death · Terror Management Theory · Death anxiety · Death awareness

· Mortality salience · Existential psychology · Existentialism · Self-esteem ·
Worldview defence · Psychopathology · Mental illness · Attachment · Materialism
The most painful state of being is remembering the future, particularly the one you’ll never
have. (Søren Kierkegaard)

There are very few recurrent themes among human beings, which emerge
seemingly in every known culture and group, as the concerns about our
mortality does. These concerns have been recorded in numerous modes of
expression. They are visible in ancient forms of arts, such as cave drawings
from the Neolithic period, just as they are on full display in the modern ver-
sions of visual arts, such as paintings, photography, and movies. They
appear in some of the earliest samples of human writings, just as they still
do in the current literature and poetry. They seem to be a central element of
worry and reflection among peoples of antiquity, just as they are in

I. Dar-Nimrod (*)
School of Psychology, University of Sydney, Camperdown, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 35

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_3
36 I. Dar-Nimrod

contemporary Western and non-Western societies. Such longevity and

endurance suggest that death is a phenomenon that is of grave centrality to
the human experience.
Death, of course, is not a uniquely human phenomenon. All biological life forms,
from the lowliest of single-cell organisms, through the different forms of plants and
flora, to the animal kingdom in its various, glorious manifestations, share the experi-
ence of arriving into this world with a (mostly undetermined) expiry date. These
biological life forms all seem to share a basic tendency – to keep death at bay for as
long as possible – commonly referred to as a survival instinct.
One of the main differences between the human experience of death and (to the
best of our understanding) the experience of other earthly life forms revolves around
our ability to think abstractly. As Kierkegaard darkly quips in the quote that leads
this chapter, just as we are able to reflect on our past, we are capable of imagining
our future, and as a part of the inevitable things to come, we are faced with inevita-
bility of our own mortal demise. As such, the combination of the common-to-all-life
forms biologic instinct to protect our continuous existence, on the one hand, and our
species’ unique ability to realise that we will all fall short in this quest sooner or
later, on the other hand, brings about a most pronounced existential angst, which
philosophers (Heidegger, 2014; Kierkegaard, 1849; Sartre, 1956), anthropologists
(e.g., Becker, 1973), and, more recently, psychologists (e.g., Greenberg et al., 1986;
Yalom, 1980) have been attempting to unpack and reflect upon.

1 The Denial of Death

Ernest Becker, a cultural anthropologist, has penned an influential, Pulitzer Prize-­

winning book, which attempts to capture the processes involved in the human reali-
sation that our most basic life goal will eventually be thwarted by the unassailable
fact of the ultimate failing of the flesh. The Denial of Death poetically and painfully
captures the tension between our organismic drive for survival and our abstraction
capabilities, stating:
This is the paradox: he is out of nature and hopelessly in it; he is dual, up in the stars and
yet housed in a heart-pumping, breath-gasping body that once belonged to a fish and still
carries the gill-marks to prove it. His body is a material fleshy casing that is alien to him in
many ways—the strangest and most repugnant way being that it aches and bleeds and will
decay and die. Man is literally split in two: he has an awareness of his own splendid unique-
ness in that he sticks out of nature with a towering majesty, and yet he goes back into the
ground a few feet in order to blindly and dumbly rot and disappear forever. It is a terrifying
dilemma to be in and to have to live with. The lower animals are, of course, spared this
painful contradiction, as they lack a symbolic identity and the self-consciousness that goes
with it. (Becker, 1973, p. 23)

Becker (1973) does not only identify the dilemma faced by the self-conscious
organisms that we are. He also suggests that the same elements that give rise to that
agonising paradox of our existential concerns, namely, our high intelligence and
Death Awareness and Terror Management Theory 37

ability to think abstractly, are also the elements that were utilised to device the
mechanisms to overcome the seemingly futile quest for eternal existence. He identi-
fies mechanisms that he argues to have evolved to allow us to overcome the paraly-
sis that accompanies the realisation of our mortality, arguing, as many before him
did, that religion often offers a portal to transcend the limitations of the flesh.
Religion in his view offers one the opportunities to use our abstract thinking to
imagine and construct a post-mortem life unbound by the imperative of the tempo-
rary biological existence, solving the paradox in its entirety by offering a literal
eternal existence. The Ernest Becker Foundation (n.d.) has published accounts that
delve more specifically into the interplay between Becker’s scholastic syntheses and
different religions, such as Buddhism, Protestantism, and Judaism; these interesting
accounts may be explored here: http://ernestbecker.org/this-­mortal-­life/religion/.
However, whereas many scholars (e.g., Chidester, 1990; Kierkegaard, 1849;
Norenzayan et al., 2009) agree on the general role of religion in addressing existen-
tial concerns, Becker (1973) also identifies additional mechanisms that he argues to
have evolved to address these concerns. He postulates that being part of a society
with (at least perceived) enduring cultural values, mores, norms, and practices
allows one to experience a version of virtual immortality. This process is facilitated
by the Cartesian dualistic sense of mind and matter in which the mind, or our imma-
terial self, is viewed as consisting of those cultural elements, which need not obey
biological disintegration imperatives. He goes even further to suggest that culture,
which he sees as a collective fabrication of commonly held views about reality, has
evolved in the first place to help us deal with our death awareness and the anxi-
ety it brings. As such, one may view the endurance of one’s culture, even after their
own passing, as bringing about symbolic immortality, as they view of their true
selves revolving around this shared understanding of reality, rather than through the
biological limitations of the flesh.
Becker (1973) also recasts earlier psychoanalytic constructs through his primary
focus on our evolved denial of death’s inevitability. One construct of focus, which
he identifies as an evolved adaptation to thwart the paralysis that accompanies
humanity’s death awareness, is self-esteem. Becker argues that viewing oneself as a
central figure in the universe, a narcissistic quest to create a heroic self-image, is
rooted in our quest to deny our own mortality through a grandiose attempt to build
a lasting legacy he terms ‘an immortality project’.

2 Terror Management Theory

Becker’s (1973) understanding of death awareness served as the main inspiration

for the dominant social psychological theory on how death awareness affects our
emotions, beliefs, attitudes, motivation, and, ultimately, behaviours. Three graduate
students from the University of Kansas in the late 1970s, Jeff Greenberg, Tom
Pyszczynski, and Sheldon Solomon, found Becker’s theoretical arguments inspira-
tional and went on a decades-long quest to further extend the conceptual work he
38 I. Dar-Nimrod

originated and garner empirical evidence for the still-growing expansion of our
understanding of the role of death awareness in everyday life.
Terror Management Theory (TMT; e.g., Pyszczynski et al., 1999) offers a dual-­
process model revolving around people’s reactions to death awareness. It draws a
vital distinction between conscious and non-conscious mortality cognitions as the
responses that follow these different modes of death awareness are fundamentally
different (Greenberg et al., 1994; Pyszczynski et al., 1999).
TMT (e.g., Greenberg et  al., 1986) follows Becker’s (1973) argument that
thoughts of one’s own death induce an anxiety (i.e., terror) so consuming that it can
lead to functional paralysis. According to the theory, the immediate response to
these terrifying thoughts is to engender proximal defences. Some of these responses
may prove beneficial as in the case of increased survival-related vigilance, such as
greater actionable plans-related health threats (e.g., Routledge et  al., 2004), and
some that are regularly painted in unfavourable light in the psychological litera-
ture – responses revolving around suppression of the threatening cognitions (Arndt
et al., 1997; Pyszczynski et al., 1999). The motivation behind this active suppression
is to overcome the debilitating horror by distancing oneself from death as much as
possible through vigilance, denial, or distractions. Pyszczynski et al. (1999) argue
that these immediate responses represent a ‘rational, threat-focused (reaction)…
when thoughts of death are in current focal attention’ (p. 835).
In line with this account, and perhaps quite counter to our naïve intuition, there
is little evidence to suggest that the response to actively contemplating one’s own
death (vigilance, denial, and suppression according to TMT accounts) is mediated
by conscious affective experiences. At first blush, it seems reasonable to predict that
mortality thoughts would lead to overt experience of negative affect, such as anxi-
ety. However, most studies that measure self-reported affect following activation of
thoughts about one’s own death find no support for such a prediction, instead show-
ing that whether one thinks about one’s own death or about their favourite television
program, (e.g., Norenzayan et al., 2009), a visit to a dentist (e.g., Menzies & Dar-­
Nimrod, 2017), or even if they were not asked to think about anything in particular
(Rosenblatt et al., 1989), there is no clear indication of different reported affective
experiences, providing support for the suppression prediction. However, one may
wonder if the findings that participants do not tend to report greater anxiety follow-
ing an activation of death thoughts may be indicative of a reporting bias rather than
actual successful suppression. To address this possibility, Rosenblatt et al. (1989)
assessed anxiety or arousal-related physiological responses after activation of death
cognitions to avoid the trap of biased reporting. They found that, similar to the self-­
report results, participants did not significantly differ in their blood pulse rate or
skin conductance as a function of thinking about their own death, compared with
thinking about eating and food, or if they were not instructed to think about any-
thing specific.
Whereas the common immediate response to consciously thinking about one’s
death is suppression, once the thoughts about death are supressed, TMT researchers
argue that they non-consciously linger. To demonstrate this presence of non-­
conscious death awareness, TMT experiments often use a non-obtrusive measure of
Death Awareness and Terror Management Theory 39

death thought accessibility, which takes the form of a word completion task (e.g.,
Dar-Nimrod, 2012; Greenberg et al., 1994). Participants in this task are given a list
of words (e.g., 20) with blank spaces representing missing letters, which they are
required to add so that they end up with an English word. The partial words they see
contain two different intertwined sets: one set that can be completed by either death-­
related words or non-death-related words and a (larger) filler set that can be com-
pleted with only non-death-related words (designed to reduce the chances that this
measure itself will activate death cognitions). The accessibility of death thoughts is
then assessed by summing up the number of word completions that use death-­
related words. For example, a person may see the following partial word ‘G R A _
E’ and complete this task by placing a single letter where one is missing (repre-
sented by the ‘_’). In this case, they may put a ‘P’ (or ‘C’ or ‘D’ or ‘T’…) to create
the word GRAPE (a non-death-related word), or they may put a ‘V’ to create the
word GRAVE (a death-related word). Indeed, in line with the distinction between
proximal (conscious) and distal (non-conscious) death awareness, studies regularly
find increased non-conscious death thoughts accessibility following a mortality
saliance prime (for a review, see Hayes et al., 2010).
The distal death awareness that lingers once the suppression process kicks into
gear has been the focus of the vast majority of the research that has been carried out
under the Terror Management theoretical umbrella. In line with Becker’s (1973)
account, the (original) theory (Greenberg et  al., 1986; Pyszczynski et  al., 1999)
postulates that human beings have evolved to utilise two intertwined psychological
mechanisms to ameliorate the detrimental anxiety that follows the suppression of
conscious death awareness: self-esteem and cultural worldview defence. These
mechanisms provide a buffer against terrifying existential cognitions by eliciting a
sense of symbolic immortality for those who perceive themselves to live up to their
culturally prescribed standards, and as a result, non-conscious accessibility of death
cognitions is reduced.
TMT researchers postulate that self-esteem is ‘a sense of personal value that is
obtained by believing (a) in the validity of one’s cultural worldview and (b) that one
is living up to the standards that are part of that worldview’ (Pyszczynski et  al.,
2004, pp. 436–7). Note, unlike Becker’s (1973) argument that a narcissistic self-­
heroism view of oneself is designed to keep death anxiety at bay, TMT offers a more
palatable description of this mechanism, but they both converge on the perception
that this positive self-view plays a role in attenuating the fears of one’s own ulti-
mate demise.
Embedded in the TMT definition of self-esteem, while also being an independent
mechanism argued to pacify death anxiety, TMT (e.g., Greenberg et  al., 1986;
Pyszczynski et al., 1999; Solomon et al., 1991) suggests that cultural worldviews
serve an important role in our understanding of the effects of death awareness.
Echoing Becker’s (1973) focus on the importance of one’s culture in providing a
sense of symbolic immortality, TMT argues that distal death awareness should lead
us to become more protective of our cultural worldviews in order to attach our sense
of personal existence to a more enduring construct than our own corporal being,
namely, the social structure that surrounds us, with all its glorious (and at times
40 I. Dar-Nimrod

unsavoury) derivatives, such as its symbols, practices, values, and reputation. By far
the most researched element of the theory, different manifestations of the defensive
responses following activation of non-conscious death awareness have been demon-
strated in many empirical studies, as we will explore in greater depth in the follow-
ing sections.
As the theory gained traction in the late 1980s and the 1990s, additional research-
ers have started investigating potential phenomena related to death awareness
through the TMT lens. As part of this growing prominence of the theory, in the late
1990s, an additional mechanism, which functions to ameliorate death anxiety, has
been proposed – the ability to create meaningful, close personal relationships.
Human beings are a social species whose flourishing is closely related to the
evolution of the social skills honed through successive generations for numerous
millennia. Many psychological studies and theories have revolved around under-
standing the different features of our species’ sociality, and an entire subdiscipline
of psychology (i.e., social psychology), as well as full scientific disciplines (e.g.,
sociology, anthropology), emerged to address this central feature of our existence.
In 1998, a pair of Israeli researchers, Victor Florian and Mario Mikulincer, proposed
that one’s ability to create and maintain nourishing personal relationships may also
serve as a protective mechanism from the terrorising thoughts of our mortality.
One central theory in psychology that focuses on a person’s ability to success-
fully maintain rewarding personal relationships is the Attachment Theory. John
Bowlby (1969, 1973), one of the main conceptualisers of Attachment Theory,
argued that early interactions with parents (and, at times, other caregivers) shape the
orientations that influence impending relational functioning in myriads of manners.
One suboptimal orientation encompasses individuals who display anxious attach-
ment, which is characterised by fears of abandonment, rooted in negative views on
the person’s entitlement to be loved, casting long shadows on these individuals’
existing strong desire for closeness and intimacy (Mikulincer & Shaver, 2007).
Another presentation of a challenging attachment style is an avoidant attachment.
The hallmarks of this orientation revolve around avoidance and self-sufficiency that
manifest in common withdrawal from close, intimate relationships (for a review, see
Shaver & Hazan, 1993). On the rewarding side of attachment orientations, or styles,
people with a secure attachment style allow themselves to rely on close others when
they need support, which manifests itself in a sense of security and safety (i.e., ‘a
sense that the world is generally safe’; Mikulincer & Shaver, 2007, p. 21).
Adult attachment styles were found to relate to the regulation of experiences of
distress. Individuals with a secure attachment style regularly report the belief that
they are capable of effectively coping with distress and challenging occurrences
(e.g., Mikulincer & Florian, 1995; Shaver & Hazan, 1993), often through the use of
support from close others. They also tend to avoid protectively twisting their views
of the self, the stressful event, or the world around them (Mikulincer, 1997, 1998).
On the other hand, insecure (avoidant or anxious-ambivalent) individuals seem to
experience heightened levels of distress and lower levels of efficacy beliefs in their
ability to cope with those events, often leading to reporting of distortions in their
views of the self and the world (for a review, see Mikulincer & Florian, 1998). Thus,
Death Awareness and Terror Management Theory 41

attachment styles are involved in response to a wide array of threats that are unre-
lated to death. That said, as the foundation of the TMT is that death awareness
presents a stressful event that lingers in the unconscienced mind, the distress-­
ameliorating features of secure attachment style – shown to apply for varied sorts of
stressors  – have been argued to also reduce defensive reactions identified by the
theory, as it does in those other areas (Mikulincer & Florian, 2000).
The availability of the existential anxiety buffering defence mechanisms, accord-
ing to TMT, allows us to function with relatively ease despite the hypothesised para-
lysing terror, even if, as we will see in the next sections, they may introduce various
personal and societal costs at times. The question that arises, however, is what hap-
pens to individuals who are either inapt in their utilisation of these mechanisms or
otherwise fail to reduce accessibility of death awareness?
Early TMT researchers (Simon et al., 1996) suggested that depression may arise
through individuals’ reduced ability to derive sufficient meaning from their cultural
worldviews to gain a sense of symbolic immortality. Similarly, failure to success-
fully counter paralysing death awareness has been suggested to lead to different
manifestations of anxiety disorders (Strachan et al., 2007). Strachan et al. (2007)
argued that death thought accessibility increases phobic responses among individu-
als with such tendencies (e.g., heighten anxious reactions to spiders among arach-
nophobic individuals). They also suggested that a failure to manage death anxiety
leads individuals with obsessive-compulsive propensities to experience an increased
desire to regain control over their lives, manifesting in exacerbation of their obses-
sive and/or compulsive tendencies. These arguments also resonate with other
researchers who maintained that obsessive-compulsive disorder stems from death
anxiety, highlighting the central role death takes in most presentations of the
obsessive-­compulsive disorder (OCD), such as fear of death due to pathogens that
is central to the compulsive washing subtype or the fear of violent home invasions
that haunt compulsive checking subtype individuals (Menzies et al., 2015).
A sweeping argument has been made by Iverach et al. (2014) on the role of death
awareness in psychopathology. Building on previous research and clinical observa-
tions, these researchers postulate that death anxiety is a central transdiagnostic con-
struct underlying mental health pathology in its entirety. This audacious suggestion
departs from, and subsumes, the common focus on specific psychopathological
manifestations, such as anxiety disorder and depression, as independent phenom-
ena, offering a new conceptualisation of mental illness as a whole. Iverach et al.
(2014) highlights the common clinical observation that individuals who present for
therapy with a specific disorder (e.g., fear of heights) may receive successful treat-
ment for their condition just to later present with a completely different disorder
(e.g., major depression), seemingly unrelated to their first diagnosed condition.
Termed the revolving door of psychopathology, Iverach et al. (2014) suggest that
death anxiety lies at the heart of the individual’s struggle with mental illness, and
thus, even successful treatment for specific manifestations in forms of particular
disorders is insufficient, as the core underlying struggle – coping with death anxi-
ety – is left unaddressed. This provocative argument may also prove to bring about
a significant new direction in reducing the huge personal and societal tolls of mental
42 I. Dar-Nimrod

illness if true as there are indications that cognitive behavioural therapy can be
effective in reducing death anxiety (Menzies et al., 2018b; also, see different voices
and perspectives discussing treatments for death anxiety in Menzies et al.’s, 2018a,
excellent edited volume).

3 Empirical Support for Terror Management Theory

Whereas Becker’s (1973) account is theoretical in its approach, investigators who

contribute to TMT-related research have focused on deriving testable hypotheses
from the theory to assess whether its different tenants stand up to empirical scrutiny.
This experimental approach resulted in a diverse set of studies spanning over
30  years and hundreds upon hundreds of experiments. These studies have taken
place in a large number of countries and cultures, from North America (e.g., Dar-­
Nimrod, 2012), through Europe (e.g., Goncalves Portelinha et  al., 2012) and the
Middle East (e.g., Mikulincer & Florian, 2000), to East Asia (e.g., Heine et  al.,
2002) and Oceania (e.g., Menzies & Dar-Nimrod, 2017). The results of these stud-
ies most often find support for different phenomena explained most clearly through
the TMT perspective, suggesting a seemingly universal psychological process in
line with the sweeping claims made by the theory.
The experimental approach revolves around activation of death awareness and
assessing specific outcomes, processes, moderators, and possible protective or exac-
erbating elements. However, our society in inundated with direct and vicarious
reminders of death. Death is one of the most frequent features in daily activities,
such as news consumption and television watching (e.g., DeSpelder & Strickland,
2002), and as such may be viewed as a chronically accessible theme, rendering any
experimental activation superfluous, as one needs not make accessible what is read-
ily accessible all of the time. However, TMT does not focus on the death construct
in general; instead, the death awareness it discusses revolves around the intersection
of death and self – the awareness of our own personal mortality. As such, not every
mention of death would suit experimental activation needs; instead, researchers
have used myriad ways to lead people to think about their eventual death, such as
the completion of measures designed to assess fear of death and dying (e.g.,
Rosenblatt et al., 1989), television or movie clips, which focus on an individual’s
death through the use of the dying person’s own point of view (Dar-Nimrod, 2012),
presenting video clips containing fatal accident footage (Nelson et al., 1997), and
even proximity to a funeral home (Pyszczynski et al., 1996). Among the different
experimental death awareness activation methods, there is one that has been used
most frequently; this method revolves around asking study’s participants to reflect
on their own death using a writing exercise task. This successful prime (commonly
referred to as the mortality salience prime or MS prime for short) asks the partici-
pant to pen a very short essay in response to the following two questions: (a) ‘Please
briefly describe the emotions that the thought of your own death arouses in you’,
and (b) ‘jot down, as specifically as you can, what you think will happen to you as
Death Awareness and Terror Management Theory 43

you physically die and once you are physically dead’ (e.g., Arndt et  al., 1998,
p. 1218). Armed with appropriate tools to activate death thoughts, we can now look
at various findings that have provided empirical support for TMT.

3.1 Evidence for the Effects of Proximal Reminders of Death

Proximal reminders of one’s own death, according to TMT, lead to suppression and,
thus, are not expected to lead to an increase in the accessibility of death cognitions.
Greenberg et al. (1994) provided support for this claim with evidence that individu-
als who are asked to contemplate their own death showed increased accessibility of
death thoughts only after they engaged in a different task (reading a mundane pas-
sage) after the contemplation. Individuals who completed the death thought acces-
sibility measure immediately after the contemplation did not show a significant
increased accessibility of those thoughts compared with individuals who were asked
to reflect on a favourite television show.
The lack of accessibility of the death construct, however, does not mean that
individuals are not affected at all by reminders of their own death. As one of the
elements that accompanies suppression is denial, Greenberg et al. (2000) demon-
strated that immediately following a death prime, individuals report their own dis-
positional levels of emotional expressiveness differently if they believed (based on
experimentally induced bogus information) that this construct predicts longevity,
such that their own expressiveness was more in line with longer survival. Individual
in a control condition did not show the same protective pattern.
Apart from the often negatively viewed suppression and denial, research has also
found beneficial outcomes from proximal reminders of death. For example,
Routledge et al. (2004) found that women showed greater interest in protective sun
exposure products immediately after a mortality salience prime, but not after a delay
(nor did they find it when the women contemplated dental pain instead of death),
showing positive health-behaviour intentions. Similar findings for other health
behaviours were found (e.g., Arndt et al., 2003).

3.2 Evidence for the Effects of Distal Reminders of Death

Studies on the proximal effects of death awareness constitute a less dominant role
in TMT-related research. The theory and the empirical research that follows mostly
focus on the processes that take place once the death construct is supressed but
ironically become more accessible outside conscious awareness. The theoretical
distal defence mechanisms are then theorised to kick into gear to enable the person
to manage their death anxiety. These mechanisms – self-esteem, worldview defence,
and the ability to create and maintain close relationships – are widely researched,
garnering much support for the theory in the last 30 years.
44 I. Dar-Nimrod

3.2.1 Evidence for the Protective Role of Self-Esteem

The ability to see oneself as a meaningful contributor to the world around us, to
maintain positive self-views as a member of the culture we uphold as valuable, is
one of the mechanisms that TMT postulates allow us to overcome our existential
paralysis. Indeed, the first publication on the theory (Greenberg et al., 1986) was
titled ‘The causes and consequences of a need for self-esteem: A terror management
theory’. The evidence in support of the role of self-esteem in ameliorating existen-
tial anxiety, however, is mixed.
Harmon-Jones and colleagues (1997) found that individuals with high self-­
esteem (either dispositionally or manipulated) did not have to resort to another
defensive mechanism (i.e., worldview defence) to manage their existential anxi-
ety following a distal MS prime. They also offered evidence that high self-
esteem protected individuals from experiencing heightened death thought
accessibility following the immediate suppression of the prime, seemingly
allowing for the suppression to continue. This set of studies, along with others
that produced similar support for the ameliorating properties of high self-esteem
(e.g., Goldenberg & Shackelford, 2005; Kashima et al., 2004), provides support
for this basic claim of TMT.
On the other hand, there is also evidence for the opposite phenomenon  –
high self-esteem amplifying people’s worldview defence responses following
a mortality prime. For example, McGregor et al. (2007) found that individuals
with high self-­esteem showed more zealous responses following such a mor-
tality prime, compared with individuals with low self-esteem, indicating
greater worldview defence reactions. Similar conceptual findings were dem-
onstrated by others (e.g., Landau & Greenberg, 2006; Taubman-Ben-Ari &
Findler, 2006).
In an attempt to reconcile these inconsistent findings, Schmeichel et  al.
(2009) investigated whether it is the nature of the self-esteem measured that
may have caused this pattern. Previous studies on the role of self-esteem in
TMT research utilised measures of explicit self-esteem, in which individuals
traditionally self-­report how positively they see themselves. Schmeichel et al.
(2009) evaluated implicit self-esteem instead. Using measures that focus on
how individuals associate themselves with positive features instead of how
explicitly laudatory they are about themselves, they found that individuals with
high implicit self-esteem (dispositionally or manipulated) tended not to resort to
worldview defence after a mortality prime, while individuals with low implicit
self-esteem did. In line with this research, in a summary of their meta-analytic
findings on the role of self-esteem following mortality primes (MS), Burke,
Martens, and Faucher (2010, p.  185) stated that ‘(i)n sum, self-reported self-
esteem appears to increase the defensive response to MS, whereas self-esteem
measured in more subtle ways—via manipulations and implicit measures—
appears to diminish the response to MS’.
Death Awareness and Terror Management Theory 45

3.2.2 Evidence for the Protective Role of Cultural Worldview Defence

Arguably, the most intriguing construct in TMT is cultural worldview defence. The
reason for the intrigue is that this construct subsumes numerous, diverse elements
and phenomena, reflecting the richness of our cultures themselves. To show cultural
worldview defence, one may demonstrate affinity to cultural values or symbols,
practices or norms, and models or reputation. Alternatively, one may show greater
proclivity to deride or reject norms or practices of other cultures. The richness of
culture as a construct translated to cultural worldview defence being the most com-
monly studied element in TMT research.
The first empirical set of studies to assess the predicted use of cultural world-
view defence following a mortality salience prime (Rosenblatt et  al., 1989,
Experiment 1) evaluated whether a reminder of our mortality, followed by a dis-
tracting task to allow that allows for the distal effects to emerge, is a classic
example that highlights both the examined phenomenon and the methodological
ingenuity that became a hallmark of many TMT-inspired studies. In the study, the
researchers sent out study packages to 22 American municipal judges, in which
half of them were asked to reflect on their own death and then to complete a filler
task assessing their affect. All the judges were presented with a bail-setting task
for the release of a women accused of prostitution (after the mortality prime for
the judges who received these additional materials). The amount of the bail was
considered an indication of punitive tendencies towards to accused. Prostitution
is commonly viewed as a moral violation in the American (and many other) cul-
ture, so in line with TMT prediction that one would become more defensive of
their (in this case moral) cultural worldview, it was expected that the judges who
contemplated their death prior to setting the bail amount would be more punitive.
The findings provided support for the prediction, as the judges in the death con-
dition set up higher bail than those in the control condition. Particularly striking
was the size of the observed effect. Despite the fact that municipal judges regu-
larly set bail for alleged prostitution charges, the judges in the death condition set
a bail amount that was nine(!) times larger ($455) than judges in the control
condition ($50).
Similarly, TMT research has been used to demonstrate a litany of other defen-
sive responses following distal mortality primes. It has shown people primed with
their death demonstrating greater respect towards a person who lauds our national
reputation or worthiness (e.g., Arndt et al., 1997; Greenberg et al., 1990), greater
derision of a person who criticises it (e.g., Greenberg et  al., 1990; Norenzayan
et al., 2009), and finding increased culpability in a car accident for a foreign (vs
domestic) car manufacturer, compared with control participants. Research also
demonstrated increased aggression, following a mortality prime, towards indi-
viduals who oppose one of the most prominent features of our worldview – politi-
cal persuasion (McGregor et al., 1998). In line with predictions that our Western
culture encourages conspicuous consumption and thus death reminders should
engender greater materialistic tendencies (Arndt et al., 2004), it has been demon-
strated that people experience greater desire for materialistic goods (e.g.,
46 I. Dar-Nimrod

Dar-Nimrod, 2012; Mandel & Heine, 1999) after death reminders. These findings
represent only a fraction of the myriad of relevant studies on the worldview
defence effect, showing a more consistent pattern than the one found for the self-
esteem effect (Burke et al., 2010).

3.2.3 Evidence for the Protective Role of Close Relationships

The latter addition to the defence mechanism from existential anxiety  – secure
attachment – has also received substantial empirical support. Mikulincer and Florian
(2000) found that reminders of one’s death led individuals with insecure attachment
styles to show the expected increased derisive view of crimes (i.e., a worldview
defence response) but did not significantly affect securely attached individuals. In
the same vein, manipulating a sense of secure attachment led individuals to prefer a
less violent approach for the worldview threatening terrorism (Weise et al., 2008).
In a recent review and meta-analysis of the empirical studies on the role of close
relationship in attenuating the unsavoury effects of death awareness, Plusnin et al.
(2018) found 73 empirical studies that evaluate this role. They concluded that ‘peo-
ple respond to MS by increasing efforts to initiate new close relationships and main-
tain preexisting ones by engaging in beneficial processes that foster intimacy and
partner retention (e.g., increased commitment, forgiveness, intimacy striving, attrac-
tion, approach motivation, and adaptive jealousy) and preventing the manifestation
of detrimental attitudes and behaviors (e.g., decreased fear of intimacy and rejection
sensitivity)’. However, they acknowledged that these effects are not observed uni-
formly, stating that ‘(v)arious dispositional and situational factors inhibit peoples’
intentions to gravitate toward close relationships for anxiety relief’ (p. 335).

3.3 Evidence for the Role of Death Awareness

in Mental Illness

To assess support for the claim that death anxiety is a transdiagnostic construct that
underlies mental illness rather than a relevant construct for a specific disorder only,
we should find that the expression of the disorders (i.e., their symptoms) relates to
the patient’s fear of death. To establish this relationship, ideally, one would want to
demonstrate two elements. First, we would predict that among individuals with a
mental illness, their death anxiety correlates with the severity of their symptoms.
Second, we would expect that priming patients with various mental disorders should
lead them to exhibit disorder-specific elevation of symptoms.
To assess the first condition, exploring the relationship between death anxiety
and psychopathology reveals numerous correlational studies that assessed the rela-
tionships between fears of death and symptoms’ severity among individuals with
various disorders. Death fears were assessed using a variety of measures, and the
Death Awareness and Terror Management Theory 47

findings provide ample indications that patients with different diagnoses who report
greater death anxiety also experience more severe disorder-related symptoms.
Whether they are diagnosed with schizophrenia (Lonetto & Templer, 1986), depres-
sion (Thorson & Powell, 2000), specific phobias (Menzies et  al., 2019), general
anxiety disorder (Menzies et al., 2019), separation anxiety disorder (Caras, 1995),
obsessive-compulsive disorder (OCD; Menzies & Dar-Nimrod, 2017; also its vari-
ous subtypes Menzies et  al., 2020 for publication), body dysmorphic disorder
(Menzies et al., 2019), post-traumatic stress disorder (Martz, 2004), somatic symp-
tom disorder (Menzies et al., 2019), schizotypy personality disorder (Easden et al.,
2019), alcohol use disorder (Menzies et al., 2019), or an eating disorder (Le Marne
& Harris, 2016), a positive relationship was found between self-reported death anxi-
ety and the severity of the disorder. In addition, a recent study found very substantial
correlations between death anxiety and the psychopathology’s severity (i.e., life-
time number of diagnoses, distress, depression, anxiety, and stress scores), ranging
from r  =  0.55 to r  =  0.75(!), among a large treatment-seeking, clinical sample,
consisting of individuals with various mental illnesses (Menzies et al., 2019).
The evidence for the second proposition, regarding the effect of priming mortal-
ity on mental health patients’ symptomology, is much scanter at this time. Menzies
and Dar-Nimrod (2017) found that priming death among patients with OCD (com-
pared with priming dental pain) led individuals with the compulsive washing sub-
type to show increased cleaning behaviour when given the opportunity (e.g., longer
washing time, increased use of soap). This difference was not found among compul-
sive checking subtype individuals whose symptoms do not relate to cleaning behav-
iours. Similarly, patients with a body scanning disorder (i.e., panic disorder, illness
anxiety, or somatic symptom disorder) showed more dire self-evaluations related to
bogus, purportedly health-relevant body indicators (e.g., one’s teeth colour predicts
their metabolism), following a death prime while taking longer time to assess their
indicators (Menzies et al., 2021), compared with a non-death-related aversive prime
(a visit to the dentist). This effect was not found among a different clinical group of
patients whose symptoms are not related to health vigilance (i.e., depressed indi-
viduals). The nascent experimental work assessing the second claim also provides
support for the transdiagnostic role of death anxiety in psychopathology, but there
is a clear need for much more research in this space to be able to make confi-
dent claims.

3.4 Individual Differences in the Use of Defensive

Mechanisms in the Face of Death Awareness

As Plusnin et al. (2018) indicated above, dispositional elements play a role in the
use of relational defences for death awareness (e.g., gender; Birnbaum et al., 2011).
However, a host of additional individual differences have been shown to moderate
responses to mortality primes in other domains as well.
48 I. Dar-Nimrod

Apart for previously discussed differences in theoretically foundational charac-

teristics, such as self-esteem and attachment styles, studies have shown that a vari-
ety of traits and demographic variables attenuate responses to reminders of death.
For example, following a mortality prime, age has been shown to moderate health-­
behaviours intentions (Bozo et al., 2009); political orientation moderated responses
to politically relevant expressions of worldview defence (Greenberg et al., 1992);
health optimism moderated health-behaviour intentions as a response to conscious
thoughts about mortality (Arndt et al., 2006); authoritarianism moderated responses
related to nationalistic reputation (Greenberg et al., 1990), as did subclinical depres-
sion (Simon et al., 1996); and perceptions of death moderated punitive responses
towards social transgressors (Florian & Mikulincer, 1997). Thus, despite the lack of
focus on individual differences (apart for self-esteem) in the original theory, subse-
quent experimental work provides a more nuanced picture, illuminating the role of
personal characteristics in responses to mortality salience.

4 Criticisms of Terror Management Theory

An array of different studies has been reported challenging specific theoretical

extensions of TMT, without necessarily undermining its foundation. For example,
the heightened materialism hypothesis (Arndt et al., 2004) has been challenged by
research in Africa on death rituals (e.g., Bonsu & Belk, 2003). Similarly, TMT’s
extension on the evolution of disgust (Cox et al., 2007; Goldenberg et al., 2001), has
been challenged by other research and findings (Fessler & Navarrete, 2005).
A more condemning, recent research has targeted the heart of the empirical sup-
port for the theory. As part of a decade-long renewed focus on the replicability of
psychological experimental research, commonly known as the ‘replication crisis’,
researchers have attempted to conduct exact replications of TMT’s previous, classic
studies (e.g., Klein et al., 2019), finding that these previous effects did not replicate.
Combined with the fact that many of the early classic TMT studies (e.g., Rosenblatt
et  al., 1989; Greenberg et  al., 1990) demonstrated their effects using extremely
small samples, which would have been impossible to publish in the leading journals
they were published in today due to power concerns, these methodological concerns
are quite substantial. However, more recent studies have found that these TMT
effects were replicable when using sufficiently large samples (Chatard et al., 2020).
Further, a meta-analysis of 277 experiments (Burke et al., 2010) found support for
TMT’s predicted effects on a myriad of variables, with little evidence of publication
bias towards finding an effect that may indicate questionable research practices
(although this meta-analysis was published prior to the breakout of the replication
crisis and thus did not use the most updated analyses to assess such a bias).
Another distinctive feature of the research on TMT (but not only, e.g., Dar-­
Nimrod & Heine, 2011, for the heritability coefficient) is its lack of cultural repre-
sentativeness. On the one hand, as indicated above, experimental support for the
theory has been found in many countries across the globe. On the other hand, the
Death Awareness and Terror Management Theory 49

vast majority of this research has been conducted in WEIRD (Western, educated,
industrial, rich, and democratic) societies that have been argued to provide poor
representations of people as a species (Henrich et al., 2010). As the theory claims to
capture some of the most basic psychological processes of our species, additional
research with underrepresented samples from non-WEIRD societies, such as people
from Africa, South Asia, South America, and perhaps most desirable people from
hunter-gatherer societies, is sorely needed.
Finally, following Becker’s (1973) lead, TMT’s fundamental focus has revolved
around death awareness. Its entire premise is established on the specific, unmedi-
ated claim that the combination of our unique ability for abstract thinking accompa-
nied by a biological mortality imperative gives rise to paralysing existential terror.
However, more recent theoretical accounts challenge the idea that it is the construct
of death that uniquely leads to the numerous observed effects in TMT-inspired stud-
ies. Instead, these accounts suggest that the documented responses arise from a
different fundamental construct, which death just happens to activate.
One such proposed alternative construct is uncertainty. McGregor et al. (2001,
p. 473) argue that the ‘main hypothesis is that when faced with the threat of personal
uncertainty, participants cope by spontaneously emphasizing certainty and convic-
tion about unrelated attitudes, values, personal goals, and identifications. A seem-
ingly rigid and defensive way to do this might be to become more zealous about
social attitudes and groups (i.e., going to extremes)’. As such, death is viewed as
one (but not only) major cause for uncertainty (i.e., what happens to us when we
die?), leading to what Claude Steele (1988, p. 267) termed ‘fluid compensation’ – a
process in which a perceived threat in one domain (e.g., uncertainty) causes bolster-
ing of existing beliefs in a different domain (e.g., reinforcing a cultural dogma). The
Uncertainty Management Theory received support from various studies, showing,
for example, that just like mortality salience led university students to greater deni-
gration of a person critical of their institution (a common type of TMT finding), so
did a prime that asked them to reflect on how our memories change and evolve
through time, reducing our certainty about important events in our lives (McGregor
et al., 2001, Study 3; for additional empirical support for the uncertainty construct,
see also McGregor et al., 2010; Nash et al., 2011).
Another competing theory, which aims to subsume TMT by substituting the con-
struct of death with an alternative, is the Meaning Maintenance Model (MMM;
Heine et al., 2006). The theory contend that humans evolved to create mental repre-
sentations of the world around them for survival purposes, and these representations
(i.e., schema) create expectations about the world. When such expectations are
threatened, existential concerns arise and different mechanisms may be set in
motion to address the threatening experience (Proulx & Inzlicht, 2012); the fluid
compensation process (Steele, 1988) is one of these mechanisms. The MMM does
not only attempt to subsume TMT by arguing that death violates our intrenched
schema of self-continuity (Heine et al., 2006) but also argues to subsume additional
prominent psychological theories (e.g., cognitive dissonance; Randles et al., 2015).
As in the case of Uncertainty Management Theory, the MMM provides ample
empirical evidence, demonstrating that violations of existing mental representations
50 I. Dar-Nimrod

of the world, just like death, lead to compensatory processes, with cultural world-
view defence being one (but not the only one) such process (e.g., Proulx & Heine,
2008; Proulx et al., 2010). They also demonstrate that a common pain relief medi-
cine can reduce compensatory reactions to such existential concerns (whether they
would be presented as a death prime or a schema’s threat), offering a modern sub-
stitution for the evolved compensatory mechanisms, common to TMT and its com-
peting theoretical accounts alike (Randles et al., 2013).

5 Summary

This chapter revolves around theoretical accounts for the effects that death aware-
ness has on our affect, thoughts, and behaviour. Terror Management Theory, the
most dominant psychological account of existential concerns, argues that the com-
bination of our ability to contemplate our own mortality as a biological imperative
and our organismic survival instinct leads to paralytic existential dread. It contends
that evolved mechanisms  – self-esteem, cultural worldview defence, and secure
attachment style – allow us to overcome this paralysis through bolstering our self-­
worth, various cultural-promoting behaviours, such as denigrating violators of our
cultural norms or reputation, or through seeking greater intimacy with close others.
Empirical evidence supporting these suggestions, as well as delineating occasional
moderators of the effects of death awareness, were also reviewed.
Whereas TMT faces its share of critiques, both methodological and conceptual,
it has been one of the most generative theories in social psychology in the past
30 years, helping us illuminate many new directions relating to intergroup relations,
intrapersonal processes, psychopathology development processes, and many other
psychological phenomena. Even if future research will be able to provide conclu-
sive evidence that one of the competing accounts to TMT (e.g., MMM, Uncertainty
Management Model, the Compensatory Control Model; Shepherd et al., 2011) bet-
ter captures the phenomena that have been discovered through mortality priming,
the realisation that our death awareness can trigger such a variety of psychological
responses will still remain as a vital part of our knowledge about the way that our
mind works.

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Fears of Death and Their Relationship
to Mental Health

Matteo Zuccala and Rachel E. Menzies

Abstract  The fear of death has been argued to be an important transdiagnostic

construct, which underlies a wide range of psychological disorders. Death anxiety
features centrally in many conditions, such as specific phobias, panic disorder,
somatic symptom-related disorders, obsessive-compulsive disorder, and post-­
traumatic stress disorder. In addition, recent research highlights that death anxiety
may even be associated with disorders that seem ostensibly unrelated to mortality,
such as social and separation anxiety disorders, mood disorders, eating disorders,
and psychotic disorders. In this chapter, we explore the evidence for the role of the
fear of death in various mental health disorders. While theoretical understandings of
the role of death anxiety in some conditions may need to be developed further,
empirical research nevertheless supports its status as a transdiagnostic construct.
Thus, it may be important to address underlying death anxiety in therapeutic inter-
ventions if treatment outcomes are to be maintained and the recurrence of further
mental health problems is to be prevented.

Keywords  Death anxiety · Psychopathology · Mental health · Anxiety disorders ·

Eating disorders · Somatic symptom disorders · Obsessive-compulsive disorder ·
Post-traumatic stress disorder · Social anxiety disorder · Specific phobias · Panic
disorder · Agoraphobia · Mood disorders · Psychotic disorders

1 Introduction

In recent years, transdiagnostic constructs have gained increasing attention in clini-

cal psychology. This is largely due to high comorbidity rates among mental health
conditions, with studies finding that lifetime rates of mental illnesses are around

M. Zuccala · R. E. Menzies (*)

University of Sydney, Camperdown, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 57

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_4
58 M. Zuccala and R. E. Menzies

double those of current disorders (Menzies et al., 2019; Simon et al., 2007). Further,
Iverach et al. (2014) have described the “revolving door” often observed in mental
health services in which a person may present with one disorder and receive an
apparently effective treatment for this condition only to return to treatment at a later
timepoint with a different disorder (p. 590). This clinical observation and support-
ing empirical data suggest that common threads underlying various mental health
conditions may be unaddressed by current treatments.
One transdiagnostic construct that has been argued to play a role in this “revolv-
ing door” phenomenon is the fear of death. Death anxiety has been argued to under-
lie much of psychopathology (Iverach et al., 2014). For example, fears of death may
create a sense of meaninglessness and loss of control and may result in maladaptive
coping strategies such as avoidance (Yalom, 2008). Of relevance to this topic is
Terror Management Theory (TMT), which is the leading theoretical perspective on
death anxiety and human behavior. According to this account, humans have two
main buffers against the terror of death: cultural worldviews and self-esteem (for a
complete review of TMT, see chapter “Death Awareness and Terror Management
Theory”). The majority of studies examining TMT have used a “mortality salience”
design in which participants are primed with either a reminder of death or in the
control condition, a topic that is unrelated to death. Recently, studies using the mor-
tality salience paradigm have revealed that death anxiety drives a range of clinically
relevant behaviors, demonstrating the causal role of this construct in mental health.
In this chapter, we will review the theoretical and empirical evidence for the impor-
tant relationship between death anxiety and psychopathology.

2 Anxiety Disorders

2.1 Specific Phobias

Nearly a century ago, Kingman (1928) proposed that death anxiety lay at the heart
of all phobias. Consistent with this idea, the most common specific phobias (e.g.,
heights, flying, spiders, snakes) all have the potential to directly result in death, an
observation noted by evolutionary accounts for the development of phobias. Death
anxiety has been argued to underlie various specific phobias by serving a protective
function across the evolution of our species. For instance, needle phobias have been
proposed to have evolved in humans in response to often fatal injuries sustained
across our history from skin penetration (i.e., stabbing or piercing from teeth, claws,
sticks, spears, and arrows; Hamilton, 1995). Similarly, in addition to the clear adap-
tive role a fear of spiders and snakes may serve, Mulkens et al. (1996) found that
phobias of animals may have developed due to cultural associations concerning
particular animals and increased risk of disease and contamination. Phobias of
bodily fluids (e.g., blood, vomit) may be similarly explained by an evolutionary
protection against death, with such fluids offering a risk of infection and illness.
Fears of Death and Their Relationship to Mental Health 59

Further, Veale (2009) argued that a specific phobia of vomiting might be driven by
an individual’s prior memories of vomiting that involved a feeling of suffocation,
choking, or death. In light of these theoretical links between death anxiety and vari-
ous specific phobias, some have argued that phobias develop as a means of focusing
fears of death into a more concrete and manageable threat (Strachan et al., 2007).
From this perspective, avoidance of the phobic object can be understood as a way of
fending off death.
In addition to these theoretical arguments, a handful of studies have explored the
relationship between death anxiety and specific phobias empirically. For example,
de Jong and Merckelbach (1998) found moderate correlations between death-related
disgust sensitivity (e.g., self-reported disgust in response to touching cremation
ashes or a dead body) and both spider phobia severity (r = 0.32) and blood injury
fear (r = 0.30). Further, one recent study found a large correlation (r = 0.66) between
claustrophobia severity and death anxiety, among a small sample of individuals
diagnosed with the disorder (Menzies et al., 2019). Another study involved asking
participants with a specific phobia of heights to rate the likelihood of fatality from
falling on a scale from 0 (“no injury”) to 100 (“death”) prior to and while climbing
a ladder (Menzies & Clarke, 1995). The findings revealed that compared to control
participants, those diagnosed with acrophobia were more likely to predict that a fall
from a ladder would result in death, and their estimates of fatality significantly pre-
dicted their avoidance behaviors (i.e., the number of ladder rungs they chose not to
climb; Menzies & Clarke, 1995). Similar results emerged from a follow-up study
investigating the relationship between fatality estimates and avoidance of spiders
among those with a spider phobia (Jones & Menzies, 2000).
Lastly, one experimental study investigated the causal role of death anxiety
among individuals who met diagnostic criteria for a spider phobia (Strachan et al.,
2007). Participants in the mortality salience condition showed greater avoidance of
spider-related stimuli, as well as increased threat perception (i.e., rating spiders as
being more dangerous to humans), compared to participants in the control condi-
tion. Notably, this effect was only found among those with a spider phobia, and
reminders of death had no significant effect on behavior among the matched con-
trols (Strachan et al., 2007). Thus, death anxiety has been experimentally shown to
drive phobic responding among those with a fear of spiders. However, despite strong
theoretical arguments drawing from evolutionary psychology, further research is
needed to clarify whether death anxiety plays a causal role in other types of specific
phobias.

2.2 Panic Disorder

Death anxiety has been argued to play a central role in panic disorder (Furer &
Walker, 2008; Starcevic, 2007). Verbal reports and clinical observations of those
with panic disorder indicate that concerns around illness, such as worries about suf-
fering a heart attack or collapsing due to panic attack symptoms, often lie at the
60 M. Zuccala and R. E. Menzies

heart of the condition (Noyes et al., 2004). Existential concerns also manifest in the
behaviors those with panic disorder often engage in, such as hypervigilance toward
and monitoring of any possible signs of poor health (e.g., changes in heart rate),
frequent medical testing and appointments with cardiologists, and excessive reas-
surance seeking from others.
Moving beyond clinical observations, empirical findings appear to suggest a
relationship between fears of death and panic disorder symptoms. First, a large body
of research indicates that hypochondriacal concerns feature heavily in panic disor-
der (e.g., Noyes et  al., 2004; Starcevic et  al., 2009). Regarding explicitly death-­
related concerns, one study (Starcevic et al., 1992) found that individuals with panic
disorder reported scores on the thanatophobia subscale of the Illness Attitude Scales
that were more than double community norms (e.g., Noyes et al., 1999). In addition,
higher scores on this subscale were associated with more severe levels of an addi-
tional diagnosis of agoraphobia (Starcevic et al., 1992). Further, individuals with
panic disorder have been shown to report significantly higher death anxiety com-
pared to individuals with social anxiety and nonclinical controls (Furer et al., 1997).
Radanovic-Grguric et al. (2004) similarly found that individuals with panic disorder
reported significantly higher death fears compared to those with major depressive
disorder (MDD) although results from a recent study did not appear to support this
finding (Menzies et  al., 2020, 2021a, b). In addition, a substantial relationship
(r = 0.80) has been found between death anxiety and severity of symptoms among
treatment-­seeking individuals diagnosed with panic disorder (Menzies et al., 2019).
Some additional findings suggest that panic disorder emerges temporally along-
side more pronounced death anxiety. Starcevic and Bogojevic (1997) found that
35.6% of participants with panic disorder and agoraphobia also reported at one
point experiencing a “death-related phobia” (e.g., fear of funerals, cemeteries, or
dead bodies). This study also found that a “death-related phobia” was more likely
than other phobia types to share a year of onset with panic disorder (i.e., to emerge
within the same 12-month period as the diagnosis of panic disorder). This led the
authors to conclude that death anxiety is a risk factor for this disorder.
Emerging experimental findings have demonstrated that fears of death may in
fact play a causal role in panic disorder. One recent study examined whether indi-
viduals with a “body scanning disorder” (i.e., panic disorder, illness anxiety disor-
der, or somatic symptom disorder) show increased anxious responding following
mortality salience compared to those in a control condition and those with depres-
sion (Menzies et al., 2021a). Among the “body scanning disorder” group, 44% had
a diagnosis of panic disorder, while the remaining participants were diagnosed with
a somatic symptom-related disorder. This study found that for those with a “scan-
ning disorder,” reminders of death led to significant increases in time spent checking
one’s body for symptoms, perceived threat, and intention to see a medical profes-
sional in the next 2 months. This finding suggests that death anxiety plays a causal
role in behaviors relevant to panic disorder, namely, hypervigilance, threat percep-
tion or catastrophic interpretations, and reassurance seeking.
Lastly, given the theoretical relevance of existential concerns in panic disorder, a
small number of studies have explored treatments targeting these concerns. Starcevic
Fears of Death and Their Relationship to Mental Health 61

(2007) has argued that treatment for panic disorder should include modifying atti-
tudes toward both illness and death. Further, in a single case study, Randall (2001)
reported full remission of panic disorder following 3 weeks of existential therapy.
Ishiyama (1986) has similarly described using existentially oriented therapy to
reduce fear of death during panic attacks for a single case study. Of course, further
research utilizing larger sample sizes and a control condition is needed to explore
whether existential therapies may offer an advantage in treating panic disorder.

2.3 Agoraphobia

Agoraphobia, an anxiety disorder defined by marked fear of specific (often public)

situations, is often characterized by an overwhelming fear that escapes from such
situations might be difficult, help may be unavailable, and thus that the individual is
in mortal danger. It has consequently been suggested that underlying fears of dying
may drive these individuals’ fears of being in such situations (Iverach et al., 2014;
Meyer, 1975). The onset of agoraphobia has been observed to often be preceded by
traumatic events associated with death, such as a close encounter with death or the
loss of significant others (Foa et al., 1984). Many of the fears reported among peo-
ple with agoraphobia appear to be associated with death, such as an inflated antici-
pation of physical harm, heightened attention toward internal physical sensations,
health-related worries, and intense fears of catastrophic events. It has been demon-
strated that moderate and severe agoraphobia is associated with higher levels of
death anxiety among patients with panic disorder (Starcevic et  al., 1992).
Unfortunately, however, there is an absence of experimental research in this area,
limiting conclusions regarding whether death anxiety plays a causal role in
agoraphobia.

2.4 Social Anxiety Disorder

The diagnosis of social anxiety disorder is characterized by fears of negative social

evaluation and interpersonal rejection by others. While social anxiety disorder is not
the only disorder in which social fears are salient, they certainly feature most promi-
nently in this condition. Self-report evidence suggests that while not as high as those
with panic disorder, individuals with social phobia demonstrate significantly ele-
vated levels of death anxiety compared to healthy populations (Furer et al., 1997).
Large correlations between self-reported death anxiety scores and symptom sever-
ity among individuals diagnosed with social anxiety disorder have also been found
(Menzies et al., 2019).
This self-report evidence is tempered by recent research, which suggests that it
is important to understand how death anxiety relates to other transdiagnostic con-
structs if we are to understand its somewhat unclear role in social anxiety. Lowe and
62 M. Zuccala and R. E. Menzies

Harris (2019) collected self-report data from 591 individuals and found that when
controlling for intolerance of uncertainty and self-esteem, there was no significant
independent relationship between death anxiety and social anxiety symptomatol-
ogy. Recent research (Zuccala et al., 2021) found a significant correlation between
death anxiety and trait social anxiety in a sample of participants with social anxiety
disorder. Importantly though, this relationship was found to be strongly mediated by
attachment anxiety, emphasizing the need to understand the role of attachment pro-
cesses in the complex role of death concerns in social anxiety.
In addition to this preliminary self-report evidence, several empirical studies
have examined the influence of death fears in social anxiety disorder. Strachan et al.
(2007) found that when individuals high in self-reported social anxiety were
reminded about death, compared to a control topic, they spent significantly more
time avoiding a group discussion. The authors of this study concluded that remind-
ers about death exacerbate behaviors associated with social anxiety for individuals
with preexisting social fears. In a similar study, Finch et al. (2016) employed eye-­
tracking on an attentional bias task to examine whether death reminders increase
avoidance of and hypervigilance toward socially threatening faces. While death
priming did not affect social avoidance in this study, it did increase social hypervigi-
lance for those already high in self-reported social anxiety.
Recently, Zuccala and Abbott (2020) sought to further explore the role of death
anxiety in social anxiety disorder by confirming diagnosis with semi-structured
clinical interviews (rather than relying on self-report questionnaires) and control-
ling for comorbid anxiety. Results from this study indicated that when individuals
diagnosed with social anxiety disorder are reminded of death, they experience exac-
erbated physical anxiety (i.e., anxiety related to a task requiring the participant to
inhale a gas) but not social anxiety (anxiety related to a public-speaking task).
Further, this effect was not seen for individuals without social anxiety disorder.
While these results did not support the basic presuppositions of Terror Management
Theory, they nevertheless suggest an important role of death fears in social anxiety
disorder.
As the current literature stands, it is clear that mortality concerns play an impor-
tant role in social anxiety disorder. However, the exact process by which this occurs
warrants further investigation. Nonetheless, these findings generally support the
proposition that death anxiety plays a transdiagnostic role across anxiety disorders
even when the cognitive focus of disorder seems unrelated to mortality.

2.5 Separation Anxiety Disorder

Separation anxiety disorder, characterized by intense fears of separation from close

loved ones, is another diagnosis in which the anxiety clearly centers on social pro-
cesses. While it may initially appear that there is little direct connection between
death fears and separation-related anxiety, an attachment theoretical perspective
highlights how separation in early childhood would have been strongly related with
Fears of Death and Their Relationship to Mental Health 63

premature death for human children during our evolutionary history (Zuccala et al.,
2021). It is thus unsurprising that there is a corpus of peripheral evidence that points
toward a close connection between death anxiety and separation anxiety.
In a qualitative investigation in which participants were asked a single question –
“Which aspects of death do you find most fearsome?”  – Bath (2010) found that
fears about being separated from loves ones featured most prominently. This study
also discovered that individuals rated their fear of others’ dying significantly higher
than fear of their own death. A review of the death anxiety measurement literature
similarly suggests that fears about being separated from loved ones is a central com-
ponent of the “death anxiety” construct (Zuccala et al., 2019).
Nevertheless, despite the strong collateral evidence of an intimate connection
between death and separation anxiety, studies using clinical samples remain sparse.
Both death anxiety and separation anxiety have been shown to be elevated in clini-
cal populations (Walser, 1985), and unsurprisingly, the two constructs are also posi-
tively correlated (Caras, 1995; Fleischer-Mann, 1995). Revisiting the attachment
paradigm, higher death anxiety has been found to be associated with more insecure
attachment (Caras, 1995). Specifically, death anxiety is strongly associated with
attachment anxiety (but not attachment avoidance), which is defined by fears of
separation from attachment figures (Zuccala et al., 2021). In all, it is clear that anxi-
ety about separation from loved ones is intimately related to the fear of death, and
this area of interest warrants further investigation.

3 Somatic Symptom-Related Disorders

Both empirical research and verbal reports from clients suggest that death anxiety
may lie at the heart of the somatic symptom-related disorders. In conditions such as
illness anxiety and somatic symptom disorder, which replaced the diagnosis of
hypochondriasis in the most recent version of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; APA, 2013), death anxiety may manifest in a number
of ways. These include preoccupation with the idea of suffering a fatal illness,
excessive checking of one’s own body for signs of poor health, increased likelihood
of perceiving benign symptoms as threatening, and excessive reassurance seeking
from medical specialists and requests for medical tests (Furer et al., 2007; Starcevic,
2005). Given the clear relevance of existential concerns to conditions such as health
anxiety, fear of death has been proposed by numerous researchers to lie at the heart
of the somatic symptom-related disorders (e.g., Furer et al., 2007; Hiebert et al.,
2005; Starcevic, 2007; Stolorow, 1979).
A number of studies support the relevance of death anxiety to these disorders.
One early study found that scores on the thanatophobia subscale of the Illness
Attitude Scales among those with hypochondriasis were triple those of non-­
hypochondriacal psychiatric patients and six times greater than nonclinical controls
(Kellner et al., 1987). Consistent with this, a study by Noyes et al. (1999) found that
thanatophobia scores were significantly higher among those with hypochondriasis
64 M. Zuccala and R. E. Menzies

compared to those without. Moderate to large correlations were also found between
thanatophobia scores and two measures of hypochondriasis severity. In fact, out of
19 variables related to medical history (e.g., number of hospitalizations, serious
injuries, operations, and doctor visits), the correlation between thanatophobia and
scores on the Whiteley Index assessing hypochondriasis was eclipsed in size only
by “satisfaction with health” (Noyes et al., 1999).
While much of the research has been based on those diagnosed with hypochon-
driasis, similar results have been found when using the more recent DSM-5 criteria
(APA, 2013). That is, large correlations have been found between death anxiety and
severity of both illness anxiety (r = 0.75) and somatic symptom disorder (r = 0.62;
Menzies et  al., 2019). Beyond these two disorders, death anxiety has also been
shown to be relevant to those with medically unexplained symptoms (MUS). Among
a sample of 68 individuals with MUS, 33% reported a fear of death when asked
what they fear most about their unexplained symptoms (Sumathipala et al., 2008).
When participants were asked about the severity of their symptoms, qualitative
responses included “I will die and if so what will happen to the children?” “[I] won’t
live much longer” and “It may be cancer…My mother also died of cancer”
(Sumathipala et al., 2008, pp. 4–5). These findings suggest the relevance of death
fears to other somatic symptom-related disorders outside of hypochondriasis, such
as functional neurological symptom disorder.
In addition to these cross-sectional findings, experimental evidence demonstrates
that death anxiety drives a range of behaviors relevant to somatic symptom-related
disorders. That is, as described above, reminders of death have been shown to
increase time spent checking one’s body for symptoms, threat perception, and inten-
tion to visit a GP (Menzies et al., 2021a). These results were found among a sample
in which the majority of participants were individuals seeking treatment for either
illness anxiety disorder or somatic symptom disorder.
Lastly, it has been argued that treatments for hypochondriasis may need to spe-
cifically address death anxiety as a core construct (Furer et al., 2007; Hiebert et al.,
2005; Menzies et al., 2021a; Starcevic, 2005). For instance, Furer et al. (2007) pro-
pose a number of cognitive behavior therapy (CBT) strategies for reducing fears of
death among those with health anxiety. These include in vivo and imaginal exposure
to death-related situations, images, and themes (e.g., visiting hospitals or cemeter-
ies, watching films exploring death, reading news articles featuring death, or writing
one’s own will or eulogy). At present, only one study has examined the effects of a
treatment targeting death anxiety in a sample diagnosed with hypochondriasis.
Hiebert et al. (2005) conducted a trial of CBT for death anxiety among 39 individu-
als diagnosed with hypochondriasis. Participants were randomly allocated to a
group CBT treatment or a waitlist control. Those in the CBT condition received
standard treatment components for the disorder (e.g., reduction of checking behav-
iors and reassurance seeking) in addition to novel components specifically targeting
death anxiety. These included exposure to death-related situations and images, strat-
egies to help increase acceptance of death, and cognitive challenging of beliefs
toward death. At posttreatment, the CBT group demonstrated significant reductions
in both fears of death and symptoms of hypochondriasis compared to the control
Fears of Death and Their Relationship to Mental Health 65

condition (Hiebert et al., 2005). While this promising finding suggests the relevance
of fears of death to treatments for somatic symptom-related disorders, it remains to
be seen how death anxiety treatments will compare to active control conditions in
addition to how they will perform in larger-scale trials. The inclusion of standard
hypochondriasis treatment components in the CBT condition (e.g., reducing bodily
checking) also limits the conclusions that can be drawn regarding the potential addi-
tive benefit of the novel death anxiety components. Thus, while a body of research
highlights the causal role of mortality concerns in the somatic symptom-related
disorders, further research is needed to examine whether addressing these concerns
may lead to overall symptom improvement.

4 Obsessive-Compulsive Disorder

Fears of death have been argued to underlie many manifestations of obsessive-­

compulsive disorder (OCD; Menzies et  al., 2015). For example, individuals who
engage in compulsive handwashing typically attribute their behavior to attempts to
ward off fatal illnesses that could be contracted through contamination from germs.
Similarly, the compulsive checking of stovetops, electrical outlets, and door and
window locks is usually described as an attempt to prevent fire, electrocution, and
household invasion.
Consistent with these theoretical accounts, strong relationships between death
anxiety and overall OCD severity have been found across multiple studies using
clinical samples, with estimates ranging from r = 0.33 to r = 0.80 (Menzies et al.,
2019; Menzies & Dar-Nimrod, 2017). Further, this relationship does not appear to
be restricted to only one manifestation of OCD.  One recent study demonstrated
significant correlations between death anxiety and the symptom domains of con-
tamination, checking, obsessions, hoarding, indecisiveness, and need for things to
be “just right” (Menzies et al., 2020). In addition, levels of death anxiety appear to
predict the trajectory toward OCD. That is, individuals with higher death anxiety
have been shown to experience more disorders prior to developing OCD (Menzies
et al., 2021b). On the other hand, those with lower death anxiety are significantly
more likely to develop OCD as their first disorder. These findings suggest that for
highly death anxious individuals, OCD may be just one of many manifestations of
this underlying fear.
At present, two experimental studies have demonstrated that fears of death may
drive behaviors relevant to OCD.  Strachan et  al. (2007) found that reminders of
death led to significant increases in handwashing among a student sample scoring
high on compulsive washing. This study was replicated and expanded by Menzies
and Dar-Nimrod (2017), utilizing a large sample of treatment-seeking individuals
diagnosed with OCD.  The findings revealed that among compulsive washers,
reminders of death led to double the time spent handwashing in addition to signifi-
cant increases in soap and paper towel usage. Notably, these effects occurred despite
no significant difference in reported perceived cleanliness between the mortality
66 M. Zuccala and R. E. Menzies

salience and control conditions, suggesting that the reminders of death produced
behavioral change not explained by conscious threat expectancies. Thus, death anx-
iety has been shown to have a clear causal role in the contamination type of
OCD. However, it remains to be seen whether reminders of death can exacerbate
other OCD behaviors (e.g., compulsive checking), consistent with theoretical
expectations.

5 Post-Traumatic Stress Disorder

The role of death anxiety in post-traumatic stress disorder (PTSD) is relatively

clear – exposure to life-threatening events leads to beliefs about the world being
unsafe and elevates one’s fear of dying (Chung et al., 2005). Unsurprisingly then, it
is well established that self-reported levels of death anxiety are significantly corre-
lated with overall severity of PTSD (Hamama-Raz et  al., 2016; Hoelterhoff &
Chung, 2017; Vail III et al., 2019). Death anxiety has also been found to be associ-
ated with each of the three distinct symptom categories of PTSD – reexperiencing,
avoidance, and hyperarousal (Martz, 2004; Safren et al., 2003).
The role of death-related fears in this disorder is evidently pronounced, leading
several authors to emphasize the importance of addressing such fears in treatment
for PTSD (Iverach et al., 2014; Martz, 2004). Some researchers have also pointed
out that the level of death anxiety experienced at the time of trauma seemingly has
an effect on the severity of PTSD later developed (Tural et al., 2001). Psarros et al.
(2017) have consequently proposed that the “fear of imminent death” may play a
distinct and important role in our understanding of post-traumatic responses.
TMT conceptualizes PTSD as a disruption of the buffering mechanisms typically
employed to ward off underlying death anxiety (Kesebir et al., 2011; Maxfield et al.,
2014). In support of this, research shows that participants with high post-traumatic
stress do not show typical suppression effects when exposed to death reminders
(Chatard et al., 2012). Death reminders have also been found to exacerbate trauma
symptoms for individuals with high exposure to war (Chatard et al., 2012). It should
be noted, however, that recent investigation seems to challenge the notion that these
buffering mechanisms account for variations in the relationship between death anxi-
ety and PTSD symptom severity (Herr, 2018). Nevertheless, the literature strongly
supports the robust relationship between death anxiety and PTSD, suggesting that
treatment targeting death fears may be a promising direction for clinical
interventions.
Fears of Death and Their Relationship to Mental Health 67

6 Mood Disorders

There is a strong tradition of existential approaches toward treating depressive dis-

orders, and many of these existential therapies emphasize the profound death-­
related fears that underlie these pathologies (Ghaemi, 2007; Stålsett et al., 2012).
Early psychotherapy case studies have highlighted the importance of treating anxi-
ety about dying for individuals suffering from depressive disorder (Chait, 1998;
Hussian, 1983), and recent research supports these approaches, highlighting the
connection between self-reported death anxiety and the experience of depression.
Not only have elevated death anxiety scores been associated with increased depres-
sive symptomatology (Miller et al., 2012; Ongider & Eyuboglu, 2013; Thorson &
Powell, 2000), but authors have proposed that “death depression” be considered a
significant construct of its own, given its close association with underlying fears of
dying (Nassar, 2010).
In particular, death anxiety seems to play a prominent role in the development
and maintenance of depression for individuals who may be “close to death” – either
in age or in health status. The fear of death has been found to be moderately corre-
lated with depression in elderly populations aged 60 or older (Bektaş et al., 2017).
In corroboration, Bala and Maheshwari (2019) found that the very large majority
(87%) of elderly individuals demonstrated moderate or severe “death depression,”
which was strongly associated with death anxiety (correlation of r = 0.48).
Death anxiety is similarly associated with the experience of depression in indi-
viduals suffering from terminal illnesses. Various life-threatening medical condi-
tions seem to strengthen the connection between death anxiety and existential
depression (Atalay et al., 2019; Eggen et al., 2020; Grabler et al., 2018). For exam-
ple, cancer patients with death anxiety were found to have higher rates of axis I
psychiatric disorders (including major depressive disorder) as well as elevated lev-
els of depressive symptoms (Gonen et al., 2012; Krause et al., 2015), suggesting
that the approaching threat of death exacerbates one’s hopelessness about the future.
From a TMT perspective, major depression is caused by fragile buffers, limiting
an individual’s ability to invest in cultural worldviews, self-esteem, relationships,
and ultimately their ability to cultivate meaning in their lives (Maxfield et al., 2014;
Simon et al., 1998). As such, it has been proposed that individuals with underlying
depressive pathologies require stronger buffering mechanisms to defend against the
existential terror of mortality anxiety, and indeed, empirical evidence supports this.
Employing the mortality salience paradigm, Simon et al. (1996) demonstrated that
in response to death reminders, individuals with depression exhibit greater world-
view defense mechanisms in comparison to nondepressed individuals. As such,
TMT theorists propose that bolstering worldview beliefs may increase overall life
meaning among depressed individuals and be an important approach toward treat-
ment for this common mental illness.
68 M. Zuccala and R. E. Menzies

7 Eating Disorders

Despite being relatively understudied compared to other disorder types, the rela-
tionship between death anxiety and eating disorders has been explored in a handful
of studies. For example, Alantar and Maner (2008) argue that a fear of weight gain
may serve as a defense against a fear of mortality, while others have noted that indi-
viduals with eating disorders often have a preoccupation with death and annihilation
(Farber et al., 2007). However, only a few studies have empirically demonstrated
this connection. Giles (1995) demonstrated that women with anorexia nervosa
reported significantly higher death anxiety toward both themselves and others, com-
pared to age- and gender-matched controls. In addition, one recent study found that
death anxiety significantly predicted self-reported disordered eating behavior even
after controlling for perfectionism, self-esteem, and age (Le Marne & Harris, 2016).
Further, perfectionism was only a significant predictor of disordered eating when
death anxiety and self-esteem were not included in the model. This is particularly
notable given long-standing theoretical arguments that perfectionism plays a central
role in eating disorders (e.g., Fairburn et al., 2003), and these recent findings attest
to the unique rule of fears of death in relevant symptomatology.
Although limited conclusions can be drawn from such correlational and cross-­
sectional designs, they appear to be supported by experimental findings. Across a
series of experimental studies, Goldenberg et al. (2005) found that death anxiety
plays a causal role in behaviors relevant to eating disorders. Specifically, after being
reminded of death, female participants ate significantly less during a subsequent
“taste-testing” task. Experiencing a death reminder also led them to rate themselves
as being further from their ideal thinness. Notably, this effect was only found among
women, and mortality salience did not affect these behaviors among male partici-
pants. This finding further supports the argument that death anxiety may drive indi-
viduals to strive for the body shape valued by their culture (i.e., thinness for women
in Western societies) as a way of increasing one’s self-esteem and protect oneself
from existential concerns (Goldenberg et al., 2005).

8 Psychotic Disorders

Over the last few decades, some researchers have proposed an association between
fears of death and psychosis. For example, omnipotent delusions and hallucinations
have been proposed to be a defense mechanism in the face of one’s own imperma-
nence and insignificance in the face of death (Searles, 1961). Supporting this idea,
one review of psychiatric records of 205 individuals with schizophrenia found pro-
nounced preoccupation with death and annihilation (Planasky & Johnston, 1977). In
a similar vein, Walser (1985) demonstrated that individuals with schizophrenia
reported significantly higher death anxiety compared to controls. Further, positive
correlations have been found between death anxiety and schizophrenia symptoms
Fears of Death and Their Relationship to Mental Health 69

among hospitalized psychiatric patients (Lonetto & Templer, 1986). In one recent
study, Easden et al. (2016) investigated the relationship between death anxiety and
schizotypy (a personality dimension measuring one’s proneness to psychosis). The
results demonstrated that death anxiety significantly predicted schizotypy even after
controlling for trait anxiety. Lastly, a series of case studies described psychotic
patients frequently expressing concerns surrounding themes of mortality and other
existential concerns and reported full recovery following existential therapy
(Williams, 2012). Thus, a handful of studies have demonstrated an association
between psychotic disorders and existential issues, including death anxiety.
However, further research is clearly warranted to further explore this relationship
and ascertain whether death anxiety may play a causal role.

9 Treatment Implications

Increasing evidence suggests that death anxiety plays a role in a range of different
mental health conditions, cutting across a number of diagnostic constructs.
Theoretical and empirical evidence suggests that death anxiety may be a relevant
construct in eating disorders, trauma-related disorders, mood disorders, and psy-
chotic disorders. In addition, findings drawn from both correlational and experi-
mental studies suggest that fears of death play a causal role in a number of anxiety
disorders, somatic symptom-related disorders, and obsessive-compulsive disorders.
Given the demonstrated prevalence of death anxiety across these conditions,
treatments may need to specifically target this fear in order to see long-term amelio-
ration of symptoms. Current standard treatments typically do not address the fear of
death directly, often instead focusing on reducing the client’s estimated probability
of dying from one cause or another. For instance, cognitive challenging may be
conducted to disprove the client’s estimated likelihood of dying from a plane crash
in the specific phobias. Similarly, for a client with panic disorder, treatment may
involve behavioral experiments to “test out” the individual’s belief that a change in
heart rate is indicative of a heart attack. Treatments that focus solely on targeting the
“proximal threat” (e.g., the plane crash or the heart attack) fail to address the under-
lying fear of death itself, the probability of which still remains certain despite the
result of various standard CBT tasks. That is, while the client’s panic disorder or
fear of flying may be effectively eliminated, their death anxiety may potentially
manifest in a different mental health condition in the future. Thus, standard CBT
treatments that focus on disputing the client’s current threat appraisals may be per-
petuating the “revolving door” phenomenon and failing to prevent the accrual of
further mental health problems across the life span. Treatments that specifically
address death anxiety may be needed in order to ensure symptom improvement in
the long term.
70 M. Zuccala and R. E. Menzies

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Creative Approaches to Treating the Dread
of Death

Rachel E. Menzies and David Veale

Abstract  A growing body of research suggests that death anxiety may underlie
numerous mental health conditions. Given this, it is essential to develop treatments
that specifically target fears of death. This chapter first outlines how to effectively
assess for death anxiety using a clinical interview and self-report measures. Next,
various approaches to treating death anxiety are explained with a particular focus on
CBT-based techniques. Meta-analytic findings demonstrate that cognitive behav-
ioural therapy (CBT) is the most effective treatment for death anxiety, producing
significant reductions in this fear. In particular, exposure therapy has been shown to
be effective at reducing fears of death. Given this, novel death-related exposure
tasks, such as the use of films, music, games, and apps, are highlighted. In addition,
strategies such as cognitive challenging, behavioural experiments, and imagery
rescripting are discussed. Treatment approaches that normalise death and help to
cultivate an attitude of neutral acceptance of death may be particularly useful.
However, the efficacy of many of these techniques for death anxiety remains to be
seen. Further research is needed to determine whether these strategies will signifi-
cantly reduce death anxiety among those with mental health conditions and whether
this will in turn produce broad improvements in psychopathology.

Keywords  Death anxiety · Cognitive behaviour therapy · CBT · Assessment ·

Measurement · Exposure · Behavioural experiments · Psilocybin-assisted
psychotherapy

R. E. Menzies (*)
School of Psychology, University of Sydney, Camperdown, NSW, Australia
e-mail: [email protected]
D. Veale
Kings College London, London, UK

© Springer Nature Switzerland AG 2022 75

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_5
76 R. E. Menzies and D. Veale

1 Introduction

In recent years, increasing theoretical and empirical evidence suggests that death
anxiety may be a transdiagnostic construct, underpinning a range of mental health
conditions (Iverach et al., 2014; Menzies et al., 2019). Given this, standard treat-
ments that fail to directly target fears of death, instead focusing on the client’s pre-
senting problem at any given time, may in fact be contributing to the “revolving
door” often seen in mental health (Iverach et al., 2014, p. 590). That is, it is not
uncommon for an individual to experience one mental illness, to receive effective
treatment for this particular condition, only to return to therapy later in life with an
altogether different disorder and set of symptoms. If death anxiety is truly underly-
ing these conditions, then fears of death may need to be directly treated in order to
see long-term improvement in symptoms and to reduce the likelihood of future
disorders. However, if death anxiety is truly an existential given, and “the worm at
the core” of the human condition (James, 1985), is it even something that can be
reduced with treatment?
Fortunately, the evidence indicates that psychological interventions that reduce
fears of death do exist. One recent meta-analysis of randomised controlled trials
(RCTs) for death anxiety found that cognitive behaviour therapy (CBT) was par-
ticularly efficacious, producing significant improvements in fears of death com-
pared to control conditions (Menzies et al., 2018). Notably, other therapies did not
produce such a reduction, nor did death education programs (i.e., workshops that
aim to inform relevant health professionals of death-related information). The five
CBT interventions included in the meta-analysis typically focused on graded expo-
sure, both imaginal and in  vivo, to death-related stimuli. Based on these results,
exposure therapy currently appears to be the most effective means of treating fears
of death. However, it should be noted that at present, there have been no RCTs
examining the effects of such interventions on death anxiety in samples diagnosed
with mental health conditions. The vast majority of RCTs have used convenience
samples consisting of students or those in health professions (e.g., nurses) with a
minority of studies involving cancer patients.
Notably, one trial of CBT for patients with advanced cancer who were clinically
depressed found no difference between CBT and treatment as usual (Serfaty et al.,
2020). Although existential issues were discussed as they arose, fear of death was
not a primary focus. Although therapists were trained to have discussions about
death and dying (Serfaty et al., 2019), 90% of therapists did not address the issue of
dying in palliative care (Serfaty et al., 2020). Qualitative interviews with therapists
suggested they may have avoided discussion of death and dying (Hassan et  al.,
2018). This may have been because they were not relevant. However, patients and
therapists did not discuss existential issues when ACT was delivered to people with
advanced cancer (Serfaty et al., 2018). The impression was that both therapists and
patients were avoiding touching on issues around death and dying.
Given that the topic of death anxiety escapes the focus even of studies investigat-
ing terminal illness, the scarcity of studies examining this construct in mental health
Creative Approaches to Treating the Dread of Death 77

samples is perhaps unsurprising. As such, RCTs that explore whether the effects of
CBT found in non-clinical samples do indeed generalise to those with mental health
problems are sorely needed. Despite this, the finding across multiple studies that
treatment can effectively reduce death anxiety may indicate hope for improvement
among those with more severe fears. Given this, what might such treatments
look like?

2 Assessment

2.1 Clinical Interview

2.1.1 Screening for Death Anxiety

In order to treat fears of death, a detailed clinical interview exploring the client’s life
history and emotional, behavioural, and cognitive responses to death is essential. In
addition to standard questions a clinician may ask in the first assessment session, the
topic of death should be discussed specifically when death anxiety is seen as poten-
tially relevant. A simple screening question such as “Do you ever worry about your
own or another person’s death?” can be used to introduce the topic. Where there is
sufficient information to suspect that the client’s behaviours are driven by death
fears (e.g., this will often be the case for presentations related to health anxiety,
panic disorder, specific phobias, and many subtypes of OCD), this connection can
be presented to them for their feedback (e.g., “What relationship do you see between
fears of death and your current experience?”). This will then allow further assess-
ment of the topic of death specifically and help provide a rationale for delving
deeper into this area.
It is essential to try and understand the nature of the client’s fear, and time should
be spent exploring their specific worries (e.g., “What exactly are you frightened
of?”). For example, do their fears centre on their own death or that of loved ones?
Do the worries revolve around some aspect of the dying process, such as pain, or
loss of mental faculties or physical capabilities at the end of life, or does the indi-
vidual instead fear non-existence itself? Is the client worrying about not knowing
whether or not there is an afterlife or about their belief in eternal punishment after
death? Do they fear a fate worse than death, such as being buried alive, or existing
in a parallel world or different plane of existence? Identifying specific worries sur-
rounding death and dying will be a crucial step in order to assist with directly
reframing unrealistic or unhelpful beliefs later in treatment. It is important to assess
the degree of preoccupation and the nature of these processes. For example, “For
how many minutes or hours a day is death at the forefront of your mind?” More than
an hour a day would be regarded as a preoccupation. It is important to then identify
the nature of the cognitive processes, such as rumination, worry, comparing, or
self-criticism.
78 R. E. Menzies and D. Veale

2.1.2 Emotional, Cognitive, and Behavioural Responses

This assessment should examine the specific emotions clients feel surrounding
death (e.g., “When you think about death, what feelings does it bring up for you?”).
This line of questioning may help elicit the types of thoughts or images the client
has about death. For example, a client expressing fear is likely to be experiencing
catastrophic and unhelpful predictions about death (e.g., “dying is going to be pain-
ful”, or “I’ll fall apart when my partner dies”), whereas a client expressing anger is
likely to be experiencing some thoughts associated with “should” thinking (e.g., “I
shouldn’t have to lose those I love”, or “life should be longer”).
One transdiagnostic concept that appears relevant for many people with death
anxiety is the intolerance of uncertainty. It refers to the subjective negative emotions
experienced in response to the unknown aspects of a given situation (Dugas et al.,
1997; Freeston et al., 2020). Thus, for some individuals, it is not the threat of going
to hell, heaven, or nothingness. These events involve “aleatory” uncertainty that we
cannot know in advance (rather than epistemic uncertainty, where some facts are
known, but there is ambiguity). The possibility that there may be life after death can
be just as unsettling for someone with an intolerance of uncertainty as the possibil-
ity that there may be no life after death or hell. For these individuals, it is not the
valence of what happens, simply the inability to know. This may lead to them trying
to obtain further information, but this is often contradictory and leads to further
doubts and intolerance of uncertainty.
As in any comprehensive assessment, the client’s responses to their fears will
also be crucial to identify. These can be broadly divided into (1) marked avoidance
of reminders of death, (2) marked time and effort to obtain certainty and control
around death, and (3) marked procrastination in decision-making linked to death.
1. Avoidance of reminders of death (e.g., of watching the news, going to hospitals,
or suppressing thoughts related to death, making one’s will) or of things believed
to increase the likelihood of death (e.g., driving, flying, doing activities that
increase one’s heart rate or going to sleep) will often feature in these presenta-
tions. Experiential avoidance may also manifest in excessive attempts to distract
oneself or keep oneself busy, or self-medicating, such as through substance use.
2. Other behaviours that are associated with trying to obtain certainty include men-
tal review of information, excessive reassurance seeking (e.g., frequent visits to
medical specialists), and checking (e.g., of information about dying on the
Internet or physical symptoms and/or internal sensations that may signal the
end). Overcompensatory behaviours, such as excessive exercise, vitamin supple-
mentation, or investing a lot of time into nutrition or physical wellbeing, may
also be reported. Other clients may overcompensate and try to plan every detail
of what will happen at their funeral or in the execution of their will and other
consequences. Because they are not in control over such events, they may seek
excessive reassurance that everyone will comply with the instructions and have
further doubts when they do not trust their executors or receive ambiguous
information.
Creative Approaches to Treating the Dread of Death 79

3. When there is a high level of intolerance of uncertainty, there may be marked

procrastination and avoidance of making any decision, such as making one’s will
or expressing any wishes about funeral arrangements.

2.1.3 Life History

Assessment should naturally include taking a standard life history, including the
individual’s early life experiences, relationships with caregivers, major life events,
and so forth. It is also essential to enquire about what led the client to therapy. That
is, why are they seeking treatment now? Has there been a clear trigger, such as a
recent loss or diagnosis of an illness, or is the trigger for the most recent episode
unknown? In addition to this, an assessment should also enquire into the individu-
al’s experiences of death and loss, which may include near-death experiences or
confrontations with physical threats. For instance, do they remember any early
losses in their life? If so, how did they respond? How significant was the loss? How
did those around them respond to the loss at the time?
Enquiring into conversations the individual remembers in early childhood or
memories of what they were taught about death as a child may also provide useful
information. Being aware that an individual grew up in a household where death
was never talked about, or conversely, talked about by caregivers in catastrophic
ways (e.g., death may be just around the corner), will assist the clinician in under-
standing factors that may have contributed to their current pronounced fear. Attitudes
towards death held by those close to the client may also be relevant when consider-
ing the support the client will have for later exposure tasks; for example, an indi-
vidual whose family has historically refused to discuss death may present some
resistance to a client’s exposure task of discussing their own end-of-life preferences.

2.1.4 Protective Factors

In addition to assessing factors that appear to be driving or maintaining the anxiety,

examining protective factors is also valuable. For example, information about the
individual’s religious beliefs (or lack thereof) is often highly relevant as these beliefs
may serve to buffer (i.e., through beliefs in life after death) or exacerbate (i.e.,
through beliefs about eternal punishment or damnation) anxiety surrounding death.
This can be done through an open-ended question such as “What do you think hap-
pens to you when you die?” Naturally, the goal in assessing religious beliefs is to
explore what factors may be shaping the individual’s views about death rather than
challenging their worldview and spiritual beliefs. This is particularly the case for the
many individuals for whom religious beliefs appear to play a protective role and
allay some of their anxiety. In order for therapists to understand the client’s belief
system and the role it plays for them, finding a good authority on beliefs about death
in different religions may be valuable.
80 R. E. Menzies and D. Veale

One factor that has been proposed to buffer fears of death is meaning in life, with
one study finding that death reminders only increased state death anxiety for those
who lack a sense of purpose (Routledge & Juhl, 2010). Given this, a question such
as “What makes your life purposeful or meaningful right now?” (or, for those who
report feelings of meaninglessness, “What do you think would help life feel more
meaningful?” “Can you think of a time when you had a sense of purpose in life?
What did your life look like at that time?”) will likely prove useful. Assessing the
client’s sense of purpose also provides valuable information when considering treat-
ment possibilities as those reporting feelings of meaninglessness may benefit from
working on values-based living, in line with strategies from Acceptance and
Commitment Therapy (Hayes & Smith, 2005).

2.1.5 Establishing Treatment Goals

Working with the client to establish clear and practical therapy goals is often useful
to guide treatment and determine treatment success. These should be established
collaboratively, and individuals should be encouraged to develop realistic goals
based upon their values and what they have been avoiding. It is important to keep in
mind the universality of death anxiety, and clients should be steered away from aim-
ing to rid themselves of anxiety or other unpleasant emotional responses entirely.
Instead, realistic goals around acceptance or reducing anxiety and its impacts on
one’s life should be encouraged (e.g., reducing the time they spend worrying about
death each day or finally being able to visit a loved one in hospital despite some
anxiety).

2.2 Measures

In addition to the clinical interview, administering a relevant questionnaire can

prove useful in both gathering more information about client’s worries and measur-
ing the severity of their distress. Currently, few measures have been validated in
clinical samples (for a systematic review of death anxiety measures, see Zuccala
et al., 2019). However, despite the need for future measures, which are more psy-
chometrically sound, the following measures may be recommended for use in clini-
cal practice.

2.2.1 The Collett-Lester Fear of Death Scale–Revised (CLFDS-R)

The CLFDS-R (Lester, 1990) is a 32-item measure of death anxiety with four sub-
scales: death of self (e.g., “the total isolation of death”), dying of self (e.g., “the pain
involved in dying”), death of others (e.g., “the loss of someone close to you”), and
dying of others (e.g., “having to be with someone who is dying”). Most notably for
Creative Approaches to Treating the Dread of Death 81

clinical practice, the CLFDS-R is the only measure to demonstrate responsiveness

to treatment, suggesting that it may be the most valuable measure for examining
client change (Zuccala et al., 2019).

2.2.2 The Multidimensional Fear of Death Scale (MFODS)

The MFODS (Hoelter, 1979) is a 42-item measure with eight subscales: fear of the
dying process, fear of the dead, fear of being destroyed, fear for significant others,
fear of the unknown, fear of conscious death, fear for the body after death, and fear
of premature death. Although the MFODS is one of the longer measures of death
anxiety, the numerous subscales are useful to provide a more detailed portrait of the
individual’s specific fears surrounding death. The MFODS is the only death anxiety
measure at present for which clinical means exist for multiple disorders (MFODS
means are reported for 12 different disorders in Menzies et al., 2019).

3 Treatment Approaches

There are a number of treatment approaches that can be utilised for addressing the
fear of death. In order to introduce the rationale for treatment and build motivation,
it may be helpful to provide the client with an overview of death anxiety and its
treatment (see further, Furer et  al., 2007, pp.  151–153; Willson & Veale, 2009).
Working with the client to help develop a formulation of their difficulties, based on
the information gathered during the assessment, is also crucial. A comprehensive
formulation and understanding of the problem will not only help guide treatment
but will also help provide the client with a rationale as to the purpose of treatment
and what maintaining factors will be specifically targeted.

3.1 Cognitive Approaches

As the Stoic philosophers observed 2000 years ago, “it is not things themselves that
trouble people, but their opinions about things” (Epictetus., 2018, p.  11).1 This
underlying principle shared by Stoic philosophy and CBT emphasises that it is our
beliefs about events that cause us distress, not the event itself. This shared principle
is just as relevant to fears of death as it is to any other subject of fear. Each of us have
particular beliefs and attitudes towards death, and these beliefs will be associated
with feeling anger, sadness, calm, or fear in the face of it. Importantly, some of our

1
 Interestingly, Epictetus immediately follows this claim with using death as an example: “Death,
for instance, is nothing terrible (otherwise it would have appeared that way to Socrates as well), but
the terrible thing is the opinion that death is terrible” (p. 11–13).
82 R. E. Menzies and D. Veale

beliefs about death may be adaptive, such as the belief that death is universal and
thus not to be feared or that we would be understandably distressed with the death
of a loved one but would ultimately cope. Of course, there are a number of unhelpful
or unrealistic beliefs one could also hold towards death, such as viewing death as
unnatural, unfair, necessarily painful, or something that one must control. Such
beliefs will understandably create distress for the individual endorsing them. Given
this, the goal of cognitive therapy in this area is to assist the individual in coming to
a more balanced and realistic view of death, to assist in cultivating an attitude of
“neutral acceptance”, a construct that has been shown to predict reduced fear (Tomer
& Eliason, 2000).
For this purpose, careful assessment of the client’s own particular beliefs is
essential in order for those that are unhelpful to be identified. As with other anxiety
problems, introducing clients to the idea of “unhelpful thinking styles” early in
treatment will also assist with this process. The following categories of thinking
styles are often particularly relevant: fortune telling (e.g., “I know that dying is
going to be painful”, or “When my mother dies, I’ll never get over it”), awfulising
(e.g., “Dying will be absolutely horrible and I won’t be able to bear it”), “should”
statements (e.g., “I need to achieve all my goals before I die”, or “death is unfair – it
shouldn’t happen to me), all-or-nothing thinking (e.g., “If I die before I have
achieved everything I want to, then I’m a failure”), emotional reasoning (e.g.,
“Because I feel anxious about dying, it must be a horrible experience”), and over-
generalisation (e.g., “I was devastated when my uncle died, so I know I just can’t
cope with death”).
Where such unhelpful beliefs are identified and the person is cognitively flexible,
then reappraisal may help the client come to a more balanced perspective (for a
review of cognitive approaches, see Menzies, 2018). Standard lines of cognitive
techniques, such as evaluating the evidence for or against the thought and consider-
ing how likely the thought is to be true or helpful, may be useful where there is
cognitive flexibility. In addition to these, one especially useful avenue regarding
death anxiety is accepting not knowing what will happen after death and under-
standing that the process of trying to know is the problem. This is related to con-
trol – that is, individuals often tend to worry about something that is outside of one’s
control. Thus, an individual’s worries about death may involve them worrying about
things that are completely unknown and outside of their control or influence and,
thus, trying to solve them as actual problems increases their distress. This focus on
what is not known and outside of one’s control is a particularly valuable line of
questioning when one’s beliefs may in fact be realistic (e.g., “If I were to suddenly
die, my family would probably be upset for a long time”).
This view of death as outside of one’s control and being largely an unknown, and
thus unhelpful to problem solve, is at the heart of neutral acceptance, which has
been shown to predict the most positive outcomes concerning coping with death
(Tomer & Eliason, 2000). It is also at the heart of Stoicism, the ancient Greek school
of philosophy on which Aaron Beck and Albert Ellis originally based CBT and
Rational Emotive Behaviour Therapy, respectively. At the heart of the teachings of
the Stoic philosopher and ex-slave Epictetus is the idea that “happiness and freedom
Creative Approaches to Treating the Dread of Death 83

begin with a clear understanding of one principle: Some things are within your con-
trol, and some things are not” (Epictetus, 1995). One particular line of worry that
the Stoics responded to was that of non-existence. For some clients, it is not a fear
of pain or suffering that distresses them but the idea of non-being after death. The
state of not existing at all, and the notion that life will continue on despite one’s
absence, can appear to some to be too difficult to even imagine. In response to this
specific worry, Yalom (2008) suggests the use of the Stoic “symmetry” argument
and the idea that one has already experienced non-being, that is, before they were
born. This idea is expressed persuasively by Seneca, not only in his writings to the
bereaved Marcia after the death of her son (“[death] returns us to that peace in
which we reposed before we were born. If someone pities the dead, let him also pity
those not yet born”; Seneca, 2018c) but also in his Epistle:
Wouldn’t a man seem to you the greatest of all fools, if he wept because for a thousand
years previously, he had not been alive? He’s just as great a fool if he weeps because he
won’t live for a thousand years to come (Seneca, 2018b).

Reading into the philosophy of the Stoics, who wrote extensively about death and
the importance of accepting it may be particularly beneficial for clients who are
open to this (see further, Menzies & Whittle, 2022). How to Die: An Ancient Guide
to the End of Life (Romm, 2018), a collection of writings by Seneca, and A Guide
to the Good Life: The Ancient Art of Stoic Joy (Irvine, 2009) are valuable start-
ing points.
Lastly, some individuals may hold beliefs centring on death being an unjust or
catastrophic outcome. Often, such beliefs are based on the erroneous assumption
that one was always guaranteed their existence. Helping clients understand the
incredible unlikelihood of their own existence can help to shift this perception.
Richard Dawkins persuasively emphasises this idea in his opening to Unweaving
the Rainbow, noting that “we are going to die, and that makes us the lucky ones”,
given that we “won the lottery of birth against all odds” (Dawkins, 1998, p. 1). One
exercise to help clients cultivate gratitude for the unlikelihood of their existence
involves calculating the probability of their parents ever meeting in the first place
(followed by their grandparents and so on) and thus the unlikelihood of them ever
coming into being (Menzies, 2012). Clients should therefore be guided away from
the inaccurate assumption that their existence on this planet was ever guaranteed
and instead encouraged to focus on the miraculous improbability of their own
unique sequence of DNA ever appearing at all.
Given that clients know that death is ultimately inevitable, disputing the proba-
bility estimates of one specific means of death is likely to fail at addressing their
underlying fear death itself. As such, it is crucial to focus on reducing the cost of
dying rather than the probability (which, of course, will always be 100%) and to
tolerate uncertainty about what will happen after death. For some clients, the cost of
death will be viewed quite highly due to unrealistic beliefs about dying, such as “If
I die prematurely, my children will end up in social services”. To develop an alterna-
tive belief, clients can be encouraged to prepare and distribute surveys to close
friends and family, to assess their loved ones’ coping strategies and ability to care
84 R. E. Menzies and D. Veale

for their children in the event of their early death (Silver et al., 2004). Of course,
asking the client to prepare a will in the case of their early death, to arrange what
will happen to their children, will also aid in this process. Similar methods may be
used to challenge beliefs such as “My partner’s life would be completely destroyed
if I die”, or “Nobody will miss me if I die”.
Of course, being able to identify and question one’s own thoughts requires cogni-
tive flexibility and minimal perseverative thinking, which some clients may find
challenging. For clients who struggle with this skill, behavioural strategies may
prove more helpful.

3.2 Behavioural Experiments

Like CBT for health anxiety (Salkovskis & Bass, 1997), a client may be guided to
consider two opposing theories: one that is in line with their current belief (e.g.,
theory A: “If I were to die prematurely, my partner wouldn’t be able to cope, and our
children would end up in protective (social) care”) and another that proposes an
alternative (e.g., theory B: “This is a worry problem, and trying to get certainty over
what will happen if I die is the problem”). The client is then encouraged to garner
evidence for the two theories in a behavioural experiment of worrying more or less
(ABAB experiment). Thus, they may discover that if they worry more and try to
solve the problem and get more information and reassurance, they will generate
more doubts. Furthermore, trying not to solve the problem and fully accept the
uncertainty will decrease the worry.

3.3 Exposure Therapy

In modern Western society, humans are more separated from death than at any other
time in history (Willmott, 2001). Advancements in modern medicine have extended
the human lifespan further than ever before, and cultural and societal changes have
led to most deaths happening in hospitals or aged care homes as opposed to within
the family home itself. Further, whilst caring for a dying person or bathing the body
of the deceased used to be the sole responsibility of close family members, these
traditional tasks are now typically left in the hands of medical staff and the funeral
industry. Whilst these changes have arguably benefited our society in a number of
ways, they have meant that opportunities to avoid any reminder of death are now
more possible than ever before. This is particularly problematic given that avoid-
ance is one of the most common ways of coping with death anxiety (McKenzie
et al., 2017).
As discussed earlier, results from a recent meta-analysis reveal that CBT inter-
ventions that focus on graded exposure appear to produce greater improvements in
death anxiety, relative to control conditions, or alternative treatments (Menzies
Creative Approaches to Treating the Dread of Death 85

et al., 2018). The CBT interventions included in that meta-analysis used a combina-
tion of in vivo and imaginal exposure. As such, exposure therapy targeting death-­
related stimuli or situations will likely play a crucial role in ameliorating clients’
fears and testing out their expectations (e.g., testing out one’s belief that they would
not cope with even thinking about death). As in other forms of exposure therapy,
whilst there are many possible exposure tasks to face a fear of death, wherever pos-
sible, exercises for the client should be tailored to their own specific fear. For
instance, priority should be given to exposing the client to situations (e.g., funerals,
cemeteries), themes (e.g., terminal illness, losing a loved one), or stimuli (e.g.,
images of skulls or gravestones) that they typically deliberately avoid (Furer
et al., 2007).
Whilst exposure therapy is beneficial for many types of anxiety, it may be par-
ticularly useful for fears of death, given that death is the one feared situation that the
client is actually guaranteed to experience. Given this, exposure tasks can also be
seen as a way of preparing for the inevitable. In much the same way that we would
practise role plays if we had an important job interview coming up, exposure ther-
apy may increase the likelihood of us coping with death effectively. This echoes the
idea of the Stoic philosophers, who argued that it is essential to prepare for death,
given that there is no escaping it. In the words of Seneca. (2018), “Study death
always, so that you’ll fear it never”.
Imaginal exposure tasks can be particularly useful for helping clients confront
their own unique fears about death. Of course, any exposure tasks must be linked
with information garnered from the original assessment and tailored to specifically
address the feared situations and beliefs of the client. Furer et al. (2007) encourage
clients to write vivid stories imagining their own specific fears and worries about
death. For example, a client who worries about losing their parent may write a
detailed description of their mother being first diagnosed with a terminal illness,
then being by their mother’s side through the dying process, then the actual death
itself, and followed by a description of the imagined funeral and the client’s descrip-
tion of their own grieving and coping process. Similarly, a client who fears dying
themselves may write a similarly detailed story depicting their own imagined dying
process. They should write it in the first-person present tense as if it is happening
now. The story should be written as if it is through their own eyes (rather than
observing themselves) and should use as many different senses as possible, such as
describing what they see, feel, hear, and smell. It is important to focus on their spe-
cific fears (e.g., suffocating) and to include a description of the death itself. These
stories can then be read over repeatedly by the client until their ability to tolerate
their anxiety improves. Acceptance and Commitment Therapy has also popularised
a similarly creative task, involving the client writing their own tombstone inscrip-
tion and imagining their own funeral (Hayes & Smith, 2005).
There are also numerous examples of in vivo exposure tasks that may prove use-
ful. This includes visiting cemeteries, funeral homes, or hospitals (Bohart &
Bergland, 1979a, b) or reading obituaries online or in the newspaper (and in particu-
lar, looking for individuals who died at one’s own current age; Furer et al., 2007).
Preparing one’s own will, writing one’s own obituary or eulogy, making
86 R. E. Menzies and D. Veale

arrangements for a guardian for one’s children, or having discussions regarding

one’s own end of life preferences may also be valuable exposure tasks (Furer et al.,
2007; Henderson, 1990). Clients may be encouraged to make an Advance Care
Directive or living will (i.e., to formalise their decisions regarding whether or not
they want to be resuscitated, who would they like to be in charge of their care,
whether they would like to be on a ventilator, etc.) and to consider whether they
would like to opt into (or out of) organ donation. In addition to reducing the client’s
anxiety around death, these practical tasks may also help increase their sense of
control and autonomy and provide reassurance about how their passing may tran-
spire. Taking these concrete steps to ensure one’s wishes are carried out after death
may not only help clarify one’s own values and preferences surrounding death but
may also challenge one’s assumptions that others will not cope with their death by
reducing some of the decision-making burden from the family who will be bereaved.
Some clients will demonstrate resistance to these practical tasks occasionally due to
magical thinking related to the belief that planning for one’s death may increase the
likelihood of it coming about. For these individuals, it may be helpful to remind
them that their will is already written unless they do something about it. That is,
their assets will be distributed regardless but that without a will, they might end up
being distributed to people they would rather not share in their estate. Exposure
tasks also provide an important chance to test out the client’s individual beliefs. As
such, it is important to review these after an exposure task (i.e., Is this more evi-
dence for theory A, or theory B, now that you have completed this exercise?). Whilst
learning to tolerate anxiety, they are also testing out their expectation (e.g., that they
would not cope with the feelings or that the feeling would go forever), which can be
evaluated after an exposure task.
For clients who fear death due to their religious beliefs (e.g., the uncertainty of
going to hell), tasks may include discussing their beliefs and concerns with relevant
religious authorities, who may be able to provide corrective information if the
beliefs are not in line with contemporary religious teachings or that they have no
decision over what happens after death. However, it may be important for the thera-
pist to check with a religious authority about what they may be told before a client
meets them.
Fear of death often overlaps with superstitiousness. Being anti-superstitious was
originally celebrated as far back as the 1880s where rationalists would host dinners
for 13 people on Friday the 13th to walk under ladders and spill a salt shaker.
Therefore, when one of us had his 50th birthday, it was celebrated by an anti-­
superstitious and anti-necrophobia party. Thus, 13 guests were sat around each
table, and they were invited to break a mirror or put up an umbrella in the house.
There was a Grim Reaper and someone else dressed as the devil to welcome guests.
An actor played a funeral director who kindly measured people up for a coffin and
discussed their wishes for their funeral. There was even a coffin in the garden to try
out. One of the band’s numbers was to improvise on the funeral march. After dinner,
chocolates consisted of “Obols”, which could be put under one’s tongue to pay the
ferryman, Charon, to take one across the River Hades in the garden.
Creative Approaches to Treating the Dread of Death 87

The recent upsurge in popularity of the “death positive” movement also intro-
duces a wide array of creative opportunities for exposure therapy. Death positivity
is a social and cultural movement that aims to normalise death and challenge the
silence that so often surrounds it. The death positive movement has led to increased
resources for coping with death (such as user-friendly websites designed to help you
plan your funeral), death-themed festivals and workshops, clubs at which members
gather to build or paint their own coffins, and even death-themed, adult-colouring
books, through which people can mindfully colour in images of decomposition,
embalming, and funeral rites from around the world. Alongside this movement, the
last decade has seen an increase in the number of “death cafés” held worldwide.
Death cafés are not-for-profit events designed to stimulate open and honest conver-
sation about death in a non-judgemental setting. They are typically held in an infor-
mal place, such as in a member’s home or a local café, to encourage attendees to
share their views on death with friends or strangers whilst enjoying some tea and
cake. There have been over 10,000 death cafés held to date, in 70 countries, mean-
ing that they are likely to be accessible to a number of clients. Attending a death café
is likely to normalise the topic of death for a client and encourage them to face this
feared topic in a supportive and open environment.
When considering creative approaches to exposure therapy, the use of media
such as film, television, literature, and music warrants particular mention. These can
often serve as powerful tools to emotionally shift client’s perspectives on death in
addition to merely exposing them to the fear in the vein of classic exposure tasks.
Films with themes of death have been utilised as exposure tasks in prior studies
(Bohart & Bergland, 1979a, b). Movies that explore death (e.g., Beaches, The Green
Mile, or Departures) or, more broadly, themes of impermanence and the shortness
of life (e.g., Bladerunner) may be valuable. Children’s films on the topic can also be
surprisingly moving and may serve as useful exposure tasks. Animated films such
as Coco and Up explore ideas relating to continuing bonds with the deceased and
coping with the loss of a loved one. Television programs may also prove equally
valuable (e.g., Six Feet Under, and several episodes of Black Mirror, which explore
mortality, including “Be Right Back” and “San Junipero”). Songs such as Don’t
Fear the Reaper by Blue Öyster Cult, with lyrics addressing the universality and
natural aspects of death, or All Things Must Pass by George Harrison, which under-
scores the importance of embracing impermanence, can also be listened to (the
album See You in the Morning Light by Deep Pools, written and recorded after the
artist lost his father to cancer, offers a particularly vivid example of the value of
creative approaches to exploring mortality). If relevant, clients may like to consider
making one such song their ringtone to serve as periodic reminders of mortality
throughout the day.
Fiction (e.g., The Death of Ivan Ilyich by Leo Tolstoy) or non-fiction books (e.g.,
Mitch Albom’s memoir about his dying mentor, Tuesdays with Morrie; Paul
Kalanithi’s When Breath Becomes Air, a neurosurgeon’s account of being diagnosed
and eventually succumbing to cancer; Atul Gawande’s Being Mortal, and Mortals:
How the Fear of Death Shaped Human Society, written by Rachel and Ross Menzies)
all make relevant reading. The recent upsurge in the death positive movement has
88 R. E. Menzies and D. Veale

fortunately led to the publication of increasing numbers of books about death,

including Advice for Future Corpses (and Those Who Love Them) by Sallie Tisdale;
Gratitude, written by neurologist Oliver Sacks during the last few months of his life;
and Smoke Gets in Your Eyes: And Other Lessons from the Crematorium (in addi-
tion to From Here to Eternity) by mortician and death positivity advocate Caitlin
Doughty.
The value of humour should also not be understated, and material that offers a
light-hearted perspective on what is typically viewed as a dark and taboo subject can
be unexpectedly powerful. Relevant materials include films such as Death at a
Funeral, television shows such as Afterlife (a black comedy that poignantly explores
grief), or books such as Everybody Dies: A Children’s Book for Grown Ups by Ken
Tanaka or Dead People Suck: A Guide for Survivors of the Newly Departed written
by comedian Laurie Kilmartin following the death of her father.
Technology should also be considered for the creative opportunities it provides
for exposure tasks. Apps like We Croak or Kick the Bucket offer the user frequent
reminders throughout the day of their own mortality through push notifications and
accompanying quotes related to death. Gaming apps related to death may also prove
useful. One such example is A Mortician’s Tale in which the user plays as a morti-
cian working in a funeral home, proceeding through the various steps of cremation
or embalming for her deceased clientele. The death positive movement has also
seen an increase in games designed to start conversations about death with others
(e.g., The Death Deck, and Mortalls: The Death Positive Conversation Game, which
involves players answering questions such as “Would you rather die or be cre-
mated?” or “If you had just one day left to live, how would you decide to spend
it?”). In addition to being useful exposure tasks, playing a game such as these helps
to normalise the topic of death and also opens up conversations about mortality with
loved ones, which the player may find personally meaningful and valuable.

3.4 Tolerating Uncertainty

If the fear of death is associated with uncertainty paralysis and an unstructured and
disrupted routine, one of the first steps is to build a sense of safety by creating struc-
ture and routine. This overlaps with activity scheduling and involves choosing tasks
that are avoided and valued in order to create a sense of order in one’s life. This may
include a sleep routine and getting up at a regular time. Once safety is established,
it is then important to include small but novel tasks and more flexible routines. It is
important to otherwise keep their routine and gradually add more novelty and flex-
ibility of a routine to build gradual tolerance of uncertainty.
Creative Approaches to Treating the Dread of Death 89

3.5 Imagery Rescripting

Imagery rescripting (ImRs) is a transdiagnostic intervention that can be used for

aversive memories that are associated with the onset of intrusive images and still
have a sense of “nowness” (Arndtz, 2012; Veale et al., 2015). This involves trying
to provide the younger “self” with what he or she needs (usually a sense of control
over events) and developing an alternative meaning to the event. Thus, although the
efficacy of ImRs on death anxiety has not yet been empirically examined, ImRs
might be used for an aversive memory about how a close friend or relative died to
help a client come to terms with the loss and potentially develop a more helpful
meaning for it.

3.6 Psilocybin-Assisted Psychotherapy

Lastly, research is currently being carried on the role of psychedelic-assisted psy-

chotherapy for depression, anxiety, addictions, and the psychological challenges
associated with death and dying (Rucker et al., 2018). Moreton et al. (2020) suggest
that reduced death anxiety may be a key mechanism underpinning the therapeutic
effects of psychedelics and provide a review of the mechanisms through which psy-
chedelics may reduce death anxiety. There has been one controlled trial with psilo-
cybin that measured death anxiety as a secondary outcome. Griffiths et al. (2016)
used a double-blind, randomised, crossover design with 51 patients with life-­
threatening cancer and associated anxiety and depressive symptoms. In this study,
the placebo condition was a subtherapeutic dose of psilocybin. The treatment condi-
tion involved a high dose of psilocybin administered in a counterbalanced sequence
with 5 weeks between sessions and 6 months follow-up. Psychological support was
provided before, during, and after the session with psilocybin. The results showed
that the high dose was superior in terms of depressed mood and anxiety, along with
increases in quality of life, life meaning, and decreases in death anxiety. At 6-month
follow-up, these changes were sustained, with about 80% of participants continuing
to show clinically significant decreases in depressed mood and anxiety. No serious
adverse events were reported, and significant associations between mystical-type
experiences and enduring positive changes were observed. Further research is
needed to clarify the potential efficacy of psychedelic-assisted psychotherapy for
death anxiety.
90 R. E. Menzies and D. Veale

4 Conclusion

Increasing evidence suggests that death anxiety may be a driving factor in a number
of different mental health conditions. Given the transdiagnostic role of this con-
struct, there is a need for treatments that directly target the client’s underlying fear
of death rather than merely addressing the overt symptomatology of a particular
disorder. CBT interventions that focus on exposure therapy have been shown to
reduce death anxiety across a number of studies. As such, creative exposure exer-
cises will prove valuable in enabling the client to face their feared situations sur-
rounding death. Other CBT techniques such as cognitive challenging and behavioural
experiments are also likely to help target maladaptive or unrealistic beliefs about
death although empirical evidence is needed to demonstrate the efficacy of these
techniques on death anxiety. At present, only a small number of RCTs have demon-
strated the efficacy of CBT in reducing death anxiety, and studies in clinical samples
are lacking. Further research is essential to determine whether these aforementioned
strategies will be effective in ameliorating fears of death among those with mental
health conditions.

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 Part III
Isolation
Existential Isolation: Theory, Empirical
Findings, and Clinical Considerations

Peter J. Helm, Ronald F. Chau, and Jeff Greenberg

Abstract  Yalom (1980) identified three forms of isolation: intrapersonal, interper-

sonal, and existential. This chapter focuses primarily on existential isolation, both
as an existential reality and as a subjective experience. Existential isolation refers to
the inherent unbridgeable gap between any two beings and the impossibility of
knowing with certainty how anyone else experiences the world. The chapter begins
with discussion of existential isolation as an existential reality and how awareness
of it can be threatening to a species that relies upon shared social validation for
meaning and psychological security. The chapter then examines the consequences
and potential benefits of confronting existential isolation, considers how existential
isolation relates to other existential concerns, and reviews empirical research on the
topic. The chapter concludes with a discussion of ways in which psychotherapy
could help clients develop resources to manage the anxiety associated with aware-
ness of existential isolation.

Keywords  Existential isolation · Identity · Meaning · Freedom · Death · Terror

management theory · Meaning maintenance · Existential loneliness

1 Introduction

Therapists and mental health workers have recognized the prevalence of social dis-
connection for a long time, and the consequences of disconnection are well docu-
mented (e.g., Holt-Lunstad et al., 2015). Chapters “Isolation, Loneliness and Mental
Health” and “Social Prescribing: A Review of the Literature” will primarily focus

P. J. Helm (*)
University of Missouri, Columbia, MO, USA
e-mail: [email protected]
R. F. Chau · J. Greenberg
University of Arizona, Tucson, AZ, USA

© Springer Nature Switzerland AG 2022 95

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_6
96 P. J. Helm et al.

on the most commonly researched form of isolation, loneliness. While some

researchers might dispute the degree to which loneliness constitutes an existential
concern, it is recognized as a universal experience (McGraw, 1995; Perlman, 2004).
Moreover, affiliation, social connection, and belongingness constitute key sources
of meaning that are threatened by loneliness (Van Tilburg et al., 2019), and loneli-
ness has been found to be associated with lower perceived meaning (Hicks
et al., 2010).
Nevertheless, isolation is rarely discussed in an existential context, especially
among empirical psychologists. Unlike other existential concerns (e.g., death,
meaning), research on existential isolation has remained relatively sparse. Yet recent
efforts have begun to investigate the subjective experience and awareness of exis-
tential isolation and compare its consequences to those of other forms of isolation
(e.g., Helm, Greenberg, et al., 2019a; Pinel et al., 2017).
The present chapter will focus on existential isolation, both as an existential real-
ity and as a subjective experience. This chapter will start with a discussion of the
definition of existential isolation as described by Yalom’s (1980) Existential
Psychotherapy. It will consider how awareness of existential isolation can be threat-
ening to a species that relies upon shared social validation for meaning and psycho-
logical security. The chapter then examines the consequences and potential benefits
of confronting existential isolation. The chapter then considers how existential iso-
lation relates to other existential concerns, reviews empirical research on the topic,
and concludes with a discussion of potential ways in which psychotherapy could
help alleviate existential isolation in those negatively affected by it.

2 Existential Isolation

Existential psychotherapist Irvin Yalom (1980) describes three types of isolation:

intrapersonal, interpersonal, and existential. Intrapersonal isolation “is a process
whereby one partitions off parts of oneself” (p. 354). In severe cases, this process
can refer to clinical disorders (e.g., dissociative disorders) but can also refer to any
fragmentation of the self, such as instances in which a person suppresses their own
thoughts or desires, mistrusts their own judgments, or knowingly acts
inauthentically.
Yalom (1980) notes that interpersonal isolation, “generally experienced as lone-
liness, refers to an isolation from other individuals” (p  353). Interpersonal (i.e.,
between person) isolation is most frequently conceptualized as social isolation or as
loneliness. Social isolation (e.g., Child & Lawton, 2017) is understood as an objec-
tive lack of relationships or contact with others (i.e., one is physically separated
from others). Though, as Yalom argues, interpersonal isolation is most often experi-
enced as loneliness, which refers to the subjective and distressing feeling associated
with dissatisfaction with one’s social contacts (e.g., Peplau & Perlman, 1982), it
should be noted that interpersonal isolation can also be experienced positively as in
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 97

solitude, which often is viewed as a restorative experience and a venue for creative
or religious experiences (see Coplan & Bowker, 2014; Mansfield et al., 2019).
The third type of isolation is existential isolation, which “refers to an unbridge-
able gulf between oneself and any other being. It refers, too, to an isolation even
more fundamental—a separation between the individual and the world” (Yalom,
1980, p. 355). When a person becomes aware of their existential isolation, they may
feel as if no one understands their perceptions, that they are alone in their subjective
experience (Pinel et al., 2017). Yet if interpersonal isolation refers to “between per-
son” separation, then wouldn’t existential isolation fall into this category? Indeed,
in Yalom’s extended discussion of existential isolation, he refers to it as a “vale of
loneliness” (p.  356) and suggests interpersonal and existential isolation are so
closely related that the boundaries between them are semipermeable. Moreover, the
subjective experience of the two forms of isolation “may feel the same and mas-
querade for one another” (p. 355).
Thus, what makes existential isolation unique? Yalom (1980) proposes that exis-
tential isolation does not ultimately stem from interpersonal relationships but rather
exists as an existential reality (i.e., it flows from the givens of existence). In other
words, all humans across time and space must contend with existential isolation
(e.g., Sullivan et  al., 2012). Insofar that humans can only experience the world
through their personal sensory organs and cannot read another’s mind, no matter
how close two individuals get, there always exists “an unbridgeable gulf” between
people preventing them from truly knowing firsthand the experience of another
(Mueller, 1912). Becker (1971) describes awareness of existential isolation as
emerging out of developmental processes; as we develop a theory of mind, we real-
ize that “we come into contact with people only with our exteriors—physically and
externally; yet each of us walks around with a great wealth of interior life, a private
and secret self” (p. 28).
This awareness of one’s inherent isolation is particularly problematic for a spe-
cies that continuously relies upon abstract symbolic representations of the world
(e.g., Becker, 1971; Berger & Luckmann, 1966; Rank, 1945). From an existential
perspective, there is no inherent meaning or purpose to life, and thus humans invest
in socially constructed and maintained symbolic conceptions of reality that imbues
life with meaning, order, and permanence (Becker, 1971; Greenberg et al., 1986;
Kierkegaard, 1981). These symbolic organizations can range from microlevel (e.g.,
feeling confident in one’s basic conceptions and interpretations of reality) to macro-
level (e.g., abstract symbolic belief systems such as national or religious identity)
conceptions (e.g., Arndt et al., 2013). Importantly, because these abstract represen-
tations are ultimately fictions, their validity depends upon social validation and
agreement.
Many theories across disciplines underscore the importance of socially shared
and constructed bases of psychological processes (e.g., Asch, 1952; Barrett, 2017;
Becker, 1971; Cooley, 1964; Echterhoff et al., 2009; Festinger, 1954; Mead, 1934).
For example, Festinger’s (1954) theory of social comparison asserts that the validity
of our personal beliefs depends upon shared belief by similar others. Similarly,
98 P. J. Helm et al.

research on reflected appraisals argues that people learn about themselves most
directly from others rather than from introspection or self-observation (Vazire,
2010). Becker (1971), and later terror management theory (Greenberg et al., 1986;
Routledge & Vess, 2019), argues that socially shared belief systems ultimately
address core fundamental human concerns (e.g., How did I get here? What is the
meaning and purpose of my life?).
Awareness of one’s existential isolation threatens to thwart the protective nature
of these symbolic constructions of reality. Existential isolation is the awareness that
one is ultimately alone in their interpretation of reality (i.e., one can never truly
know with certainty the subjective experiences of another), thus undermining the
protective function of socially constructed symbolic conceptions (Pinel et al., 2004).
For example, imagine a devout Christian is listening to a lecture from a Buddhist
monk on the cycles of reincarnation and finds herself intrigued and comforted by
these notions. Meanwhile, other members of her congregation are reacting with hor-
ror and disbelief. The listener realizes she is having very different reactions than
those around her and, even more concerning, having reactions that may be at odds
with her current belief system. She becomes aware her perceptions may not be
shared by those around her, and if the doctrine of another religion is more comfort-
ing than her own, which should she believe? In essence, awareness of her existential
isolation (i.e., uniqueness of experience) threatened the foundation of her socially
constructed beliefs. A wide variety of research finds that when people’s sense of
shared reality is undermined, it can leave them feeling uncertain and vulnerable
(e.g., Asch, 1951; Echterhoff et al., 2009).

3 Confronting Existential Isolation

“We are all lonely ships on a dark sea. We see the lights of other ships—ships that we can-
not reach but whose presence and similar situation affords us much solace. But if we can
break out of our windowless monad, we become aware of the others who face the same
lonely dread. Our sense of isolation gives way to a compassion for the others, and we are no
longer quite so frightened. An invisible bond unites individuals who participate in the same
experience—whether it be a life experience shared in time or place (e.g., attending the same
school) or simply as a member of an audience at some event.”
- Irvin Yalom, Existential Psychotherapy

Confronting existential concerns is not an easy or comfortable task (Heidegger,

1927; Kierkegaard, 1981). Like existential threats more broadly, awareness of one’s
existential isolation induces the potential for negative affect, whether consciously or
unconsciously (Sullivan et al., 2012). Yalom (1980) writes, “The experience of exis-
tential isolation produces a highly uncomfortable subjective state and…is not toler-
ated by the individual for long. Unconscious defenses ‘work on it’ and quickly bury
it—outside the purview of conscious experience” (p. 362). Thus, similar to proxi-
mal defenses in terror management theory that serve to push death thoughts out of
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 99

conscious awareness (see Burke et al., 2010, for a review), defense processes oper-
ate to bury awareness of isolation.
The primary mechanism of isolation denial is relational in nature (Fromm, 1963;
Yalom, 1980), which can include relationships with one’s work (e.g., becoming a
workaholic), orgiastic states (e.g., engaging in religious or sexual states), or confor-
mity (e.g., merging or fusing with a group, investing in interpersonal relationships).
Work on identity fusion (e.g., Swann et al., 2012), which occurs when people expe-
rience a visceral feeling of oneness with a group, is an example of extreme isolation
denial tendencies. The act of “fusion [with another person, group, cause, country, or
project] eliminates isolation in a radical fashion—by eliminating self-­awareness”
(Yalom, 1980, p. 380).
Though Yalom (1980) cautions that while no relationship can eliminate isolation
entirely (though fusion may give the impression one has), aloneness can be shared
in such a way that “love compensates for the pain of isolation” (p. 363). Echoing
sentiments expressed by Martin Buber (1970), Yalom argues that mature, authentic
relationships marked by empathy, perspective taking, and reciprocity best serve to
assuage one’s existential isolation. Through even a brief relational encounter, the
self is altered because it internalizes the encounter; “it becomes an internal refer-
ence point, an omnipresent reminder of both the possibility and reward of a true
encounter” (Yalom, 1980, p. 396). If the relational encounter is positive and authen-
tic, the internalized experience serves as a tempering of existential anxiety (Yalom,
1980). While relationships can perhaps bridge the existential gulf momentarily, and
may facilitate growth, it is ultimately incumbent upon the individual to bear the
pangs of existential stress “resolutely” (Camus, 1955; Heidegger, 1927; Hobson,
1974; Kierkegaard, 1981; Yalom, 1980). Through engaged and directed confronta-
tion with one’s existential isolation, one may develop a tolerance to be able to cope
with one’s situation.
Other thinkers have also argued that confronting existential isolation can be a
process toward growth though the meaning of growth is often poorly articulated
(see Ettema et al., 2010, for a review). Generally, a confrontation with existential
isolation is thought to have the potential to foster three types of growth. These are
personal growth, in which an individual’s potential might be actualized (e.g., Mayers
et al., 2005; Park, 2006); interpersonal growth, where one’s relationships deepen
and feelings of intimacy are heightened (e.g., Lindenauer, 1970; May & Yalom,
2000); or spiritual growth, where one relates to himself or herself in a more tran-
scendent mode (e.g., Collins, 1989). By acknowledging that one is existentially
isolated, a person may also discover their internal resources and strength in the face
of this fact. The development of such resilience may be an important first step in
living with existential isolation in an adaptive manner. It has also been suggested
that acceptance of one’s existential predicament can lead to increased empathy and
perspective taking toward others who are in the same situation.
One potential problem with this perspective is that it benefits those who already
have adequate resources in place to confront their existential anxiety—a rich get
richer, poor get poorer dilemma. Individuals who are already able to relate to others
100 P. J. Helm et al.

in secure and mature ways are most able to confront and tolerate their isolation. In
contrast, those without these resources struggle to find safety and security (e.g.,
Plusnin et al., 2018).

4 Existential Isolation in the Day-to-Day

Individuals are often isolated from others and from parts of themselves, but underlying
these splits is an even more basic isolation that belongs to existence—an isolation that per-
sists despite the most gratifying engagement with other individuals and despite consum-
mate self-knowledge and integration.
- Irvin Yalom, Existential Psychotherapy

As we have argued so far, and as Yalom articulates in the quote above, existential
isolation is an ever-present concern, persisting despite our interpersonal connec-
tions and irrespective of level of self-knowledge. Experiences with existential
threats are part of the normal range of experience of the average person within a
given culture (e.g., Sullivan et al., 2012; Tillich, 2000). Thus, confronting existential
concerns is not necessarily pathological or the result of a neurotic condition.
However, the average person, at least in Western cultures, is not likely to be aware
of, or to be able to understand when, existential concerns are influencing thoughts,
emotions, and behavior.
Factors that May Contribute to Keeping Existential Isolation Out of
Consciousness  Social psychological research has identified a variety of cognitive
biases that may combat awareness of existential isolation. For example, confirma-
tion bias is the tendency to interpret and attend to information that supports one’s
own position and to ignore information that does not support one’s attitudes (Landau
et al., 2004; Nickerson, 1998). Research on the false consensus effect (Ross et al.,
1977) suggests that people typically overestimate the number of other people who
share their beliefs and attitudes. In both cases, these projective heuristics lead to the
sense that one’s subjective beliefs are accurate and shared by others, thus reducing
the likelihood that one will become aware of their existential isolation. An American
conservative watching Fox News and an American liberal watching CNN are both
likely to feel like their views are shared much more than they really are.
Other work suggests that as we develop close and intimate relationships, we
naturally tend to assume the other person shares our internal perspectives. For
example, work with people in satisfying and stable relationships reveals that they
tend to perceive similarities with their partners even when these similarities are not
evident in reality (e.g., Murray et al., 2002). These egocentric assumptions help the
individual to feel understood and satisfied in their relationship, but ultimately, these
assumptions are distortions and serve a protective function against isolation aware-
ness. Other research suggests that people will even change their own views to coin-
cide with others in uncertain situations (Asch, 1951; Echterhoff et al., 2009), thus
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 101

perhaps ignoring their own intuitions to avoid confronting their fundamental

isolation.
Anxiety buffers may also contribute to keeping awareness of existential isolation
at bay. Theories of psychological defense (e.g., terror management theory, anxiety
buffer disruption theory, meaning maintenance model; see Hart, 2014) propose that
humans are motivated to protect themselves from potentially anxiety-evoking
threats by investing themselves in a variety of buffers including close relationships,
self-esteem, and cultural worldviews. From these perspectives, anxiety buffers
function to allow us to operate with relative psychological equanimity in the face of
existential concerns (e.g., inevitable death, inherent isolation). Research has found
that strong anxiety buffers ameliorate anxiety and are associated with better health.
For example, research has found that high self-esteem (either dispositionally or
experimentally elevated) attenuates the threat of death (e.g., Greenberg et al., 1992;
Harmon-Jones et al., 1997) and is associated with greater mental and physical health
(e.g., Kernis, 2005). Along these lines, it is reasonable to expect strong anxiety buf-
fers to also mitigate the threat of existential isolation.
Factors that May Contribute to a Greater Propensity to Experience Existential
Isolation  In contrast to the various mechanisms and processes that serve to keep
existential out of focal awareness, other factors may contribute to a greater propen-
sity to experience fundamental isolation. Aside from the more straightforward prop-
osition that weak anxiety buffers (e.g., low self-esteem, weak interpersonal
relationships, doubting one’s cultural worldviews) would therefore contribute to
elevated existential isolation, cultural factors are also likely important.
Researchers have identified a range of dimensions upon which cultures vary. One
commonly researched dimension is individualism-collectivism (Triandis, 1995).
Individualist societies (e.g., the United States) tend to value the individual over the
group, and people tend to prioritize their personal goals over the goals of others.
Collectivist societies (e.g., Japan) tend to value in-groups (e.g., family, organiza-
tion) over individual needs. In individualistic cultures, people tend to think of them-
selves as discrete and tend to use others as a source of social comparison to confirm
their uniqueness (Cross et  al., 2011; Markus & Kitayama, 1991). In collectivist
cultures, people tend to think of themselves in relational terms (e.g., friend,
coworker) and tend to use others as a way to determine if they are fulfilling their
relational obligations (Cross et al., 2011). A society’s level of individualism may
influence the degree to which its members are likely to experience existential isola-
tion. Insofar that individualistic people see themselves as distinct from others and
place greater value on their personal experiences and goals while downplaying the
perspectives of others, they should be more likely to become aware of their funda-
mental disconnection from others. In contrast, members of collectivistic cultures,
who are constantly aware of the needs and perspectives of others, should be less
likely to become aware of their fundamental disconnectedness (Pinel et al., 2020).
102 P. J. Helm et al.

5 Relating Existential Isolation to Other

Existential Concerns

Many thinkers have argued that existential concerns are interrelated and awareness
of one may activate another (e.g., Pyszczynski et  al., 1990; Tillich, 2000;
Yalom, 1980).
Death  Yalom (1980) argues awareness of one’s own death ultimately leads an indi-
vidual toward a confrontation with their fundamental isolation and writes, “Each of
us enters existence alone and must depart from it alone” (p. 9). Though a person
may be surrounded by family and friends, though others may die at the same time
or for the same cause, “at the most fundamental level dying is the most lonely
human experience” (Yalom, 1980, p. 356). By this reasoning, contemplating one’s
inevitable death leads one to a realization of their inherent isolation. In the reverse
direction, death is arguably the highest order, or most distal source, of existential
threat (Pyszczynski et  al., 1990; Tillich, 2000). Without the threat of nonbeing,
other existential threats would lose their impact. Thus, any confrontation with exis-
tential isolation should ultimately lead one toward death-related concerns.

Meaning  An existential framework suggests that humans live in an inherently

meaningless and absurd world. Yet humans strive to create and maintain systems of
meaning, which provide buttresses against existential angst. A confrontation with
meaninglessness leads the individual to feel as though the world is chaotic and
human endeavors are pointless (e.g., Kierkegaard, 1981; Tillich, 2000). Awareness
of one’s existential isolation may undermine one’s sense of meaning (Kuperus,
2018). Given that systems of meaning are ultimately substantiated by confidence in
social validation, awareness that one can never truly have their subjective feelings
validated by another leaves the structures of meaning on insecure foundations. In
this sense, the threats of existential isolation and meaninglessness may have a bidi-
rectional relationship.

Freedom  The existential concern of freedom refers to the ability to choose one’s
path at any moment (e.g., Sartre, 2001), leading humans to cope with the responsi-
bility of self-creation. Awareness of authorship implies that others are therefore not
responsible for one’s actions, and thus, one must contend with the isolation of self-­
creation (e.g., Yalom, 1980). In other words, awareness of choice (and the corre-
sponding responsibility) leaves the individual vulnerable to existential isolation
because the individual is alone in having to make and live with their choices.

Identity  The concern of identity refers to the inability to have full knowledge of
oneself and arises through the courage to be part of groups or through affirmation
processes. These processes reflect differences in personal and social identity (e.g.,
Castano et al., 2004). Personal identity refers to identification with the self, restricted
to one’s body and being. Social identity, in contrast, extends beyond the self and
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 103

refers to identification with a group or community. Social identity theorists (e.g.,

Hogg & Mahajan, 2018; Tajfel, 1978) argue that social groups in part function to
assuage existential concerns. Yet as discussed, effectively merging with a social
group may be thwarted by awareness of one’s inherent separateness from others.
Moreover, Yalom (1980) discusses a primary consequence of self-awareness, and
inward focus is an awareness of one’s existential isolation. Insofar that the problem
of identity illuminates inward focus and requires an individual to self-create, it
should also activate a potential for awareness of one’s existential isolation.

6 Empirical Research on Existential Isolation

Assessment Measures  There has been very little research focusing on existential
isolation compared to other existential concerns (i.e., death, meaning) though
recently, researchers have begun to study this experience empirically. Until recently,
most papers considering existential isolation focused on qualitative experiences of
patients in palliative care or with psychological disorders (e.g., Ettema et al., 2010;
Kazanjian & Choi, 2013; Mayers et al., 2002; Mayers & Svartberg, 2001). There
have been two prominent exceptions to this trend. Mayers and colleagues (Mayers
et al., 2002) developed an Existential Loneliness Questionnaire (ELQ) to assess the
experience among women with HIV, and Pinel and colleagues (Pinel et al., 2017)
developed a trait Existential Isolation Scale (EIS), which measures the degree to
which individuals regularly feel as though others do not or cannot understand their
subjective perceptions and experiences. This scale has also been adapted to assess
state or in-the-moment experiences of existential isolation.
The ELQ has multiple items that specifically reference HIV diagnoses and was
found to correlate very highly with general loneliness, depression, and purpose in
life in a sample of women with HIV, suggesting the questionnaire may assess a
construct that overlaps with other constructs, at least in clinical samples. The EIS
scores showed small to moderate correlations with general loneliness, demonstrate
stability over time, and showed adequate concurrent and discriminant validity with
related constructs. The majority of the research highlighted below focuses on work
utilizing the Pinel et al. (2017) scale.

Correlates of Existential Isolation  Empirical work has examined the extent to

which awareness of existential isolation relates to a variety of social psychological
phenomenon in an attempt to underscore the utility of assessing isolation in an exis-
tential sense rather than only interpersonally. One such body of research has found
that existential isolation is indeed associated with a weakened anxiety buffer (Helm
et al., 2019b). As reviewed above, humans have various anxiety buffers (i.e., cul-
tural worldviews, self-esteem) in place that buffer against potential anxiety-­inducing
threats (for a review, see Burke et al., 2010). Terror management research has found
that when these anxiety buffers are threatened, they no longer prevent our
104 P. J. Helm et al.

c­ onsciousness from contemplating death, and death thoughts become more acces-
sible in consciousness.
Emerging work, however, has begun to focus on baseline death-thought acces-
sibility, which is conceptualized to be indicative of a weak or fragmented anxiety
buffer (e.g., Hayes et al., 2010). Researchers reasoned that if existential isolation
threatened the foundations of our anxiety buffers (i.e., undermined the social valida-
tion of these symbolic conceptions), then it would be associated with elevated death
thoughts. Indeed, existential isolation was found to be associated with elevated
death-thought accessibility and that reminding participants of their existential isola-
tion increased death thoughts compared to control primes (Helm et  al., 2019b).
Moreover, this work found that existential isolation was associated with less impor-
tance of one’s national identity and lower self-esteem. Importantly, the relationship
between existential isolation and death thoughts could not be explained by loneli-
ness though the relationship between loneliness and death thoughts could be
explained by their mutual relationship to existential isolation.
Other work has examined how existential isolation may relate to attachment ori-
entations. Guided by research that found loneliness to be associated with insecure
attachment (e.g., Hazan & Shaver, 1987), researchers proposed that individuals who
have a history of relationships with unavailable, rejecting, and inconsistently atten-
tive attachment figures should be high in existential isolation. Consistent with these
propositions, researchers found existential isolation to predict both attachment
avoidance and attachment anxiety (Helm et al., 2020a) though existential isolation
was more related to attachment avoidance than to attachment anxiety. Interestingly,
those with secure attachment consistently reported low existential isolation, mirror-
ing Yalom’s (1980) assertion that mature relationships may buffer existential
isolation.
In similar research focusing on how existential isolation may impact community
relationships, Pinel et al. (2020) found participants with higher existential isolation
were less likely to endorse humanitarian values (e.g., “one should be kind to all
people”) and prosocial behaviors (e.g., “I donate to local causes”). Complementing
the finding above that existential isolation predicts less identification with one’s
group, these works suggests that those who are most aware of their existential isola-
tion may also feel less integrated with, and supportive of, their local communities.
Other work (Park & Pinel, 2020) examined how existential isolation may vary
culturally. In a study conducted in South Korea, they found average levels of exis-
tential isolation to be lower than those found in the United States. Moreover, exis-
tential isolation was negatively correlated with collectivism, such that the greater
one’s collectivist values, the lower their reported existential isolation. In a different
series of studies conducted in the United States (Helm et al., 2018), existential isola-
tion was found to be higher among men than women, and this difference was
explained by differences in communal value endorsement, mirroring the
cross-­cultural findings. These studies complement research that finds self-reported
loneliness to be lower in more collectivist cultures (e.g., Heu et al., 2019).
Given that feelings of existential isolation are conceptualized as the sense that
others do not, or cannot, understand one’s subjective experiences, it makes sense
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 105

that individuals with nonnormative experiences may report elevated levels of exis-
tential isolation (e.g., Kazanjian & Choi, 2013; Mayers & Svartberg, 2001). Yawger
and colleagues (Yawger et al., 2020) found that individuals with minority identities
(e.g., non-White, nonheterosexual, heavy weight1) reported higher existential isola-
tion than their majority identity counterparts (i.e., White, heterosexual, non-heavy
weight). In other work examining individuals with nonnormative experiences, Helm
and colleagues (Helm et  al., 2020b) found that student veterans reported higher
existential isolation than did other undergraduate students. Moreover, student veter-
ans who interacted with other veterans at least occasionally reported lower existen-
tial isolation than those who rarely interacted with other veterans. These studies
suggest that interacting with, or thinking about, individuals with a common identity
or shared experience may serve to temper feelings of existential isolation.
Previous qualitative and conceptual studies on existential isolation have found it
to be inherently connected to death awareness, especially among those in end-of-­
life care (e.g., Bolmsjö et al., 2019). Recent research has also begun to examine the
empirical relationship between existential isolation and mental health. Multiple
studies have found existential isolation (though some utilizing an indirect assess-
ment) to be correlated with depression (Kretschmer & Storm, 2017; Mayers et al.,
2002), stress, and anxiety (Constantino et al., 2019). In another study, Helm and
colleagues (Helm et  al., 2020a) compared the effects of existential isolation and
loneliness on depression and suicide ideation and found them to have independent
and unique effects. This study also found existential isolation and loneliness inter-
acted to predict depression, such that individuals who had both elevated existential
isolation and loneliness reported an average depression that qualified for mild clini-
cal depression. Thus, individuals who are experiencing multiple types of isolation
may be the most prone to mental health concerns.
Taken together, these preliminary research findings suggest there are important
antecedents and consequences to the experience of existential isolation. Helm and
colleagues (Helm et al., 2019a) recently articulated a state trait existential isolation
model, which focuses on how high existential isolation can be a temporary state
triggered by a specific situation; it may be context dependent, and it can be experi-
enced consistently over time as a trait. Situations or events that may elicit elevated
state existential isolation are likely those where an individual is aware she or he is
having a different experience or reaction than others (either from another person or
a group). Though this model is theoretical and has not been fully tested, Helm and
colleagues (Helm et al., 2019b) found asking participants to write about an existen-
tially isolating event increased state existential isolation. More broadly, it seems
likely that the trait form of high existential isolation, because of its chronic nature,
is most likely to impact mental health negatively.

1
 Heavy weight status was characterized by individuals with a body mass index (BMI) above 25
(calculated by participant’s height and weight), and those with non-heavy weight status had a BMI
at 25 or below (Centers for Disease Control, 2016).
106 P. J. Helm et al.

7 Implications for Psychotherapy and the Treatment

of Existential Isolation

Given the association between existential isolation and poorer mental health and
negative affect, it is worth exploring psychotherapy’s utility in alleviating the pangs
of existential isolation and its effects on psychological well-being. We can approach
existential isolation treatment from two directions. First, we can address existential
isolation directly by reducing a client’s propensity to become aware of existential
isolation through authentic relationships. Second, we can address existential isola-
tion indirectly by attending to its aftereffects and specifically anxiety and the ero-
sion of meaning.
Yalom (1980) argues that psychopathology can stem from avoiding existential
isolation because it can lead to problematic defense mechanisms. One individual
might avoid the terror of existential isolation by attempting to fuse with another,
losing their sense of self by dominance or subservience to another in a dependent
relationship. Another might blindly conform to their in-group and vilify out-groups,
denigrating the “other.” Still another might engage in compulsive sexual relation-
ships to heal their sense of aloneness.
The psychotherapist can help the client become aware of maladaptive patterns of
behavior stemming from avoidance of existential isolation and assist the client in
developing more productive patterns of behavior associated with approaching their
existential isolation. Along these lines, Yalom (1980) argues perhaps the most
important element of therapy, transcending the therapist’s theoretical orientation, is
the therapeutic alliance between the therapist and patient.
Though there is disagreement about precisely defining the therapeutic alliance, it
refers to the bond between the client and therapist and a sense of collaboration,
warmth, and support (e.g., De Re et al., 2012). Almost 40 years of psychotherapy
research has found the therapeutic alliance to be an important aspect of successful
treatment, a consistent predictor of therapy outcomes, and one of the core mecha-
nisms in the change process (De Re et al., 2012; Kuutmann & Hilsenroth, 2012).
There are many recommendations for the therapist who wants to cultivate authentic
relationships with clients. Kaiser (1965) emphasizes the importance of honest com-
munication and a dispositional interest in people, sensitivity to duplicity, and the
absence of theoretical views or neuroses that interfere with communication. Sequin
(1965) describes a “psychotherapeutic eros” or genuine, nonreciprocal caring for
the client’s well-being and growth as essential for authentic connection. Similarly,
Rogers (1951, 1980) suggests bringing an attitude of unconditional positive regard,
empathy, and authenticity to every client session (see also Norcross, 2010).
Each of these recommendations emphasizes fostering authentic encounters by
relating to the client in a genuine, caring fashion. Yalom (1980) maintains that
authentic relationships allow the therapist to “enter the patient’s world and experi-
ence it as the patient experiences it” (p. 409). Thus, the therapeutic alliance may
directly reduce existential isolation via an authentic encounter within the therapy
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 107

room. Though the therapist-client relationship is temporary, the client can realize
from this experience that such genuine connections are possible and enriching. This
realization can motivate a client to seek and establish similar authentic connections
with others.
Yalom (1980) argued that group therapy sessions can also be valuable for clients
to practice recognizing their own and others’ patterns of maladaptive responding to
existential isolation (e.g., inauthentic relating) and sharing these perceptions with
each other. These group relationships can also improve the quality of future rela-
tionships by serving as “dress rehearsals” for new modes of relating.
Drawing from empirical research cited earlier, support groups organized around
specific social identities may be particularly useful in directly reducing existential
isolation. Though it is impossible to truly bridge the existential gap between human
beings, group meetings among individuals who share an identity or experience can
help validate their experiences and give the impression that others can understand
their experiences. For example, consider the treatment of addiction. Uncomfortable
awareness of existential isolation could lead to substance use as a means to alleviate
the negative feelings associated with it. Group therapy can serve as a venue for
addicts to recognize and discuss their maladaptive patterns of behavior in response
to existential angst (Kelly et al., 2020; Rogers & Cobia, 2008). This venue would
presumably be additionally helpful for those feeling the pangs of existential isola-
tion because others attending the group have had similar experiences, thus reducing
their sense of existential isolation. As quoted above, “an invisible bond unites indi-
viduals who participate in the same experience,” and group therapy sessions provide
such an experience.
A key issue that drives maladaptive behaviors associated with existential isola-
tion is that people often opt for inauthentic relationships to manage the anxiety and
negative affect associated with it, yet these relationships are likely to be ineffective
long-term solutions (Kassel, 2010). Cognitive behavioral therapies (CBT) focus on
modifying unhelpful cognitions and behaviors. Given that clients may have such
distorted beliefs about the utility of engaging in inauthentic relationships, a program
for altering patterns of thought and behavior that supports more authentic modes of
relating may be helpful.
The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders
(UP; Barlow et al., 2018; Farchione et al., 2012) is an emotion-focused CBT devel-
oped to treat the entire range of anxiety and unipolar mood disorders. UP combines
the key features of many CBT modalities, including changing maladaptive cogni-
tive evaluations, emotion-based action tendencies, discouraging emotion avoidance,
and promoting emotion exposure. In particular, UP emphasizes understanding the
nature of emotions (i.e., associated bodily sensations, cognitions, behaviors), the
adaptive function of emotions (e.g., anxiety teaches us to be careful), and recogniz-
ing and changing maladaptive responses to these emotions. From the perspective of
UP, a client’s instinctive reaction to engage in inauthentic relationships to avoid the
anxiety of existential isolation might be a maladaptive “emotionally driven behav-
ior.” In addition, the client may have maladaptive beliefs that support this behavior,
108 P. J. Helm et al.

such as “my partner and I are one; I can lose myself in my partner.” This belief is
false because there is no way to eliminate existential isolation no matter how close
you become to someone. Therefore, part of the work from a UP standpoint is the
identification of these problematic patterns of thought and behavior, understanding
the nature and universality of the anxiety associated with existential isolation, and
practicing an approach orientation toward these feelings while attempting to relate
to other people in a new and authentic way.
Acceptance and Commitment Therapy (ACT; Hayes et al., 2006; Hayes et al.,
2011) is another popular, approach-oriented CBT. ACT focuses on cultivating psy-
chological flexibility through mindful acceptance of emotions and connection with
one’s values and taking committed action to live a meaningful life despite emotional
difficulties. Like UP, ACT can teach individuals to accept the anxiety associated
with existential isolation while simultaneously helping them to respond to it in a
more adaptive way. For instance, a client could cultivate mindful acceptance of their
anxious response to existential isolation while at the same time choosing to connect
with their values (e.g., authenticity) and practice courage and vulnerability as they
open up to others in a genuine way.
Both UP and ACT serve to address existential isolation in both direct and indirect
ways. As mentioned, UP and ACT facilitate movement away from inauthentic rela-
tionships toward authentic relationships. Specifically, beyond the authentic connec-
tion possible through a good therapeutic alliance, these cognitive behavioral
approaches involve guidance, support, and homework that assists clients in building
authentic relationships outside the therapy room, thus providing opportunity to
reduce existential in the real world.
Perhaps less obvious, ACT also addresses existential isolation indirectly by
addressing the erosion of meaning possibly stemming from existential isolation
(Hayes et  al., 2011). As mentioned, existential isolation is problematic in that it
undermines the social validation that supports one’s worldview. ACT explicitly
focuses on connecting a client to their values and fosters their commitment to taking
action to live a meaningful life, which can also strengthen a client’s perceived mean-
ing in life and faith in their worldview.

8 Concluding Remarks

Existential isolation is an inherent component of the human condition. It is impos-

sible to know with certainty that anyone else experiences the way you perceive the
world or truly understands your subjective experiences. Awareness of one’s existen-
tial isolation can threaten the symbolic foundation of our systems of meaning and
psychological security. A confrontation with one’s isolation often leads to defensive
behaviors aimed at pushing it out of conscious awareness, but many theorists con-
tend that confrontation can ultimately lead to growth. Empirical studies have found
that existential isolation relates to a variety of mental health concerns (e.g.,
Existential Isolation: Theory, Empirical Findings, and Clinical Considerations 109

depression, suicide ideation), cultural factors (e.g., collectivism), and interpersonal

factors (e.g., insecure attachment style, minority status). Treatment considerations
should focus on the healing aspects of the therapeutic alliance and the insights
offered by recent cognitive behavioral therapies.

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Isolation, Loneliness and Mental Health

Isabella Ingram and Peter J. Kelly

Abstract  In this chapter, we discuss two conceptualisations of loneliness: a singu-

lar construct and a multidimensional construct that can be experienced in both
social and emotional forms. Based on these two views of loneliness, we discuss
measurement approaches and difficulties capturing loneliness, which can be a
highly subjective experience. We review two key theories that may help to explain
how loneliness arises, is maintained and may be overcome. These are cognitive
theories of loneliness and the social identity approach. The chapter goes on to high-
light the significant physical and mental health implications of loneliness, including
proposed mechanisms by which health affects loneliness and conversely how lone-
liness can affect health. Finally, we discuss research about the relationship between
loneliness and various forms of psychopathology, including depression, anxiety,
psychosis and substance use disorders. Empirical studies are reviewed throughout,
and clinical implications of this evidence are highlighted.

Keywords  Loneliness · Mental health · Theory · Measurement · Depression ·

Anxiety · Psychosis · Substance use disorder

1 Interpersonal Isolation and Loneliness

Interpersonal isolation refers to the loneliness created by social distance. Loneliness

is described as a distressing emotional experience that results from a discrepancy
between the relationships an individual perceives they have and those that they
desire (Peplau & Perlman, 1982). A sense of belonging is a fundamental human
need (Maslow, 1943). Loneliness has been argued to serve an evolutionary function,
such that positive social interactions are affectively rewarding for humans, while

I. Ingram (*) · P. J. Kelly

School of Psychology, University of Wollongong, Wollongong, NSW, Australia
Illawarra Health & Medical Research Institute, Wollongong, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 115

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_7
116 I. Ingram and P. J. Kelly

social deprivation and the experience of loneliness are punishing (Baumeister &
Leary, 1995). Early evolutionary perspectives suggest that the feeling of loneliness
serves to protect individuals from the danger of remaining socially isolated
(Baumeister & Leary, 1995). Thus, the feeling of loneliness triggers us to seek
social connectedness, trust, cohesiveness and collective action, all of which are
needed to ensure safety and wellbeing (Cacioppo et al., 2014).

2 Conceptualisation and Measurement of Loneliness

Throughout the literature, loneliness has been considered as both a one-dimensional

construct and a multidimensional construct. This multidimensional conceptualisa-
tion encompasses different forms of loneliness that depend on the different types of
relationships that are present and fulfilling in one’s life. Weiss (1973) proposed that
different relationships fulfil distinct interpersonal needs and that loneliness will be
experienced differently depending on which of six social provisions is unmet. These
social provisions are (1) attachment, which is provided by relationships in which a
sense of safety and security is received; (2) social integration, provided by relation-
ships centred on shared interests; (3) opportunity for nurturance, provided by rela-
tionships in which others rely upon the individual for their wellbeing; (4) reassurance
of worth, provided by relationships in which the individual’s competence is recog-
nised by others; (5) reliable alliance, derived from relationships in which an indi-
vidual can obtain tangible assistance from others; and (6) guidance, provided by
relationships in which others can be relied upon for advice and assistance
(Andersson, 1998; Russell et al., 1984; Weiss, 1973).
Based on the premise that not all relationships can fulfil all of these needs, Weiss
(1973) proposed that loneliness was comprised of two distinct types of loneliness:
social loneliness and emotional loneliness. Social loneliness results from a defi-
ciency in social relationships in which an individual feels as though he or she
belongs and shares common interests. Emotional loneliness is proposed to result
from the lack of attachment to another person who affirms one’s values or upon
whom the individual feels he or she can rely for emotional support. This type of
loneliness is most often associated with romantic relationships and close friendships
(Weiss, 1973). Weiss’s two-factor conceptualisation of loneliness has been widely
accepted across the literature (DiTommaso & Spinner, 1997), with a number of
theoretically derived measurement tools having been developed based on this typol-
ogy (de Jong Gierveld & Van Tilburg, 2006; DiTommaso & Spinner, 1993).
Measures of loneliness have been subjected to critical analysis in the literature.
This is largely due to the lack of theoretical clarity in conceptualising loneliness as
distinct from related constructs such as social isolation and solitude and whether
loneliness is best conceptualised as a singular or multidimensional construct. The
most commonly used measure of loneliness is the University of California Los
Angeles Loneliness Scale (UCLA; Russell et  al., 1978), which has undergone a
number of revisions (see Russell et  al., 1980; Russell, 1996). This measure has
Isolation, Loneliness and Mental Health 117

demonstrated good psychometric properties; however, it only captures the two types
of loneliness proposed by Weiss (1973). Other measures of loneliness, such as the
De Jong Gierveld scale (de Jong Gierveld & Van Tilburg, 2006), have been criti-
cised due to omitting the terms ‘lonely’ or ‘loneliness’ in order to avoid cueing
participants. Additionally, some measures such as the 3-item loneliness scale
(Hughes et al., 2004) appear to capture objective isolation (little social contact with
others) rather than the more subjective state of loneliness (perception that one is
alone) (Beller & Wagner, 2018). Researchers have raised concerns over the face
validity of such measures (Shiovitz-Ezra & Ayalon, 2012), and this has led to diffi-
culties understanding the effects of loneliness on health and wellbeing (e.g., Beller
& Wagner, 2018). Despite this, the UCLA continues to be the most widely used and
psychometrically sound, measure of loneliness, and its broad use allows for com-
parisons of loneliness to be made across differing populations. There is also an
8-item version available, which might be more useful for practitioners who do not
want to use the full 20-item version (Roberts et al., 2016).

3 Theoretical Understandings of Loneliness

3.1 Cognitive Approaches

Cognitive theories take an individual-level perspective to explain how loneliness

arises. It is proposed that expectations about the quality or quantity of interpersonal
relationships influence the way people evaluate relationships and in turn how they
feel about their relationships (Cacioppo & Hawkley, 2005). The widely applied cog-
nitive discrepancy theory (Peplau & Perlman, 1982) explains that loneliness arises
when our individual need for social inclusion is high, yet our social environment is
incongruent to this need. Additional perspectives of loneliness have been born from
this theory, including a ‘loneliness reduction perspective’, in which individuals seek
social connections when their environment is inadequate to provide a sense of
belonging, and a ‘loneliness perpetuation perspective’, in which the feeling of lone-
liness may lead to a desensitisation to experiences that are socially rewarding
(Vanhalst et al., 2015). This perpetuation of loneliness may be due to a range of
cognitive attributions that are characteristic of lonely individuals.
Attributions are a cognitive construct that have received some attention within
the loneliness literature. Attribution theory suggests that in attempts to explain the
cause of their loneliness, lonely people are likely to attribute causality (Heinrich &
Gullone, 2006; Michela et al., 1982). This is due to an attribution style that is inter-
nal and stable; that is, these individuals believe their loneliness is due to some short-
coming of their own (internal) and that this shortcoming is unchangeable (stable)
(Anderson, 1999; Solano, 1987; Vanhalst et al., 2015). For example, a longitudinal
study compared prominent attributions of chronically lonely (i.e., a number of
years; Shiovitz-Ezra & Ayalon, 2010) adolescents to those who were not chroni-
cally lonely. Participants of this study were required to rate attribution and
118 I. Ingram and P. J. Kelly

emotional responses to vignettes depicting social inclusion and social exclusion

situations. The findings revealed that those who were chronically lonely were more
likely to deem social inclusion as being due to external circumstances (e.g., coinci-
dence) and to attribute social exclusion to their own internal and non-­changing fac-
tors (e.g., their likeability) (Vanhalst et al., 2015).
In conjunction with an internal and stable attribution style, a range of social cog-
nitions and attitudes have been found to be characteristic of lonely individuals. In
particular, lonely individuals have been found to have a hypervigilance for social
threat, negative expectations of relationships and unhelpful biases to social cues
(McHugh et al., 2018). In a large review of studies involving children, adolescent
and adult samples, attentional biases for social threat, negative attributions, negative
evaluations of self and others and expectations for rejection were found to be com-
mon and pervasive cognitive traits in those who were lonely (Spithoven et al., 2017).
Social expectations are closely tied to the concept of schemas. Schemas are inter-
nal models of the world, constructed in early childhood and often enduring into
adulthood. These are comprised of cognitions, memories, emotions and physiologi-
cal sensations (Young et al., 2006, p. 7). Young (1995) proposed a number of mal-
adaptive schemas that are interpersonally oriented and likely to be relevant to
isolation and loneliness. These include ‘social isolation/alienation’, ‘dependence/
incompetence’, ‘enmeshment/underdeveloped self’, ‘abandonment/instability’,
‘mistrust/abuse’ and ‘approval-seeking’. Maladaptive schemas and unhelpful social
cognitions paradoxically serve to maintain loneliness over time (Cacioppo et  al.,
2015). Figure 1 illustrates the role of social cognitions in maintaining feelings of
loneliness and, in particular, the role of attributions and self-defeating thoughts.
Specifically, lonely individuals are vigilant to signs of threat in their social world
(e.g., signs of others negatively evaluating them). These inherent biases may mean
that these individuals find evidence in their environment to confirm their beliefs
about self and others. Confirmation of such beliefs is likely to lead these individuals
to behave in socially counterproductive ways, such as withdrawing from others,
avoidance of social contact and sabotage of social relationships. These behaviours
in turn might elicit responses from others that maintain the individual’s sense of
isolation and expectations of their relationships.
Cognitive theories of loneliness offer insight into the intrapersonal and interper-
sonal processes that serve to maintain loneliness. However, this approach poten-
tially fails to address fully the wider social context within which individuals live
(Mann et al., 2017). In the next section, we describe a theory that accounts for the
influence of individuals’ group and community connections—the social identity
approach.
Isolation, Loneliness and Mental Health 119

Fig. 1  Model of perceived social isolation (loneliness) and social cognition. (From Cacioppo and
Hawkley (2009), reproduced with permission from author L. Hawkley)

3.2 Social Identity Approach

The social identity approach (SIA) was developed in the social psychology field of
intergroup relations and is composed of social identity theory (SIT; Tajfel & Turner,
1979) and self-categorisation theory (SCT; Turner et al., 1987). The social identity
approach describes how social groups shape identity and affect behaviour in both
helpful and unhelpful ways. SIA recognises that one’s identity is informed by both
their individual attributes and traits and also by the social groups to which they
belong. Categorisation of individuals into groups based on shared attributes facili-
tates identification with those social groups (Hogg, 1996). Ongoing affiliation with
such groups then fosters a sense of identity that becomes part of an individual’s
self-concept (Tajfel & Turner, 1979). Changes to one’s social network can also
bring about shifts in identity in terms of one’s group memberships and subsequently
their values, norms and behaviours (Dingle et al., 2015). Through the lens of SIA,
loneliness is considered to arise from a loss or lack of identification with social
groups. This suggests that individuals experiencing adversity or undertaking a
period of transition or social identity loss (e.g., through relocation, separation, ill-
ness or retirement,) are most vulnerable to loneliness.
120 I. Ingram and P. J. Kelly

Social group memberships are considered to be protective against loneliness

since they offer opportunities to cultivate close relationships with others through
shared meaning. Research has found that belonging to a group that offers meaning
and purpose to the individual can lead to an improved sense of self-worth (van
Veelen et al., 2016), decreased loneliness, improved mood and increased wellbeing
(Cruwys, Dingle, et al., 2014; Cruwys, Haslam, et al., 2014; Williams et al., 2019).
The function of group memberships is likely to be dependent on which of the social
needs are being fulfilled for the individual, as per the Weiss (1973) notion that dif-
ferent social groups fulfil different social needs. The SIA to understanding loneli-
ness extends beyond the individualised perspective offered by cognitive theories.
Through utilising the SIA, one can move beyond the view that it is the lonely indi-
vidual’s inherent beliefs, thought processes or traits that are causing them to feel
lonely. Instead, loneliness can be understood by the influence of the social groups to
which the individual feels they do or do not belong. See chapter “Social Prescribing:
A Review of the Literature” for a description and evaluation of SIA informed inter-
ventions for loneliness.

3.3 Combined Approach to Understanding Loneliness

Together, cognitive theories and SIA offer an expansive perspective on how loneli-
ness can arise and persevere. Membership and identification with different social
groups are likely to be dependent on how people evaluate themselves and others
within these groups (i.e., social cognitions) (Roth et al., 2018). In addition, people’s
expectations of social relationships and their inherent beliefs about their self and
others will be largely affected by their group identification (i.e., their social identity)
(e.g., Watson et al., 2007). As such, these theories can be used to inform one another
and to help explain how and why individuals become and stay lonely. Research has
found that social identity can shape one’s attribution style and in turn attenuate feel-
ings of depression (Cruwys, South, et al., 2014). In addition, a qualitative study of
older adults found that cognitions associated with fear of rejection and fear of losing
preferred identities were key barriers to overcoming loneliness and participating in
social activities (Goll et al., 2015). Together, these findings point to the necessity of
addressing attributions, social cognitions and schemas and group-based social iden-
tities in order to overcome loneliness and highlight the conjoint role of cognitive
theories and SIA in explaining social behaviour and subsequent loneliness.

4 Loneliness, Health and Psychopathology

Amongst the general population, loneliness has consistently been linked to poor
physical and mental health (Beutel et al., 2017; Christiansen et al., 2016; Hawkley
et  al., 2008; Segrin et  al., 2018). Research that has examined the relationship
Isolation, Loneliness and Mental Health 121

between loneliness and physical health has found that somatic complaints, sleep
disturbances (Cacioppo et al., 2002, 2015), fatigue (Jaremka et al., 2014), poorer
cardiovascular functioning (Cacioppo et al., 2002) and chronic illness (Petitte et al.,
2015) have all been found to be associated with higher levels of loneliness. This
relationship is potentially explained by lonely individuals exhibiting higher sys-
temic inflammation biomarkers (see Nersesian et al., 2018). Similarly, loneliness
has been associated with poor health behaviours (e.g., substance use, smoking, less
exercise, poor nutrition) (Christiansen et al., 2016; Stickley et al., 2013).
The relationship between loneliness and health is proposed to be reciprocal in
nature, such that poor health may lead people to feel lonelier (potentially through
variables such as one’s physical functional ability or isolation) (Savikko et al., 2005;
Shankar et al., 2017) or the experience of loneliness may cause people to experience
poorer health (potentially via altering one’s physiology) (Luo et  al., 2012).
Loneliness has been proposed to affect health through the experience of stress
(Christiansen et al., 2016; Segrin et al., 2018), whereby lonely people have been
found to report higher levels of stress compared to people who are not lonely
(Cacioppo et al., 2003; Segrin & Passalacqua, 2010). Stress may be especially prob-
lematic for people experiencing loneliness because they often lack social supports
to help them manage stress and other mental health problems (Cacioppo et al., 2003).
The negative impact of loneliness on the physical and mental health of individu-
als has been well established. Overall, findings related to loneliness and health have
been so well documented that the negative physical and mental health effects of
loneliness have been compared to risk factors for mortality, such as smoking, physi-
cal inactivity and obesity (Holt-Lunstad et al., 2015), with a number of first-world
countries now having established national campaigns to tackle loneliness (e.g.,
Australian Coalition to End Loneliness; Campaign to End Loneliness, UK;
Connect2Affect, USA).
Research examining mental health variables and loneliness has found loneliness
to be consistently linked with poorer quality of life (Theeke et al., 2014) and low
self-esteem (Vanhalst et al., 2013). In addition, lonely people typically have higher
rates of mental health disorders including depression and anxiety (Richardson et al.,
2017), schizophrenia (Tremeau et al., 2016) and features of suicidality (McClelland
et al., 2020; Schinka et al., 2012; Stravynski & Boyer, 2001). The remainder of this
chapter is dedicated to discussing the relationship between loneliness and psycho-
pathology, including depression, anxiety, serious mental illnesses and substance use
disorders.

4.1 Loneliness and Depression

Depression and loneliness are often highly correlated constructs, which share some
common causes and intrapersonal features such as poor social skills, shyness, poor
self-esteem, introversion, lack of assertiveness, an external locus of control (Blai,
1989), neuroticism (Mund & Neyer, 2016) and a maladaptive attribution style
122 I. Ingram and P. J. Kelly

(Anderson, 1999). However, these experiences are distinct, where loneliness is

more specifically related to social deficits, and depression is a diagnosed disorder
caused by a broader range of difficulties (Blai, 1989). Depression has been linked to
both social and emotional forms of loneliness; however, one study found depression
to be best predicted by emotional loneliness (Russell et al., 1984).
Early research that explored the relationship between loneliness and depression
found that approximately 50% of people who reported feeling lonely also reported
feeling depressed (Rubenstein & Shaver, 1982). Several studies have suggested that
loneliness may have a causative role in depression. This has been found across a
range of ages and stages of life, such as adolescents, college students and elderly
people, whereby feelings of loneliness predicted subsequent depression up to
3  years later (Green et  al., 1992; Joiner et  al., 2002; Koenig & Abrams, 1999).
Conversely, depression has not been found to predict subsequent loneliness in some
studies (e.g., Richman et al., 2016). The direction of this relationship suggests that
targeting loneliness, and related social constructs, such as enhancing social support
and sense of belonging can improve depressive symptoms in some samples (Dingle
et al., 2021; Cruwys et al., 2013, 2014; George et al., 1989).
The relationship between loneliness and depression may be explained by factors
such as self-esteem and self-concept. Since social relationships largely constitute
people’s self-concept via their group memberships, loneliness (or a subjective lack
of social relationships) is likely to lead to negative self-conception. Additionally,
those who are not satisfied with their social world, or do not feel that they belong,
may not derive a sense of validation from their networks, which in turn impacts
one’s self-concept. Poor self-concept and self-esteem are, in turn, highly character-
istic of depression. The mediating role of self-concept has been studied amongst a
sample of community-dwelling adults. This study found that loneliness predicted
depression over a 2-year period and that confusion in one’s self-concept mediated
this relationship (Richman et  al., 2016). Such findings suggest that self-concept
may be an important clinical target for depressed individuals who also report feel-
ings of loneliness.

4.2 Loneliness and Anxiety Disorders

Anxiety disorders are highly prevalent with a global lifetime prevalence of up to

34% (Bandelow & Michaelis, 2015). While there is a range of anxiety disorders,
social anxiety disorder, panic disorder, agoraphobia and generalised anxiety disor-
der are most likely to be implicated in loneliness. A primary underlying feature of
these anxiety disorders is a hypervigilance to threat and cognitions that drive social
behaviour. This hypervigilance to social threat can lead to the use of safety behav-
iours and engagement in avoidant behaviours. Such avoidance can, in turn, prevent
the individual from being in situations that might disconfirm their beliefs about their
social world. Such cognitions are not only implicated in the cycle of anxiety but are
also characteristic of loneliness (see section above about loneliness and cognitive
Isolation, Loneliness and Mental Health 123

theory). Like most forms of psychopathology, the causal direction of the relation-
ship between anxiety and loneliness remains unclear, and it is likely that this rela-
tionship is reciprocal.
Loneliness has been proposed to affect anxiety through enhancing one’s vigi-
lance to social threat. According to the evolutionary perspective of loneliness, those
who are lonely should feel unsafe (in the absence of groups that provide collective
action and safety). This lack of safety should in turn trigger feelings of anxiety and
subsequent patterns of thinking that are characteristics of anxiety disorders
(Cacioppo et al., 2006). Empirical findings suggest loneliness is related to avoidant
thinking styles (over and above intrusive thoughts) (Cacioppo et al., 2006). Such
findings support the notion that loneliness appears to be more likely to be related to
social anxiety disorder over alternate anxiety disorders, such as obsessive-­
compulsive disorder (Eres et  al., 2020). While most research appears to explore
social anxiety and loneliness above other forms of anxiety, a recent review con-
cluded that there is a scarcity of research examining indicators of social isolation
(including loneliness) as a risk factor for social anxiety. While cross-sectional stud-
ies suggest a strong relationship between social anxiety and loneliness across a
range of age groups, the review refrained from making conclusions about the causal
nature of the relationship (Teo et al., 2013). Social anxiety disorder is characterised
by cognitions related to embarrassment and fear of negative evaluation by others.
Typical of social anxiety disorder, those who experience extreme discomfort during
social interactions may avoid social situations, withdraw from others and conse-
quently become isolated and lonely. A longitudinal study found that social anxiety
directly predicted loneliness, and the authors attributed this finding to the avoidance
of social contact that is characteristic of social anxiety, which in turn meant oppor-
tunity to reduce loneliness was hindered (Lim et al., 2016).
Behaviourally, agoraphobia and social anxiety disorder are not dissimilar. The
behaviours characteristic of both can take the form of subtle avoidance (e.g., avert-
ing eye gaze) to complete social avoidance and withdrawal. Despite these similari-
ties, social anxiety and agoraphobia are usually cognitively distinct. Agoraphobia,
in which one fears situations in which they may be unable to escape should anxiety
intensify, tends to be propelled by beliefs about control and safety in public situa-
tions (associated with having a panic attack in public). Like social anxiety disorder,
the disabling effects of agoraphobia mean opportunities for social contact that can
alleviate loneliness are significantly reduced. Through the lens of the social identity
approach, loneliness can be alleviated through the sense of belonging and social
identity that is derived from group memberships.
Paradoxically, social anxiety disorder and agoraphobia make the notion of seek-
ing out social groups seem somewhat impossible for many individuals. Identification
with certain groups is proposed to affect treatment outcomes for social anxiety dis-
order. A study by Meuret et al. (2016) found that the extent to which one identified
with an in-group (other people who experience anxiety) and an out-group (people
who do not experience anxiety at clinical levels) following a cognitive behaviour
therapy intervention predicted social anxiety symptom severity. That is, closer iden-
tification to both groups predicted fewer social anxiety symptoms. While not
124 I. Ingram and P. J. Kelly

empirically tested in this study, the sense of belonging and acceptance that accom-
panies closer social identification may directly or indirectly influence symptoms of
social anxiety.
Overall, cognitions and behaviours characteristic of anxiety disorders are likely
to contribute to social isolation and feelings of loneliness. Reduced opportunity for
social contact in order to alleviate loneliness is often the result of the safety-seeking
and avoidant behaviours that accompany anxiety. Conversely, those who are lonely
may view their social environment as threatening, which in turn can enhance symp-
toms of social anxiety. For clinicians, the identification of symptoms of anxiety and
addressing these cognitions and behavioural outcomes may be necessary in order to
alleviate loneliness. Additionally, when treating anxiety disorders, it may be neces-
sary for clinicians to include initial and ongoing assessments of loneliness.

4.3 Loneliness and Psychosis

Loneliness is highly prevalent amongst people living with serious mental illnesses,
such as psychosis (Stain et al., 2012). Loneliness appears to be pervasive for many
individuals experiencing psychosis, regardless of the onset (early or late) of psy-
chotic symptoms or the presence or absence of positive symptoms. Additionally,
little research has found that severity of psychotic symptoms (both positive and
negative) is related to loneliness (see Lim et al., 2018).
Loneliness has been proposed to affect psychotic symptoms, just as psychotic
symptoms are likely to affect feelings of loneliness. A common feature of psychotic
disorders is poor theory or mind, or social understanding, meaning often people
with psychosis have difficulty initiating and maintaining functioning relationships
(Stain et al., 2012). Such difficulties in interpersonal interactions are likely to leave
a person vulnerable to social isolation and subsequent feelings of loneliness. While
people with psychosis typically report reduced access to social supports (Lim et al.,
2018), even those who do have social networks in place may not derive a subjective
sense of belonging and support from these networks.
Social adversity has been proposed to be a risk factor for the development of
psychotic symptoms such as paranoia (Lim et  al., 2018). People with psychotic
disorders face high rates of social marginalisation, which in turn can contribute to
the development of internalised stigma and negative perception of self and others
(Corrigan et al., 2011). It has been proposed that one way to cope with such stigma
may be to choose not to identify with a devalued social group or to decide not to
disclose one’s stigmatised identity (Camacho et al., 2020). However, such denial of
this identity has been shown to be associated with enhanced distress and reduced
treatment compliance amongst people with mental illnesses (see Meuret et  al.,
2016, for a complete discussion). Acceptance of this social identification is one
challenge that people who experience psychosis may experience, and a lack of iden-
tification with social groups may in turn enhance feelings of loneliness (see earlier
discussion related to the social identity approach to loneliness).
Isolation, Loneliness and Mental Health 125

Self-concept and self-esteem appear to be largely at play in the dynamic between

loneliness and psychosis, with studies consistently finding a correlation between
loneliness and self-esteem amongst people with psychosis (see Lim et al., 2018). It
has been proposed that loneliness may affect psychotic symptoms, such as paranoia,
through the experience of anxiety and related cognitions surrounding one’s accep-
tance by others (Sündermann et al., 2014). Anxiety has been long observed to trig-
ger delusional thoughts and hallucinations. As discussed in the preceding section of
this chapter, loneliness and social anxiety are highly correlated constructs, which
appear to feed into one another. When lonely, one may become socially anxious due
to distorted social cognitions, appraisals of social threat and reduced social contact/
opportunity to disconfirm these maladaptive social appraisals. The maintaining
cycle may in turn reinforce both feelings of loneliness and anxiety, which in turn
may exacerbate psychotic symptoms, such as delusions surrounding social humili-
ation or subjugation.
Loneliness may further impact on psychotic symptoms through functional and
structural aspects of one’s social network. When lonely or isolated, individuals are
unlikely to have a supportive confidant in which they can discuss symptoms of psy-
chosis with. As such, the ability to consider alternatives to any unusual ideas they
may experience might be hindered by the absence of a confidant who can provide
more normalising explanations. This reduced access to support and correcting
explanations may in turn exacerbate paranoia (Garety et al., 2001).
Taken together, literature that examines loneliness amongst people with psycho-
sis suggests that symptoms characteristic of psychosis, such as an impaired theory
of mind, and reduced social functioning make this population vulnerable to loneli-
ness. Loneliness in turn is likely to affect psychotic symptoms through enhanced
social anxiety, related social cognitions and reduced access to confidants that may
be necessary in order to challenge and overcome these cognitions.

4.4 Loneliness and Substance Use Disorders

Loneliness has been linked to problematic substance use in numerous studies. In

particular, loneliness has been associated with tobacco use (Beutel et  al., 2017),
increased alcohol use and dependence (Akerlind & Hornquist, 1992; MacNeill
et  al., 2016) and illicit drug use (Cacioppo et  al., 2002; Stickley et  al., 2014). A
number of studies have found that people with substance use disorders (SUD) are
lonelier than non-clinical comparators (Hosseinbor et  al., 2014) and that people
who are actively using substances may be lonelier than those who are in recovery
(Allen et al., 1981; Elton & Hornquist, 1983).
While these studies provide a basis for the belief that people with SUD are vul-
nerable to loneliness, there is little understanding of whether loneliness is an ante-
cedent to, or a consequence of, substance dependence or perhaps both (see Ingram,
Kelly, Deane, Baker, & Dingle, 2020). Few studies have examined the direction of
the association between loneliness and substance use; however, some research
126 I. Ingram and P. J. Kelly

points to loneliness as a precursor to substance use. For many members of the gen-
eral population, substance use has been reported to serve as a social facilitator
(Phillips et al., 2018). Individuals who have high needs for social approval are prone
to increased substance use (Caudill & Kong, 2001).
The social function of substance use has been explored in a review by Cooper
et al. (2015). This study sought to examine personality traits and social and cogni-
tive motives for alcohol, marijuana and tobacco use across a range of populations,
life stages and countries. Findings from this review suggested that beliefs that alco-
hol can be used to attain positive social outcomes and to help regulate affect are
widespread and that these beliefs predict use-related outcomes. The findings were
mixed for other substances where light marijuana use was linked to social and con-
formity motivations, and tobacco use was driven by habit and withdrawal cues.
Despite this, the review revealed that substance use serves a social function of
enhancing connections with others and that this can be influenced by individuals’
sense of insecurity and social discomfort (Cooper et al., 2015).
In contrast, substance dependence may be a precursor to loneliness due to stigma,
the transient nature of social networks and limited social supports available during
addiction and recovery. People with SUD have been found to be subject to estrange-
ment from social contacts and, as such, may have significantly less access to social
support (Phillips & Shaw, 2013) and a greater proportion of interpersonal difficul-
ties (Segrin, 2001). Additionally, people with SUD may make and maintain rela-
tionships that meet their needs at the time of active substance use, but once in
recovery, their social needs are likely to have changed (e.g., toward non-using con-
tacts). There is evidence to suggest that greater engagement with networks of people
supportive of recovery can sustain longer maintenance of recovery (Frings & Albery,
2015). As such, when in recovery, there may be a need to avoid those situations and
relationships that perpetuate ongoing substance use and to connect with people who
support one’s recovery (Best et al., 2011). While the rationale behind such ideas is
to best facilitate one’s recovery from addiction, this process is likely to increase the
risk of loneliness for people with substance use problems, particularly those that are
in the early stages of recovery.
A recent review of 41 studies that examined loneliness in people with SUD
(Ingram, Kelly, Deane, Baker, Goh, et al., 2020) found preliminary evidence to sug-
gest that people with substance use problems are lonelier than the general popula-
tion (i.e., Ingram et al., 2018) and that females and those who were younger may be
lonelier (although the mean age of these samples varied). This review also con-
cluded that for people with SUD, loneliness was consistently related to poor physi-
cal and mental health across studies that included these variables. Since data were
predominantly correlational in nature, the causal sequence of these relationships
cannot be determined, and it is possible that loneliness leads to poorer health, or
those experiencing poorer health become lonelier, or both. While it remains unclear
whether differences in loneliness exist based on type of substance of dependence, a
consistent finding was that higher severity/duration of substance dependence is
related to higher loneliness. No research has clarified the causal direction or dynamic
of this relationship, but it is possible that those who use substances to a greater
Isolation, Loneliness and Mental Health 127

extent (i.e., higher severity) are also those who are more likely to have difficulty
maintaining relationships and/or to be stigmatised in society and ultimately become
lonelier as a result of social isolation and stigma.

5 Conclusion

This chapter highlights the conceptualisation of loneliness as a multidimensional

construct, encompassing both social and emotional forms. The experience of these
different types of loneliness is largely dependent on the types of relationships that
are missing from one’s life. Loneliness is implicated in poor physical health to the
extent that it predicts poorer cardiovascular functioning, fatigue and chronic ill-
nesses. While loneliness may alter physiology (through stress) to impact upon one’s
physical health, physical health can also impact upon feelings of loneliness. This is
likely to be due to objective social isolation that can result from stigma attached to
health conditions or reduced functional ability that restricts social contact.
Furthermore, loneliness plays a key role in a number of mental health conditions. In
this chapter, we discussed the relationship between loneliness and depression, anxi-
ety disorders, psychoses and substance use disorders. Taken together, discussions
presented throughout this chapter suggest that loneliness can contribute to, and be
an outcome of, several significant mental health conditions. Due to the cognitions
and social behaviours that are shared perpetuators of both loneliness and psychopa-
thology, assessing and targeting loneliness in clinical interventions are likely to
have positive implications for recovery from mental health conditions.

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Social Prescribing: A Review
of the Literature

Genevieve A. Dingle and Leah S. Sharman

Abstract  This chapter presents an overview of interventions to address loneliness

including individual therapies, group interventions and community-based
approaches. We argue that individual cognitive behaviour therapy is neither neces-
sary nor sufficient to address loneliness. Instead, we advocate for applying cognitive
behaviour therapy strategies to help people overcome cognitive barriers to connect-
ing with others, implemented within their social contexts. Such cognitive barriers
include stigma, fear of negative evaluation and mistrust of others. The chapter
describes some novel group and community approaches. The Groups 4 Health pro-
gram for people experiencing loneliness (Haslam et  al., J Consult Clin Psychol
87(9):787–801, https://doi.org/10.1037/ccp0000427, 2019) and Groups 4 Belonging
program for people in addiction recovery (Dingle et al., Taking social identity into
practice. In: Frings D (ed) Handbook of alcohol and alcoholism, Elsevier, London,
2020) help participants to overcome loneliness and social anxiety through recon-
necting with existing groups and joining new groups that are meaningful to them.
Another approach is social prescribing, which provides a non-clinical referral path-
way for isolated people to engage with community groups that help to meet their
social needs aligned with their interests (such as arts, exercise and educational
groups). We summarise evidence that social prescribing to community groups is
effective for managing loneliness in diverse populations.

Keywords  Loneliness interventions · Social prescribing · Group programs ·

Stigma · Fear of negative evaluation · Mistrust

G. A. Dingle (*) · L. S. Sharman

School of Psychology, The University of Queensland, St Lucia, QLD, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 135

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_8
136 G. A. Dingle and L. S. Sharman

1 Addressing Loneliness

Loneliness is not a diagnosed health condition, and as such, it has tended to be

under-recognised and treated within psychology practice. That said, clinicians
should be alert to signs of loneliness in their clients due to its association with a
range of mental health conditions, such as those described in chapters “Existential
Isolation: Theory, Empirical Findings, and Clinical Considerations” and “Isolation,
Loneliness and Mental Health”. Furthermore, we can apply many cognitive behav-
ioural strategies to the causes and effects of loneliness. In this chapter, we will
briefly describe how individual interventions have been applied to clients who expe-
rience isolation and loneliness. Based on this research evidence, we argue that indi-
vidual cognitive behaviour therapy is neither sufficient nor always necessary to
address loneliness. Instead, we advocate for applying cognitive behaviour therapy
strategies to help people overcome barriers to connecting with others, implemented
within their social contexts such as families, places of study and work and broader
communities. Group interventions in the community provide excellent opportuni-
ties for practicing new ideas and social skills within a safe social context. Tailored
and link worker-supported referral to such community groups is at the heart of
social prescribing.

2 Individual Therapy

As earlier researchers have pointed out, simply bringing lonely people together does
not result in the development of friendships, and health services designed around
mental health symptom management are not optimally effective in helping clients
to develop social networks or friendships (Stevens, 2001). Nevertheless, a range of
strategies for reducing loneliness and/or social isolation have been evaluated and
have revealed four primary strategies used in loneliness interventions:
1. Improving social skills, including practical skills, such as learning conversational
skills, interpreting non-verbal social cues, as well as friendship enrichment
training.
2. Enhancing social support through the creation of support groups for people with
a common issue, such as weight loss groups and groups for those undergoing life
transitions, such as retirement or bereavement. These interventions are usually
supported by professionals, rather than groups created within communities, and
run by peers.
3. Programs that increase opportunities for social interaction. These tend to revolve
around the natural formation of relationships through involvement in a new
activity such as volunteering to deliver food parcels to others in the community
(Pilisuk & Minkler, 1980).
4. Addressing maladaptive social cognition, often in combination with social skills
training. These are often CBT-based programs, primarily in groups, and tend to
Social Prescribing: A Review of the Literature 137

attribute the cause of loneliness to cognitive biases (e.g., irrational, self-­defeating

thoughts) that result from increased vigilance to social threats (Cacioppo &
Hawkley, 2009).
The efficacy of these types of intervention for loneliness have primarily been evalu-
ated using qualitative methods (Cattan et  al., 2005; McWhirter, 1990; Perese &
Wolf, 2005; Rook, 1984) with mixed findings. However, many of the qualitative
studies have been found to be of low quality with many not resulting in reductions
to loneliness. To better understand the evidence around interventions for loneliness
using higher-quality research, a meta-analysis reviewed the evidence from quantita-
tive studies (Masi et al., 2011). This review included 50 studies of loneliness inter-
ventions and revealed that much of the literature was characterised by single-arm,
pre-post and non-randomised studies. Overall, the effect sizes were modest and only
the randomised studies showed significant mean effect sizes. Of these, studies that
addressed maladaptive cognition were found to be more effective than those attempt-
ing to improve social skills, enhance support or increasing opportunities for social
contact.
More recent interventions have attempted to use technology to decrease feelings
of loneliness. This has included the development of a smartphone application called
+Connect that delivers daily positive psychology content to users for 6 weeks (Lim
et al., 2020). A pilot evaluation of the app with 12 participants experiencing psycho-
sis found high levels of engagement and completion of the 42-day course. There
was tentative evidence that using the app may reduce loneliness, with scores
decreasing from pre-intervention to 3 months post-intervention. A majority (90%)
of participants agreed that +Connect helped them to increase their social confi-
dence, enjoy life, look forward to being with other people and feel more connected
with others. A related pilot of the +Connect app with 9 participants diagnosed with
social anxiety disorder (SAD) and 11 participants with no mental health conditions
indicated that the app is less acceptable for young people with SAD (Lim et al.,
2019). The drop-out rate was nearly twice as high among participants with social
anxiety compared to the others. Loneliness scores decreased over time in both sub-
groups. Although the participants with SAD reported that +Connect was easy to
understand and helped them accept their mental health symptoms, many reported
dissatisfactions with aspects of the app, including creating new relationships and
increasing social confidence. The authors indicated that further refinements were
being made to address this feedback (Lim et al., 2019).
Taken together, these findings suggest that focusing on individual risk factors
and traits underlying loneliness is not enough. There is a clear need to embed loneli-
ness interventions within social groups and communities to help people to over-
come barriers to connecting with others. We will consider group interventions and
social prescribing to community group programs in the following sections.
138 G. A. Dingle and L. S. Sharman

3 Group Interventions

Group interventions are common in hospital mental health services, where patients
might attend a group therapy session every day. They are also common in outpatient
services where participants typically attend group sessions once a week for, say,
6–10  weeks (Bieling et  al., 2013). There is ample evidence that group cognitive
behaviour therapy (CBT) is effective for common presenting complaints such as
social anxiety (Piet et al., 2010), depression (Oei & Dingle, 2008) and substance use
disorders (Carter-Sobell & Sobell, 2011). Group CBT offers participants a space to
share and normalise their experiences of mental illness with other group members.
Challenges to distorted thoughts may be more powerful coming from other group
members than from the therapist. Further, exposure therapy in a group setting pro-
vides a safe environment with immediate feedback and support from group mem-
bers. But is group CBT effective for managing loneliness?
A study of 92 adults attending an intensive group CBT program assessed loneli-
ness, indexed by social isolation schema scores (Schmidt et al., 1995) assessed at
the beginning and end of the program. This study found that social isolation schema
scores decreased significantly during group CBT but only among participants who
formed a strong identification with the therapy group (Cruwys et al., 2014). This
idea that group identification is a key mechanism in its effectiveness is drawn from
the social identity approach (Tajfel & Turner, 1979; Turner et al., 1987). Originally
developed in the social and organisational psychology fields, this framework has
more recently been applied to a range of health conditions and populations (Haslam
et al., 2018; Jetten et al., 2012). According to the social identity approach, groups
can influence a person’s health and wellbeing in both positive and negative ways.
Interestingly, groups do not have to be formal therapy groups to influence partici-
pants’ mental health and wellbeing. Research shows that arts groups, such as choir
singing, music production and creative writing, and exercise groups, such as yoga
and futsal, help vulnerable people to increase their wellbeing over time to the extent
that they identify with their group (Cruwys et al., 2018; Forbes, 2020; Kyprianides
& Easterbrook, 2020; Williams, Dingle, Jetten, & Rowan, 2019). These benefits of
group identification occur irrespective of what the group does together. One of the
mechanisms for the effect of community-based groups on mental wellbeing is
through the development of a sense of belonging (Williams, Dingle, Calligeros,
et al., 2019) – in other words, helping participants to overcome their loneliness. We
will come back to this point in the section on social prescribing.

4 Groups 4 Health

The social identity framework underpins the Groups 4 Health program (Haslam
et  al., 2016, 2019), a group intervention designed to help individuals strengthen
their social connections and overcome loneliness. Although it is not framed as a
Social Prescribing: A Review of the Literature 139

CBT program, elements such as psychoeducation, goal setting, problem solving and
social support are common to both approaches. The program comprises five ses-
sions over 8 weeks, and groups typically have around six participants and two facili-
tators. The first session seeks to raise participants’ awareness of the beneficial
effects that social group memberships have for health and, conversely, the costs of
neglecting the social dimensions of health. This session also emphasises peoples’
capacity to counter these effects by self-managing their groups and group-based
resources. The second session engages participants in the process of social identity
mapping (SIM) (Bentley et al., 2019; Cruwys et al., 2016), which allows them to
visualise their social group networks and psychological resources. The map is then
used as the basis for discussion of how people would ideally like their social groups
to be in the future and to identify any gaps in their group networks.
The third session helps participants to develop strategies to identify and
strengthen their existing valued groups memberships and identities. The fourth ses-
sion uses the Groups 4 Health group as a model for developing new social group
connections whilst also identifying which connections to develop. Participants are
assisted to write a social plan of action that they work on for the next month until
the final session. Session five is a booster session in which facilitators help to trou-
bleshoot any problems that participants have encountered in implementing their
social plans. Participants create another SIM and compare it to their earlier map to
examine how their networks have changed over the course of the program. The
skills that have been learned across the course are reviewed and key messages rein-
forced with the goal of encouraging long-term maintenance.
The Groups 4 Health program improves a number of outcomes. In a proof-of-­
concept study involving 26 young people completing the program and 25 controls,
Groups 4 Health demonstrated effectiveness in reducing social anxiety and loneli-
ness and increasing life satisfaction and social functioning (Haslam et al., 2016). A
full trial in which 120 participants were randomly assigned to Groups 4 Health
(G4H) or treatment-as-usual (TAU) provided further evidence to support the pro-
gram. In this trial, G4H produced a greater reduction in loneliness (d = −1.04) and
social anxiety (d = −0.46) than TAU (d = −0.33 and d = 0.03, respectively). G4H
was also associated with fewer general practitioner visits at follow-up (d = −0.33)
and a stronger sense of belonging to multiple groups (d  =  0.52) relative to TAU
(d = 0.30 and d = 0.33, respectively). Depression declined significantly in both G4H
(d = −0.63) and TAU (d = −0.34) (Haslam et al., 2019). Several adaptations to the
Groups 4 Health program for various populations are currently being evaluated. The
next section describes the Groups 4 Belonging program that was developed for peo-
ple in recovery from addiction problems.
As mentioned in chapter “Isolation, Loneliness and Mental Health”, loneliness is
a particularly common experience among people seeking treatment for substance
use disorders, with around 70% reporting that loneliness is a serious problem for
them (Ingram, Kelly, Deane, Baker, Goh, et al., 2020; Ingram et al., 2018; Li et al.,
2017; McDonagh et  al., 2020). Loneliness is challenging for recovery as it is a
potential antecedent to substance use. It is also associated with hypervigilance for
social threats and can lead a person to distance themselves from others (Layden
140 G. A. Dingle and L. S. Sharman

et al., 2018). A qualitative analysis of interviews with adults in residential treatment

revealed several key cognitive barriers to building new (sober) group memberships,
including stigma, mistrust and fear of negative evaluation (Ingram, Kelly, Deane,
Baker, & Dingle, 2020). Let us examine each of these in turn and then explore how
the Groups 4 Belonging program addresses these in an intervention.

5 Cognitive Barriers to Connecting with Others

5.1 Stigma

Stigma can adversely affect health and wellbeing in several ways (Haslam et al.,
2018). In depressed young people, for instance, the non-disclosure of depression
contributes to social distance and loneliness (Achterbergh et al., 2020). When the
stigma is thought to be justified, it prevents people from identifying with others who
share that stigma. Rusch and colleagues found that self-prejudice can exacerbate the
effects of mental illness because self-discrimination means that people fail to pursue
employment or independent living opportunities (Rüsch et al., 2005). Stigma often
leads to the marginalisation and devaluation of substance-using groups and the cre-
ation of unhelpful ‘us-them’ divisions between those who need help and other mem-
bers of society who might be able to provide it. Several studies have found that
people with substance use disorders are more highly stigmatised than people who
experience other health conditions (Corrigan et al., 2017; Room, 2005). Stigma sur-
rounding certain behaviours (such as using substances during pregnancy or being
drunk in a public place) and groups (such as people who inject drugs) are widely
accepted, culturally endorsed and enshrined in policy and the law. This also means
that in addition to the many challenges that people with substance abuse problems
confront when they go into treatment, they must also deal with the fact that they
belong to a highly stigmatised social group. Stigma has numerous consequences
including ill treatment by others and loneliness (Hörnquist & Akerlind, 1987; Itzick
et al., 2019). One way to overcome stigma is to provide a safe space for people to
share their experiences and to feel accepted and regarded as a whole person rather
than just a diagnosed health condition.

5.2 Mistrust

A second cognitive barrier to joining with others who might provide social support
is mistrust, an abiding belief that others are likely to treat you badly or harm you in
some way. Roper and colleagues compared scores on the Young Schema
Questionnaire (which assesses the mistrust/abuse schema as well as 15 other mal-
adaptive schemas) from 50 people with alcohol use disorders with scores from 50
Social Prescribing: A Review of the Literature 141

control participants (Roper et al., 2010). They found that the mistrust/abuse schema
was the most strongly endorsed maladaptive schema in the alcohol sample
(Mdn = 4.1 out of 5) and was markedly higher than in the controls (Mdn = 1.9).
Participants endorsed the mistrust schema significantly less strongly (Mdn = 3.0)
after a brief residential alcohol treatment involving group cognitive behavioural
therapy, indicating that supportive group contexts can help people to overcome their
mistrust. This is important because mistrust of others exacerbates difficulties access-
ing and engaging with health providers (Merrill et al., 2002). Mistrust is particularly
common among individuals with a history of interpersonal abuse or neglect, a sub-
stantial subgroup in any alcohol treatment service (Perryman et al., 2016). Clearly,
mistrust beliefs have the potential to act as a barrier against joining new groups and
communities because people are vigilant to potential interpersonal threat and tend
to avoid getting close to others and sharing their experiences for fear of being
manipulated or let down in the process.
I think …I’ve made myself feel lonely because of the trust issues I have with people. So, I
pushed myself away even further. Like, I’ve been asked, had the question put to me, why
don’t you want to…why can’t…why won’t you let anyone love you? – Elise, female resident
in alcohol and other drug rehabilitation (Ingram, Kelly, Deane, Baker, & Dingle, 2020)

5.3 Fear of Negative Evaluation

Social anxiety disorder is another disorder that commonly co-occurs with alcohol
use disorders. A fear of negative evaluation explains the link between the two disor-
ders as well as coping motives for disordered drinking (Stewart et al., 2006). Fear of
negative evaluation is a fear of making a mistake or appearing to be nervous, stupid
or awkward in front of others, of attracting scrutiny and evaluating the consequences
of such scrutiny as severe. Fear of negative evaluation is a core feature of social
anxiety and loneliness. For example, Lim and colleagues recruited 1000 people
aged 18–87  years old from the general community to complete online question-
naires on three occasions over a 6-month period (Lim et  al., 2016). Results of a
cross-lagged model controlling for trait levels and prior states indicated that earlier
loneliness predicted future states of social anxiety, paranoia and depression.
However, in the same model, social anxiety was the only predictor of future loneli-
ness. It appears that fear of negative evaluation prevents people from reconnecting
with former groups who they have had conflict with in the past and may also act a
barrier to joining new groups because affected individuals are concerned that others
will judge them negatively and reject them.
I really can’t share in the meeting because I’m just scared that I’m going to be judged. –
Nathan, male in alcohol and other drug rehabilitation (Ingram, Kelly, Deane, Baker, &
Dingle, 2020)

To summarise, stigma, mistrust and fear of negative evaluation present cognitive

barriers that must be overcome if people are to successfully develop sober social
142 G. A. Dingle and L. S. Sharman

networks to support their ongoing recovery. People in treatment for substance use
will need to identify these potential barriers and to learn skills to overcome them in
an intervention that focuses on managing their social group-based social identities.
A new intervention called Groups 4 Belonging aims to give people the knowledge
and strategies they need to increase their social group belonging and reduce feelings
of loneliness whilst addressing these cognitions.

6 Groups 4 Belonging

Groups 4 Belonging comprises six 90-minute group sessions. It adapts content from
three of the five Groups 4 Health modules and extends on these to include compo-
nents of mindfulness-based cognitive behaviour therapy to target particular barriers
experienced in addiction contexts that might undermine their capacity to connect
with others in ways that support their recovery (Dingle et al., 2019, 2020). The first
session includes psychoeducation and a card-sorting activity about the relative
importance of social factors for health and longevity alongside of other well-known
health factors such as exercise, diet, smoking and weight. Facilitators then guide
participants to create an SIM to visualise their own social networks. Session two
focuses on the meaning and consequences of loneliness, and participants learn how
to identify and address thoughts and feelings associated with loneliness. They prac-
tice two mindfulness exercises as strategies for detaching from these unhelpful
thoughts and sensations that are risks for drinking.
In the third session, participants are taught to differentiate between the quantity
and quality of their social connections. They complete an imagery exercise to help
identify their values in relationships and explore how the groups identified in their
SIM groups reflect important values that they hold. The focus of session four is
reconnecting with existing social groups. Participants consider how groups cur-
rently meet their needs and how they anticipate these groups will meet their needs
as they progress through the recovery pathway. They complete an exercise in how to
manage knock-backs. They also discuss stigma and how it may be overcome to con-
nect with others. Social goals are developed for reconnecting with known groups.
Their social goals are further developed in session five with a focus on developing
new group memberships. Here, participants explore group-based activities in their
community and ways to overcome any fears they have about facing negative evalu-
ation from others. Participants continue working on their social goals between ses-
sions. The sixth (and final) session reviews participants’ progress on their social
goals and focuses on overcoming barriers associated with mistrust. It also includes
an exercise in which participants use music listening as an alternative to mindful-
ness practice for regulating negative emotions.
The Groups 4 Belonging program was piloted to explore demand for (recruit-
ment, attendance and retention) and acceptability of the program with individuals in
residential substance use treatment. Over half of the people attending the services
were interested in participating in Groups 4 Belonging. Of 41 participants who
Social Prescribing: A Review of the Literature 143

commenced the program, 20 participants completed the program per protocol. In

terms of acceptability, the average number of sessions attended was 3.7, and satis-
faction with the program was high, with 95% of participants reporting they enjoyed
Groups 4 Belonging. It was concluded that Groups 4 Belonging may be feasible for
delivery in residential substance use treatment services (Ingram, Kelly, Haslam,
O’Neil, Deane, et al. 2020). This program shows preliminary evidence in support of
integrating cognitive therapy strategies with group- and community-building strate-
gies to help participants to overcome loneliness. For people who are not attending a
structured program such as Groups 4 Belonging, another approach to building group
and community connections is called social prescribing.

7 Social Prescribing

Social prescribing is a relatively new model of healthcare that provides patients with
non-medical supports through reconnection to the community. This model was
developed as an innovative way to move beyond the medical model and address the
wider social determinants of health (Kimberlee, 2013; Woodall et al., 2018). One
rationale for social prescribing is that patients who frequently present to general
practitioner (GP) clinics with complex physical or mental health problems are often
presenting because of unmet social needs, namely, loneliness (Cruwys et al., 2018).
In fact, it is estimated that 10% of patients attending GP clinics account for between
30% and 50% of appointments. Social prescribing enables GPs and other health and
social care professionals to refer people experiencing loneliness or social isolation
to a range of community services that can address these social needs. Whilst there
is no widely agreed model for social prescribing, schemes commonly involve three
components: (1) a referral into the program via a GP, allied health professional,
community member or self-referral, (2) consultation with a link worker (also known
as wellbeing coordinators or community development workers), and (3) the use of
local voluntary groups and community organisations. Simply talking about com-
munity programs with patients or giving them a brochure does not constitute social
prescribing. Instead, it would be considered ‘sign posting’ due to the absence of
several important ‘ingredients’.
One key ingredient for successful social prescription is the link worker who sup-
ports clients to engage with social programs provided by third-sector organisations
in the community. These are carefully selected based on the individual’s interests
and needs and could involve anything from volunteering with meal delivery to play-
ing croquet to joining a swimming squad (Kellezi et al., 2020). Link workers utilise
diverse methods of communication, planning and adaptation, both to their clients’
needs, who often have varying levels of chronic illness and physical disability, and
with community group facilitators who may need extra guidance to support these
clients. Their role involves not only working with clients to co-develop a health plan
and supporting their engagement with new group(s) but also ensuring that clients’
other health and social needs that may be barriers to social engagement are taken
144 G. A. Dingle and L. S. Sharman

care of (Sharman, Hayes, McNamara & Dingle, 2022). This can, and often does,
include advocating for clients in other spaces, such as welfare, disability support
and within mental healthcare (Bertotti et al., 2018; Kellezi et al., 2020; Sharman,
Hayes, McNamara & Dingle, 2022; Woodall et al., 2018). In this sense, social pre-
scribing has been described as having the potential to develop a ‘holistic health
service’ where social, physical and mental health concerns can be addressed (Kellezi
et al., 2019).
Advocacy in the role of link workers is most often to address various health and
social barriers to joining and engaging in groups. Anecdotally, the most common
barriers described by Australian link workers and clients in the United Kingdom are
financial, transport and mental health barriers, namely, social anxiety (Kellezi et al.,
2019; Sharman, Hayes, McNamara  & Dingle, 2022). Although barriers for each
person can be wide-ranging, the link worker’s role in overcoming these cannot be
underestimated. They utilise an array of strategies to ensure that clients are in the
best position to re-engage in the community and their preferred groups. For social
anxiety, these strategies may be simply attending groups with clients or introducing
group facilitators to clients before an initial session, or it may involve referral to
counsellors or psychologists. Overcoming transport issues, although often inter-
twined with financial barriers, have involved catching a bus with a client so they
know the route to take and can feel confident, whilst financial issues are often
addressed through links with social welfare programs as well as attempts to find the
most low-cost or free programs that still suit clients’ wants and needs.
Whilst link workers are involved in physically connecting clients to groups and
helping them overcome the barriers they face to attendance, the success of that con-
nection is not guaranteed. Although we do not yet know which groups work and for
who, successful social prescribing is dependent on the quality of the relationship
with other group members and the strength of the therapeutic relationship with link
workers. This has been reflected by clients and link workers:
I felt as though they gave me the chance to reason out that I was getting better. I listened to
them. I knew what was going on in my head, but I couldn’t always, I didn’t always want to
tell anyone. I seemed, with the link-worker, I seemed as though I could get over that more
quickly. He wasn’t demanding. He was very quiet and very gentle with it, and that is the way
that I needed somebody to be, to maybe listen to me, really listen to me, and hear what I was
saying, if you can understand that. Client (Kellezi et al., 2019)

…the success of the program is really dependent on the relationship the wellbeing coordi-
nator has with the client. If they can develop a relationship of trust and rapport, that they
feel that they can engage in something and be taken on that journey, then they feel safe to
be able to do that and to engage and to be able to - They feel like somebody’s listened to
them, somebody really understands what their needs are, somebody really wants to bring
them into be engaged in something that they’re interested in. Link worker (Sharman, Hayes,
McNamara & Dingle, 2022)

…but it’s the sense of belonging and inclusion that comes with being part of a group that I
think really has the most benefit for people who are experiencing social isolation and lone-
liness. Link worker (Health_and_Wellbeing_Queensland, 2020)
Social Prescribing: A Review of the Literature 145

Whilst evidence of the various benefits of social prescribing continues to emerge, it

has so far been limited in terms of providing clear guidance about what groups work
and for whom. Evaluating these schemes can be complex due to the diverse array of
group programs available, the time taken to gain benefits with varying levels of link
worker intervention and relatedly, the wide-ranging health issues and circumstances
of the clients. This has led to several studies with poor methodological quality and
a lack of standardised theory and outcome measures. Indeed, a review of 15 quanti-
tative social prescribing programs with strict entry pathways (i.e., health practitio-
ner referral only) found that research in this area is significantly limited by studies
with poor design, including lack of follow-up, and small sample sizes (Bickerdike
et al., 2017).
This lack of robust evidence, of course, does not mean social prescribing does
not lead to improvements. The evidence base for social prescribing programs, incor-
porating quantitative and qualitative evaluations with wide-ranging measures across
studies, demonstrates that social prescribing programs are effective for improving
health and wellbeing among clients (Chatterjee et  al., 2018). Specifically, this
review of 86 articles found that social prescribing programs reduced feelings of
loneliness and social isolation and led to improvements in sociability and commu-
nication (Chatterjee et al., 2018). A variety of other key outcomes were also observed
from the research reviewed, such as improvements to physical health, anxiety,
depression, increased self-esteem, feelings of control and empowerment.
Furthermore, qualitative evaluations have shown that clients enjoy their relation-
ships with link workers where they feel a sense of trust and ability to confront their
social problems, feel a sense of belonging and connection to their social groups and
are generally satisfied within their social prescribing schemes (Carnes et al., 2017;
Kellezi et al., 2019; Wildman et al., 2019).

8 Conclusion

Whether lonely people develop skills and strategies to self-manage their social
group connections (by attending programs such as Groups 4 Health or Groups 4
Belonging) or do this with the assistance of a cognitive behaviour therapist or link
worker, it appears that trustworthy relationships with group facilitators and link
workers are important, and the person’s interests and needs are central to the co-­
designed social plan. Further, clients need to feel welcome and safe within the
groups they attend, and this relies in part on the skills and sensitivity of the com-
munity program facilitators and the other members of the group. Social prescribing
to community groups is an emerging area and one that requires a validated theoreti-
cal framework and robust research with the use of randomised control trials to
ensure the best quality of evidence. Although it is early days for social prescribing,
this approach has exciting implications for how we view health and wellbeing. No
longer confined to specialised medicalised care in hospitals and clinics, social pre-
scribing shifts the agent of health to the client and the space for health to homes,
146 G. A. Dingle and L. S. Sharman

places of study and work and the broader community. Loneliness is fundamentally
a social problem that is best addressed within these social contexts.

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s12913-­018-­3437-­7
 Part IV
Identity
Identity and the Courage to Be:
From Kierkegaard to Covid-19

Paul Rhodes

Abstract  Who am I? How can I be true to myself? How can I be authentic given
the world I live in? These questions have been explored by existentialist philoso-
phers, positioning courage in the face of dread as central to the development of a
unique, embodied identity. Rather than being a fixed construct, based solely on the
circumstances of birth or prescribed roles and stereotypes, identity can be created,
after experience and despite anxiety, fleeting, liminal a part of the continued process
of individuation. In this chapter I will trace the existentialist approach to identity,
from the spiritual dimensions of Kierkegaard and Tillich to the humanist self-­
determined reinvention of Sartre. I will consider the ontology of selfhood further,
particularly through the fleeting temporal and storied conceptualizations of
Heidegger and Ricoeur, highlighting our identity as a continuous process of becom-
ing. Heidegger and Merleau-Ponty will also remind us that identity cannot be
understood with reference to materiality, specifically our historicity (being in the
world) and corporeal body. Any discussion of roles and stereotypes, however, must
also consider oppression and marginalization as primary threats to non-being. I will
consider critical existentialisms, including the feminism of Simone de Beauvoir, the
post-colonialism of Fanon, and the identity politics of Judith Butler. Lastly we will
turn to the dynamics of identity in an era of global dread, exploring the ways in
which the anthropocentrism of traditional existentialism is inadequate for the crises
of climate and Covid-19.

Keywords  Identity · Becoming · Courage · Existentialism

We only become what we are by the radical and deep-seated refusal of that which others
have made of us. (Sartre, cited in Judaken, 2006, p. 168)

P. Rhodes (*)
School of Psychology, University of Sydney, Camperdown, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 153

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_9
154 P. Rhodes

1 Vignette

Oscar Wilde, poet, playwright, and journalist was one of the most enduring literary
characters of the late nineteenth-century Britain, an aesthete, concerned with the
beauty of things in themselves rather than their inherent meaning. He was a tremen-
dous artistic success, publishing The Picture of Dorian Gray (Wilde, 1891) written
in contempt for bourgeois society, the story of a hedonistic man who sells his soul
for eternal youth. His satire, The Importance of Being Earnest (Wilde, 1895), fol-
lows similar themes, positioning irreverence as a preferred morality to the social
customs and rituals of Victorian England. Schultz (2001) highlights the two Acts in
the narrative of Wilde’s life. This first one, of the shameless provocateur, resisting
attacks from the press with aphorisms, a Victorian Icarus. The second, once impris-
oned, a less shallow more genuine Wilde, engaged with an interiority, ‘revealed
after everything fell away’ (Schultz, 2001, p. 72.). Wilde was charged in 1895 with
gross indecency, due to his love affair with Lord Alfred Douglas. Soon after his wife
divorced him and his mother died and he never saw his two sons again. After
3 months of hard labor, he began writing a letter to his lover, which came to be titled
De Profundis (Wilde, 1905). While much of this work is performative, he describes
his suffering and despair.
I wanted to eat of the fruit of all the trees in the garden of the world ... And so, indeed, I went
out, and so I lived. My only mistake was that I confined myself so exclusively to the trees of
what seemed to me the sun-lit side of the garden, and shunned the other side for its shadow
and its gloom. (Wilde, 1905, p. 11)

Wilde describes imprisonment as “the tragically critical moment of my life” (1905,

p. 7) but also a turning point: “I am conscious now that behind all this beauty, satis-
fying though it might be, there is some spirit hidden of which the painted forms and
shapes are but modes of manifestation, and it is with this spirit that I desire to
become in harmony” (1905, p. 89). After prison Wilde is certainly a broken man,
poor, and exiled to France until his death in 1900. Regardless he reveals a different
identity, publishing two unique pieces. The Ballad of Reading Gaol (1898), written
for the proletariat, tells the story of the brutalization of the criminal class. He also
writes a letter to The Daily Chronicle, The Case of Warder Martin: Some Cruelties
of Prison Life (1897), demanding reform for children in jail.
Oscar Wilde’s story is an archetypically existential one, concerning itself with
the themes of this chapter: how to be one’s own unique self in the face of confor-
mity; accepting the threats to non-being, reconstituting oneself regardless; and ulti-
mately how to suffer in a way that deepens authenticity, realizing and remaining true
to one’s own deeper nature.
Identity and the Courage to Be: From Kierkegaard to Covid-19 155

2 Identity, Existentialism, and Christianity

The greatest hazard of all, losing one’s self, can occur very quietly in the world, as if it were
nothing at all. No other loss can occur so quietly; any other loss – an arm, a leg, five dol-
lars, a wife, etc. - is sure to be noticed. Kierkegaard (1849, pp. 32–33)

Kierkegaard (1813–1855) was arguably the Father of Existentialism, explicating the

search for selfhood well before the mainstay of the movement in the twentieth cen-
tury. He was also a Christian existentialist, paving the way for more contemporary
religious thinkers such as Tillich, Bultmann, and Barth. For Kierkegaard the great-
est threat to finding ones’ true identity was the doctrinal systems of the Church. A
focus on respectability and absolutes was for Kierkegaard an anathema to freedom:
“This falsification is really forgery brought about over the centuries, whereby
Christianity has gradually become just the opposite of what it is in the New
Testament” (Kierkegaard, 1885, p. 74).
Kierkegaard considered Christianity to be a subjective experience, mystical,
interior, emergent, one that revealed the uniqueness of the individual rather than
suppressing it for the crowd (Thomas, 1953). The search for oneself was a not a
journey of the head, but one of the heart. It involved first the experience of anguish
and despair, his “sickness unto death,” the experience of being isolated from self,
and also of not-willing-to-be-oneself, the separation from the person that God
intends you to be (Beabout, 1978). This journey is necessarily filled with fear and
trembling, anxiety resulting from the dizziness of freedom when one leaves the
crowd behind. Eventually, however, through the absurdity of faith, jumping into the
unknown, there is the possibility of a reconciliation of the finite and infinite. In this
sense one’s identity can only be found in God.
Paul Tillich was born 10 years after Kierkegaard died, but his career followed
many similar themes. He too was a man of faith, questioning the theism of the
Church is favor of the existential encounter. For Tillich God was not a being, but
rather being-itself, numinous, and accessible only through suffering (Peterson,
2015). Tillich’s ontology of courage has three types (Tillich, 1952). Central is the
capacity to face death-anxiety, the recognition of our mortality. We are courageous
when we seek our own answers for what will happen to us after death rather than
relying on the prescriptions of others. Second is moral courage, which comes from
recognizing our failings but deciding to accept ourselves anyway. Third is spiritual
courage, the capacity to face the feeling that we have no place in the world, no pur-
pose for our existence. For Tillich, self-affirmation is not a purely conscious act of
the will, but rather an acceptance, of these negative states before one enters into “the
state of being grasped by the power of being-itself” (Tillich, 1952).
156 P. Rhodes

3 Identity and Existential Humanism

3.1 Sartre and Heidegger: Identity as Reinvention

Despite its origins in Christianity, classic existentialism, personified in Sartre,

Camus, and Heidegger, is humanist, focused on identity as self-creation, based on
personal choices, rather than found in an encounter with God. For Sartre
(1905–1980), the person in search of an authentic identify must find meaning in a
world empty of God, standing alone in front of the abyss, abandoned. Selfhood
comes from the choices one makes in the face of this terrifying freedom, with iden-
tity molded by the ways one choses to find meaning to understand what is happen-
ing to you. As Sartre famously put it, “existence precedes essence”; our identity
cannot be found in human nature or predetermination, but can be constructed by us
as we see fit (Sartre, 1969).
His short story, Intimacy (Sartre, 1948b), is a study in these themes. It is the story
of a young woman called Lulu, unhappily married to her passive husband Henri,
who is depressed with the meaninglessness of her roles as wife. On the insistence of
her girlfriend, she decides to run away to Nice to live an ideal life with her lover and
recreate herself. She cannot quite believe, however, that this new self might be pos-
sible. She imagines it is a myth and returns to her husband. This story exemplifies
how, for Sartre, identity can be found in the tension between the two poles evident
in this story: firstly facticity, or current roles and their social and historical situated-
ness, including our personality traits and patterns of our behavior, and secondly
transcendence, the freedom to make oneself up without deference to norms. Identify
is found in the negotiation of these poles, between which characteristics we chose
to keep and those we seek to transform as unique (Bilsker, 1992).
Lulu, in Intimacy, however, fails in this regard and acts in what Sartre calls bad
faith, the avoidance of the discomfort and uncertainty. In this sense she withdraws
in fear from becoming the person she might be or the person she yearns to create.
Heidegger’s (1889–1976) theory of identity formation is very similar, involving
the same conflict between a retreat to our given state and one that is uniquely for-
mulated (Bilsker, 1992). Heidegger argues that we are thrown into the world, born
into a context that we did not chose, with beliefs, values, and ideas that belong to the
mass culture around us, inviting us to be passive participants (King, 2001). If we
follow we experience fallenness, choosing a foreclosure identity, becoming lost to a
public they (DeCenso, 1988). This can be a comforting position, given that anxiety
can be clouded by television, news, and gossip, each answering questions that we
ourselves did not pose. For Heidegger, an authentic identity is Dasein, or being
there, living in relation to the world while ultimately being alone (Dreyfus, 1990).
Identity and the Courage to Be: From Kierkegaard to Covid-19 157

3.2 Heidegger and Ricoeur: Identity as Momentary

To be a human being means to be on the earth as a mortal. It means to dwell. (Heidegger,

1972, p. 147)

While Sartre and Heidegger shared much in their humanist view of identity,
Heidegger introduced a temporality to the process that challenges the idea of the
self as a fixed internalized selfhood. Heidegger’s subjectivity did not involve the
development of an “I,” set apart from the flow of time, but rather a subjectivity
might be best seen as experience, a momentary encounter with the changing contex-
tual self. Human identity retains its historicity, a being in the world, perhaps also
understood in the contemporary reading of the word grounded (Escudero, 2014).
Heidegger’s Dasein is open to the world, hence differing from the interiority of
Kierkegaard. Courage comes from actively revealing oneself in the public sphere,
“to leave one’s private hiding place and showing who one is, in disclosing and
exposing one’s self” (Arendt, 1998, p. 176).
Humanist Paul Ricoeur (1913–2005) was also concerned with temporality and
identity, building on the work of Heidegger to develop his narratology. Ricoeur too
argued against essentialist versions of the human subject, such as that of the ratio-
nal, isolated Cartesian cogito. Instead, he argues for a personal identity that is not
fully stable or self-transparent, but is also not incoherent or self-alienated (Reagan,
1996). For Ricoeur, the self-relationship is achieved through narration, an active
interpretation in the present, rather than fully autonomous self-authoring. Narrative
means more than simply a story here but refers to the way that humans experience
time, the way we mentally organize our sense of the past and understand our future
potentialities (Ricouer, 1983). In this sense our identity only exists where the past
meets the future, the process of becoming is all that really exists (Morny, 1997).
When considering notions of identity, one can see that Ricoeur, while a narra-
tologist, mirrored the anti-essentialist identity negotiations of his humanist peers,
positioning the authentic human subject as a self-narrator, resisting sedimentation in
favor of innovation (Widder, 2011). Rather than negotiate between dogma and free-
dom, social mores, and self-creation, however, Ricoeur’s ontology involves one
between retrospect and prospect. Ricoeur mirrors Sartre’s existence precedes
essence, in stipulating that identity can only be narrativized retrospectively. Humans
tend to carry out emplotment, drawing together disparate past events into a mean-
ingful whole, by establishing causal and meaningful connections between them.
This occurs from the end point of the story (i.e., in the present moment). The future
should be approached with uncertainty, grasped as a set of potential narratives in
which we might take part, but also through the semantics of action, that is, as a
meaning-rich sense of possible choices, actions, and their consequences
(Ricouer, 1983).
Isak Dinesen, author of Babette’s Feast, once stated that “all sorrows can be
borne if you can put them into a story or tell a story about them” (quoted in Arendt,
1958, p. 104). This statement, often quoted by Ricoeur, highlights the hermeneutic
power that narration has against non-being and storytelling as an act of
158 P. Rhodes

self-determination (Crowley, 2003). As we tell ourselves our own story, as authors,

we appear at the junction between a known past and uncertain future. Courage
involves a willingness to dwell in this liminal space, inchoate.

3.3 Merleau-Ponty: Becoming Some-Body

The body is our general medium for having a world. (Merleau-Ponty, 1945/2012)

Like Heidegger, one of Merleau-Ponty’s (1908–1961) concerns, when considering

questions of being, was to situate consciousness in the materiality of the world,
rescuing it from abstract introspection. He was a friend of Merleau-Ponty but is
perhaps best known for his work on embodiment, arguing that notions of identity
and being cannot be separated from the corporeal (Toadvine, 2019). This has sig-
nificant implications, ushering in the body rather than Freud’s dreams as the royal
roads to the unconscious. The body, as Reggie Ray puts it, “is the unconscious, not
only in the smaller but also in the largest sense. The body is ultimately our largest
person” (Buddhist Review, 2010, para. 1).
From this position the discovery of identity cannot be done without considering
the incarnate nature of subjectivity. Without Descartes’ dualism we are left to seek
non-dissociative forms of identity which account for the fact that we are inseparable
from our skin. Embodiment theory shifts the vantage point from abstraction to
materiality. Identity starts with the subjective experience of the body-subject, expe-
rientially aware and connected to sensations of the flesh (Merleau-Ponty, 1945).

4 Existentialism and Diverse Identities

This brief history of identity formation from an existentialist perspective reveals a

shift in focus, from the interiority to situatedness, from mysticism to the contextu-
alization of selfhood in the context of time and narrative, but also the material world
of perception, action, and flesh. Courage is conceptualized as resistance, to Church
dogma, to the conformity of the masses, and to fragmentation and disembodiment,
in favor of an encounter with anxiety, aloneness, and liminality. The identity that
emerges is not fixed; it is found in God, hermeneutic, fleeting, narrated, and felt.
It is important to recognize that this classic era of existentialist thought, while
radical in its humanism, did not grapple with identity diversity as we now know it.
It was primarily a white male endeavor, failing to consider subjectivities of gender,
race, sexuality, and their intersection. Many of the thinkers discussed so far, how-
ever, did serve as critical starting points for more political existentialisms, willing to
develop complete theories regarding oppression and identity (Freeman, 2011).
Sartre, of course, influenced Simone de Beauvoir’s feminist existentialism, despite
her vehement critiques (Simons, 1986). Sartre also influenced Frantz Fanon’s black
Identity and the Courage to Be: From Kierkegaard to Covid-19 159

existentialism, particularly his book Anti-Semite and Jew (1948a). Merleau-Ponty

also brought the body to identity, opening up existentialism to feminist, black, and
gender-nonconforming bodies. Existentialism was to meet politics, and the subject
had to reckon with patriarchal, racist, and homophobic forces in the journey towards
authenticity (Levin, 2011). Existentialism also met Foucauldian post-modernity,
whereby subjectivities created by disciplinary power could be transformed by
experimental technologies of the self (McGushin, 2011).

4.1 Feminist Identity and the Male Gaze

It is fascinating that the revolution of second-wave feminism of the 1960s was heav-
ily influenced by Simone de Beauvoir who studied the work of Kierkegaard and
Heidegger with Sartre at the École Normale Supérieure (Bair, 1990). Her feminist
existentialism was explicated in her near 1000-page opus The Second Sex (de
Beauvoir, 1949), arguably the most important book of early feminism. For Beauvoir
the search for identity involves reclaiming of embodied subjectivity from a patriar-
chal culture. Women are incidental as opposed to essential, and while the man is the
Subject or Self, the woman can only be the Other (de Beauvoir, 1949). A woman is
socialized to develop the identity of a doll, passive and timid, aiming to please and
lacking in physical strength. These qualities are not her feminine essence but are
created by civilization. Central to her thesis is the idea of the male gaze that con-
structs the objectified identity of a woman. This gaze, once internalized, means the
woman continued to produce her body as an object for others. If the identity of a
woman is created by patriarchal society, however, it is not predetermined and can
therefore be self-fashioned, involving the dismantling of a lifetime of socialization
and the challenging of the myth of the woman (Curthoys, 2000; de Beauvoir, 1949).
Contemporary feminist phenomenologists, like Judith Butler, still owe much of
their thinking to Beauvoir, including her proposition that gender is performative,
built on social practices (Butler, 1990). This view also resonates with the existen-
tialist rejection of a predetermined human nature and the notion of identity as rein-
vention, self-narrated or emergent. The performativity of identity is established
through historical repetition and stylization making the appearance of innate traits
(Butler, 1993), rendering other forms of identity as abject or illegitimate. In reality
one can resist this false naturalization through critical reflection, identity claims,
and new modes of performativity.

4.2 Racism and Identity

All colonized people—in other words, people in whom an inferiority complex has taken
root, whose local cultural originality has been committed—position themselves in relation
to the civilizing language; i.e., the metropolitan. (Fanon, 1967, p. 2)
160 P. Rhodes

Frantz Fanon, the world’s leading black existentialist thinker and activist, stated in
his most famous book Black Skin, White Masks (Fanon, 1967) that Sartre’s Anti-­
Semite and Jew (1948a) contained pages that were “among the best I have ever
read” (Bernasconi, 2004). Fanon’s aim, however, was to decolonize existentialism,
given that colonialism was a total project which had rendered black identity to the
hell of non-being. Non-being occurs through the epidermalization of inferiority
(Song, 2017) or the internalization of racism. This project of negrification means
that the oppressed person must navigate the world through whiteness, struggling for
identity through white language, appearance, manners, and habits. For Fanon any
recuperation of black embodied subjectivity must be done as resistance to the impe-
rializing dominant culture.
Interestingly Vereen et al. (2017) highlight the many points of departure between
humanist white existentialism and black. Sartre, for example, challenged the
Descartian notion of “I think therefore I am” with “existence precedes essence.”
Black theory clearly proclaims, however, that “I am because we are.” While black
thought still includes the threat of non-being and the impetus for a liberated identity,
this can never be separated from the black struggle for wider sociopolitical emanci-
pation. Freedom and black authenticity become a question of justice and black
consciousness.
Despite Fanon’s credentials as an activist, he has been heavily criticized by femi-
nists. His most prominent investigation of women’s lives (Fanon, 1967), an inter-
rogation of the novel Je Suis Martiniquaise by Mayotte Capécia (1948), has been
accused as being misogynistic (Brownmiller, 1975). Fanon argued that the self-­
hatred of black women is so marked that they are driven to have sex with white men,
seen by feminists as a brutal a critique, involving the policing of black wom-
en’s bodies.

4.3 Gendered Identity

There have been few contemporary challenges to notions of identity more signifi-
cant than the dismantling of gender as a biological given. The deconstruction of
gender essentialism follows the historical existentialist discourse, given that it takes
Sartre’s reinvention to the corporeal. Simone de Beauvoir’s statement that “one is
not born, but rather becomes, a woman” exemplifies the existentialist radical com-
mitment to identity reinvention, providing a philosophical starting point for the
separation of gender from biological sex that came to underpin contemporary gen-
der politics.
Judith Butler’s seminal book Undoing Gender (Butler, 2004) takes up the cause
for gender performativity in relation to intersex and transgender individuals, argu-
ing for an anti-foundational stylistics of existence. She tells the story of David
Reimer, as evidence for the auto-production of gendered self-identity. David, an
identical twin born in the USA in 1965, had his penis destroyed during a circumci-
sion. He had a sex reassignment at 22 months and at the age of 14 rediscovered his
Identity and the Courage to Be: From Kierkegaard to Covid-19 161

masculinity and assumed a male identity. His case demonstrates that gender is free
and floating, rather than essential, with social norms only giving the appearance of
a gendered ontological core.
Houghtaling (2013) positions sexuality from an existentialist frame as follows:
“sexuality through an ontology of becoming that takes into account the diverse,
multifaceted nature of sexuality as a series of temporal experiences, attractions,
desires, sensations, practices, and identities” (p. ii). This statement places gender
firmly within the humanist commitment to emergent notions of identity, unstable
and always becoming.

5 Synthesis

The story of existentialism approach to identify has followed a shift from Christianity,
to humanism and then post-modernity. The self, once found in God, interior, gradu-
ally shifts outwards, looking into the material world, through the body, with others,
into action. Eventually we arrive at Hannah Arendt’s (1998) idea of amor mundi,
whereby an active life involves breaking free from hegemony, not just in the arena
of consciousness but also praxis. The personal has become political.
Despite these differences, however, a number of similarities can be ascertained
in respects to the approach to identity, with existentialism serving providing the
means through which subjects, historicized, can make sense of who they are. Firstly,
identity is not seen as fixed construct or trait, but rather emerges in opposition to
such conceptualizations. Identity is the antithesis of essentialism, being found in the
spiritual realm, in experience, momentary, narrated, an ontology of becoming.
Secondly, essentialist notions are socially defined but positioned by the herd as
givens. The human subject, yearning for authenticity, must resist these constructs in
order to be free. The specific objects of resistance change within each paradigm. For
Kierkegaard this meant resistance to church dogma and religious social conserva-
tism, for Heidegger the world one happens to be thrown into, and then on to the
patriarchy, the colonial, the heteronormative. The result, however, is a unique indi-
vidual, self-created and self-determining.

6 Global Dread and Identity

To a large extent the rise of existentialism occurred in direct response to the global
trauma of World War 2, given man’s search for meaning after atrocity and holocaust
(Lalka, 2005). In 1946, Sartre declared existentialism as a humanism, with man cast
into a brave, new Godless world (Sartre, 2007). The existentialist discourse casts a
long shadow, adapting to deal with contemporary problems, building on the canon,
but integrated with the post-modern thought of Foucault, given the mutual opposi-
tion to structuralism. In contemporary times, however, we are dealing with new
162 P. Rhodes

forms of global catastrophes in the form of climate change and Covid-19. What
does existentialism have to offer now in terms of the being-in-the-world? What does
it mean to have the courage to be oneself in the face of these new existential threats?

6.1 Eco-existentialism and Sustainable Biographies

Albrecht (2012) describes eco-existentialism as a new form of inquiry which

responds to the dread we experience in the era of climate change as we fear not our
own mortality, but the sustainability of all life on the planet. At its worst we experi-
ence pre-traumatic terror, in relation to the potential for eco-apocalypse. He
describes this despair as psycho-terratic, in that it no longer refers to an intrapsychic
state, but rather one that relates to our relationship to the earth. In the existentialist
tradition, he describes both inauthentic and authentic forms of existence, one
Anthropocene and the other symbiocene. The former, similar to Sartre’s bad faith,
involves an attempt to cope based on climate denialism, planetary-death denial, and
the maintenance of an anachronistic identity based on materialism. This form of
defense involves the blind following of public denialists, numbing through digital
forms of entertainment and even reactionary increases in consumerism. The latter
involves self-denial and the reconfiguration of our identity as one that is inherently
biophilic, or involving the love of nature, or sumbiophilic, involving a deeply
ingrained love of living in harmony with other species (Albrecht, 2019). Distress is
at its most pronounced when one becomes frozen in between, acutely aware of the
reality of the climate crisis but unable to shift from anxiety to grief and then the
reconfiguration to a symbiocene identity. Like Arendt (1998) this state involves the
recreation not only of an identity tied to place but also of direct action in terms of
sustainability and activism.
It is important to recognize the significance of this form of identity, one that mir-
rors Australian aboriginal conceptions (McManus et  al., 2014) but is new to the
history of existentialist thought. From the wider perspective of European philoso-
phy, it can be best understood as related to a post-human ontology, whereby the
human being is no longer central, but one species among an assemblage of many
(Wolf, 2010). Let us say we have shifted from Heidegger’s being-in-the-world to
being-in-the-world-with-all-its-species.

7 Covid-19

The Covid-19 pandemic is the perfect storm for existentialist despair, not simply
because it elicits a form of global dread but because, while threatening non-being, it
simultaneously casts us into physical isolation from each other. If death comes this
isolation amplifies, with family members excluded from one’s final moments. This
dread, or dis-ease (French & Monahan, 2020), is elevated to apocryphal myth
Identity and the Courage to Be: From Kierkegaard to Covid-19 163

through digital hyperrealism (Baofu, 2009), in a century already primed by the

semiotics of doom. Roberts and Cremin (2016) name this the Age of Catastrophe,
where dystopian dread is already primed 9/11, the GFC, Fukushima, Katrina, and
the refugee crisis. While these events caused real suffering, they are elevated to a
monolithic myth through media-saturated simulacra (Baudrillard, 1983), including
memes, CGI blockbusters, and The Walking Dead. Dread is no longer related to
original sin, or the absurd, but a product of a cultural unconscious or semiosphere
(Lotman, 2005). It is important to recognize that moral panic and doomsday sce-
narios have long been a vehicle for social control, from Salem (Reed, 2015) to AIDS
(Long, 2004) and Trump’s theocracy.
The question remains as to how we can exercise self-affirmation in the face of
both a real pandemic and a hyperreal apocalypse and what forms of identities might
be possible. What might emerge as we work our way through the fright, grief, and
post-traumatic reality of a changed world? What kind of heteroglossic possibilities
are there after resistance to freezing effects of a unitary monolithic discourse
(French & Monahan, 2020)? Arragui (2020) argues that Covid-19 provides us with
an opportunity to reconsider our relationships with multiple species which make up
the viralscape or intercorporeal scenery. As with climate change, we must reject
anthropocentrism in favor of a post-humanist identity, demoted to an assemblage
that now includes the microbal.

8 Conclusion

It has been over 170 years since Kierkegaard wrote Fear and Trembling (1848), but
the Father of Existentialism introduced the world to a discursive resource that has
maintained its relevance to the current day. The individual, faced with threats to his
identity, has drawn on this form of philosophical inquiry to inspire self-affirmation
in the face of non-being, abandonment, and the transformational potential of dread.
The threats have changed, from the dogma and conformity of the Church to the
meaningless of war; the erasure of sexism, racism, and gender-role conformity; and
contemporary global threats of climate crisis and pandemic. Our response, however,
need not, as we resist foreclosure and instead choose the path of self-creation and
authenticity.
This is not an intellectual journey, however, but an experiential one, involving
uncertainty and loss. Oscar Wilde paid the most terrible price for self-affirmation, in
an era that would not tolerate his irreverence and homosexuality, dying in Paris on
25 November 1890 from meningitis brought on by his 2 years in prison. Impoverished
and exiled, he spent his last years living in second-rate hotels and wondering the
boulevards alone. While we may not have to pay the ultimate price for self-­
becoming, the costs can still involve pain and suffering. In the end, as Wilde is
reported to have stated on his death bed, “this wallpaper and I are fighting a duel to
the death. Either it goes or I do.”
164 P. Rhodes

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Yet You May See the Meaning of Within:
The Role of Identity Concerns and the Self
in Psychopathology

Ayoub Bouguettaya, Tess Jaeger, and Richard Moulding

Abstract  Concerns and processes regarding one’s identity and “self” are arguably
a central component of existential concerns within humankind. This chapter briefly
introduces self-related constructs before looking at how they have been applied to
specific domains of psychopathology in recent empirical and theoretical works.
First, it has been argued that self-construct is a central concern driving obsessive-­
compulsive disorder (OCD), with those with obsessions having an ambivalent or
feared view of self. Second, within the OCD-related disorder of hoarding disorder,
it has been argued that perceptions of self and others intertwined with the meaning
of objects contribute to the incredible challenge that those with the disorder have in
discarding objects. Finally, within depression and eating disorders, the focus has
recently been shone on social identity processes, whereby one’s sense of self is
dynamic and influenced by one’s contemporaneous self-categorisation as a group
member. In depression, a loss of social identity has been argued to trigger pathol-
ogy, whereas in eating disorders, it has been argued that social identification with
particular groups may increase the risk of pathology.

Keywords  Self · Social identity · Obsessive-compulsive disorder · Hoarding ·

Depression · Eating disorders

Considering our own identities and our place in the world is arguably one of the
central conceits of humankind. Dale Carnegie (1981) famously proffered the notion
that when “we are not engaged in thinking about some definite problem, we usually
spend about 95 percent of our time thinking about ourselves” (p. 27). Under this
lens, psychology equally has paid a great amount of attention to the role of selves
and identity within psychopathology, and identity has arguably always been a fea-
ture of models of psychopathology. The idea that identity is a factor in mental health

A. Bouguettaya
School of Psychology, University of Birmingham, Birmingham, UK
T. Jaeger
Faculty of Health, School of Psychology, Deakin University, Burwood, VIC, Australia
R. Moulding (*)
Cairnmillar Institute, Hawthorn, VIC, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 167

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_10
168 A. Bouguettaya et al.

is not new; it has long been noted that those with stable self-concepts tend to be
healthier generally (Kelleher & Leavey, 2004). Meanwhile, those who have an
unstable self-image (Franck & De Raedt, 2007) have a negative self-image (includ-
ing due to stigma; Makkar & Grisham, 2011; Shimotsu & Horikawa, 2016), or
experience a loss of an identity (Seymour-Smith et al., 2017), and are more likely to
show signs of psychopathology. Contemporary research suggests that one’s identity
and associated self-image likely affect the likelihood of developing and recovering
from a variety of mental health conditions, and understanding “the self” in psycho-
pathology may lead to improved preventative and treatment options.
Given such a focus on identity, both at a folk-level and within psychology as a
science—and perhaps not unusually for the field—this has also led to a proliferation
of constructs and understandings of what we are talking about when we are talking
about the “self” (e.g. Brinthaupt & Lipka, 1992). In considering this issue, Leary
(2004) appealed to a need for clarity in distinguishing clearly between the processes
involved in self-awareness; the knowledge, beliefs, or feelings that people have
about themselves; and the processes involved in self-agency and self-regulation.
The self in all of these aspects is arguably involved in psychopathology. For exam-
ple, disruptions in the basic sense of self have been noted in recent models of
psychosis-­related disorders (Nelson et  al., 2012, 2019). Meanwhile, the beliefs
people have about themselves have been implicated in many anxiety and depressive
disorders, such as the anomalous considering of one’s social performance and eval-
uation of self in social anxiety (Clark & Wells, 1995) and body dysmorphic disorder
(Veale, 2004). Self-regulation approaches are also implicated, for example, in disor-
ders such as addictions and gambling (Rodda et al., 2016).
Given the preponderance of such self-related constructs and their specific rela-
tionship to forms of psychopathology, at best, here we can only hope to touch on
some illustrative examples of how self may play into particular disorders (For fur-
ther depth, see Kyrios et al., 2016). As such, in this chapter we will review a select
few from the range of mental health disorders that have been associated with the
existential construct of identity. In particular, we will discuss the “self”, and several
overlapping constructs, as they have been implicated in obsessive-compulsive dis-
order and hoarding disorder. We then turn to a new, social identity approach, as it
has been applied to depression and eating disorders. Through this lens, we hope to
illustrate how such constructs can, and we believe, should, be considered in models
of these disorders.

1 Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterised by unwanted intrusive

thoughts, images, impulses, or urges that are typically accompanied by compulsive
efforts to alleviate their associated discomfort or distress (American Psychiatric
Association [APA], 2013). It is only relatively recently that cognitive theorists have
begun to focus on the role of the self and identity in OCD. Guidano and Liotti’s
Yet You May See the Meaning of Within: The Role of Identity Concerns and the Self… 169

(1983) theoretical model of the aetiology of obsessive-compulsive behavioural pat-

terns is a notable exception. This model focuses on the role of early attachment
experiences, where a child predisposed to OCD is argued to experience both affec-
tion and indifference from their primary caregiver. This paradoxical pattern of
attachment is hypothesised to encourage the development of a fractured self-image,
for example, one that is at once lovable and incapable of being loved or demonstra-
tive of both high and low self-worth. These irreconcilable aspects of the self can be
viewed as equally compelling explanations of the same experiences and are often
supported by the individual’s interpretation of external reality. Thus, reconciliation
of the self-image and outward reality may become a primary goal. Guidano and
Liotti suggest that this tends to manifest in unyielding personal expectations regard-
ing moral or ethical conduct (i.e. adherence to strict rituals or rules). This is strongly
linked to negative self-appraisals. “‘Intrinsically’ valued moral canons become a
guide to the elimination (or control) of the ‘wicked’ part of the self and the fostering
of the ‘positive’ part”, which perpetuates “systematic doubt” (Guidano & Liotti,
1983, p. 113). At their core, such appraisals reflect existential concerns regarding
the fundamental nature of oneself and potential impact on others.
Bhar and Kyrios (2007) suggested that this self-ambivalence, or fragile sense of
self, may exacerbate OC symptoms, as intrusions tend to be viewed as particularly
imminent or meaningful when this is the case. For example, it has been argued that
intrusions may be interpreted as evidence of personal failings (Guidano, 1987;
Guidano & Liotti, 1983; Rachman & Hodgson, 1980). More recent research sug-
gests that moral self-ambivalence may play a role in increasing vulnerability to OC
symptoms (Ahern et al., 2015b) and maintaining OC behaviours (Perera-Delcourt
et  al., 2014). Subtle threats to moral self-perceptions have been associated with
activation of OC cognitive biases in OCD-related contexts (Abramovitch et  al.,
2013; Doron et al., 2012). Also following from Guidano and Liotti (1983), Doron
and colleagues (2007, 2008, 2012) have highlighted the role of “sensitive” self-­
domains—areas in which an individual lacks confidence or self-efficacy—in prim-
ing maladaptive appraisals of intrusive thoughts that undermine core self-perceptions.
General self-worth contingencies, as assessed in personal domains pertinent to
obsessional behaviour, have been associated with OC symptoms in both clinical
(García-Soriano & Belloch, 2012) and non-clinical (García-Soriano et  al., 2012)
samples. The cognitive hypothesis that neutralisation plays a role in the develop-
ment and maintenance of OCD is supported by findings that indicate such strategies
may be enacted in an attempt to restore self-worth (Ahern et al., 2015a). The implicit
assumption of constancy in the nature of character and morality (i.e. endorsing an
entity theory of morality and character) is associated with OC phenomena and
symptoms (Doron et al., 2013). As such, it is conceivable that a belief in the stability
of one’s own moral or ethical constitution—coupled with the perception of improper
personal conduct—may result in feelings of powerlessness and existential angst.
Cognitive appraisal models (CAMs) of OCD focus primarily on the relevance of
appraisals to the perpetuation of OC symptoms. For example, Rachman (1998a, b)
distinguished haphazard intrusive thoughts from obsessions by drawing attention to
the role of appraisals and perceived personal relevance. Specifically, individuals
170 A. Bouguettaya et al.

without OCD are able to disregard intrusions as relatively meaningless and irrele-
vant, whereas those with OCD interpret these thoughts as revealing hidden aspects
of the self that are deeply disturbing. Purdon and Clark (Clark & Purdon, 2016;
Purdon & Clark, 1999) postulated that egodystonic intrusive thoughts develop into
obsessions because they are perceived as threatening to the individual’s sense of
self. Rowa and colleagues have demonstrated that more upsetting intrusions contra-
dict an individual’s sense of self to a greater extent than less upsetting intrusions in
both non-clinical (Rowa & Purdon, 2003) and clinical (Rowa et al., 2005) samples.
In contrast to CAMs, the inference-based approach (IBA) foregrounds the role of
vulnerable self-themes in contributing to the development of obsessional narratives
and the reasoning processes that maintain them (O’Connor et  al., 2005). While
appraisals are relevant to these processes, they are not considered central to the
maintenance of the disorder. Proponents of the IBA have focused particularly on the
role of self-perceptions implying a feared, or harmful, self in the context of repug-
nant obsessions (Moulding et al., 2014). The feared-self construct is an extension of
personality and social psychology literature issuing from Higgins’ (1987) landmark
paper on self-discrepancy theory. In this work, Higgins outlined a process of self-­
construction that is influenced by a dynamic interplay between three interdependent
domains, including (i) the individual’s actual self, comprising the qualities they
ultimately believe they hold; (ii) their ideal self, encompassing the qualities they
aspire to possess; and (iii) their ought self, comprising the qualities they believe they
should, or are expected to, possess. The degree to which these domains are incon-
gruent with one another is posited to produce certain emotive responses. Specifically,
actual–ideal discrepancies are argued to elicit dejection-related emotions, which are
related to a perceived failure to fulfil one’s personal expectations, or to achieve posi-
tive outcomes (e.g. inability to cease engagement in compulsions). Conversely,
actual–ought discrepancies are postulated to evoke agitation-related emotions con-
sistent with a perceived inability to meet prescribed standards (e.g. powerlessness to
refrain from engagement in obsessions or compulsions).
Concerns regarding self-knowledge and development are reflected in the work of
Markus and colleagues (Markus & Nurius, 1986; Oyserman & Markus, 1990a, b),
who introduced the concept of possible selves. These are described as “the ideal
selves that we would very much like to become … the selves we could become, and
the selves we are afraid of becoming” (Markus & Nurius, 1986, p. 954). Thus, pos-
sible selves are future-oriented and can be both hoped for and dreaded. Feared or
dreaded possible selves are regarded with anxiety and apprehension. Feared possi-
ble selves are similar to Ogilvie’s (1987) contemporaneous conceptualisation of the
undesired self, which was proposed as a contrasting self-guide to Higgins’ (1987)
ideal self. Like feared possible selves, the undesired self can be understood as rep-
resenting unwanted or distressing potential future outcomes. Discrepancies between
real (or actual) and undesired selves have been linked to avoidance-based motives,
whereby individuals tend to engage in self-evaluations relative to their perceived
distance from negative or unwanted states rather than their proximity to ideal or
desired states (Ogilvie, 1987). Latent variable analysis has also demonstrated partial
support for the role of actual–undesired self-discrepancies in predicting negative
Yet You May See the Meaning of Within: The Role of Identity Concerns and the Self… 171

emotional states (Phillips et al., 2007). Carver et al. (1999) found that those whose
actual and feared selves were relatively proximal tended to experience anxiety and
guilt, which was unrelated to actual–ought discrepancies and conducive to avoid-
ance motives. These findings concur with Heppen and Ogilvie’s (2003) conceptual
replication, which found that actual–undesired self-discrepancies moderated the
relationship between actual–ought discrepancies and anxiety. The theoretical rele-
vance of dangerous, feared, or undesired possible selves to OCD is reflected in the
appraisals often accompanying “autogenous”, or repugnant, obsessions (Lee &
Kwon, 2003).
An emerging body of empirical research has demonstrated a relationship between
feared-self beliefs, OC symptoms, and associated cognitive processes. Ferrier and
Brewin (2005) tested the cognitive behavioural hypothesis that individuals with
OCD tend to appraise unwanted intrusive thoughts as indicative of hidden, unac-
ceptable aspects of the self in a clinical sample. On average, those with OCD drew
significantly more negative self-inferences in response to their intrusions than did
anxious or non-anxious controls. The authors also conducted a content analysis of
the traits encompassing the feared self that emerged from the study. Identified
themes included a “depressed/anxious self”, which was indicative of symptom-­
related self-appraisals surrounding feelings of hopelessness and dejection; a
“rejected self”, which revolved around feelings of loneliness, unworthiness, and
being essentially unlovable; a “flawed self”, which encompassed undesirable traits
that are not directly related to concerns surrounding the possibility of harm to the
self or others (e.g. self-centredness, vanity); and a “dangerous self”, which involved
concerns of potential harm to others or the thought of being crazy or uncontrollable.
The OCD group tended to endorse the latter category more often than both control
groups. This self-theme was found to be consistent with Rachman’s (1998a) clinical
descriptions of the character traits often identified by OCD clients in relation to
obsessions with repugnant themes—for example, appraisals indicative of the indi-
vidual being essentially “evil”, “dangerous”, “unreliable”, “uncontrollable”,
“weird”, “insane”, “sinful”, or “immoral” (p. 211).
Fear of self has been examined in research incorporating both non-clinical
(Jaeger et al., 2015; Nikodijevic et al., 2015) and clinical (Aardema et al., 2018,
2019; Melli et al., 2016) samples. Nikodijevic et al. (2015) found that feared-self
beliefs and high OC symptoms predicted the believability of OCD-relevant scenar-
ios and fluctuations in doubt regarding these scenarios over time. Results were con-
sistent with a mediation model, whereby feared-self beliefs partially underlie OC
symptoms. An extension of this research by Jaeger et al. (2015) was consistent with
Nikodijevic et al.’s (2015) findings. Fear of self has since been identified as a sub-
stantial unique predictor of unacceptable thoughts and impulses, independent of
negative mood states, obsessive beliefs (Melli et al., 2016), and inferential confu-
sion (Aardema et al., 2018) in clinical samples.
Although it is germane to clinical presentations of OCD observed in cognitive
literatures for more than 40 years, the role of identity and self-beliefs in OCD has
only recently become the focus of consistent research attention. Current findings
indicate that negative self-evaluative beliefs may underlie OC symptoms, thus
172 A. Bouguettaya et al.

contributing to the development and/or maintenance of the disorder. As such, these

findings are consistent with notions that domains and processes related to self are a
central component of OCD (Jaeger et al., 2021).

2 Hoarding Disorder

Given that hoarding was, until quite recently, considered to potentially be a symp-
tom dimension of OCD, it is illustrative to compare OCD with hoarding disorder
(HD) in terms of the differing role that self and identity may play within psychopa-
thology. HD is characterised by the accumulation and failure to discard possessions
to the point where the clutter becomes disabling or distressing for the individual
(APA, 2013). While hoarding is a complex phenomenon, with multiple overlapping
causal factors, including information processing deficits, unhelpful beliefs about
objects, and emotion regulation issues (Steketee & Frost, 2003), one understudied
aspect of the disorder is the role of identity. However, even outside of hoarding, as
noted by William James (1890), “…a man’s Self is the sum-total of all that he can
call his…” (p. 291), and notions of self, both individually and in relation to others,
are replete within the phenomenology of hoarding (Kings et al., 2017; Moulding
et al., 2016, 2021).
One of the aspects that differentiated hoarding from OCD is that in OCD, symp-
toms are largely egodystonic, whereas in HD, they are ego-syntonic (Rachman
et al., 2009). While notions of avoiding a feared self propagate through the OCD
literature, in HD there are considerations of how objects can instead substitute posi-
tively for self or others, with limited research supporting the relationship between
hoarding and underlying deficits in self-structure, with self-ambivalence (Frost
et al., 2007) and identity confusion both being linked to hoarding symptoms (Claes
et al., 2016). While in the case of OCD this was posited to lead to reactivity to intru-
sive thoughts or creation of negative self-relevant narratives, in hoarding it has been
suggested that alternative pathways operate. Specifically, Frost et al. speculate that
underlying dichotomous or ambivalent self-views lead individuals to seek meaning
from possessions, resulting in symptoms of hoarding and also compulsive acquisi-
tion issues. However, they also note that materialistic desires could in turn interfere
with social relationships, impairing the development of an elaborated or fully
realised self-concept.
Consistent with the notion that self can become intermingled with identity, stud-
ies have pointed to the notion of self-object fusion in hoarding, whereby the “person
that has all this stuff, it’s theirs, it’s a part of them, even ridiculous year old newspa-
pers” (Kellett et al., 2010, p. 146). A measure assessing the extent to which objects
and the self overlap was found to differ between individuals with and without hoard-
ing, was related to overall symptoms, and decreased with treatment (Dozier et al.,
2017). In a clinical sample, individuals identified as showing self–object fusion
endorsed that discarding was like letting a part of themselves go, that they experi-
enced a buzz from acquiring new things, and that they thought about the future use
Yet You May See the Meaning of Within: The Role of Identity Concerns and the Self… 173

of objects; and they were the only (albeit small) group within the study to indicate
that they drew a sense of companionship from items (Postlethwaite et al., 2020).
Further studies have investigated the multiple ways that identity can function
with respect to objects (Kings et al., 2020), reflected in conclusions from qualitative
studies that individuals with hoarding “used material possessions to reassemble the
fragments of their temporal experience into a unique space where memories, pres-
ent, and life projects join together” (Cherrier & Ponnor, 2010, p.  14). Items can
serve as a source of memory and thus self-identity in hoarding. For example, in a
study analysing cases collated from personal organisers, Roster (2015) described
“Gloria”, who hoarded hundreds of children’s books and Girl Scout craft kits, which
were said to be the key to her happy memories of her time with her daughter which
had revolved around these activities and which fortified her continuing identity as a
mother. Roster also gives the case of “Deborah”, a recently widowed former librar-
ian who they noted had particular difficulty discarding her books, reflecting her
background as a librarian and the component of that identity which reflected a rever-
ence for knowledge (Roster, 2015).
Yap and Grisham (2019) aimed to further unpack the construct of emotional
attachment to possessions. In an online questionnaire study with 532 North
American participants recruited via Amazon MTurk, they included as one aspect of
emotional attachment a specifically developed measure, The Possessions as
Memories and Self-Extensions Scale, which contained two subscales: the
Possessions as Memories (PAM) subscale aimed to address the extent to which
objects represent memories of people and events in the past, while the Possessions
as Identity (PAI) subscale examines the extent to which objects signify who they are
and would like to be. Such subscales were consistent with past studies such as the
findings of Cherrier and Ponnor (2010), that objects impart “the same emotions
[from the past] when you physically hold something”, and with Roster’s (2015) sug-
gestion that possessions impart individuality. Correlational analyses found a
moderate-­to-strong correlation with overall hoarding symptoms, with regression
analyses finding that the PAM scale contributed to difficulties discarding over-and-­
above anxiety, depression, general hoarding-related cognitions, and object attach-
ment security. They note that the imbuing of value to an object through its links with
autobiographical memories may be a significant barrier to treatment.
Most directly, Kings and colleagues (Kings et al., 2020) used photo-elicitation—
where participants photographed significant possessions in their home—along with
IPA to directly explore identity in people with HD (N = 10). Kings and colleagues
found three themes, reflecting early life factors, identity, and links to others. In
terms of themes related to identity, as previously suggested by Yap and Grisham
(2019), objects were found to represent to individuals who they were as people, for
example, “not many people have clothes that date back to the 50s, do they? Not
many; I do”. Objects also conveyed a sense of self-confidence—“I had millions of
clothes as a kid, but I used to feel good wearing that. I was teased a lot as a kid, but,
even so, I liked that dress”—and were used to defend self, where self-esteem is
“kind of fragile … so you justify your specialness in lots of other weird ways—so
objects”. Finally, objects could become physical extensions of self, such that there
174 A. Bouguettaya et al.

was “A sense of feeling whole if I have those physical things around me. If I do a
complete clean out … I’m completely gone, my identity is gone”.
Objects were also linked with others (Kings et al., 2020). Items served to remind
individuals of important attachments with others, giving a sense of warmth and
closeness. Sometimes those relationships may have been difficult, with grief being
apparent, and that sense of non-resolution appeared to function to prevent discard-
ing of the items. Further, while objects have been noted to be physical extensions of
self, they could also serve as physical extensions of others; for example, “Nora”
described taking almost all her mother’s possessions as she “felt like I was taking
my mother with me, almost like parts of her”. Participants described a sense of
responsibility to past owners of items, which appeared in addition to the responsi-
bility noted for items by Steketee and Frost (2003). Participants spoke of using
items to create new connections with others via caring for them, and conversely,
items were kept because they signified that others cared for them. Overall, then,
Kings and colleagues found that items seemed to be intimately connected to an
individual’s self-concept and also to the position of that concept within their rela-
tionship with others. While limited by a relatively highly functioning sample (all
participants acknowledged their hoarding and were seeking treatment), a resultant
measure is showing promise in relating self to hoarding symptoms (Kings
et al., 2021).

3 Examining Depression and Eating Disorders via a Social

Identity Approach

Finally, we turn to understanding the self in psychopathology through presenting

research on depression and disordered eating. In addition to the aforementioned
model by Higgins (1987) of actual vs. potential self-guides, perhaps the most
famous model of identity and psychopathology is the Beck model of depression
(Beck et al., 1983; Wright & Beck, 1983). In this model, Beck posited that depressed
individuals developed a negative self-schema or a set of beliefs about themselves
that were largely pessimistic. Beck suggested that this negative self-schema mani-
fested in a set of cognitive distortions, such as personalisation (seeing others’ nega-
tive feelings as more due to one’s self), magnification (exaggerating negative events
as more due to one’s self), and overgeneralisation (negative conclusions about one’s
self due to specific, inconsequential events). This model suggests that the tendencies
people have in their self-image against the world and the future have strong implica-
tions for the development of depression. The Beck model has strong clinical utility,
and challenging these views in cognitive behavioural therapy can reduce depressive
symptoms (Butler et al., 2006). Furthermore, longitudinal evidence has shown that
having a negative self-schema predicts the onset of depression in women, further
emphasising the value of understanding identity within psychopathology (Evans
et al., 2005).
Yet You May See the Meaning of Within: The Role of Identity Concerns and the Self… 175

However, contemporary research has suggested that cognitive models of the self
and identity (such as the Beck model) may not fully encompass the social compo-
nent of depression or other forms of psychopathology. For example, the Beck model
does contain a wider triadic component, theorising that depressed individuals also
held negative beliefs about the world and the future. Overall, however, these beliefs
are intertwined, and all three have social components. Arguably, any sense of self is
socially derived (Hogg et al., 1995). Furthermore, the world is a function of social
reality (Greifeneder et al., 2017), where even basic perceptual processes and memo-
ries can be affected by considering oneself as a group member (Luminet & Curci,
2009; Van Bavel & Cunningham, 2012; Xiao et al., 2016). Beliefs about the future
are also strongly linked to social and cultural views (Fischer & Chalmers, 2008),
and optimism and pessimism are often derived from social experiences (Higgins
et al., 1997; Smith et al., 2013). While cognitive models have therapeutic utility,
some have argued that they underestimate and undervalue social psychological
models of how people see themselves in context (Haslam et al., 2019). This is not
uncommon in psychology; in the biopsychosocial model of health and psychology,
social psychology is the least studied component (Suls et al., 2010) but has been
suggested to have the largest impact on health (Haslam et  al., 2019). Therefore,
understanding a social psychology model of the self in addition to a cognitive model
may have significant implications for preventative and therapeutic approaches to
psychopathology.
One newer theoretical approach (the social identity approach or SIA) has made
significant advances in how identity relates to psychopathology. The SIA, which
combines social identity theory (Tajfel & Turner, 1979) and self-categorisation the-
ory (Turner et al., 1987), was originally developed to understand how social groups
influence people but has been since expanded to understand social psychology and
health (Haslam et al., 2018). The core premise of this theory is that an individual’s
self-concept is tied not just to their personal identity (i.e. their attributes that stand
in contrast to all others) but also to the categories (groups) that an individual is a part
of (Turner & Oakes, 1997). When this group membership is made salient, that mem-
bership provides a sense of self—or a social identity—which then affects their
behaviours, thoughts, and feelings in a variety of modalities (Reicher et al., 2012).
This approach suggests that identity is fluid, constantly being constructed against
social contexts, and that social groups are a major source of information on our-
selves. Being part of a group, in this approach, also improves one’s self-esteem by
providing positive distinctiveness (Tajfel & Turner, 1979). Therefore, the SIA sug-
gests that group joining provides an additional sense of self, which in turn improves
mental health.
This approach has provided new ways of understanding mental health generally,
and it is bolstered by research showing the importance of socialisation to health
generally. Generally, research (N = 308,849) suggests that the more socially con-
nected a person is, the longer they live (Holt-Lunstad et al., 2010). SIA research
provides a strong rationale as to why; it has found that merely identifying with a
group improves one’s self-esteem (Steffens et al., 2017). Being part of more groups
also improves health; research on retirees found that being part of multiple groups
176 A. Bouguettaya et al.

(i.e. having more social identities) improves life satisfaction, and a lack of social
identities had reverse effects (Steffens et  al., 2016). However, not all groups are
equal; identifying with some groups can cause and sustain mental health issues, like
substance abuse (Dingle et al., 2015a, b).
The SIA has expanded existing knowledge of the causes of depression.
Longitudinal research has shown repeatedly that a lack of social connectedness (i.e.
a lack of social identities) predicts depressive symptoms later in life, even after
controlling for a number of other factors (Cacioppo et al., 2006, 2010). Similarly,
depression is usually triggered by a loss in one’s social sphere, such a loss of work,
or relationship breakdown—or, in other words, a loss of a social identity (Paykel,
1994). Furthermore, SIA research has found that a lack of social group membership
predicts relapse of depression (Cruwys et al., 2013).
More recently, research into disordered eating has shown that social identifica-
tion has a role in disordered eating formation as well. Decades of evidence has
shown that eating behaviour is socially bound (Cruwys et al., 2015; Higgs, 2015;
Higgs & Ruddock, 2020; Robinson, 2015), and classic research suggests that being
part of certain groups increases disordered eating behaviour (Crandall, 1988). Social
identification with particular groups, such as being a cheerleader, may increase dis-
ordered eating risks (Greenleaf et al., 2009). In fact, there is likely an interaction
effect; low self-esteem is also a prospective predictor for eating disorder develop-
ment (Button et al., 1996), and joining a group generally is done to improve self-­
esteem (Tajfel & Turner, 1979). Joining high-status groups is also more desirable
than lower-status groups (Ellemers et al., 1988), and it is likely the same groups that
display disordered eating have a high status in their context (e.g. cheerleaders).
Therefore, it may be that those with a low self-esteem are drawn to groups that
increase disordered eating. Overall, however, it is likely that identity and self-esteem
play a central role in disordered eating development, with social identity able to
explain specific facets of disordered eating pathology (Allison & Park, 2004;
Bouguettaya et al., 2019b).
Social identity can also be used to understand recovery from mental illness, espe-
cially in disordered eating and depression. A recent meta-analysis showed that these
SIA interventions can improve recovery from a variety of illnesses (Steffens et al.,
2019). In fact, in one study using both community group (e.g. soccer group) and
group therapy samples, researchers found that the strength of identification with that
group moderated the recovery from depression; a higher identification was associ-
ated with greater recovery (Cruwys et al., 2014). Similarly, multiple studies have
suggested that shifting one’s social identity from an “eating disordered” self to a
recovery self or alternative group is often reported by participants in eating disorder
recovery (Bouguettaya et  al., 2019b; Dark & Carter, 2019; Ison & Kent, 2010).
These studies suggest that when an individual undergoes reappraisals or shifts their
identity—including their social identity—their recovery is enhanced.
Furthermore, while it is not a focus of this chapter, understanding the role of
identity in therapeutic approaches may improve existing therapies. For example,
elements of psychopathology can also be reduced through understanding the social
identity approach, including addressing perfectionism in disordered eating.
Yet You May See the Meaning of Within: The Role of Identity Concerns and the Self… 177

Perfectionism in disordered eating is notoriously difficult to treat (Soenens et al.,

2007), but understanding perfectionism as a drive toward an improved social iden-
tity means it is possible to use social identity principles of comparative contrast (i.e.
identity content can be shifted depending on the frame of reference). One of our
recent studies demonstrated that classic social identity paradigms could be used to
accomplish a reduction in a type of perfectionism that predicts disordered eating
(Bouguettaya et al., 2019a), although future research in clinical samples is needed.

4 Conclusion

This chapter has served as a whistle-stop tour regarding some ways in which iden-
tity and psychopathology may be intertwined. We began by noting that “self” is
actually a multifaceted construct that is used in multiple ways, from noting that
disturbances in basic “mineness” in psychotic disorders to an elaborated discussion
of how self-guides and self-structure may make one vulnerable to intrusions and
feared-self narratives in OCD. We proceeded to contrast this with the OCD-related
disorder of hoarding, where it was suggested that the pathology was an attempt to
bolster identity, and that self itself could be imbued within objects, both in terms of
individual identity and self-in-context with others. Finally, we noted an exciting
emerging approach to identity that holds promise to combine more fully the “psy-
cho-” and the “social-” of the biopsychosocial model. From this approach, how
people see themselves and their social groups are intertwined, and the centrality of
identity in a variety of mental health conditions, suggests that acknowledging iden-
tity processes can lead to improved mental health. It would suggest that existing
approaches to the self and mental health (including those of OCD and hoarding)
could potentially be supplemented by newer research into social identity.

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Clarifying Identity and the Self in a CBT
Context

Michael Kyrios, Kathina Ali, and Daniel B. Fassnacht

Abstract  Two important psychological frameworks, self psychology and cognitive

behavioural theory, are brought together in this chapter as one way of advancing our
understanding of the role that identity and ‘the self’ play in psychological distur-
bance and its treatment. Numerous definitions of the self have been discussed across
multiple disciplines, and these are referred to either implicitly or explicitly in cogni-
tive behavioural formulations of psychopathology. Researchers have consistently
emphasised the complex transactional associations between psychological distur-
bance and ruptures in self-structures or self-processes such as self- identity, esteem,
regulation, stability, cohesion, complexity, incongruence, discrepancy, schemas and
ambivalence. Furthermore, early developmental influences are known to impact on
the emergence of both the self and a range of psychological disorders, which could
also impact on aspects of psychological treatment. Moreover, while cognitive
behavioural therapy (CBT) is considered the gold standard treatment for many psy-
chological disorders, efficacy and targets of treatment vary widely from disorder to
disorder, with the emergence of the Third Wave of psychological therapies focusing
attention on the need to target a broader range of factors in CBT to improve out-
comes, inclusive of the self. For instance, the emergence of successful strategies
targeting dysfunctional self-processing in disorders such as social anxiety and bor-
derline personality has seen greater interest specifically in evidence-based self-­
related interventions. Such considerations are important in evolving CBT, inclusive
of advancing personalised approaches to psychological treatment, as well as pre-
ventative mental health, education and even public mental health policies.

Keywords  Self · Identity · Cognitions · Psychopathology · CBT · Attachment

M. Kyrios · K. Ali · D. B. Fassnacht (*)

Flinders University, Adelaide, South Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 185

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_11
186 M. Kyrios et al.

1 Introduction: Why Bring Together the Self

and CBT Literatures?

This chapter brings together two important psychological frameworks, that of self
psychology and cognitive behavioural theory, as one way of advancing our under-
standing of the role that ‘identity’ and ‘the self’ play in psychological disturbance
and its treatment. There are multiple reasons for bringing together these distinct
areas, inclusive of diagnostic and treatment implications. From a diagnostic per-
spective, ruptures in the self are seen as important in disorders as diverse as
obsessive-­ compulsive spectrum disorders, personality disorders and psychoses
(Kyrios et al., 2016). While evidence-based interventions such as cognitive behav-
ioural therapy (CBT) have transformed how we treat psychological conditions
(Hofmann et al., 2012; McMain et al., 2015), there has been a tendency for services,
mental health policies and professional training programmes to focus on reducing
symptoms rather than on the features of individuals presenting with psychological
disturbance. The result of this tendency is that we develop gold standards for treat-
ment that use a ‘one-model-fits-all’ framework rather than individualising
approaches to interventions. Associated with this is the use of evidence that exam-
ines group rather than individual outcomes, thus limiting clinical decision-making
for discrete presentations.
Clinical acumen and findings from clinical trials support that not all individuals
with particular presenting problems respond to gold standard treatments similarly.
In fact, efficacy and effectiveness studies for even those conditions that evidence
supports are best suited to CBT demonstrate less-than-adequate recovery rates. For
instance, a recent meta-analysis of randomised controlled trials (RCTs) for adults
with obsessive-compulsive disorder (OCD) concluded that only 32% of patients had
recovered at posttreatment and follow-up compared to control conditions where 3%
and 21% recovered at posttreatment and follow-up, respectively (Fisher et  al.,
2020). More positively, meta-analysis of published RCTs targeting anxiety disor-
ders in children and adolescents reported recovery rates of 47.6–66.4% compared to
around 21% across waitlist and active treatment conditions; however, recovery rates
for individuals with comorbid autistic spectrum conditions were lower at 12.2–36.7%
(Warwick et al., 2017). Hence, there is room for improvement in outcomes follow-
ing CBT across a range of disorders where CBT is often regarded as the gold stan-
dard treatment.
Advancing knowledge of self-related factors that maintain dysfunction and pre-
dict outcome could help guide which additional factors to target in interventions.
For instance, a meta-analysis of the efficacy of interventions that target social iden-
tification to improve health and well-being, inclusive of anxiety, depression, cogni-
tive health and stress, found moderate magnitude effects, with greater impact
associated with augmented social identification amongst participants (Steffens
et al., 2019). Constructs associated with identity and the self are beginning to re-­
emerge as important factors in understanding and treating psychological disorders
(Kyrios et al., 2016).
Clarifying Identity and the Self in a CBT Context 187

2 What Is Identity and ‘The Self’?

The terms ‘self’ and ‘identity’ remain ill-defined concepts. From simple characteri-
sations to more complex analyses, the concepts have demonstrated longevity due to
their face validity and cross-theoretical embeddedness. Hammell (2006) explains
that ‘in general, “identity” is used to refer to one’s social “face” – how one perceives
how one is perceived by others’. ‘Self’ is generally used to refer to one’s sense of
‘who I am and what I am’ (p. 185). However, terms ‘identity’ and ‘the self’ are often
used interchangeably, as we do in this chapter, and both are considered transactional
outcomes of ongoing social interaction and self-agency.
Historically, the concept of ‘the self’ has been discussed across multiple disci-
plines, including psychology, psychiatry, sociology and philosophy. Contributing to
discourse is the fact that ‘the self’ is a complex multidimensional and transactional
construct with developmental determinants and outcomes (Baumeister, 1998). For
instance, Leary and Tangney (2012) identified 66 self-referential phenomena,
acknowledging there is little research examining their interdependence. Katzko
(2003) further noted that ‘…the term “self” is used by too many different theorists
in too many different ways…’ (p. 84).
Descartes’ early statement ‘I think therefore I am’ (Descartes, 1967) highlights
one of the main initial challenges in thinking about ‘the self’, i.e. disentangling the
individual who has a subjective thinking experience from being the object of that
thinking. The challenges are reflected in Locke’s (1960) late seventeenth-century
contention that the ‘self’ corresponds to the person engaged in the thinking (the ‘I’)
through to the eighteenth-century philosophers such as Hume (2014) who consid-
ered the ‘self’ separately from the individual who was having the experience. Hume
considered the ‘self’ to be akin to a mental construction of the same individual (the
‘Me’) that could be appraised in relation to various qualities, inclusive of one’s pos-
sessions or social status and personal characteristics such as moral values.
Subsequently, William James (1890) conceptualised the ‘self’ as comprising both
subjective (‘I’) and empirical or observed (‘Me’) attributes. More recently, Gallagher
(2011) emphasised two further features of self: (a) one’s basic or core self (self-
hood) which comprises implicit awareness of one’s experiences or consciousness
(‘ipseity’) and (b) the narrative self, comprising one’s external or social experience
of self and including constructs such as social identity, self-concept, self-image and
other related self-cognitions.
Discourse within the psychopathology arena has seen multiple constructs, pro-
cesses, structural features and content areas related to the self that have been identi-
fied and studied using a range of theoretical frameworks, including psychodynamic,
sociological, narrative, neuroscientific and cognitive. There is a complex interaction
between various factors in how the self relates to psychopathology, and, while there
are some commonalities between some disorders, there are multiple areas that
require ongoing research to delineate aspects of self related to specific disorders
(Kyrios et al., 2016). Nonetheless, following the recent advent of the post-rationalist
and Third Wave of cognitive behavioural therapies, for example, acceptance and
188 M. Kyrios et al.

commitment therapy (ACT) (Hayes, 2016) and mindfulness-based cognitive ther-

apy (Segal et al., 2002), there has been ever-increasing interest in constructs related
to the self in the CBT field.
The ‘self’ is imbued with processes, organisational structures, contents and out-
comes. It has been described as schema, prototype, cognitive representation, multi-
dimensional hierarchical construct, narrative sequence, linguistic descriptor and
elaborate theory, amongst others (Brinthaupt & Erwin, 1992), and is considered to
be a summation of who the individual is. To simplify the complexity of the literature
on the self, one can focus on two particular factors: (a) self-structures and
related  self-processes, including terms such as conscious versus unconscious,
explicit versus implicit and strategic versus automatic processing; self stability and
integration; and self cohesion, complexity, discrepancies, incongruence, ambiva-
lence, contingencies and sensitivities, and (b) self-content, inclusive of self-­schemas,
beliefs and appraisals.
The earlier psychodynamic theories focused mainly on the former, while cogni-
tive behavioural theories and treatments have tended to focus on the latter. An
important contribution of psychoanalytic theories is the way in which they initially
construed self-structures as underpinning the development of psychological disor-
der and included both conscious and unconscious elements in their construction of
self. Freud (1916) considered that key features of ‘self’ were often concealed from
conscious awareness and that the interplay of the id, ego and superego essentially
determined human behaviour. In psychodynamic theories, self-identity is princi-
pally considered a representation of the self in relation to others, particularly one’s
early parental relationships (Westen, 1992).
Psychodynamic approaches brought the social context into sharper focus, with
later researchers such as Turner and colleagues introducing social identity theory
which proposes that individual’s self-concepts are derived from perceived member-
ships to certain social groups (Tajfel & Turner, 1979). From a social perspective, the
self in the form of self-identity or self-concept could change with the knowledge of
or emotional attachment to a specific group. Such approaches have not necessarily
concerned major therapeutic recommendations within the CBT world but have been
associated with approaches to improving health and well-being within broader ther-
apeutic frameworks (Steffens et al., 2019).
To date, despite theoretical underpinnings emphasising the importance of self-­
constructs in cognitive behavioural theory (Clark et al., 1999), self or identity has
not been incorporated systematically into CBT. Cognitive models have, however,
incorporated self-constructs as phenomena that encompass specific content and
mindsets, expectations and judgement biases and attentional or information pro-
cessing that maintain psychopathology (Oyserman & Markus, 1998). The notion of
‘the self’ has been featured both implicitly and explicitly in many cognitive behav-
ioural accounts of psychopathology and resulting interventions, with a particular
emphasis on self-content and some additional focus on information processing
(Kyrios et al., 2016).
While rational emotive therapy (RET), a prototypical CBT, was based on the
foundation that psychopathology results from irrational beliefs and thoughts (Ellis,
Clarifying Identity and the Self in a CBT Context 189

1962; Ellis & Dryden, 1997), the self was not discussed explicitly; however, RET
does implicate the way in which irrational beliefs are pertinent to subject matter
relating to the self. An example of a primary irrational belief would be ‘I must be
successful in order to be worthy’, while secondary rational alternative beliefs could
include ‘Even when I fail in a specific task, people understand and still accept me’.
Later iterations of cognitive approaches were more explicit regarding the impact
of self-cognitions on psychopathology. From Beck (1967, 1976) through to post-­
rationalists (e.g. Guidano & Liotti, 1983; Mahoney, 1974) and schema-based theo-
rists or therapists (Markus, 1977, 1990; Young et al., 2003), the self and, in particular,
self-contents and self-processes have been implicated in the aetiology of anxiety,
depression and other disorders.
In his foreword to Kyrios and colleagues’ book outlining the self in understand-
ing and treating psychological disorders across the diagnostic spectrum, Beck states
that the self-concept is ‘…a unifying feature…of …disorders…The notion that we
have something in us that expresses itself in so many ways is puzzling, yet elegant
and exciting’ (Beck, 2016, p. X).
However, emphasising that we are only at the beginning of an appreciation of
how the ‘self’ impacts on psychopathology and its treatment, Beck also goes on to
say that ‘Up to now, we have had to dip in and out of the literature to piece together
the various perspectives on the self in such disorders…When psychological disor-
ders are understood as disorders of self, clinicians can apply a fresh perspective
towards treatment’ (Beck, 2016, p. X).

3 Selected Self-Constructs, Self-Structures, Self-Processes

and Self-Contents

The next section describes a range of self-constructs, self-structures and self-­

processes of particular interest to understanding and treating psychological disor-
der, as well as features of self-content.

3.1 Self-Contents and Self-Schemas

Within the cognitive tradition, the self is seen as a representation of information

relating to the individual and consists of descriptions about one’s identity, beliefs
about one’s attributes and self-expectations and future forecasts for one’s self. While
there are aspects of these that can lie outside of one’s immediate awareness, con-
scious or strategic thinking can facilitate self-knowledge. Negative self-appraisals
are seen typically across the range of disorders but may be particularly potent if an
individual places greater significance on specific perceived deficiencies. For exam-
ple, placing importance on others’ perceptions of one’s social performance and
190 M. Kyrios et al.

ability to manage or control one’s emotional reactions to perceived criticism consti-

tutes vulnerabilities to social anxiety, while having high expectations about one’s
body shape or weight is associated with perceptions about one’s worth in eating
disorders. Decreased self-confidence and self-criticism in anxiety is particularly
activated in specific situations, while depression is associated with more global and
pervasive negative self-views such as poor self-worth and self-blame.
Furthermore,  negative self-beliefs can also act as a selective filtering or guiding
system for self-related information. Moreover, negative or harsh self-critical evalu-
ations, particularly when made in comparison to others, are an integral part of the
‘cognitive triad’ where negative views of the world or others, the future and one’s
self form the characteristic basis of the depressogenic individual (Beck et al., 1979).
Theorists within the CBT tradition differentiate three major levels of cognition
associated with psychopathology. These three levels can all be applied to the con-
cept of ‘the self’ – (a) negative automatic thoughts or appraisals, which tend to be
situation specific but based on other levels of cognition (e.g. ‘I can never express
myself clearly when I have to speak publicly’); (b) maladaptive beliefs/assumptions
(e.g. ‘I can never be as good as others in public speaking’); and (c) maladaptive self-­
schemas (e.g. ‘I am an inherent failure in everything I do’) – and all three levels
form part of the diathesis-stress framework of psychopathology. For instance, indi-
viduals who maintain depressogenic appraisals, beliefs or schemata (i.e. the diathe-
sis) are considered more likely to develop depressive symptoms following negative
events (i.e. the stress) (Beck, 1967). In addition, attentional biases add to the encod-
ing of information and responses to situations (Beck & Clark, 1997). What is less
clear is the distinctiveness or nature of the relationships between each of these levels
of cognition.
While appraisals tend to be situation specific and beliefs/assumptions are gener-
ally more easily malleable, schemas are relatively enduring internal repositories of
world or self-representations that direct how we process, organise and manage
experiential information and how we typically respond to such information (Clark
et al., 1999). The evolutionary advantage of schemata is their ability to facilitate
information processing and responses, often automatically, efficiently and out of
one’s conscious awareness or effortless control. The disadvantage of maladaptive
schemata is their propensity to be self-perpetuating, even in the presence of discon-
firmatory information, by guiding the information to which we attend.
Self-related schemas are considered ‘cognitive generalisations about the self,
derived from past experience, that organise and guide the processing of self-related
information contained in the individual’s social experience’ (Markus, 1977, p. 64).
Self-schematic content can differ from disorder to disorder; for instance, a focus on
inherent failure or defectiveness may be associated with depression, while threat
and vulnerability relate to anxiety disorders, body appearance and size to eating
disorders and defective moral worth to obsessional presentations. While negative
self-content in the form of schemas, beliefs and appraisals is known to predict psy-
chopathology (Kyrios et  al., 2016), the relationship between the valence of their
content and psychopathology is likely to be more complex. For instance, Dozois
(2007) and Dozois and Dobson (2001), support the interconnectedness of specific
Clarifying Identity and the Self in a CBT Context 191

negative self-schemas with depressive presentations characterised by poorly inter-

connected positive schema representations. Bryant and Guthrie (2007) reported that
negative coping beliefs predicted traumatic distress, while higher prior self-worth
ratings were found to protect from post-traumatic stress disorder (PTSD) severity
(Yuan et al., 2011). The responses of individuals with negative self-beliefs to trauma
differ with their expectations about the impacts of the trauma (e.g. ‘I won’t be able
to manage’), predictions regarding their future (e.g. ‘I’ll never be able to cope’) and
self-appraisals (‘That I couldn’t stop this happening is proof that I’m worthless’)
facilitating ongoing distress.
A further factor to consider with respect to valence is the dynamic balance
between positive and negative self-schema content and individuals’ unique interpre-
tive styles when managing specific activating situations. For example, whereas
some individuals receiving praise for an achievement might balance out depresso-
genic schemas relating to failure, in others, the same event may lead to emotional
distress due to the perceived pressure by others or the added expectation of future
achievement. Furthermore, positive and negative self-beliefs and their balance may
have unique impacts on psychological adjustment (Garamoni et  al., 1991; Prieto
et al., 1992). More recently, the balance between positive and negative affect and
cognitions has also impacted on well-being frameworks and interventions (Fava
et al., 2017).
Finally, self-schemas, irrespective of their valence, interact with stressful life
events in the development of emotional disturbance. Janoff-Bulman’s (1989) ‘shat-
tered assumptions theory’ proposes that the experience of trauma can change how
affected individuals view themselves and the world. Three inherent assumptions
(the overall benevolence of the world, the meaningfulness of the world and one’s
self-worth) constitute core schemas, and when traumatic events shatter these, dis-
tress and trauma ensue until affected individuals can rebuild a supportable and adap-
tive assumptive world. In a recent evaluation and extension of the theory, Williamson
et al. (2020) examined these processes in the context of perceived perpetration of
morally ambiguous or reprehensible acts in cohorts of military/service personnel
and the general public. The researchers reported that PTSD severity was associated
with having experiences that violated belief systems important to one’s identity and
for which there was no way to atone for actions that were discrepant with one’s
beliefs. The authors contend that trauma transpires when individuals tie threats to
meaning and self-esteem to the process of identity formation. Singer (2004) com-
mented that ‘…To understand the identity formation process is to understand how
individuals craft narratives from experiences, tell these stories internally and to oth-
ers, and ultimately apply these stories to knowledge of self, other and the world in
general’ (p. 438).
192 M. Kyrios et al.

3.2 Self-Structures and Self-Processes

Such considerations speak to structural and process aspects of self, which also
include stability and consistency of self-concept over time. Poor stability of self-­
views has been a feature of numerous psychological disorders such as borderline
personality disorder (BPD; Zeigler-Hill & Abraham, 2006). For instance, Santangelo
et  al. (2017) reported that BPD patients demonstrated greater instability in self-­
esteem and affect which were both highly interrelated and associated with symptom
severity. Disturbances in self-consistency are also a feature of disorders such as
social anxiety disorder, PTSD and BPD (Kyrios et al., 2016), whereby maladaptive
regulation of the roles and self-representations that an individual maintains are dem-
onstrated in, for example, erratic relationships, discrepant behaviours, a sense of
emptiness or purposelessness and inconsistent goals (Westen & Cohen, 1993).
Research effort has also focused on other specific aspects of structure relevant to
psychopathology, including the clarity, cohesion and complexity of self. The term
self-clarity refers to the ‘extent to which the contents of an individual’s self-concept
are clearly and confidently defined, internally consistent, and temporally stable’
(Campbell et al., 1996, p. 141). If self-views lack clarity, they are prone to down-
ward revisions, particularly if individuals feel they do not meet perceived standards
(Pelham & Swann, 1989). Concepts such as self-ambivalence (Bhar & Kyrios,
2007), self-discrepancies (Higgins, 1987, 1989), maladaptive contingencies
(Crocker & Wolfe, 2001) or sensitivities in self-esteem (Doron et  al., 2008) and
feared self (Ferrier & Brewin, 2005; Melli et al., 2016) are aligned with poor cohe-
sion in self-views.
Many theorists regard the self-concept to be a non-unitary construct, with mul-
tiple contingencies used by individuals to evaluate self-worth (Crocker & Wolfe,
2001). Self-complexity refers to ‘…the number of aspects one uses to cognitively
organize knowledge about the self, and the degree of relatedness of these aspects’
(Linville, 1985, p. 97). Individuals vary in the number of elements that comprise
their sense of self (e.g. social roles, traits, goals), as well as the distinctiveness and
associative networks of these ‘self-aspects’. Individuals reporting greater self-­
complexity (i.e. a greater number and greater distinctiveness of self-aspects) are
considered less at risk of depression and illness following periods of high stress
(Hershberger, 1990; Kalthoff & Neimeyer, 1993; Linville, 1987). Self-complexity is
thus thought to operate as a resilience or protective factor against the detrimental
effects of severe stress. However, empirical support has been mixed, with overly high
degrees of self-complexity possibly also associated with poorer cohesion or less
integrated core identity (Rafaeli-Mor & Steinberg, 2002). Brown and Rafaeli (2007)
found support for the functional advantage of complexity and integration, with a
greater number of self-aspects and more overlap amongst self-aspects associated
with lower depression levels. Managing variance amongst individuals in the quality
of integration with respect to the range of self-aspects into a whole or coherent
sense of self is an implicit foundation of many strengths-based approaches to CBT
that (a) encourage the development of new attributes that can be more easily
Clarifying Identity and the Self in a CBT Context 193

integrated into existing positive personal resources and (b) discourage contingen-
cies that maintain personal limitations.
Additional self-related factors that impact on adjustment and are closely associ-
ated with self-complexity include (a) the degree of consistency versus discrepancy
in self-appraisals; (b) the degree to which individuals place significance on specific
aspects of self, content themes or contingencies; and (c) the degree to which self-­
definition is cohesive or stable. Along these lines, self-discrepancy theory (Higgins,
1987), which focuses on the consistency between different aspects of self, is a major
contribution to understanding the impact of self on psychopathology. Accordingly,
individuals vary in how they see themselves currently (i.e. their ‘actual’ self), how
they would like themselves to be (i.e. their ‘ideal’ self) and how they think they
should be (i.e. their ‘ought’ self). Discrepancies between these aspects of self place
individuals at risk of psychopathology, with particular discrepancies associated
with specific affective states, i.e. actual-ideal self-discrepancies related to dejection-­
related emotions (e.g. depression), while actual-ought discrepancies matched to
agitation-related emotions (e.g. anxiety). Despite methodological limitations and
discrepant findings, studies have supported these relationships (Boldero & Francis,
2000), although the translation of such insights into specific intervention strategies
has not necessarily formed part of traditional CBT conceptualisations of existing
treatment strategies, at least explicitly.
Recent literature further reflects the specificity or particular relevance of self-­
construals to distinct aspects of psychopathology. As examples, research has been
undertaken in examining ipseity (i.e. the disturbance of the basic sense of self) as a
trait marker in schizophrenia (Nelson et al., 2014) and disruptions in attachment and
the capacity to mentalise in personality disorder (see Fonagy & Luyten, 2009). Our
own research has focused on OCD following on from the clinical and theoretical
work of Guidano and Liotti (1983). In order to describe the impact of unwanted,
feared or inconsistent aspects of the self in OCD, researchers have used terms such
as ‘self-incongruence’ or ‘self-ambivalence’ (Guidano & Liotti, 1983) and ego dys-
tonicity (Rowa et al., 2005). Guidano and Liotti (1983) suggest that individuals with
OCD are ambivalent about their self-concept, experiencing positive and negative
self-evaluations simultaneously regarding their worth, particularly from a moral
perspective. The resulting uncertainty generates attempts to find confirmatory evi-
dence for positive self-views through compulsions, predisposing them to attend to
threats to self-esteem. Experimental evidence has supported the impact of compul-
sions on decreasing degrees and confidence in self-worth (Ahern & Kyrios, 2016).
With respect to specific content areas related to OCD, Guidano and Liotti (1983)
focused on moral worth, indicating that self-worth in OCD is highly contingent on
maintaining perceived high moral standards. Furthermore, Ferrier and Brewin
(2005) found that those with OCD were characterised by a ‘feared self’ which was
more likely to comprise immoral characteristics as self-evident in their intrusions.
Aardema et  al. (2018) reported that participants with OCD and eating and body
dysmorphic disorders reported significantly greater fear of self than non-clinical
and anxious/depressed controls, concluding that ‘fear of possible self’ may be rel-
evant for a range of psychological disorders where negative self-perceptions prevail.
194 M. Kyrios et al.

In a recent systematic review examining the relationship between select self-­

constructs and OCD, Godwin et  al. (2020) found that both fear of self and self-­
ambivalence predicted obsessive-compulsive symptoms and argued that
interventions for OCD ought to encompass a component to address fear of self and
self-ambivalence.
Moreover, Doron and colleagues (Doron et al., 2007, 2008) examined a range of
specific self-domains in which they conceptualised individuals with OCD as expe-
riencing ‘sensitivity’ or vulnerability. Vulnerable individuals place a high value but
concurrently feel incompetent in such domains. Using both clinical and non-clinical
cohorts, the researchers concluded that obsessive-compulsive beliefs and symptoms
are associated with sensitivity in the domains of morality, perfectionism and
achievement. There are questions about the specificity of findings to OCD.  For
instance, neither Bhar and Kyrios (2007) nor Bhar et al. (2015) found differences in
self-ambivalence between OCD and anxiety disorder cohorts, signifying that
ambivalence may constitute a general vulnerability (Godwin et  al., 2020).
Nonetheless, there may be particular clinical significance to such constructs in
OCD.  For instance, Bhar et  al. (2015) reported that changes in self-ambivalence
predicted recovery status at posttreatment for patients with OCD during CBT. Despite
its status as the ‘gold standard’ treatment for OCD (McKay et al., 2015), with only
half of affected individuals with OCD responding to CBT, these findings indicate
that an additional treatment focus on self-ambivalence could improve outcomes.

4 Developmental Considerations in Delineating Identity

and ‘The Self’

Self-constructs and their developmental precursors have both been regarded as sig-
nificant in the aetiology of various disorders (Guidano & Liotti, 1983; Mikulincer &
Shaver, 2016). Importantly, developmental factors have been seen to be critical in
the development of self-construals. In particular, the concept of ‘attachment’
impacts crucially on how individuals see themselves and the world. Central to
attachment theory is the precept that humans have an ‘attachment behavioural sys-
tem’ that activates greater proximity to attachment figures at critical times, such as
those where individuals feel uncertain or distressed, in order to facilitate subjective
feelings of safety and security (Bowlby, 1988). Over time, humans are able to inter-
nalise their attachment figures, although key learning experiences over critical
developmental periods may lead to differential states of assumed security. Early
experiences of attachment figures as available, supportive and responsive are likely
to lead to positive ‘working models’ or mental representations of others and the
world as secure and of oneself as worthy or competent. In contrast, when attach-
ment figures fail to reliably engender security, individuals develop concerns about
the trustworthiness of the world, others and oneself in managing threats; hence,
Clarifying Identity and the Self in a CBT Context 195

rather than a sense of security developing, humans learn to be anxious or avoid

potential threats and ambiguities.
Two attachment style dimensions, attachment anxiety and attachment avoidance,
are associated with distinct patterns of relationship quality, emotional regulation
and behavioural predispositions (Mikulincer & Shaver, 2004). The avoidance facet
is typically associated with distrust and doubts about others and oneself, emotional
distancing and behavioural avoidance, while the anxiety factor is accompanied by
anxious concerns about others’ availability, low confidence and hyperactivating
compensatory strategies comprising active attempts to achieve support and love
with associated anger and despair if it is not provided (Cassidy & Kobak, 1988). In
turn, both attachment anxiety and avoidance are associated with a broad range of
psychological conditions (Mikulincer & Shaver, 2016).
Of particular relevance to this chapter, negative attachments impact on self-­
construals (Guidano & Liotti, 1983). Mikulincer and Shaver (2004) argued that
secure attachments allow an individual to develop a cohesive, stable and adaptive
self-structure. Insecure attachments inevitably lead to doubts about one’s own worth
and higher levels of self-criticism, poor self-efficacy and personal styles that defend
against perceived social threats, pessimism and worthlessness. Following the work
of Hazan and Shaver (1990), Bartholomew and Horowitz (1991) developed a frame-
work that conceptualised adult attachment styles as comprising positive and nega-
tive working models of self and relationships with others. Specifically, they defined
four archetype attachment patterns comprising various combinations of positive or
negative self-construals and positive or negative views of others. Subsequent
research has supported this conceptualisation of the interrelationships between
attachment, self-aspects and psychopathology.
For instance, our own research in OCD with clinical and non-clinical cohorts
supports the associations between adult attachment insecurities and symptom sever-
ity, even after controlling for depression (Doron et  al., 2009, 2012). Seah et  al.
(2018) further examined the association of insecure attachment, self-ambivalence
and obsessional beliefs as vulnerabilities to OCD severity using an analogue cohort.
They supported the impact of attachment anxiety on self-ambivalence and the
impact of attachment, self/identity and cognitive factors on OCD severity. While
many studies have been undertaken with analogue samples, there is ample evidence
from clinical  cohorts supporting the association of symptom severity and self-­
construals across the OCD spectrum (Dunai et al., 2010; Kyrios et al., 2018). The
consistency of such findings supports the need to develop interventions that target
self-construals and specific beliefs, and to account for the idiosyncrasies of attach-
ment patterns, in treatment. As discussed earlier, while some treatment approaches
explicitly target such matters, CBT has tended to be less explicit in its focus on
attachment and self-related structures. The following section discusses the literature
and provides further suggestions as to how to incorporate matters relating to self
and attachment into CBT.
196 M. Kyrios et al.

5 The Self and Treatment Considerations

There are important therapeutic implications to the quality of an individual’s attach-

ments and the nature of one’s self-construals. While psychodynamic therapies hold
such considerations central to their frameworks (cf. concepts such as transference
and countertransference and the structure of the psyche), traditional CBT therapies
tend to de-emphasise the importance of the therapeutic relationship and underscore
the salience of therapeutic strategies with somewhat of a focus on self-content and
completion of homework tasks (Clark, 2016). While much has been written about
the role of the therapeutic relationship on psychotherapy outcomes (see Cuijpers
et  al., 2019 for a recent review), all psychotherapies require a level of alliance,
engagement and transactional communication between therapist and client. From a
meta-analysis of CBT studies, Kazantzis et al. (2018) concluded that there is strong
evidence for the importance of both the therapeutic alliance and the use of home-
work exercises with respect to outcomes.
The quality of interactions between therapist and client will be impacted at least
in part by their respective attachment styles. Therapists use their understanding of
clients’ current attachment style and sense of self to facilitate adaptive engagement
processes in treatment, inclusive of: (a) enabling a sense of security; (b) supporting
the development of a ‘shared model’ that underpins treatment targets; (c) deciding
how best to communicate and what ‘stance’ to take in developing an alliance with
the client; (d) motivating clients to undertake required out-of-session tasks; and (e)
modelling important values such as self-acceptance and self-compassion. Level of
engagement is particularly important as it increases treatment adherence and com-
pliance. To accomplish all this, therapists may need to adjust their interactive style
by understanding how the client’s sense of self and all its associated phenomena
(i.e. content, structure, etc.) have been impacted by the client’s developmental and
attachment experiences to that point. For instance, in the treatment of BPD, it is
imperative to build a strong therapeutic alliance, including the ability to repair rup-
tures and enable corrective relational experiences, in order to slowly correct the
client’s attachment disorganisations. Only after a successful therapeutic alliance has
been established and ruptures have been repaired can the integration of other inter-
ventions aimed at, for example, emotion regulation be initiated (Liotti &
Farina, 2016).
Shorey and Snyder (2006) recommend that assessment of client’s attachment
styles should comprise a standard component of case conceptualisation and treat-
ment planning. Analysis of explicit and implicit self-structures, self-processes and
self-contents associated with an individual client’s symptoms could help with access
to more core or consequential cognitions, behaviours and maladaptive predisposi-
tions, as well as strengths and coping strategies. In turn, this could facilitate the
development of a case formulation or ‘shared model’, i.e. a map that is shared
between therapist and client linking the self with the relevant phenomena that main-
tain symptoms and pathology for that individual. The ‘shared model’ is the corner-
stone of CBT and is developed through a process of guided discovery (the ‘Socratic
Clarifying Identity and the Self in a CBT Context 197

dialogue’ is central to this) and collaborative empiricism. Such a model is also

imperative for the motivation and engagement process as it addresses issues and
goals that are important to the client. However, there is a paucity of reviews on the
impact of specific elements of the therapeutic alliance, such as collaborative empiri-
cism and Socratic dialogue (Kazantzis et al., 2018).
As noted by Clark (2016), further to considerations regarding engagement and
motivation, determining the impact of implicit and explicit self-structures and self-­
processes would further be useful in facilitating positive treatment outcomes. For
instance, targeting complexity of an individual’s self-identity may assist in tailoring
cognitive interventions to either reduce or strengthen the importance of certain self-­
attributes. In OCD, for example, an individual’s self-worth often relies on one or
two specific overvalued domains (e.g. morality, achievement, control, ought or ideal
‘self’), and intrusions frequently challenge the sense of competence in such domains,
resulting in distress and maladaptive responses. When targeting the self in treat-
ment, a specific emphasis can be placed on expanding a client’s self-concept by
exploring and identifying other important domains, developing strategies to increase
other skills and challenging the rigidity and importance of that one specific domain
(Doron & Moulding, 2009). Alternatively, more adaptive behavioural manifesta-
tions of those domains can be practiced. Further, the degree of congruence or inter-
connectedness of positive and negative self-attributes could be addressed or
challenged which may lead to specific attitudes or activities to modify certain ele-
ments of a dysfunctional self (e.g. self-compassion). Despite the importance and
value of considering incongruent self-aspects and their impact on emotional distur-
bance in a case formulation, this frequently does not occur in therapy.
While a variety of CBT methods implicitly take the self into account, clinical
techniques can be used to target the self specifically; for example, a focus on both
broad (e.g. self-esteem) and specific self-related structures (self-ambivalence), con-
tents (e.g. perfectionism) and processes (e.g. self-focused attention) can be used
effectively in treatment. Further, traditional cognitive and behavioural techniques
could be augmented with ACT-based values exercises, mindfulness strategies and
behavioural exercises all of which could be tailored to specific self-constructs. In
addition, narrative approaches offer useful pathways to understanding and working
with self-construals (Singer, 2004). Regardless, the therapeutic relationship pro-
vides the context to address the self strategically using specific strategies, including
unconditional positive regard, active listening and a neutral response to negative and
maladaptive thoughts and behaviours, as well as graded psychoeducation, to help
clients experience a greater sense of security and to develop an assumption of posi-
tive regard (secure attachment) to normalise their experiences.
The inclusion of self-based interventions can offer significantly augmented out-
comes for specific disorders when compared to traditional treatments. For example,
in social anxiety, researchers have found added benefits to the inclusion of self-­
imagery rescripting, schema-focused interventions, behavioural experiments and
modification of processing through attentional training, task concentration training
and attentional bias modification procedures (Gregory et al., 2016). In particular,
the use of self-based augmented strategies such as the use of video feedback to
198 M. Kyrios et al.

facilitate imagery rescripting, behavioural experiments and attentional training has

been found to lead to lower attrition, a greater proportion of participants experienc-
ing clinically significant change and significantly higher effect sizes relative to a
control treatment without augmentation with self-interventions (McEvoy et  al.,
2015). Interestingly, attentional bias modifications are being used more broadly in
areas where self-focused attention is maladaptive, such as the experience of chronic
pain (Liossi et al., 2020).
A further  example  comes from a recent study evaluating the addition of self-­
identity components to group cognitive behavioural therapy for hoarding disorder
demonstrated larger-than-usual effect sizes for hoarding and depressive symptoms
at follow-up (O’Connor et al., 2018). While these studies highlight the importance
of understanding the phenomenology associated with dysfunction and targeting rel-
evant self-related factors,  further research is needed to investigate the additional
effect of addressing self-concepts in treatment. Nonetheless, evidence to date high-
lights the importance and potential benefits of a deeper focus on the self  (Chia
et al., 2021).

6 Future Directions

There are a number of directions that can be taken in the future with respect to pro-
moting our understanding of the interrelationships between self-constructs and psy-
chological dysfunction and in facilitating the use of that knowledge to develop more
efficacious treatments.
Further research is needed to increase our understanding of the self and identity
and to develop integrated frameworks that link dimensions of self reliably across
disorders or dysfunctions. The self is a complex and dynamic construct and incor-
porates the experience of objective, subjective and contextual/interrelational char-
acteristics. That complexity is considered a strength of the construct as it allows its
incorporation into multiple frameworks; however, the lack of a common language
about the self or agreement about its relevant dimensions, particularly those associ-
ated with psychological adjustment, has led to imprecision about its very definition
and its various facets, undermining multidisciplinary or collaborative research
within even the same disciplines. Clarity around operationalisation of the ‘self’ and/
or a consensus language could act as a bridge that facilitates multidisciplinary
research.
An additional research direction relates to the developmental prequelae of self-­
construals. The cognitive behavioural literature warrants further longitudinal
research that follows the development of self and its co-relationship with psycho-
logical adjustment while also reliably identifying attachment and self-based risk
factors for psychopathology in general and for specific disorders. The outcomes of
such studies offer the potential to develop self-based taxonomies of psychological
function and dysfunction based on attachment and self-dimensions. Such advances
could help form a roadmap for integrating existing formulations of psychological
Clarifying Identity and the Self in a CBT Context 199

disorders and their treatments or developing new treatments that target key dimen-
sions of self or identity (structures, processes and cognitions).
Given the relatively limited efficacy of existing evidence-based treatments with
respect to recovery, there is a clear need for ongoing review of existing interventions
and  development of new therapies  targeting self/identity. Maturing our existing
knowledge base of the self in specific disorders into new treatment protocols ought
to be a priority. Furthermore, the integration of self-based intervention strategies
into existing treatments to augment efficacy is necessary across a broader range of
disorders and dysfunctions. Naturally, the ongoing evaluation of the efficacy and
cost-effectiveness of self-based interventions is critical, as is the development of
effective training programmes and workshops to disseminate skills throughout the
mental health workforce and relevant trainees. Finally, given links between self/
identity, psychological adjustment and developmental factors, we need to consider
early intervention and prevention programmes, either through public mental health
or parenting programmes (prevention), self-development courses potentially dis-
seminated through educational facilities (prevention) and self-augmentation strate-
gies for those at risk or in the early stages of onset (early intervention).
As a parting comment, cognitive behavioural theory and its associated treatments
have given us a multitude of options for treating psychological disorder, offering
hope and recovery to all with the lived experience of a range of conditions and per-
sonal challenges. Greater knowledge about the self, identity and attachment and
how these factors impact on all of us offers further hope.

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Section IV
Freedom
Freedom, Responsibility and Guilt

Thomas Heidenreich and Alexander Noyon

Abstract  Among the existential concerns that have become relevant for CBT, the
three interconnected concepts of freedom, responsibility and guilt play an important
role. Freedom, in this context, is understood as the ability to deliberately choose
between different (behavioural) possibilities; responsibility (for one’s actions or
inactions) is a direct consequence of freedom. Rollo May (Freedom and destiny.
W. W. Norton, New York, 1981) has emphasised that destiny sets limits to this free-
dom. This chapter explores the existential concept of freedom and its potential
implications for psychopathology and CBT: being free to choose implies that a large
number of options (those not chosen) must be ignored. Not taking conscious deci-
sions may look like a safe thing to do at first but will probably lead to ending up in
life situations that are arbitrary rather than value-based. Freedom is a prerequisite
for responsibility: if humans are free to choose, they are responsible for the choices
they make and (in the constraints of destiny) for the course of their lives. Potentials
that are not realised due to bad decisions may to lead to “ontological guilt” and
regret. We will conclude with a brief outlook on potential clinical implications that
will be detailed in the chapters following this one.

Keywords  Existential therapy · CBT · Freedom · Responsibility · Guilt ·

Ontological guilt · Behaviourism · Cognitive-behavioural therapy

1 Introduction

I shall be telling this with a sigh

Somewhere ages and ages hence:
Two roads diverged in a wood, and I –
I took the one less travelled by,
And that has made all the difference.

T. Heidenreich (*)
Hochschule Esslingen, Esslingen am Neckar, Germany
e-mail: [email protected]
A. Noyon
Hochschule Mannheim, Mannheim, Germany

© Springer Nature Switzerland AG 2022 207

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_12
208 T. Heidenreich and A. Noyon

(Robert Frost: The Road not Taken)

The history of philosophy as well as that of literature, music and other forms of art
is full of themes that relate to the topics of freedom, responsibility and guilt: from
seemingly trivial decisions such as “Should I stay or should I go now” (The Clash)
to Hamlet’s famous monologue “To Be or not to Be...” – decisions between different
forms of behaviour (based on the freedom to choose between them) play a major
role in human lives. The aim of this chapter is not to attempt an exploration of the
extent of freedom people have in the face of a deterministic world – rather, we will
try to elucidate how (a) people are able to choose between different, and  often
incompatible, life options and what the consequences are (freedom), (b) how the
choices people make during their life are related to responsibility and (c) how free-
dom and responsibility are related to guilt and regret.

2 Freedom

Freedom is just another word

for nothing left to lose.
(Kris Kristofferson: Me and Bobby McGee)

Writing a chapter on freedom for a book on “Existential concerns and cognitive-­

behavioural procedures” has several potential starting points: first, the exploration
of freedom as an existential concern, and second, the history of freedom in the his-
tory of CBT. We will start with a broader overview of freedom in a philosophical
and political sense and then turn to freedom in existential psychotherapy and will
finally address the history of freedom in behaviourism, cognitive therapy and new
“third wave” CBT approaches. As will be demonstrated, early behaviourism and
existential philosophy did not see eye to eye on the topic of freedom. Yet, freedom
and its relevance for therapy have gained influence within the CBT tradition in the
works of A.T. Beck and Albert Ellis.

2.1 Freedom as a Concept in Philosophy and Politics

Man is condemned to be free.

(Jean-Paul Sartre, 1943/1956)

The question “Are human beings free to choose whatever option they want or is life
pre-determined by religious fate or natural determinism”  – sometimes called the
problem of free will or free-will problem – has haunted philosophy and psychology
for centuries if not millennia, and it is highly unlikely that a definitive answer will
be found in the near future. Historically, there are a large number of philosophical
(e.g. O’Connor & Franklin, 2020), political (e.g. Arendt, 1961) and psychological
(e.g. Skinner, 1971; May, 1981) publications on freedom and its relation to other
Freedom, Responsibility and Guilt 209

topics. Dating back at least to the Stoics of ancient Greece and Rome (Bobzien,
1998), the question of how much freedom humans have in a potentially predeter-
mined or deterministic world has been discussed intensely – a discussion that con-
tinues to this day (O’Connor & Franklin, 2020). With his Philosophical Inquiries
into the Essence of Human Freedom, the German idealist philosopher Schelling
(1809/2006) has paved the way for the understanding of freedom in existential phi-
losophy (Heidegger, 1971) and later existential psychotherapy (Yalom, 1980).
Freedom in Existential Philosophy  In existential philosophy, freedom is one of
the major themes for a number of authors (e.g. May, 1981, Yalom, 1980; see Noyon
& Heidenreich, 2012, for an overview). As mentioned above, Heidegger, in his
Being and Time, interprets freedom as the “[f]reedom to choose and grasp oneself”
(in the German original: “Freiheit des Sich-selbst-wählens und -ergreifens”)
(Heidegger, 1927/1962, 1967, p. 188).1 As is well known, Heidegger’s language is
highly idiosyncratic und thus hard to read, but the basic concept is easily grasped:
humans have the potential to imagine what they could be (“Seinkönnen”), and they
have a choice to either follow the call of what Heidegger terms “conscience” to this
“could-be” or stick to what everybody (the “Man”, which has nothing to do with the
current use of the English term “man”) does and expects. The state of not living up
to one’s potential is termed “Uneigentlichkeit” by Heidegger – again, a word that is
often translated as “authenticity” (Varga & Guignon, 2020). Varga and Guignon’s
sophisticated analysis of the term “Eigentlichkeit” and its translations are as follows
(online document without page numbers):

The most familiar conception of “authenticity” comes to us mainly from Heidegger’s Being
and Time of 1927. The word we translate as ‘authenticity’ is actually a neologism invented
by Heidegger, the word Eigentlichkeit, which comes from an ordinary term, eigentlich,
meaning ‘really’ or ‘truly’, but is built on the stem eigen, meaning ‘own’ or ‘proper’. So the
word might be more literally translated as ‘ownedness’, or ‘being owned’, or even ‘being
one’s own’, implying the idea of owning up to and owning what one is and does (…).
Nevertheless, the word ‘authenticity’ has become closely associated with Heidegger as a
result of early translations of Being and Time into English, and was adopted by Sartre and
Beauvoir as well as by Existentialist therapists and cultural theorists who followed them.

Freedom is also a central concept in the philosophy of Jean-Paul Sartre (most

famously in Being and Nothingness, 1943/1956; see also Baggini (2002) for an
analysis of Sartre’s Essay “Existentialism is a Humanism”) and Karl Jaspers, who
introduced the concept to psychiatry and psychotherapy (Bormuth, 2013).
Freedom in a Political Sense  In the context of this book, including an analysis of
the concept of freedom in a political sense is not possible. We will thus only men-
tion a number of political authors who have become influential for existential con-

1
 1967: year of publication of the German edition used for this article; 1927: year of publication of
the original version in German; 1962: year of publication of the English translation of the original.
Please note that for all works originally published in a language other than English, both the
original and the translated version will be cited (e.g. 1927/1962), the first year indicating the origi-
nal version (e.g. 1927), the second the English translation used (e.g. 1962).
210 T. Heidenreich and A. Noyon

cepts: Hannah Arendt, a former student of Martin Heidegger’s, wrote a famous

chapter on “Freedom and Politics” (Arendt, 1961, p. 191), where she proposed an
understanding of freedom based on social interactions:

... by freedom I do not mean that heritage of humanity which philosophers define in a vari-
ety of ways and isolate, to their own satisfaction, as one of the inherent attributes of man.
(…) Basically, whether I enjoy freedom or suffer the reverse depends upon my intercourse
with my fellow men and not on my intercourse with myself.

It should be noted that this intersubjective stance towards freedom is in line with
Sartre’s thinking (existentialism is a humanism). The political consequences of psy-
chological freedom were described by Erich Fromm in his book Escape from
Freedom (1941). Based on his empirical work in Germany in the late 1920s and
early 1930s (before fleeing the Nazi system), he argued that freedom is a frightening
process and that a potential escape from freedom is to fall back into autocratic
thinking.
Freedom and Decision Making  As the material discussed so far shows, freedom
(or its opposite) manifests itself in the choices people make. We will not be able to
discuss this in detail here, but both the literatures on decision theory (Peterson,
2017; Resnik, 1987) and on judgement under uncertainty (Kahneman et al., 1982;
Pisano & Sozzo, 2020) would be interesting to explore against an existential
background.

2.2 Freedom as an Existential Concern

Freedom and Its Connection to the Other Existential Concerns  Death, free-
dom, isolation and meaninglessness are the four existential concerns that Irvin
Yalom describes in his seminal book Existential Psychotherapy (1980). We will not
explain these concepts in our contribution because they are dealt with in other chap-
ters of this book (see Dar-Nimrod in Chapter “Existentialism and Its Place in
Contemporary Cognitive Behaviour Therapy” of this book on the role of death and
death awareness, Helm and Greenberg in Chapter “Existential Isolation: Theory,
Empirical Findings, and Clinical Considerations” of this book for isolation and
Kuperis in Chapter “On the Need for Meaning” on meaning), but it is crucial to note
that there are important links of freedom to the other three existential concerns of
death, meaninglessness and isolation: death is a natural boundary to life  – this
means that humans can’t postpone decisions infinitely but rather that sooner or later
it will be too late for some actions. Simone de Beauvoir developed a highly interest-
ing thought experiment in her novel All Men Are Mortal (de Beauvoir, 1946/1992)
where an Italian count is made immortal. While enjoying some aspects of this early
on, his life becomes more and more meaningless since he can take all decisions
without real consequences (because he could choose the other way round during his
next cycle of life) – for a more Hollywood-style treatment of the same issue, see
Freedom, Responsibility and Guilt 211

“Groundhog Day” with Bill Murray. Similarly, there is a close connection between
freedom and meaning: making healthy choices in life will lead to experienced
meaning, whereas failing to choose or choosing wrongly will lead to meaningless-
ness. May (1981, p. 6) has argued that “[f]reedom is thus more than a value itself: it
underlies the possibility of valuing; it is basic to our capacity to value. Without
freedom there is no value worthy of the name”. The link between freedom and isola-
tion is multifold: decisions taken with personal freedom will very often involve
other people and therefore have the potential of interpersonal isolation. Similarly,
intrapersonal isolation (dissociating from personal experiences and potentials) and
existential isolation (Yalom’s assumption that there is an unbridgeable distance
between individuals) can be linked to the concept of freedom.

Freedom as a Topic in Therapy  The complete second part of Yalom’s Existential

Psychotherapy is devoted to the concept of freedom, and, rather than starting with a
theoretical or philosophical essay on freedom, Yalom relates clinical case examples
that show the practical meaning of freedom for therapy in a variety of situations.
One example is that of a patient who tells her therapist that her behaviour is con-
trolled by her unconscious, and another is that of a therapist who has a “can’t bell”
that he always rings when a patient uses the word “can’t”. An example that might be
encountered nowadays is a patient who tells his therapist that his “addiction centre”
had been triggered and that his “dopamine kick” had caused a relapse (notably, a
similar example from Yalom features “the unconscious”). The therapist’s answer
“And did your dopamine also buy the bottle of whisky?” puts it in a nutshell. Yalom
argues that even these seemingly trivial instances can point to deep existential
issues. Identifying the existential roots of these different therapeutic situations is of
uttermost importance, and Yalom uses the works of both Martin Heidegger
(1927/1962) and Jean-Paul Sartre (1943/1956) as a foundation for his reasoning.
Among the existential psychotherapists, Rollo May, who was a close friend of
Yalom’s (Yalom, 2017), has dealt with the topic of freedom extensively. In his book
Freedom and Destiny that appeared one year after Yalom’s Existential Psychotherapy,
he  – like Martin Heidegger  – relates to the work of Schelling (see above) and
describes freedom and its interrelation to destiny in the following way:
This personal freedom to think and feel and speak authentically and to be conscious of so
doing is the quality that distinguishes us as human. Always in paradox with one’s destiny,
this freedom is the foundation of human values such as love, courage, honesty. Freedom is
how we relate to our destiny, and destiny is significant only because we have freedom. In
the struggle of our freedom against and with destiny, our creativity and our civilizations
themselves are born. (May, 1981, Foreword)

A few pages later (May, 1981, p. 5), he specifies:

What, then, is the nature of freedom? It is the essence of freedom precisely that its nature is
not given. Its function is to change its nature, to become something different from what it is
at any given moment. Freedom is the possibility of development, of enhancement of one’s
life; or the possibility of withdrawing, shutting oneself up, denying and stultifying
one’s growth.
212 T. Heidenreich and A. Noyon

May distinguishes two kinds of freedom: freedom of doing vs. freedom of being.
Freedom of doing is defined in the following way: “Freedom is the capacity to pause
in the face of stimuli from many directions at once and, in this pause, to throw one’s
weight toward this response rather than that one” (May, 1981, p. 54). In contrast,
freedom of being is described as “Whereas the ‘freedom of doing’ refers to the act,
the ‘freedom of being’ refers to the context out of which the urge to act emerges. It
refers to the deeper level of one’s attitudes and is the fount out of which ‘freedom of
doing’ is born” (May, 1981, p. 55).
Also, Viktor Frankl2 (1946/1995) has explored freedom and its relevance for psy-
chotherapy. He uses the term “pandeterminism” to characterise the (in his opinion
incorrect) assumption that all freedom is an illusion because everything can be
explained causally. On a psychological level, this means that humans are puppets on
a string rather than active agents and don’t have any influence on their life courses.
Thus, in a predetermined world, there can be no responsibility for one’s actions.
Equally misleading, according to Frankl (1946/1995), is the so-called psycholo-
gism – the assumption that there is no fate at all and that everything that happens is
a direct consequence of one’s thoughts or behaviour. Thereby, psychologism negates
the existence of fate or coincidence since everything can be explained causally.
Consequently thought through to the end, pandeterminism means that people have
no freedom of choice but only an illusion of it (“Everything is fate – you are not
responsible for anything”), while in the psychologistic world view, everything
depends exclusively on the inner world of the person (“Anything goes  – you are
responsible for everything”).
Overall, existential approaches to psychotherapy tend to take a middle ground:
while conceding that there are facts that can’t be influenced by individuals/that fall
outside the realm of individual freedom (termed “destiny” by Rollo May, 1981),
there is still plenty of room for free decisions. Following Sartre on a philosophical
level and Yalom in existential psychotherapy, we assume that the reality of human
life includes parts on which human beings can decide themselves (“freedom”) as
well as events that enter life randomly and uncontrollably (“destiny”). Independent
of the exact amount of freedom that is attributed to humans, there is one major con-
sequence: responsibility (at least to some degree) for one’s actions. We will explore
this in the next section.
Also, some clinical disorders such as depression are closely linked to the theme
of freedom: regret over not having lived the potentialities of life may play an impor-
tant role in depression (see Chapter “Failed Potentialities, Regret and Their Link to
Depression and Related Disorders” of this book).

2
 Exception to 1: The year mentioned second does not indicate the year of publication of the English
version but that of a more recent German edition.
Freedom, Responsibility and Guilt 213

2.3 Freedom in Behaviourism, Cognitive Therapy and New

Developments in CBT

Current CBT has come a long way since the first behavioural publications, and the
discussion of freedom, free will and the like has changed tremendously over the
decades. We will address each of these phases in turn.
Freedom in Behaviourism  Historically, the first works of behaviourism came
after the first philosophers that are considered to be “existential” (e.g. Kierkegaard,
who published The Concept of Anxiety in 1844), but some of them (e.g. Watson,
1913) appeared earlier than important existential philosophical works (such as
Being and Time in 1927 and Being and Nothingness in 1943), and many of the influ-
ential works of existential psychotherapy appeared during a time when behaviour-
ism was the dominant psychological philosophy of science.
From Watson’s early work (Watson, 1913, p. 163), the aim of behaviourism was
to eliminate all references to consciousness: “The time seems to have come when
psychology must discard all reference to consciousness; when it need no longer
delude itself into thinking that it is making mental states the object of observation”.
Since “freedom” as defined in a psychological sense is not empirically observable
(“mentalist”), it is part of what Watson calls “absurd terminology” (p.  166f) and
should therefore be eliminated from psychology.
About 40 years after Watson’s manifesto of behaviourism, B. F. Skinner wrote a
highly influential book that carries the word “freedom” in its title  – as can be
expected, this word is not used in affirmative sense but rather as something to be
overcome: Beyond Freedom and Dignity (Skinner, 1971). Skinner puts all emphasis
on the environment and rejects the idea that a mentalistic concept of freedom is use-
ful. Rather, he places freedom in the realm of operant conditioning:
Freedom is an issue raised by the aversive consequences of behaviour, but dignity concerns
positive reinforcement. When someone behaves in a way we find reinforcing, we make him
more likely to do so again by praising or commending him. (Skinner, 1971, p. 45)

And, on the next page:

Man’s struggle for freedom is not due to a will to be free, but to certain behavioural pro-
cesses characteristic of the human organism, the chief effect of which is the avoidance of or
escape from so-called ‘aversive’ features of the environment. (Skinner, 1971, p. 46)

Consequently, the emphasis of the analysis shifts from what Skinner terms the
“autonomous man” to the control of the environment:
By questioning the control exercised by autonomous man and demonstrating the control
exercised by the environment, a science of behaviour also seems to question dignity or
worth. […] A scientific analysis shifts the credit as well as the blame to the environment,
and traditional practices can then no longer be justified. These are sweeping changes, and
those who are committed to traditional theories and practices naturally resist them. (Skinner,
1971, p. 26)
214 T. Heidenreich and A. Noyon

The struggle for freedom and dignity has been formulated as a defence of autonomous man
rather than as a revision of the contingencies of reinforcement under which people live. A
technology of behaviour is available which would more successfully reduce the aversive
consequences of behaviour, proximate or deferred, and maximize the achievements of
which the human organism is capable, but the defenders of freedom oppose its use. (Skinner,
1971, p. 124)

In spite of Skinner’s refutation of “autonomous man”, only one year after the publi-
cation of Skinner’s book, Ryback (1972) argued that existentialists and behaviour-
ists failed to see their “common ground” which he sees in the underlying humanistic
assumption. One reason could be the language used in behaviourism: “However,
Behaviourists still lack the semantically ‘warmer’ language with which to commu-
nicate their increasingly broadening scope of activities” (Ryback, 1972, p. 53). As
we will see, this “warmer language” entered the historical scene not from the
Skinner box but from a new development called “cognitive therapy”. It should be
noted that despite the contemporary preponderance of “cognitive-behavioural ther-
apy”, these used to be two different approaches to therapy back in the early days:
behaviour therapy with its emphasis on Skinner boxes and the like and cognitive
therapy as the work of two psychoanalysts who were dissatisfied with the practice
of their traditions.
Freedom in Cognitive Therapy  When A. T. Beck and his colleagues published
Cognitive Therapy of Depression (Beck et al., 1979), it stood in sharp contrast to the
rejection of mentalist concepts by Skinner and other behavioural writers. While
“freedom” as a topic is not mentioned explicitly in this book, it is one general
assumption that cognitive content such as thoughts can be changed more or less
freely. In 1970 already, Beck defined cognitive therapy as a set of operations focused
on a patient’s cognitions (verbal or pictorial) and on the premises, assumptions and
attitudes underlying these cognitions.
The second founding father of cognitive therapy, Albert Ellis, wrote a text that
deals with the very topic of freedom: in a response to a paper by Lucien Auger (“Are
Human Beings Free?”, 1987), he describes his position in the following way: “I
tend to be, however, a little more in favor of free choice or free will than he is”
(Ellis, 1987, p. 54). He continues (p. 55) by stating that “human freedom seems to
have some degree of reality –especially when it is backed by reflective thinking. For
men and women are future-oriented as well as stuck in the conformist past and they
can therefore choose to go through present pain for future gain (as when they give
up smoking or fight to the death against political tyrannies so that their children may
live in freedom)”.
(…) [H]umans  – as rational-emotive therapy particularly emphasizes  – can change their
cognitions and interpretations. This very ability, I (along with George Kelly) would say,
gives them at least some measure of freedom or “free will”. Limited yes but still existent.
(Ellis, 1987, p. 56)

Freedom in ACT: Freely Chosen Values  As for acceptance and commitment

therapy (ACT) and other new developments in CBT (sometimes termed “third
Freedom, Responsibility and Guilt 215

wave”), freedom in the sense of this chapter is most prominent in the work with
values. The term “values” has a very specific meaning in acceptance and commit-
ment therapy. Wilson and Dufrene (2009, p. 64) define values as

freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns

of activity, which establish predominant reinforcers for that activity that are intrinsic in
engagement in the valued behavioural pattern itself.

In our context, the words “freely chosen” are of course paramount. Since the defini-
tion above is quite technical, we will briefly examine Fletcher and Hayes’ (2005,
p. 321) elucidation of the term “values”:
Values differ from goals in that they are not objects to be attained, but rather are directions
that integrate ongoing patterns of purposive action. In the case of values, language is useful
in that it serves to link actions in the present into a coherent pattern of effective action. ACT
exercises use the processes of acceptance, defusion, present moment awareness, and so on
to clear the way for clients to identify valued domains of life (e.g., family, relationships,
work). In choosing life directions that are meaningful, clients are able to disengage from the
verbal processes that drive behaviours based on social compliance, avoidance, or fusion,
and shift toward more appetitive forms of behavioural regulation.

It should be noted that in this paragraph, the expression of “choosing life directions
that are meaningful” has a definitive “existential ring” to it – both choice (rooted in
the possibility of freedom) and meaning are two of the most central concepts of
existential psychotherapy.
It would be beyond the scope of this chapter to examine the role of freedom in
other new developments in CBT such as mindfulness-based cognitive therapy
(MBCT; Segal et al., 2013), dialectical behaviour therapy (Linehan, 1993) or behav-
ioural activation (Jacobson et al., 2001). Nevertheless, it should be noted that free-
dom (of choice) tends to play a major role in these newer developments. In MBCT,
for instance, it is one of the major aims to inhibit dysfunctional ruminative process-
ing associated with low mood – the freedom to refrain from action is very impor-
tant. Behavioural activation, like ACT, emphasises the role of choosing values (and
engaging in them through actions).
Taken together, freedom in the sense provided by existential psychotherapists
was refuted by early behaviourists as being mentalistic – however, it is highly com-
patible with the cognitive therapy approach, and it plays a major role in modern
“third wave” CBT approaches.

3 Responsibility

Can you take responsibility for this?

(Fritz Perls)

Similar to the concept of freedom, responsibility is a concept that is relevant in a

variety of contexts  – from moral responsibility in philosophical ethics (Talbert,
2019) to political responsibility (e.g. Tholen, 2018). Having discussed the concept
216 T. Heidenreich and A. Noyon

of freedom in great detail, we will deal with the concept of responsibility in a much
more concise way as most of the issues related to the existential concern “freedom”
are closely related to responsibility. Leaving aside the philosophical debate on com-
patibilist vs. incompatibilist accounts of the relationship between determinism and
free will (and resulting responsibility of an individual; see Talbert, 2019), we may
assume that freedom (in whatever amount) is a prerequisite for responsibility: if all
actions are predetermined, it is impossible to make an individual responsible for
their deeds.
Responsibility in Existential Philosophy  In existential philosophy, Sören
Kierkegaard (1844/2015) has placed great emphasis on the responsibility for one’s
actions and the resulting anxiety because making choices means deciding against all
other options. Similarly, other existential philosophers have stressed the responsi-
bility resulting from free will (see Noyon & Heidenreich, 2012).

Responsibility in Existential Psychotherapy  Much of what has been discussed in

the context of freedom also applies to responsibility: Yalom (1980) places an empha-
sis on patients’ avoidance of responsibility (and, thus, the denial to accept the idea
of freedom). Drawing on the work of Kaiser (1955), he discusses clinical case
examples and literature that deal with avoidance of responsibility. In his view, it is
important for patients to take responsibility for those facts in life they can control
but also to be aware of “destiny” that is uncontrollable.
What are the clinical implications for failure to take on responsibility? Yalom
(1980) describes a prolonged delay of decisions rooted in a deep form of existential
anxiety towards taking responsibility for one’s actions. This anxiety is much deeper
than a single pending decision. A phenomenon closely related to responsibility is
certainty: some clients don’t move forward in the decision process because they
want to achieve some kind of “absolute safety” to take the right decision. This very
often goes hand in hand with the idea that the “right decision” will make everything
possible and thus will have no negative consequences. This illusion is a misinterpre-
tation of the existential fact of responsibility: there is no choice that does not come
with the fact that it is a decision against all other options. The things that are not
chosen are associated with non-existence, nothing, not-being (Le néant; Sartre,
1943/1956). Rejecting responsibility can be understood as a dysfunctional reaction
to the anxiety that is inherent in freedom. Trying to avoid this kind of anxiety is
highly dysfunctional because even the decision not to choose is a choice and is regu-
larly associated with the avoidance of action. On the other hand, taking on respon-
sibility for things that are not controllable (e.g. a diagnosis of cancer) can be quite
harmful.
In summary, responsibility rests on the assumption that humans are free to
choose their actions at least to some degree – in psychotherapy, a major task is to
find out which actions are under the control of patients and which are not.
Freedom, Responsibility and Guilt 217

4 Guilt

The years rolled slowly past

And I found myself alone
Surrounded by strangers I thought were my friends
I found myself further and further from my home, and I
Guess I lost my way
There were oh-so-many roads
(…)
(Bob Seger: Against the Wind)

Just as responsibility is a direct consequence of freedom, the possibility to be guilty

is a direct consequence of responsibility: being guilty is only possible when at least
two conditions are met – (a) there is responsibility for one’s actions (meaning that
somebody is able to freely choose between alternatives), and (b) the harm caused (to
others) was done intentionally. This is echoed in legal systems all over the world
where there is a distinction between killing somebody intentionally vs.
accidentally.

4.1 Three Forms of Guilt According to Yalom

Yalom (1980) proposes a distinction between three forms of guilt: neurotic, actual
and ontological guilt. Since ontological guilt is of paramount importance in the
context of this chapter, we will deal with the other two forms of guilt only briefly.
Neurotic Guilt  In Yalom’s psychodynamic approach to existential psychotherapy,
neurotic guilt is conceptualised in a psychoanalytic way. Phenomenologically, neu-
rotic guilt in this sense characterises a number of mental disorders: in major depres-
sive disorder, for example, one criterion is “Feelings of worthlessness or excessive
or inappropriate guilt nearly every day” according to DSM-5 (American Psychiatric
Association, 2013). Similarly, guilt may play a role in obsessive-compulsive disor-
ders (Shapiro & Stewart, 2011).

Actual Guilt  As stated above, actual guilt implies intention of one’s action (or
inaction) and an ability to choose this action among other options. Guilt is some-
thing that is unavoidable in life (even though humans can try to minimise their nega-
tive impact on other people and nature). For Frankl (1946/1995), guilt is one part of
the “tragic triad” (together with suffering and death). For him, not experiencing
guilt is a sign of psychopathology rather than health (i.e. in antisocial personality
disorder).
218 T. Heidenreich and A. Noyon

4.2 Ontological Guilt

The form of guilt most relevant in the current context is what is called ontological
guilt (or sometimes existential guilt). In contrast to guilt resulting from harming
others (actual guilt), ontological guilt refers to falling short of one’s possibilities.
We will briefly consider the existential philosophical background of ontological
guilt and then turn to therapeutic implications as discussed by Yalom (1980).
Ontological Guilt in Existential Philosophy  Although a large number of existen-
tial philosophers have written on this topic, it is Heidegger’s classical account (in
paragraph 58 of Being and Time) (Heidegger, 1967, p.  280; 1927/1962) that has
remained influential to this day (Elgat, 2020). The respective section in Being and
Time is titled “Anrufverstehen und Schuld” (Summons and Guilt), and it describes
the summons (by conscience) to a more authentic way of life and the ontological
guilt that inevitably grows from the impossibility of ultimately bridging the gap
between realising all of our “ownmost” possibilities for relating to our existence. In
Heidegger’s own words (original version):

Das Anrufen des Man-selbst bedeutet Aufrufen des eigensten Selbst zu seinem Seinkönnen
und zwar als Dasein, das heißt besorgendes In-der-Welt-sein und Mitsein mit Anderen.
(Heidegger, 1967, p. 280)

We will not try to provide a translation but rather to highlight some central points:
“Anrufen des Man-selbst” means that an everyday person is called (by conscience)
to actualise her/his innermost self (in the German original, “eigensten” is the super-
lative of “own”). This actualisation is not in some speculative cosmos but rather
within the world and in the being with others.
Karl Jaspers (1932/1969) is more concerned with the ontic aspects of guilt (those
related to life in the world) than with the ontological. He conceives guilt as one of
the “boundary situations” that are characteristic for human life. Just by grasping life
and its possibilities, humans restrict others. Even trying to do nothing doesn’t solve
this problem because this too has consequences.
Ontological Guilt in Existential Psychotherapy  Yalom (1980) draws from the
above passage by Heidegger and specifies what he calls “existential guilt” as the
failure to live life as fully as possible. This feeling of guilt is of course uncomfort-
able, but it may be very constructive in helping people overcome this impasse and
move in a direction that is more in line with the authentic self. Breitbart (2017,
p. 510), in a more recent paper, summarises this basic idea in a clear way:

This responsibility to create a life involves creating a unique life (one only we could have
lived – authentic to us), and to live this life to its fullest potential, thus creating a life of
meaning, purpose, direction, growth, and transformation, and becoming valued members of
a culture and the world with meaning. Most, if not all of us, fail at this impossible task.
Falling short of this responsibility leads to what existentialists describe as existential guilt,
the notion that I could have done more, and that I missed opportunities or failed in
some ways.
Freedom, Responsibility and Guilt 219

Clinically, working with ontological guilt can be rewarding as well as challenging.

As a rule, the more options patients have in their lives, the easier it is to mine thera-
peutic gold from the mine of ontological guilt – consider the lyrics by Bob Seger at
the beginning of this paragraph: assuming that he is still at an age where he can
change things, we might ask questions such as “what did you neglect during these
last years” and will try to activate some of these things. Other life circumstances
make working with ontological guilt more challenging: this is especially true in
end-of-life care and terminal illness, where there are only limited options to change.
Again, in Breitbart’s words (Breitbart, 2017, p. 511):
Ultimately, it comes down to the singular choice of forgiving yourself for being an imper-
fect, vulnerable human being. Forgiving yourself for merely being human—all too human.

One can see an interesting parallel here to Erikson’s eighth and last stage of psycho-
social development  – a successful completion of this stage is associated with “a
sense of coherence and wholeness” (Erikson, 1982, p.  65), while the opposite is
described as despair.

5 Regret

I’d rather be sorry for something I’ve done

Than for something that I did not do.
(Kris Kristofferson and Rita Coolidge)

After taking a close look at freedom, responsibility and (ontological) guilt, we have
arrived at a potential everyday consequence of these: regret. As we have seen, to
authentically realise all potential aspects of one’s personality is impossible, so life
will very likely always contain regret over unlived potentials to a smaller or larger
degree. Nevertheless, the amount of regret over this will vary greatly between peo-
ple (and in individual people at different times of their lives). We will not explore
regret in more detail at this point (see the next two chapters of this book) but rather
want to stress the fact that expectations of people (and what they are supposed to do
in a “successful” life) are shaped by the cultures they live in as well as their “authen-
tic” self – one example is a study published by Orna Donath, an Israeli sociologist,
on regret of women associated with raising children (Donath, 2015): while many
western societies proclaim that raising children has to be highly rewarding (espe-
cially for women), some seem to feel different. Similarly, many people devote most
of their time to pursuing money and job success – very often at a very high cost for
other areas of life.
It should also be noted that societies (and in part commercial interests) shape
expectations of what people think they should do during their lives (and, in this way,
avoid regret): so-called bucket lists consisting of things people want to do or experi-
ence before “kicking the bucket”; some of these bucket list items tend to be com-
mercially available (go skydiving), while very often, interpersonal aspects (like
re-engaging in the relationship to an alienated family member) are much more
220 T. Heidenreich and A. Noyon

important. Morgan Freeman and Jack Nicholson (in the movie with the same title)
beautifully exemplify this shift from commercially available items to relevant per-
sonal ones.

6 Conclusions

This chapter has delved into the basic concepts of existential philosophy and exis-
tential psychotherapy. In a book titled Existential Concerns and Cognitive-­
Behavioural Procedures: An Integrative Approach to Mental Health, this might
seem a bit out of place and far removed from CBT procedures. But we believe that
the opposite is the case: dealing with these philosophical roots enables therapists to
see the deeper aspects of seemingly irrational behaviour. For example, a student
who enters therapy with a diagnosis of mild depression and who shows difficulty
deciding on potential job offers can be understood in a “narrow” sense where we as
therapists do the usual decisional balance and motivational stuff. Having the back-
ground of existential thinking may enable us to see some of the real depth of a seem-
ingly simple decision. This becomes especially prominent when we meet clients
who have taken (in retrospect) unwise decisions or who have tried to refrain from
deciding. These more clinical aspects will be explored in the two following chapters
by Ross Menzies: His first  chapter deals with  “Failed Potentialities, Regret and
Their Link to Depression and Related Disorders” and shows direct links of these
ways of reasoning to CBT constructs such as a ruminative response style and post-­
event rumination, while his second chapter deals with “Reframing the Past and the
Treatment of Existential Guilt and Regret”.

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Failed Potentialities, Regret and Their
Link to Depression and Related Disorders

Ross G. Menzies

Abstract  A variety of studies have linked mood disorders to a ruminative style of

thinking, particularly involving events and happenings from the past. When an indi-
vidual’s early expectations of life are not met, depression may follow. In existential
terms, depression may be linked to an individual failing to embrace the potentiali-
ties afforded by freedom. Post-event rumination, usually involving shorter time
frames, has also been linked to social anxiety disorder, with individuals thinking
over social encounters and how these were interpreted by others. Finally, regret and
shame over early happenings can be involved in a range of pure obsessions, illness
anxiety disorder and related conditions. It will be argued that all of these phenom-
ena can be understood in existential terms and that this analysis is more in keeping
with the way clients express their difficulties than typical cognitive and behavioural
formulations.

Keywords  Rumination · Depression · Social anxiety disorder · Obsessive-­

compulsive disorder · Existential freedom · Maximising · Existentialism ·
Metacognition · Health anxiety

1 Freedom, Failure and Depression

As we have seen in Chapter “Freedom, Responsibility and Guilt”, the freedom to

make choices is one of the existential givens that all humans must confront. Although
it might superficially seem to be a positive aspect of living, freedom presents us all
with great challenges. Many writers have argued that making choices comes with
tremendous responsibility. As Menzies and Menzies (2021) point out in their sum-
mary of the work of Sartre and the French existentialists, in choosing actions you

R. G. Menzies (*)
Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 223

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_13
224 R. G. Menzies

are signalling your decisions to the broader community. Others may fairly assume
that you see your choices as good ones for a person to make (see further Sartre,
1999). For example, if you refuse to get a COVID-19 vaccination, you might, unfor-
tunately, influence others to do the same (Menzies & Menzies, 2021).
In addition, there is a seemingly infinite number of lives from which to choose.
As Nietzsche (1974) suggests, the death of God, at least in terms of popular influ-
ence, has opened up these possibilities by eliminating a simple set of rules to obey.
You must create your own path, and in creating it you will have defined yourself and
fashioned your essence. It is for this reason that Sartre (1999) famously declared
that ‘existence precedes essence’. Accordingly, the decisions and directions of our
life are not to be taken lightly. Freedom is, in many ways, a heavy weight that we
must drag through our entire lives. Sartre (1999) declares that we are ‘condemned
to be free’ with decisions to be made at every turn. As Menzies and Menzies (2021)
remind each of us, we are mortal and will get only one shot at living truly and
authentically. Each of us has only one chance to define oneself. Bravery will be
needed if we seek authenticity, as Gerard Kuperis (2018, p. 49) demonstrated with
the following simple, but compelling, example:
Let’s say I go to college, since all my friends go to college, my teachers have been preparing
me for this step, and it’s very clearly the expectation of my parents, who have never even
mentioned the possibility that I do anything else. For Sartre, this kind of pattern shows us
exactly how we deal with our freedom: while we could choose to work and travel the world,
build a cabin in the woods, or pursue some other dream, we typically do not do it, precisely
because it would be our own choice, and thus our own responsibility. If I do choose my own
actions and I, for example, run out of money in a remote part of China, if I break an arm, or
if I fail to save money for my retirement, I can only blame one person: myself.

With decision-making, regret inevitably may arise. Of course, regret is not necessar-
ily a negative thing. Several studies have shown that regret may promote learning.
Making mistakes and regretting them may positively influence planning for the
future (e.g. Epstude & Roese, 2008). Bailey and Kinerson (2005) demonstrated that
past behaviours that elicited regret were less likely to be repeated. Further, Shani
et al. (2015) found that individuals who feel responsible for missing future opportu-
nities experience increased feelings of regret. These findings, taken together, sug-
gest that regret may play an important role in driving growth, maturation and
adaptive change in behaviour. However, it is also well established that regret and
rumination about perceived mistakes in the past are linked to the severity of depres-
sive episodes (Roese et al., 2009). How do we reconcile these competing findings?
One possibility is that regret is activated by multiple psychological processes,
some of which are adaptive while others are not. Along these lines, decision justifi-
cation theory (DJT; Connolly & Zeelenberg, 2002) suggests that there are two com-
ponents of decision regret: self-blame for making a bad choice and comparative
evaluation of the outcome. On the face of it, this model allows for the possibility
that regret could be adaptive or maladaptive, depending on which process domi-
nates in any individual. If regret is largely driven by a rational comparison of out-
comes that could inform future choices, growth would be expected. On the other
Failed Potentialities, Regret and Their Link to Depression and Related Disorders 225

hand, if regret is driven by self-blame for the past decision, deterioration in self-­
esteem, self-efficacy and mood might be expected.
Kraines et al. (2017) were the first researchers to examine DJT in the context of
depression. Sixty-five participants (27 never depressed, 24 formerly depressed and
14 currently depressed) read two scenarios designed to elicit regret and rated the
degree to which they experienced self-blame, comparative evaluation regret and
overall regret. The two scenarios are described below:
Scenario 1
Imagine that you are leaving a party where you were drinking alcohol. A friend suggests
that you call a cab but you decide to go ahead and drive yourself home. You arrive home
safely, but in the morning you realize that you had been too drunk to drive. You drove
through an area of town that usually has many pedestrians and quite a bit of traffic and you
realize that things could have ended in disaster.
Scenario 2
Imagine that you are deciding whether or not to vaccinate your 1-year-old child against
a serious disease. The disease can have serious, negative long term effects on your child’s
health and can even end in death. The vaccine is reliable and quite safe. Only 1 out of every
10,000 children given the vaccine have the bad side effect (complete blindness). You con-
sult doctors, vaccine experts, and friends who all agree you should vaccinate your child.
You consider carefully and decide to vaccinate. You are unlucky and your child suffers the
side effect of blindness.

After reading each scenario, participants were asked to rate how much they would
regret the decision they made (i.e. overall regret), how much they wished the results
had turned out differently (i.e. comparative evaluation regret) and how much they
would blame themselves for their decision (i.e. blame regret). Few differences were
reported between groups, with no differences observed in overall regret or compara-
tive outcome regret. Notably, however, currently depressed participants demon-
strated greater self-blame regret compared to the never depressed group. The authors
concluded that major depressive disorder is associated with increased self-blame
regret, but not comparative outcome regret.
Other explanations for the data are, of course, possible. For example, the failure
to find differences between groups in comparative evaluation regret may have been
due to floor and ceiling effects. Wouldn’t every participant, regardless of mental
health status, have given the highest possible rating to desiring another outcome
than blindness in Scenario 2? The findings need replication and extension in other
experimental and quasi-experimental designs and in other research laboratories.
Still, the difference in blame regret between depressed and never depressed partici-
pants is an important finding that is consistent with considerable research on rumi-
nation in depression.
226 R. G. Menzies

2 The Problems of Rumination

A central feature of depression is rumination and often about the past (Nolen-­
Hoeksema et al., 2008; Papageorgiou & Wells, 2004). Rumination is a maladaptive
process since it is not goal directed. It involves repetitive thinking, typically about
the perceived causes (i.e. antecedent events) of the sufferer’s depressed state, and
does not involve active problem-solving (Nolen-Hoeksema et al., 2008; Papageorgiou
& Wells, 2004). Importantly then, as Joormann and Stanton (2016) point out, it must
be differentiated from adaptive cognitive strategies such as problem-solving or
reappraisal, in which the individual reframes or reinterprets their circumstances.
Since the focus of rumination is so often about the choices and behaviours that have
led to the depressed state, rumination and regret often go hand in hand.
A ruminatory style of thinking has been shown to be a prognostic indicator of
depression proneness (for a review, see Nolen-Hoeksema et al., 2008). In controlled,
single-session laboratory settings, individuals with a tendency toward rumination
have been shown to experience longer episodes of psychological pain following a
mood induction trigger (e.g. sad music) (see Watkins, 2008 for a review). The exten-
sion of the depressed state that occurs with rumination may be one of the ways in
which it acts as a maintaining factor in the mood disorders. Longer bouts of sadness
following any negative trigger give greater opportunities for the depressed mood
state to further influence negative appraisal, driving ever deeper depression (see
Lyubomirsky & Tkach, 2004, for a review).
Given the negative consequences of rumination, why would anyone engage in it?
Wells (2019) argues that stable, incorrect metacognitive beliefs about rumination
lead some individuals to maintain the practice in a futile attempt to self-regulate
emotion. These faulty metacognitive beliefs (e.g. ‘ruminating helps me to cope’)
motivate the individual to ruminate which, as Nolen-Hoeksema et al. (2008) have
shown, increases and maintains emotional distress. According to Wells (2019),
these faulty metacognitive beliefs are causal factors in psychiatric disorders, a posi-
tion that is supported by considerable experimental evidence (see Sun et al., 2017
for a review).
Not all metacognitive beliefs involved in depression are positive. Papageorgiou
and Wells’ (2003, 2004) metacognitive model of depression emphasises positive
and negative beliefs about rumination that are typically found in the depressed per-
son. Positive beliefs focus on the claimed utility of rumination (e.g. ‘It will help me
find answers to my problems’; ‘It helps me cope’). These positive beliefs motivate
the individual to begin rumination in the face of an internal or external trigger. Once
stuck in a ruminatory cycle, negative metacognitive beliefs may take over (e.g.
‘rumination about my past is uncontrollable’), reducing the individual’s self-­efficacy
to exit the ruminatory process. The negative beliefs drive an ever-increasing hope-
lessness in the individual, stuck in a loop exploring the regrets of the past, the pain
of their present and the futility of their future. The ruminatory process increases the
accessibility of negative emotions and thoughts, thus maintaining depressive symp-
tomatology. The model has intuitive appeal and considerable face validity. It is
Failed Potentialities, Regret and Their Link to Depression and Related Disorders 227

usually well received when explained to depressed clients who typically have clarity
about their metacognitive beliefs about rumination. Evidence from a range of stud-
ies has shown that positive and negative metacognitive beliefs are strongly related
to both the ruminatory style of thinking and depression (Kraft et al., 2019; Kubiak
et  al., 2014; Papageorgiou & Wells, 2003, 2009; Roelofs et  al., 2007; Weber &
Exner, 2013; Yilmaz, 2016).
In sum, positive and negative metacognitive beliefs drive the individual to more
and more rumination that maintains the depressed state. For our purposes, however,
it is the content of the depressed individual’s thoughts that is most instructive. As we
have seen, most of the thoughts do not involve problem-solving, reframing or other
adaptive strategies. On the contrary, the depressed ruminator becomes locked in the
regretted actions and moments of their past that bring them further down (e.g. ‘why
did I leave England?’, ‘if only I’d told her I loved her before it was too late’, ‘I chose
the wrong career – I could have achieved so much more’). Regret about the past
dominates the depressed mindset (Beck et  al., 1987) and arises from the conse-
quences of existential freedom. Choosing the ‘wrong’ forks in the road can lead one
into a cycle of rumination about failed potential that can dominate years of a per-
son’s life. After all, as one client recently pointed out, ‘The choice I made has
changed my life forever. I don’t get a second chance at life’. The combination of
freedom and the inevitability of death makes the choices of a life seem even more
critical to many who reflect negatively on their life’s story (Menzies & Menzies, 2019).
Regret has even been linked to suicidality, particularly among the middle aged
and elderly. Bruine de Bruin et al. (2016) examined the relationships between indi-
vidual differences in maximising (i.e. striving for the right decision), levels of
regret, negative decision outcomes and suicidal ideation and behaviours in an
elderly sample with depression and a group of controls. They found that scores on
the three individual-difference measures (i.e. maximising, regret and outcomes)
were worse for psychiatric patients than for nonpsychiatric controls. Further, these
scores were significantly correlated to clinical assessments of depression, hopeless-
ness and suicidal ideation. Several other findings are notable in this interesting
study. First, maximising was associated with depression, even after controlling for
life decision outcomes. That is, the very act of striving for the right decision was
linked to depression. Second, repetitive regret (or what we might describe as rumi-
nation about perceived mistakes of the past) significantly mediated the relationship
between maximising and measures of depression and suicidality. Taken together,
the findings suggest that individuals who seek perfect decisions could be at risk for
clinical depression and suicidality because of their proneness to regret. The authors
conclude by arguing that ‘regret regulation’ should become the new target for treat-
ment of late-life depression.
228 R. G. Menzies

3 Social Anxiety Disorder and Post-event rumination

While much has been written about depression driven from regret over earlier life
events and choices, minor social actions in everyday life can become the bane of the
daily existence of those with social anxiety disorder (SAD). Post-event rumination
involves excessive reliving of minor aspects of social situations that have passed.
The individual becomes consumed by self-evaluation of their social performance,
going over the choice of words in a sentence, the amount that they spoke, their
answers to questions and a range of related social phenomena. Much of the time
taken up in post event rumination is spent exploring the things that the individual
believes, in hindsight, that they should have said or done differently. In essence
then, one can conceive of post-event rumination as an expression of the pain that
comes from existential freedom.
There is now a large body of research demonstrating that, unsurprisingly, the
frequency of post-event rumination predicts how negatively an individual assesses
their social performance (Abbott & Rapee, 2004; Dannahy & Stopa, 2007). Further,
the very act of ruminating tends to guarantee a negative perspective. After all, how
many social encounters, if closely scrutinised, could be said to be free of any social
error or imperfection? Given that the process of post-event rumination inevitably
leads to a negative view of one’s social performance, again one can fairly ask why
individuals with social anxiety disorder would engage in it? Clark and Wells (1995)
argue that the effort to find social errors relates to beliefs that the individual holds
about social performance and its consequences, e.g. ‘If I make mistakes, then others
will reject me’. Unfortunately, as Clark and Wells (1995) point out, the process of
ruminating on negative social behaviours makes these more salient, dominating the
memory of the social encounter. This produces a biased and negative record of
social performance that may increase social anxiety in similar, future encounters. In
this way, post-event rumination plays a critical role in the maintenance of social
anxiety disorder.
The psychological pain produced by post-event rumination among those with
social anxiety disorder may be partly responsible for the high use of alcohol in this
condition. Considerable research has shown dramatically increased odds of having
an alcohol use disorder (AUD) among those with SAD, compared to non-anxious
controls (see Oliveira et al., 2018 for a review). Alcohol use can lead to a decrease
in post-event processing for several reasons, none the least of which is that memory
impairments mean there is little to process. Ogniewicz et al. (2019) have shown that
alcohol-induced decreases in post-event processing predicted intoxication in fol-
lowing social encounters but only for those who are high in social anxiety. Thus,
individuals with social anxiety disorder may inadvertently learn to use alcohol as a
strategy to reduce negative cognitive processes. While this may work, the emer-
gence of an alcohol use disorder is a significant price to pay for reduced rumination.
Of course, there may be more direct existential reasons for AUD and other drug
problems. The inevitability of death, the truth of my existential isolation and the
inherent meaninglessness of one’s life may drive substance use problems. Menzies
Failed Potentialities, Regret and Their Link to Depression and Related Disorders 229

et al. (2019) have shown strong positive relationships between death anxiety scale
scores and the severity of alcohol use disorders. Menzies and Menzies (2021)
argue that:
The inevitability of my decline and decomposition is a fate beyond the skills of western
medicine. Some people turn to substances to sedate themselves from the truth with the
soma of their choice – a ‘holiday from the facts’ – be it alcohol, hallucinogens, or literal
pain killers for their existential aches. p. 278

4 Regret and Obsession

The existential theme of freedom seems to be particularly prominent in obsessive-­

compulsive disorder (OCD). Indecisiveness has long been seen as a hallmark of the
disorder, with many individuals depending on others to make choices for them
(Krochmalik & Menzies, 2003). Even small decisions, like choosing which size can
of butter beans to buy or choosing a recipe from a cookbook to prepare, can become
impossible. Some individuals with OCD attempt to avoid choice altogether by
applying simple rules that remove the sufferer from the decision-making process
(e.g. opening a cookbook at random and preparing whatever recipe appears). Others
just get stuck in indecisiveness, unable to move forward in any meaningful way.
Menzies and Menzies (2019) interviewed individuals with OCD with themes of
existential freedom emerging in their analysis of transcripts. As one participant
starkly put it:
… if I went to my dad tomorrow and said, “Dad, I want to travel the world,” he’d book me
a flight in an instant. That pisses me off even more, the fact that I know I can do anything,
and I choose not to because I’m worried about it. That upsets me more than anything in the
world. When I have all these options, everything, and I fucking choose not to do them, for
one reason or another. I could go travel the world, see everything, do all these beautiful
things, but I wouldn’t enjoy it. It upsets me, it really upsets me. p. 252

Menzies and Menzies (2019) point out that this man’s response reveals the dual
nature of freedom that existentialist philosophers and contemporary existential psy-
chotherapists (e.g. Irvin Yalom) describe. First, the seemingly infinite number of
behavioural choices before us creates anxiety for fear of regret (‘I know I can do
anything, and I choose not to because I’m worried about it’). Second, the feared
regret so limits the individual’s freedom that they are unable to pursue anything
meaningful (‘That upsets me more than anything in the world’). In the case described
above, the sufferer certainly appears, as Sartre put it, ‘condemned to be free’.
Freedom seems a punishment to him rather than a prize. How can one proceed in the
face of these pains? Menzies and Menzies (2019, p.  253) argue that it is about
achieving balance:
As part of our existence in this world, we must all find a balance between the two: to live as
freely as possible, unburdened by the restrictive baggage of our worries, but also to navigate
the overwhelming number of choices we could make and still continue to act. If we want to
230 R. G. Menzies

make the most of our time on earth, we can neither succumb to the terror of our paralysing
freedom, nor can we inadvertently lock ourselves into prisons of our own making.

While the most common forms of OCD relate to cleaning/contamination and harm-­
checking, an extraordinary range of obsessions exist, many of which are directly
related to the existential theme of freedom. In particular, the form of the condition
typically referred to as ‘real-event’ OCD involves scrutiny of an action or actions
that the individual has taken in the past and an exploration of what these may mean
about the person and their worth/value (de Silva, 2003; Einstein & Menzies, 2003;
Marks, 2003). The events involved in real-event OCD are many and varied, although
most commonly they have occurred in adolescence or early adulthood. In general,
the critical factor is that the sufferer experiences horrific shame and regret and
judges the event to speak to a fundamental flaw in their character that renders them
forever worthless. They may ruminate endlessly about the event, attempt to work
out why it occurred and consider what people in the general community would think
of them if they found out (Menzies & Menzies, 2021). Events described in case
reports and chapters focusing on clinical descriptions include:
Stealing underwear from an aunt’s bedroom
Punching someone in a schoolyard argument
Pouring an alcoholic drink for a friend who was already intoxicated
Stealing money from a parent’s purse
Sleeping with a friend’s partner
Noticing, but not looking away, the underwear of a friend while playing a game

Typically, real-event OCD is accompanied by poor or limited insight. The individ-

ual fails to see the event in the context of their age and maturity at the time. Instead,
the sufferer argues that the chosen action reflects a failure in the person’s make-up
that renders them worthless, not deserving of the support and care of others.
Unsurprisingly, secondary depressions are common in real-event OCD, as the rumi-
nation leads to increasing regret and shame that drives self-esteem lower and lower
over years or even decades (see further Menzies & Menzies, 2019).
The existential theme of freedom relates to a second class of obsession. In
aggressive obsessions individuals fear that they may suddenly act out in a violent
way, causing harm or death to loved ones, strangers or even the self. Typically, their
fears are triggered by intrusive thoughts or images of the violent action. There are
many different arguments that sufferers mount in defence of their fear. First, the
mere presence of the thought is seen as threatening: ‘why would I have the thought
if it’s not a possibility’. Second, the individual may point to aspects of their past that
they believe reveal a vulnerability to violence, e.g. ‘Maybe this is why I learned
martial arts when I was young – I must like to hurt people’ (see further Menzies &
Menzies, 2019). Third, some will argue that even good people can just ‘snap’ and
cause havoc. They will point to news reports of seemingly balanced people who
suddenly shoot people in their workplace or others who walk out of their home one
day and suddenly leap in front of a train. Finally, some fear that the mere repetition
of the thoughts in consciousness will make them dangerous: ‘I’m not a bad person,
and I don’t want these things to happen. But if the thoughts keep coming I could just
Failed Potentialities, Regret and Their Link to Depression and Related Disorders 231

find myself doing it without even thinking’. Unfortunately, as in many forms of

OCD, the individual with aggressive obsessions typically tries to supress their
thoughts which only increases their frequency, increasing the individual’s belief that
the feared outcome is likely (Marks, 2003; Salkovskis & McGuire, 2003).
All presentations of aggressive obsessions can be seen through an existential
lens. In essence, the central threat rests on the idea that one could do the behaviour
in question. That is, the sufferer is physically capable of lifting a baby and throwing
it off a balcony, or pushing someone in front of a car, or jumping in front of an
oncoming train. What’s more, as we have seen, the obsessional patient may point
out that some individuals do engage in such behaviours (Einstein & Menzies, 2003;
Menzies & Menzies, 2019). So, once again, this form of mental health problem
comes down to distress related to existential freedom. Each of us is capable of an
alarming range of behavioural choices. Not all of these choices have positive
outcomes.

5 Health Anxiety and Related Disorders

Some classes of disorders seem more logically linked to death than freedom, but the
latter theme may also be involved. This appears to be true for the health-related
anxiety problems. Menzies et al. (2019) found strong relationships between death
anxiety and severity of several mental health problems including illness anxiety
disorder, panic disorder and somatic symptom disorder. This is not surprising given
the fact that these conditions typically involve concern about serious medical ill-
nesses. However, in addition to fears of death, these disorders also confront the
sufferer with constant decision-making about whether to seek medical assessment
or ignore their worries and perceived signs and symptoms. In fact, concern about
this decision-making can become as debilitating as the core symptoms themselves.
The DSM-5 (American Psychological Association, 2013) identifies two subtypes
of illness anxiety disorder, namely, care-seeking and care-avoidant. The care-­
seeking subtype overuses medical assessments and testing as a means of reassurance-­
seeking. The care-avoidant subtype, fearful that their worries could be confirmed by
medical assessments, generally avoids doctors. Of course, many sufferers do not fit
neatly into these categories, and most individuals with illness anxiety disorder are
constantly consumed by the freedom to see a doctor or ignore their concerns. Many
express a desire for rules to aid the decision-making process (e.g. if a symptom
remains for two weeks, I will see a doctor). In essence, this strategy amounts to an
attempt to bypass existential freedom by taking the choice out of the hands of the
sufferer (see Scarella et al., 2019 for a review).
Interestingly, decision-making regarding medical appointments may be influ-
enced by reminders of death. In this way, existential freedom and death anxiety may
be acting in concert in health-related disorders but also in other disorders. Menzies
et al. (2021) used a mortality salience design to examine the effect of reminders of
death on body scanning behaviours and the decision to seek medical assistance. A
232 R. G. Menzies

total of 128 treatment-seeking participants with either a body scanning disorder (i.e.
panic disorder, illness anxiety disorder or somatic symptom disorder) or a non-­
scanning disorder (i.e., depression) were randomly allocated to either a mortality
salience or control condition. Mortality salience was achieved by the insertion of
two innocuous questions about death in a large battery of questionnaires, ensuring
that the purpose of the study was disguised. Following this, participants were pre-
sented with a series of images of various body parts, which purportedly predicted
particular life outcomes, and asked to check their own body and select the image
that most closely matched their own. As hypothesised, mortality salience produced
an overall increase in body scanning, as measured by the time taken to select the
image that they believed matched their own body part. However, this only occurred
for participants with a body scanning disorder and only if they were told the image
predicted a health-relevant outcome (e.g. allergic reactions). When participants
were told that the body images predicted other outcomes (e.g. personality character-
istics), no increase in scanning occurred. More importantly, from an existential free-
dom point of view, mortality salience increased intention to visit a medical specialist
across both groups of participants. That is, regardless of one’s disorder, subtle
reminders of death increased the desire of those with a mental health condition to
seek medical assessment.

6 Summary

Sartre (1999) saw humankind as condemned to be free. I must choose, and have
been choosing right across my life, from an infinite number of forks in the road in
terms of the actions that I take, the actions that I reject and the words that I say.
Superficially, this may be seen as a positive aspect of life, but, as we have seen, it
can cause crippling pain, disabling indecision and a lifetime of regret dominated by
a sense of failed opportunities. This chapter has explored several disorders through
the lens of existential freedom. The disorders were chosen as exemplars of the prob-
lems of freedom, but the reader should be assured that they are not the only condi-
tions in which this existential theme is critical. For example, in eating disorders the
choice to eat or reject a food item can be occasioned by tremendous pain, indecision
and fear of later regret and shame. The sufferer of body dysmorphic disorder must
choose between remedial action (e.g. surgery) and the safety (but accompanying
sadness) of inaction. The pathological gambler must decide to ignore their encour-
aging thoughts (‘I can win it all back tonight’) or risk further loses and ever-­declining
financial resources. It is fair to say that existential freedom is riddled through the
bones of most of the mental health disorders in one form or another. It is the goal of
therapy to help the sufferer navigate these forks in the road toward adaptive choices
that lead the individual out of their stuckness and toward a functional existence
focussed on the present moment.
Failed Potentialities, Regret and Their Link to Depression and Related Disorders 233

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Reframing the Past and the Treatment
of Existential Guilt and Regret

Ross G. Menzies

Abstract  Regret over past actions can haunt sufferers with a range of disorders. At
the heart of the CBT response, to regret is the Stoic practice of letting go of things
beyond our control. Stoic philosophers from Greece and Rome argued that desires
for outcomes beyond our control are at the centre of human pain and suffering. They
urged us to limit our desires to activities and outcomes that fully rest in our own
hands. This chapter will explore contemporary CBT for regret and shame through
the lens of applied Stoicism. In addition, a range of specific techniques borrowed
from the treatment of obsessions will be shown to have potential in battling regret.
Finally, the use of self-compassion, mindfulness and novel approaches for regret
regulation will be explored.

Keywords  Regret · Stoicism · Self-compassion · Mindfulness · Obsessive-­

compulsive disorder · Rumination

1 Regret and Its Role in Mental Health

For so many individuals who enter psychotherapy, it is the events of their past, near
and far, that they wish to discuss. Missed opportunities, foolish mistakes and the
cost of these errors can occupy the mind for years or even decades. Menzies and
Menzies (2019) argue that Shakespeare’s tragedies have remained popular over cen-
turies largely because they focus on being defeated by our own weaknesses of char-
acter or momentary decisions, an experience familiar to many. Clients in
psychotherapy regularly discuss such experiences (Beazley, 2004; Kyle, 2014): ‘If
only I’d told her I loved her’, ‘if only I’d seen the signs’, ‘if only I’d taken him
seriously’.

R. G. Menzies (*)
Graduate School of Health, University of Technology Sydney (UTS), Ultimo, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 235

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_14
236 R. G. Menzies

The desire to get decisions right, to optimise outcomes in all our actions and
choices, is referred to as ‘maximising’. Unfortunately, the characteristic is not as
positive as it might superficially sound. ‘Maximising’ has been linked to mid-life
and late-life depression, but the relationship appears to be heavily mediated by one’s
proneness to regret (see Chapter “Failed Potentialities, Regret and Their Link to
Depression and Related Disorders”). The effect is so marked that Bruine de Bruin
et al. (2016) suggest that ‘regret regulation’ should become a new target for treat-
ment in late-life depression, although the authors offer few suggestions about what
this might include, and few clinical trials for regret exist. This is surprising, because
the management of regret is not new, with teachings on the topic going all the way
back to the early Stoics.

2 Stoicism and the Principle of Desire

Stoicism is a Hellenistic school of philosophy founded by Zeno of Citium in the

third century BC. Informed by its system of logic, Stoicism proposed that the prac-
tice of virtue is both necessary and sufficient to achieve eudaimonia – happiness or
‘good spirit’. By living an ethical life, and practising the cardinal virtues (i.e. wis-
dom, courage, justice and temperance), the Stoics believed one could shed the nega-
tive emotional experiences that dominate the lives of so many (see further
Pigliucci, 2017).
In its original Greek form, Stoicism centred on logic, physics and ethics. Those
that studied with Zeno were to begin with logic, and this formed the basis of the
philosophy. As Irvine (2009) argues, the emphasis on logic was a natural conse-
quence of Stoicism’s emphasis on man as a rational being. However, by its adoption
in the Roman world, the focus had shifted to the search for tranquillity, heavily
derived from the field of ethics in Zeno’s original conception (Irvine, 2009).
Stoicism, at least in theory, offered its followers a life free of the negative emotions,
including regret.
The possibility of a contented life rested largely on the Stoic argument that nega-
tive emotional experiences were driven largely by the interpretation of events and
happenings rather than by the events themselves. As Epictetus (2014, p.  54)
famously put it, ‘Men are disturbed not by things but by the view they take of them’.
This perspective lies at the heart of cognitive behavioural therapy (CBT) as it
emerged in the 1960s and 1970s. Notably, early CBT leaders, particularly those
writing on cognition, regularly cited Epictetus as the basis of their ideas. Beck’s
(1976) overview in Cognitive Therapy and the Emotional Disorders and Ellis’s
(1977) opening in Anger: How to Live With and Without It both include Epictetus’s
famous quote. Rational living, as Beck and Ellis argued, involves adopting perspec-
tives on events that can be said to be both logical and adaptive. Since our emotional
state is largely determined by our perceptions of the world, the Stoic position, and
that of contemporary CBT practitioners, rests on the idea that we need to reframe
Reframing the Past and the Treatment of Existential Guilt and Regret 237

maladaptive thoughts, beliefs and attitudes in order to achieve a positive experience

of living (see further Irvine, 2009).
A central idea of Stoicism relates to desire or more specifically what it is appro-
priate to desire. The early Stoic scholars argued that desire aimed at things beyond
our control is the chief cause of anxiety and other negative emotional experiences
(see Pigliucci, 2017 for a review). In contrast, if desire is placed only on outcomes
completely within one’s control, one can achieve a state of lasting contentment. For
example, if I desire a cheese sandwich, and have both cheese and bread in my home,
no anxiety will arise. I can control the outcome, and therefore there is no probability
of my desire being thwarted. But if I desire another person to like me (or even love
me), my potential employer to select me for a job or to pass a difficult and unseen
examination, anxiety will necessarily arise. The desire of things that are beyond my
complete control logically implies that I may, or may not, achieve my desired out-
come. Since the possibility exists that I will not meet my desire, anxiety must occur.
Desire for things beyond one’s control sets up an endless, lifelong pattern of
craving followed by either relief (when the desire is achieved) or disappointment,
anger, envy and regret (if the desired outcome is not met). This, of course, is the
lifelong experience of so many people. Following this logic, I can only overcome
the negative emotions if I shed desire for things that are beyond my complete con-
trol. That is, for objects or events that are beyond my control, the Stoics taught us to
aim for a state of indifference.
Of all the Stoic philosophers, Epictetus makes the point most forcefully. He
counsels us to note carefully the things that we desire and categorise these into
things that are within and beyond our control. He declares:
The chief task in life is simply this: to identify and separate matters so that I can say clearly
to myself which are externals not under my control, and which have to do with the choices
I actually control. When then do I look for good and evil? Not to uncontrollable externals,
but within myself to the choices that are my own. (Epictetus, 2014, p. 57)

Chief among the matters that are outside of our control are the actions and happen-
ings from our past. It is indisputable that the events of the past are, by definition, not
within my current control. One may be able to take new decisions to deal with the
after-effects of past choices, but the past choices cannot be unmade. Regret about
the past, from a Stoic point of view, makes no sense at all, and since a central goal
of Stoicism was applying our rational abilities, regret (or even interest in the past) is
to be rejected. The idea is echoed in the opening words of Eckhart Tolle’s (1997)
bestseller The Power of Now, ‘I have little use for the past and I rarely think about
it’ (p. 1). And so, to the practising Stoic, the goal is to achieve indifference to the
choices that one has made, regardless of the consequences that have followed them.
While the Stoic position seems logical, how can someone feel unmoved by ‘bad’
happenings once they have occurred? Don’t regret and despair after the events seem
understandable, if not warranted? Who would not regret driving a car when intoxi-
cated, if it resulted in a death? As Irvine (2009) points out, the solution of Epictetus
to such events was to consider them unavoidable – to believe in ‘the Fates’. In Greek
mythology, the Fates were a group of three weaving goddesses who were said to
238 R. G. Menzies

assign individual destinies to mortals at birth. And so, regret about our own past
choices, and anger at the choices of others that have harmed us, makes no sense. The
tragic events of our past were always going to happen.
Fatalism was important in Stoic thinking but seems out of place in a modern
world. We no longer believe in mystical sisters weaving the thread of our lives.
However, one additional technique that can prove useful is borrowed from the anger
literature in what amounts to an argument against free will. Laurent and Menzies
(2013, pp. 175–176) tell us:
The angry speak a lot about the ‘choices’ people make (mostly the bad ones), and are loathe
to ‘excuse’ wrongful behaviour. But there is something fundamentally unscientific about
anger. Logically speaking, if you believe someone should have acted differently, presum-
ably you believe they could have acted differently. But being who they were, and seeing
things as they did, at that moment in time there’s strictly only one thing they ever would
have done.

These authors urge us to accept who we have been at each moment in our past and
do the same for others around us. In an argument similar to that raised by Carol
Dweck in her work on the growth mindset (see Dweck, 2006), Laurent and Menzies
(2013) point out that while we are ever-changing organisms that can grow and
develop, our past actions and choices are simply a reflection of our thoughts, beliefs,
attitudes and habits at the time:
The decisions we believe we’re making freely are all in fact determined by a dense thicket
of crisscrossing cogs and causes – biographical, physiological, cultural, psychological, neu-
rological and environmental. They don’t come out of nowhere. We are incredibly complex
creatures, entwined in incredibly complex situations, which makes our choices often seem
baffling and unpredictable; but we are nonetheless, ultimately, biological machines that
obey the laws of physics just like everything else. p. 177

The outfielder who drops the catch was doing his best. He could train more and
learn new techniques for the future. But feeling guilt at who he was, and the opera-
tion of his visual and motor systems at the moment of the dropped catch, makes
little sense. And so it is with our choices and actions over time. Acceptance that they
were a reflection of the operation of millions of neuronal connections and calcula-
tions is an important part of letting go of regret.

3 Amor Fati

Some authors go further than simply accepting the events of the past. Many have
argued that we need to embrace the life that has arisen from the collective decisions
of the past. This notion relates to Nietzsche’s (1994, p. 32) notion of loving the fates:
My formula for greatness in a human being is amor fati: that one wants nothing to be dif-
ferent, not forward, not backward, not in all eternity. Not merely bear what is necessary, still
less conceal it – all idealism is mendacity in the face of what is necessary – but love it.
Reframing the Past and the Treatment of Existential Guilt and Regret 239

The brilliancy in Nietzsche’s stance lies in what it achieves. First, the individual
who adopts it becomes the master of regret and also shame. In embracing all things
past, in truly loving them, shame, humiliation, regret and all emotional pain simply
melt away. The supposed missed opportunity for love is embraced. The violent acts
of one’s youth are embraced. The mistreatment of an ageing parent is embraced. It
is who I was at the time. It is my truth as I developed. In wanting the past to be a
different one is wanting to have been a different person. But if I see myself as a
developing machine, all the moments of my past are part of that development. The
supposed mistakes become moments in which I have been able to develop or grow.
From this point of view, they do not need to be lamented.
Amor fati relates strongly to the willing acceptance expressed in acceptance and
commitment therapy (ACT). Hayes and Smith (2005) describe acceptance as a will-
ing embracing of the things that have happened in a life and the emotions that we
have felt. Like Nietzsche, ACT does not promote a begrudging acceptance of cir-
cumstances. On the contrary, Hayes and Smith (2005) call for an enthusiastic accep-
tance that arises from the disarming view that one wouldn’t change it even if one
could. Only then has one achieved genuine acceptance.

4 Learning to Live with Doubt

As the treatment of regret is in its infancy, many of the relevant concepts and con-
structs will likely be borrowed from other areas of clinical psychology. A key con-
cept in the contemporary management of obsessive-compulsive disorder, which
may prove useful in the battle with regret, is learning to live with doubt (de Silva,
2003). Individuals with OCD have been shown to be intolerant to uncertainty
(Salkovskis & McGuire, 2003). This intolerance, in combination with an elevated
need to control outcomes, may lead to continued checking (of locks, gas stoves,
etc.) to ensure that the desired outcome is achieved. Testing, to gain certainty, may
occur right across the spectrum of OCD problems. For example, the individual with
sexual obsessions may spend hundreds of hours over years or decades testing and
retesting their sexual response to same-sex individuals they see on the street as a
means of gaining certainty about their heterosexuality (Einstein & Menzies, 2003).
According to the cognitive model of OCD (see Salkovskis & McGuire, 2003),
sufferers must come to accept that seeking certainty reinforces the condition by
rewarding checking behaviours that become rituals over time. Only by learning to
live with doubt can the sufferer cease to test and thereby reduce and eliminate their
checking behaviours. The checking has lost its purpose, and the sufferer drops their
caring over establishing ‘the truth’. The same approach has been taken in illness
anxiety disorder and panic disorder. The sufferer is encouraged to live with doubt.
Perhaps I will have a heart attack today? Perhaps that throbbing in my temple is a
brain tumour? Perhaps there is something fundamentally physically wrong with me
that has been missed in medical examinations in the past? The battle to establish the
truth is ended as the sufferer is encouraged to recognise that the emotional pain of
240 R. G. Menzies

seeking certainty is greater than any benefit that would emerge from continued test-
ing. After all, establishing that one pain is benign is typically quickly followed by
another pain arising (Menzies & Menzies, 2019).
This approach can be used with regret over missed opportunities and ‘mistaken’
actions. Let’s consider supposed missed opportunities for romantic attachment. One
depressed patient revealed hundreds of hours of rumination over more than a decade
about not speaking up about his romantic feelings for a co-worker. Subsequently
she was asked out by a colleague, whom she dated for more than a year before she
left the company to take a job overseas. His pain continued, ruminating on the ques-
tion of what would have happened ‘if only I’d spoke up earlier, before he asked her
out’. He was consumed by what might have been and what had become of his lost
love since that time. From a ‘learning to live with doubt perspective’, the individual
is left with no need to ruminate about the hundreds of opportunities when they could
have spoken up, re-examining and exploring each scene. Online checking of her
current activities and imagining how good it could be to have become a part of her
life are also parked by this approach. Rather than trying to establish the truth or
otherwise of what they fear, the sufferer accepts the outcome. Maybe a life with her
would have been amazing? Maybe it would have collapsed? Perhaps she would
have said yes if I’d asked her out earlier? Perhaps she wouldn’t have? Living with
doubt counters regret in many situations because it demonstrates that we can’t know
what outcomes would have arisen from our decision in the first place. In combina-
tion with Stoic indifference to things beyond one’s control, and Nietzsche’s embrac-
ing of our history, we have a powerful set of emerging tools in battling regret.

5 Self-Compassion

Other transdiagnostic concepts and therapy approaches have been used in dealing
with regret, shame and the rumination that may arise from them. In Beazley’s (2004)
popular work on regret, the notion of self-compassion is an important one. He asks
his readers to understand that they should treat themselves fairly, considering all the
contributing factors at the time of any decisions that they have taken. Beazley gives
the example of Joan, a researcher in a small drug company, who stole a colleague’s
idea and developed a patent for it. She amassed a fortune in royalties and consider-
able acclaim from her peers. But Beazley (2004) tells us that, even as she spent her
money, she became progressively lonely and unhappy. Friendships were lost, and
she declined into a pattern of seeking more and more success. She became isolated
from people who had previously supported her.
Treatment for Joan’s regret, which was dominating her waking hours, empha-
sised the need to look at her behaviour with more compassion and understanding.
Beazley (2004) tells us:
As Joan struggled to make sense of what she had done, she thought back to the way she had
been at the time of her betrayal and at the beginning of her regret. She was not trying to
excuse the betrayal or minimize it, but she was trying to understand how she could have
Reframing the Past and the Treatment of Existential Guilt and Regret 241

committed what she now considered a despicable act. She remembered how insecure she
had been growing up in a poor family and how desperate she was to make money, to become
famous, to do anything that would fill the emptiness inside her. She recalled how often her
father had told her that she was foolish to get a graduate degree and that she would never
make it in the man’s world of medical science. She remembered how driven she had been
to prove him wrong, to impress him with her money and her success, and to gain approval.
She also recalled how selfish she had been in those days, how singularly concerned she was
with herself, and how little she had counted friendships except as contacts to further her
career. (p. 24)

Beazley (2004) tells us that as Joan began to process who she was at the time, she
began to develop compassion for herself. Joan was able to put her behaviours in
their appropriate context rather than judge them from her more mature stance that
had involved decades of growth and experience. She came to realise that to have
done ‘better’ at the time was simply not possibly being who she was.
Neff and Germer (2018) describe self-compassion as a process in which we learn
to be a good friend to ourselves. In essence, it asks us to offer the same loving care
to the self that we would offer to another who had made mistakes and was struggling
with them. They argue that self-compassion consists of three core elements that are
to be depended on when we are in pain: self-kindness, common humanity and mind-
fulness. Self-kindness is likened to ‘putting a supportive arm around our own shoul-
der’ (p. 10). It amounts to showing the same support to the self that we might hope
from a loving friend. Common humanity refers to the recognition that we are human
and that, like all humans, we are capable of significant mistakes and weaknesses.
That we all share the experience of failure and misjudgement is an integral part of
their Mindful Self-Compassion (MSC) programme. How can we expect standards
that are inconsistent with being human? Mindfulness involves being aware of the
present moment in a non-judgemental way. Importantly, Neff and Germer (2018)
emphasise that self-compassion emerges from mindfulness rather than being sepa-
rate to it:
Mindfulness invites us to open to suffering with loving, spacious awareness. Self compas-
sion adds, ‘be kind to yourself in the midst of suffering’. Together, mindfulness and self-­
compassion form a state of warmhearted, connected presence during difficult moments in
our lives. p. 2

Their 8-week Mindful Self-Compassion (MSC) programme consists of a myriad of

practical exercises relevant to overcoming regret. These include exercises to (1)
identify how I treat others as a friend; (2) identify how I treat the self in difficult
circumstances or in the face of failure or misjudgement; (3) identify differences in
these two ways of relating; (4) mindfully experience the pain of regretted actions by
describing and recording the feelings experienced; (5) identify erroneous assump-
tions that might be driving this pain (e.g. ‘no one would make such a stupid mis-
take’); (6) emphasise our shared humanity in facing such mistakes; (7) write
responses to the self, in a gentle and compassionate way, as if writing to another self
(e.g. ‘It’s okay to make mistakes. I’ll be here to support you whatever happens’); (8)
reflect on the experience of MSC and how it differs from the previous responding
with regret and shame; (9) measure one’s growing sense of self-compassion; (10)
242 R. G. Menzies

journal examples of self-compassion; (11) identify core values; (12) practise self-­
appreciation; (13) and touch the present moment.
Clinical trials of the MSC programme are still in their infancy. Neff and Germer
(2013) report the findings of two small trials with encouraging results. Study 1 was
a pilot study that examined change scores in 21 adults from pre- to post-treatment
with the MSC programme. Significant improvements on self-compassion, mindful-
ness, depression, anxiety and stress were reported. Unfortunately, no measures of
guilt and regret were taken. Study 2 was a randomised controlled trial with 52 par-
ticipants allocated to either MSC or a waitlist control group. Compared with the
control group, intervention participants reported significantly larger increases in
self-compassion, mindfulness and well-being. Gains were maintained at 6-month
and 1-year follow-ups. Again, measures of regret, shame or guilt were not taken.
Despite this, gains in mindfulness and mood do suggest that MSC may be effective
in reducing backward-in-time thinking with a regret-driven, ruminatory style. More
research on the programme is clearly needed.
Self-compassion has been lauded as a critical component of narrative gerontol-
ogy. Stevens (2019) has argued persuasively that self-compassion is needed to
enable the elderly to process the ‘dark stories’ of their lives rather than simply nar-
rate inauthentic accounts of their experiences. To the present author’s knowledge,
no trials of this approach exist at the present time. Finally, several authors have
suggested that the MSC programme could be used for the guilt and shame experi-
enced by veterans of military service (McKinney, 2021) and those with a history of
trauma (Gladstone, 2021). Again, no trial evidence is available at the present time.

6 Touching the Present Moment

Integral to MSC is mindfulness practice, defined as awareness of the present experi-

ence with acceptance. The concept and practice of mindfulness proposed by Neff
and Germer (2018) does not differ, in its essentials, from that suggested by Williams
and colleagues in mindfulness-based cognitive behavioural therapy (MBCT) or
similar exercises in acceptance and commitment therapy (ACT). Essentially, all of
these therapies involve ‘touching of the present moment’ which logically should be
integral to managing regret. After all, to regret necessarily involves sending the
individual into their past. As we saw in Chapter “Failed Potentialities, Regret and
Their Link to Depression and Related Disorders”, much of the experience of those
with a ruminatory style of thinking is backward in time.
Reframing the Past and the Treatment of Existential Guilt and Regret 243

7 Future Directions in Regret Regulation

Recent reviewers of this field (e.g. Schwartz & Ward, 2004; Västfjäll et al., 2011;
Zeelenberg & Pieters, 2007) suggest that additional strategies offering promise in
preventing or dealing with regret include (1) eliminating maximising, in order to
make decisions easier and reduce their psychological costs; (2) choosing not to
track the performance or outcomes of non-chosen options once a decision is made,
so as to prevent regret; (3) promoting gratitude, by focusing on ways that life could
have been worse; and (4) recognising the role of chance and external factors in deci-
sion outcomes, so as to reduce self-blame. While each of the strategies has merit,
some are very difficult to achieve clinically. For example, tracking the outcomes of
jobs or investments not taken, or the activity of unrequited or unfulfilled or rejected
love attachments, seems particularly difficult to stop. Regret, bitterness and jealousy
can haunt individuals for decades after relationship failures or false starts.
Baumeister, Wotman and Stillwell (1993) explore the psychological consequences
for being rejected, either in a relationship or before one ever formed. The impacts
are many and complex and centre on humiliation and lowered self-esteem. They
argue that a common pattern of one-sided romantic love involves a less attractive
person becoming infatuated with a more attractive person who does not reciprocate
the feelings:
The reason for the rejection may lie in the fact that people are generally not attracted to less
desirable others. If this is generally recognized, however, then the rejection carries the sym-
bolic message that the would-be lover lacks sufficient desirable qualities to be a suitable
partner for the rejector. p. 390

Romantic rejection before, or even during a relationship, can become a symbolic

evaluation of one’s deficient worth. Unsurprisingly, this may create a sense of
humiliation and significantly impact self-esteem. The effort to restore self-esteem
may drive individuals to check on previous partners or would-be lovers, seek assur-
ance that they have not ‘outperformed’ them in life’s journey and drive regret about
the ways in which the sufferer approached the potential relationship (e.g. ‘I should
have spoken earlier’). In any event, choosing not to track one’s forgone choices and
options may be difficult to resist. It is suggested that increasing motivation to stop
checking might be achieved by examining the pain occasioned by the internet and
social media searches.
Baumeister et al. (1993) make the interesting point that it is not just the rejected
individuals that suffer in cases of unreciprocated romantic attraction. Those who
reject, expressing their existential freedom by actively choosing to leave an estab-
lished relationship or reject a new one on offer, have also been shown to suffer. The
decision to reject can lead to the same regret that can occasion any decision at a later
time point. This may occur because of later failed relationships or rumination about
the reasons for the rejection in the first place. Baumeister et al. (1993) report that in
unrequited love, would-be lovers looked back with both positive and intensely nega-
tive emotions, whereas rejectors are almost uniformly negative in their narrative
accounts. Rejectors may feel guilt at hurting someone and, as stated above, may
244 R. G. Menzies

regret their decision. Again, rejectors may also engage in checking behaviours to
see how their would-be lover has fared across time, although ruminating and brood-
ing following unrequited love are more common among those rejected.
Of course, humiliation and the hit to self-esteem of rejection will lead some to
more than brood. Coleman (1997) explored the other impacts of these emotions,
finding that violence and abuse often follow rejection, particularly if leaving a for-
mer romantic attachment. 141 female undergraduates completed questionnaires
examining violence and threatening behaviours in former heterosexual relation-
ships. Participants were placed in control, harassed or stalked groups based on their
responses. Unsurprisingly, women who had been more verbally and physically
abused during relationships were more likely to be stalked after relationships. Anger
and violence are linked to narcissistic tendencies in men, who are particularly
affronted by the possibility of rejection (Hamberger & Hastings, 1986; Laurent &
Menzies, 2013). Violence against women in relationships remains one of the mod-
ern scourges of all societies around the globe (see Ellsberg et al., 2014 and Ali et al.,
2016 for reviews).

8 Concluding Comments

Regret is a transdiagnostic construct that arises from existential freedom. Individuals

must choose directions throughout their lives, effectively ruling out alternative
choices as they go. We are, as Sartre (1999) declared, ‘condemned to be free’.
Unfortunately, for many individuals, rumination about past choices can dominate
the present and drive depressive illnesses, particularly from the mid-life onwards
(see further Chapter “Failed Potentialities, Regret and Their Link to Depression and
Related Disorders”). The management of regret has been neglected in clinical psy-
chology, potentially because it has been seen as just another construct that can be
tackled with standard approaches in cognitive therapy. However, given the impor-
tance of freedom in existential philosophy, regret deserves a closer examination. It
is suggested that future research, at the very least, seek to (1) examine the presence
of regret across the full range of mental disorders, (2) explore its role as a potential
mediator and maintaining factor in mental health disorders and (3) build an evi-
dence base for the variety of treatment procedures and approaches that have been
suggested. To date, there is a paucity of studies that have specifically targeted this
common emotional experience.

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 Part VI
Meaning
On the Need for Meaning

Gerard Kuperus

Abstract  Sartre (Essays in existentialism. Carol Publication Group, 1999, p  34)

famously declared that “man is nothing else but that which he makes of himself.”
Using the central tenet of existential thinking “existence precedes essence,” Sartre
claims that a person must determine themselves through their choices and actions.
This chapter examines the claim that man’s search for meaning is a critical part of
dealing with the existential confusion that comes from being thrust into an inher-
ently pointless world. Existentialism can be exciting but also utterly confusing. The
chapter seeks to explore some ways in which one can break out of our crust and find
new perspectives.

Keywords  Meaninglessness · Meaning · Nietzsche · Sartre · Sailing · Danger ·

Creativity · Life · Existentialism · Responsibility

1 Introduction

Comet “Neowise” is flying over us, about 100 million kilometers away from the
earth. An icy space rock flying at a speed of 231,000 km per hour, followed by a
tail – it is a magnificent sight. The next time the comet will be visible from earth will
be 7000 years in the future. Who will be around then? The rock doesn’t care if any-
one will be around to watch that event. Either way, it will just carry on in its point-
less task of circling around the sun, indifferent to spectators. Neowise confronts us
with our own position and makes us feel small, irrelevant. The comet has no mean-
ing and seems so meaningful. The earth, life, humanity: it all seems rather insignifi-
cant as this comet is flying over. Is there any meaning aside from the temporary
meaning we provide it in this moment?

G. Kuperus (*)
Philosophy Department, University of San Francisco, San Francisco, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 249

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_15
250 G. Kuperus

Sartre (1999, p. 34) summed up existentialism in the form of the sentence “exis-
tence precedes essence.” We start with existence, without any given meaning or
purpose. For Sartre, and most existentialists, God does not exist. If there is no
design, no reason, no meaning to existence, then what? Our lives are perhaps as
pointless as that of a comet, and a lot less glamorous! Should we despair, celebrate,
create meaning, accept the absurdity of our existence, or…? Certainly, existential-
ism as a philosophical movement includes thinkers who emphasize the crisis that a
lack of meaning can bring, such as Schopenhauer, Kierkegaard, and Heidegger,
whereas others, such as Nietzsche, have emphasized the opportunities this presents.
Again others, especially Sartre, present us with the responsibility that the absolute
freedom of existentialism casts upon us. All these philosophers provide us with
ideas that challenge a traditional conception of existence, namely, that our existence
has some kind of purpose and meaning. In a world without a God who designed
purpose and thus meaning to our existence, we are left in a rather pointless and
meaningless world. Needless to say, in a secular society this existential insight that
there is no designed purpose to our existence is recognized widely but difficult to
accept. It can be met with a sense of anxiety, a false sense of freedom, or a combina-
tion of both. Either way the insight has significant consequences on all of the factors
that influence who we are and should be: from the conception of ourselves to the
relation with others and our social and natural environments.
What is meaning in an existentialist context? How would one reconcile the
meaning we attribute to a comet circling the sun? The short answer is that there is
only meaning in so far as it is constituted by humans. This definition of meaning
created by humans can often become confused with the notion of truth. As
Nietzsche points out in the essay On Truth and Lies in an Extramoral Sense: “What
is the truth? A moveable host of metaphors, metonymies, and anthropomorphisms:
in short, a sum of human relations which have been poetically and rhetorically
intensified, transferred, and embellished, and which, after long usage, seem to a
people to be fixed, canonical, and binding. Truths are illusions which we have
forgotten are illusions” (Nietzsche, 2001, p.  67). The meaning of words has
become truths, in which we forget that those words, including all the concepts
used in the natural sciences, are indeed generated by humans. As Nietzsche
reminds us: “After all, what is a law of nature as such for us? We are not acquainted
with it in itself, but only with its effects” (Ibid. p. 68). Indeed, the fact that con-
cepts such as “gravity” are human constructions is mostly forgotten. We accept
these concepts and theories as facts and forget they are one of many possible
approaches to explain phenomena. Since we build theories on other theories, we
find in fact multiple layers of truth. Thus, Nietzsche (2001) claims that science
becomes a scaffolding of concepts, which we are holding up to avoid the collapse
of science, and most of all ourselves. Because beyond those theories and concepts
no meaning exists. There is no truth, and meaning does not exist beyond the one
we humans provide it, and this meaning does not only become engrained in our
conception of reality. It is our conception of reality, and we are (rightfully) worried
about the nothingness that lies beyond it.
On the Need for Meaning 251

2 Language: Scaffolding or New Meaning?

Famously, for Schopenhauer (2020), nihilism leads to suffering. As we are con-

stantly trying to find meaning in a world without any absolute meaning, we are liv-
ing in a constant tension of that contradiction. Yet, different from Schopenhauer, for
Nietzsche (2001) the meaninglessness of the world is a fact to be celebrated. His
existentialist philosophy led to a re-evaluation of all values and a joyful science. He
argues that if there is no meaning, no truth, and thus no absolute values, we can cre-
ate our own. This is where nihilism and the lack of meaning become a powerful and
positive tool for existentialism. Indeed, we do not have to stick to the given values
and meanings, but rather we can generate new ones and reinvent ourselves and our
society. However, this is not easy, and Nietzsche points out the difficulties of this
endeavor. We easily feel homesick and lost in a world without any direction.
Embracing the meaninglessness of existence by creating meaning for ourselves is
far from “a walk in the park.” Yes, we should laugh and create a joyful or gay sci-
ence, since life is without meaning, and thus we should laugh at all those who take
it so seriously. Yet, if there is nothing to hold on to, we can become lost and without
any direction. We might indeed crave those strict rules of the church, because we
know what we should and should not do. Or we hold on to the “scaffolding” pro-
vided by the concepts of our scientific discipline. Without those concepts humans
can feel lost: this fear of the unknown is often what drives individuals to hold on to
strict meanings and hold on to them as truths  (Nietzsche, 1976). This is where
Nietzsche challenges us, and he challenges himself, by writing in a new language, a
language of “spring weather” as he suggests in the preface to The Gay Science. Yet,
even that language itself worried Nietzsche, as they might become truths. This is his
worry, expressed at the end of Beyond Good and Evil: “what are you after all, my
written and painted thoughts. It was not long ago that you were still so colorful,
young and malicious, full of thorns and secret spices – you made me sneeze and
laugh – and now? You have already taken off your novelty, and some of you are
ready, I fear, to become truths: they already look so immortal, so pathetically decent,
so dull!” (Nietzsche, 1998, p. 236).
This comes from one of the best and certainly most powerful writers in the his-
tory of philosophy. Dull and decent? Those are not exactly the words that come to
mind when reading Nietzsche. Yet, this is the curse of language: anything commit-
ted to language to some degree solidifies. It is well known that Nietzsche eventually
collapsed, and while the true cause of Nietzsche’s illness will never be known, it has
been speculated that the ultimate consequences of his philosophy became
unbearable.
Existentialism defies the idea that there is any absolute meaning or truth. Yet, that
does not mean there are no meanings at all. In fact, Nietzsche speaks of perspectives
(a variety of different meanings one could say) and strongly suggests we need as
many as possible. He argues that all philosophers who have approached truth with
awkward and improper methods have led to a “narrowing of our perspective”
(Nietzsche, 1968, p. 292). Thus, he proposes what can he called a “perspectivism,”
252 G. Kuperus

which suggests that all “truth” is an interpretation from a particular perspective and
that there is no limit to the number of possible perspectives. The lack of any abso-
lute truth will not necessarily devalue the significance of humans striving to recog-
nize and search for truth. Nietzsche’s philosophy is not simply a relativism, as he
admits that “there would be no life at all if not on the basis of perspective estimates
and appearances” (Ibid. 236). Truth in an absolute sense does not exist, yet without
any “truth,” the human race, nor any other form of life, could survive. It is within
this context that he proposes that a perspective is the “basic condition of all life”
(Ibid. 193). To say it differently: we constantly need to find meaning. Indeed, how
could we possibly live without something to hold on to? While the lack of truth can
be overwhelming, Nietzsche’s philosophy is an optimistic one especially because it
empowers humans.
Part of Nietzsche’s existentialism is the attack on dualistic thinking, which tries
to solidify meaning into truths. Nietzsche replaces the “or” often into a “beyond.”
Famously, the choice between “good and evil” becomes the attempt to move
“beyond good and evil.” This is an entirely different ethical approach that chal-
lenges the history of Western Ethics. Instead of working with just these two catego-
ries, Nietzsche asks us to rethink ethics and morals. In the Christian system of good
and evil, an abortion is evil. Period. When that value system disappears, we actually
have to ask questions, such as about the value of life, the rights of women over their
own bodies, or what to do if a severe disorder is detected in a fetus. The overarching
question then becomes which of those values is to be prioritized. Instead of the
dualistic either/or, we find now many gray areas between, or beyond, good and evil.
Likewise Nietzsche (2001) is critical of the mind and body dualism, set up by
Descartes, and challenges the idea that we can think without a body. The body is
emphasized over reason, as his language constantly emphasizes that we are animals,
driven by our bodily desires and instincts.
Nevertheless, he points out that in philosophy a belief in a specific perspective is
required. Nietzsche’s own position (his belief) is that a true philosophy does not
exist, but that there “is only a perspective seeing, only a perspective ‘knowing’”
(Ibid. 555). This perspectivism is necessary for life and for the intellect or philoso-
phy. We cannot do away with it. Moreover, perspectivism does have meaning and
can become more meaningful: “the more affects we allow to speak about one thing,
the more eyes, different eyes, we can use to observe one thing, the more complete
will our ‘concept’ of this thing, our ‘objectivity’ be” (Ibid.).1 For Nietzsche perspec-
tivism as meaning can, thus, be more or less complete. In other words, perspectiv-
ism challenges black and white definitions of truth and value. In that it moves
beyond dualistic thinking.
If there is no absolute meaning to life and we can (and even should) create our
own meaning, how do we go about this? One answer can be identified in how
Nietzsche and Heidegger emphasize the significance of language. The point of lan-
guage, in Heidegger, is that, as he puts it himself, it opens up the world to us. In

 (Ibid.).
1
On the Need for Meaning 253

doing so it can either limit us or expose us to new perspectives. Language and the
words we use show the world in a particular way. It is how meaning is constituted.
For those who speak more than one language, this is easy to recognize: certain
expressions and words are not translatable from one language in the other. This is
especially clear when it comes to feelings and emotional ways of connecting to the
world. While most of the languages we are familiar with have minimal discrepan-
cies, indigenous languages often provide an entirely different reality. Robin
Kimmerer discusses how in Pottawatomi, the language of her native people, a bay
is not named with a noun, but with a verb: “to be a bay” (Kimmerer, 2020, p. 55).
An entity such as a bay is considered as a dynamic and living thing, not as a dead
object (as, e.g., the English language does), she argues. Even without going into the
details of that particular example, it is fascinating to think about the meaning that
such an indigenous language provides, as it allows one to express and recognize the
natural world as animate, whereas languages such as English make such animate-
ness difficult to express. Heidegger (1962) suggested that the German language fails
to grasp the meaning of being and thus uses both Ancient Greek and a redetermina-
tion of the German language to create a new kind of language to bring being out of
oblivion. He is certainly not alone in such efforts.
Languages themselves are dynamic, and within each language new meanings
constantly emerge. Medical terms are a good example of this. Learning disabilities
or attention deficit disorder has existed long before their medical definitions were
actually established, that is, since they got an official name. The name of a disabil-
ity, disease, or illness makes it possible for medical professionals to diagnose it in
the first place. There are also many illnesses, such as Alzheimer’s or dementia, that
lack precision and should probably be divided into several different ones.
Thus, we see that language has a significant role in creating meaning and either
generating, averting, or distracting attention. Certain words are avoided, because of
their negative meaning. During the COVID-19 crisis, my wife overheard a person
describing symptoms (cough and fever) of a friend or family member. The person
added “well, let’s not call ‘it’ by it’s name.” In Camus’ novel The Plague, the medi-
cal doctors and the town officials initially refused to use the words “pest” or “plague”
even among themselves because of the horrific connotations the word has. We see
that by accepting or refusing a particular name (such as “COVID-19” or “pest”),
reality is changed. The refusal to accept that we are in the midst of a pandemic does
have actual consequences. Likewise diagnosing a patient correctly is crucial in the
treatment of the patient and to, for example, prevent further infection. In summary,
language is forming the world as it is instrumental in how humans view the world
and how they relate to it, act in it, and feel about and understand themselves.
Heidegger and Nietzsche continuously struggle with language, and their own use
of language correlates directly to their respective philosophies. When reading
Nietzsche (1968, 2001), we find something very powerful in that language. Yet, we
should not be deceived by that language: behind the power lies uncertainty and great
complexity. When encountering the language of Heidegger, the opposite feeling
might quickly set in: his language is complex and might seem clumsy and forced,
254 G. Kuperus

until one gets into it and starts to speak that language. It is an interesting transforma-
tion that I have encountered in many of my students.
Heidegger (1962) as a thinker who wants to open up our approach to reality
presents us with a new language. He uses existing terms in unconventional ways, for
example, by using the word Dasein (literally “being-there”) for the human being.
Truth itself is described as “opening up,” which suggests that there is a multitude of
ways in which things can open up, depending among other things on the words we
use. Instead of a single truth, we end up with a multiplicity of truths.
Nietzsche’s (1968, 1998, 2001) “perspectivism” highlights the value that multi-
ple perspectives provide. This means, for example, that we do want the perspective
of the natural sciences, that of the philosopher, the poet, the villain, and the priest.
Likewise we want the perspectives from different cultures, in which one is not more
true than the other, but truth is this multiplicity. Indeed, we want as many perspec-
tives as possible, and this translates into Nietzsche’s “dynamic” writing style. As he
writes in the preface to the Gay Science, it is a book to “experience.” Indeed, the
reader moves through Nietzsche’s moods, emotions, and styles. Those themselves
can be considered perspectives.
Yet, Nietzsche also points to the danger of his philosophy: his own philosophy,
including perspectivism, can become a truth. As we have seen earlier, these are
indeed the challenges of existentialism: the lack of meaning and truth itself becomes
a truth. Or perspectivism itself can become the absolute truth of all perspectives. If
we accept relativism, anything goes, and we can end up in an existence that does not
provide any kind of fulfillment. Can we live in a world without direction? More
importantly, does such a philosophy in which we move away from traditional values
open the door for chaotic behavior of violence and oppression? It is well-known that
Nietzsche’s thought has been mutilated and used as anti-Semitic Nazi propaganda
and that Heidegger has been associated with the Nazis. While the first is clearly an
abuse of Nietzsche’s thinking, and the second is a complicated issue, the question of
what exactly warrants against such a development should be asked. In a world with-
out meaning, we can create our own values, and anything is possible. Yet, anti-­
Semitism, sexism, or racism are not the result of existentialism. These xenophobic
tendencies do exist independently of existentialism. Even more, we can suggest that
in existentialism, any kind of oppression is the result of a life that is not lived well.2
Indeed, the fact that anything is possible leads Sartre to a moralistic path. Even
while there is no meaning to life, that does not mean there are no consequences to
our actions. What we do and do not do matters. For Sartre we have to take full
responsibility for not only our own actions but also those of others. After witnessing
the violence of WWII and the holocaust, Sartre critically assesses his generation
and urges us to take responsibility. I might not be able to stand up against an armed

2
 This point is arguably made in The Stranger by Camus (1989) in which the main character,
Meursault, wastes his life away with an attitude of indifference. Nothing matters to him, whether
he loves or not, hates or not, and he never makes any choices. Things just happen to him, including
him shooting another human being, an Arab. The underlying racism is a result of indifference to
one’s own life and the inability to love and make choices.
On the Need for Meaning 255

soldier, or a soldier has to follow commands. Yet, both are acts of bad faith, cases in
which one seeks an excuse for either action or inaction, by suggesting there is no
choice. Not acting is, however, not passive. It is an active choice. For Sartre there is
always a choice and thus a responsibility. I can choose to not risk my own life in
order to save another life, but the point is that it is still a choice. In summary, the
lack of meaning, for him, presents a great difficulty.

3 Leaving the Land Behind

Existentialism thus provides us with an ethics, a demand to create a meaningful life,

i.e., a life that will be worth living. Of course, many of us are, like Tolstoy’s Ivan
Ilyich, living insignificant lives following paths already carved out for us. I will now
discuss a few people who have undertaken extraordinary endeavors. Without sug-
gesting that we all should do something similar, I want to think here about ways in
which we can break out of the mold.
The two main people I want to discuss are solo circumnavigators Bernard
Moitessier and Ellen MacArthur. Sailing around the world is no small feat, certainly
not when it is non-stop and done single-handedly. To provide a sense of the chal-
lenge, it involves rounding Cape Horn, a place to fear, with its tremendous heavy
waves (up to 100 ft high or 10-story buildings), strong winds, strong currents, and
the occasional iceberg to keep things interesting. Around 800 ships have wrecked
here, and an estimated 10,000 lives of sailors have been lost. It is estimated that
since Mount Everest opened in 1957, more people have climbed to the top of Mount
Everest than people have sailed around Cape Horn. About 60 people have ever
sailed around the world solo non-stop. Sailing by oneself around the cape is a tre-
mendous challenge, because one is indeed by oneself. When part of a non-stop cir-
cumnavigation, one is already exhausted from being at sea for several months,
having dealt with all kinds of weather, breakdowns, difficult repairs, navigating,
while constantly trying to sail as fast as possible.
Why use this example of the challenge of sailing solo around the world? Besides
my personal interest, Nietzsche does mention crossing oceans frequently. Take for
example what in The Gay Science is called “In the horizon of the infinite.” Nietzsche
writes: “We have left the land behind and boarded the ship!” (Nietzsche, 2001,
p. 124). Leaving the land is here a metaphor for leaving the meanings and values
provided by the church and society. Where does that lead us however? “Now, little
ship, watch out! By your side lies the ocean; true, it does not always roar, and some-
times it lies there like silk and gold and daydreams of kindness. But the hours are
coming when you will recognize that it is infinite, and that there is nothing more
terrifying than infinity” (ibid). Endless possibilities without any guidance present
themselves here. It is first appealing yet ultimately terrifying. As Nietzsche contin-
ues: “Oh, the poor bird that felt itself free and now collides with the walls of this
cage! Alas, when homesickness for the land comes over you, as if there had been
more freedom there – and there is no longer any ‘land!’” (Ibid). This is the great
256 G. Kuperus

contradiction existentialism reveals: freedom itself is terrifying even to such a

degree that strict guidance and clear rules can appear to provide more freedom.3 We
are – in Sartre’s (1999) and Heidegger’s (1962) words – forlorn, lost and afraid of
our own freedom. Nietzsche uses here the notion of “homesickness,” presumably an
implicit reference to the early romantic thinker Novalis, who wrote that all philoso-
phy starts in homesickness. Indeed, all philosophy up to now has for Nietzsche been
a farce, a sickness that is trying to cure itself by constructing truths. Thus, Nietzsche
suggests we have to leave this behind and face and embrace our homesickness to
become who we are.
What now if we take the metaphor of the ocean literally. Such a move is gener-
ally speaking a poor idea at best, but we find some interesting similarities in the
ideas of actual ocean sailors. The two people, already mentioned, are MacArthur
and Moitessier. Starting with the latter, in 1969 Moitessier participated in the first
ever non-stop solo race around the world. While many people wonder why anyone
would want to sail non-stop around the world, Moitessier reversed the question:
why return to land? After sailing around the three capes, he could not bring himself
to return to Plymouth even while he possibly might have won the race. It would
have been sailing “from nowhere to nowhere” (Moitessier, 1975, p. 142). Instead he
rounded Good Hope and Leeuwin one more time, before he finally returned to land
in Tahiti.
Moitessier (1975) describes how he and his boat Joshua “wanted to be left alone
with ourselves.” What he finds in the sea is “the rediscovery the Time of the Very
Beginnings, where each thing is simple” (p. 105). He realizes that it would be hope-
less to explain why he does not want to return and finish the race: “How can I tell
them that the sounds of water and the flecks of foam on the sea are like the sound of
stone and wind, and helped me find my way? How can I tell them all those nameless
things…leading me to the real earth?” (Ibid. 156). Moitessier has actualized his
place and himself in this place; he is truly here, and he is repulsed by the thought of
returning to a place where no one seems to be in one’s place. He makes an attempt
to explain his decision, by using Steinbeck’s metaphor of the monster in the Grapes
of Wrath. This is first of all the tractor that “rapes the earth” after the bank has taken
over the land. Indeed, for Steinbeck the bank is the other monster, yet Moitessier
mostly focuses on the machinery that determines our pace and way of living. While
anchored in Tahiti, he witnesses the construction of roads and parking lots, killing
trees and the soul of the place. “Lots of people believe that the bulldozer and the
concrete mixer don’t think. They’re wrong: they do think. They think that if they
don’t have any work to do, they won’t earn any money, and then their slaves won’t
be able to buy the fuel and oil they need to go on living and go on thinking serious

3
 Indeed, thinkers such as Immanuel Kant (2001) point out that in a society without rules, civil
freedom is not even possible. I can only be truly free, Kant argues, within the context of restrictions
that protect me. The freedom that Nietzsche and the other existentialist envision is a more radical
freedom in which societal and individual freedoms are opened up completely. The way we live
together can be radically altered. The meaning of everything, including society and life, is
entirely open.
On the Need for Meaning 257

thoughts” (Ibid. 177). How can one return to the monster, after having spent months
at sea at the pace of a sailboat? A simpler, slower, fuller life is what he envisions
through a reflection on bicycles: “we would ride bikes in the city, there wouldn’t be
those thousands of cars with hard, closed people all alone in them, we would see
youngsters arm in arm, hear laughter and singing, see nice things in people’s faces;
joy and love would be reborn everywhere, birds would return to the few trees left in
our streets and we would replant the trees the monster killed. Then we would feel
real shadows and real colours, and real sounds; our cities would get their souls back,
and people too” (Ibid. 164). It is a beautiful reflection on our tragic situation, the
cause of which is centered in the car, the bulldozer, and all the other monsters that
have destroyed the soul of the places in which we live. Moitessier has found his own
soul back in the sea and cannot bring himself to return to “the monster.”
Ellen MacArthur has several records on her name. In 2002 she nearly won the
Vendee Globe, a very competitive race around the world, non-stop and single-­
handed. While the race is brutal and dangerous (fatalities are not uncommon, and in
the most challenging years only a third of the sailors have been able to finish), she
describes the experience of the sea as one of absolute freedom and a feeling of space
and timelessness. After completing the Vendee Globe MacArthur had a similar
experience to that of Moitessier. She did not want the journey to end, and she
describes how the most difficult moment of the circumnavigation and the race was
leaving her boat after finishing. She embraces Moitessier’s insight that “People who
do not know that a sailboat is a living creature will never understand anything about
boats and the sea” (4). Furthermore, like Moitessier, she became an environmental
activist. She founded the MacArthur foundation, an organization that promotes cir-
cular economies, which promote to “use things rather than use them up” (MacArthur,
2012) (TED talk). Her turn to promoting a more sustainable economy is based on an
insight she gained from sailing around the world: “All we have out there, is every-
thing we have and we have no more (TED talk).” While this is first of all a reflection
on the food and other supplies she brought for being months at sea, it is moreover
an insight that relates to the earth that sustains us.
What is interesting in this regard, too, is that Moitessier realized that no one
would understand his decision to not finish the race and return to land. He knows
that his insights are pure madness to others. Like Nietzsche he has to use metaphors
in order to express the freedom offered by the sea. MacArthur doesn’t have to
explain because she returns to shore and finishes the race, but what the welcoming
crowd does not understand is that this very moment is the hardest of the whole race.
As I wrote above, I am not suggesting we should do something as extreme as
Moitessier and MacArthur. Their journeys don’t have to be repeated (which would
just create another herd). Yet, their insights provide us ways to open up our eyes as
well as a new perspective on the lives we are living. What they realized at sea, away
from the daily craziness, is that we are not truly choosing our lives ourselves. The
lives we live are not our own and are ultimately lacking authenticity. Both Moitessier
and MacArthur come to similar realizations that led to a motivation to do something
else. Nietzsche speaks about a homesickness, which indeed can lead one to a change
in attitude; to act differently; to find, or rather create, purpose; and so forth. In order
258 G. Kuperus

to establish a new home, one could say, one first needs to be lost. This obviously
takes courage, not only to set out to sail on the ocean (literally or metaphorically)
but moreover to challenge the existing world, its economy, values, morals, and its
truths. Yet, that is exactly the existential challenge we all face: there is no set path;
we have to create our own, sail around obstacles, and face challenges head on.

4 Conclusion

One interesting aspect about approaching existentialism through sailors is that

Nietzsche, in many ways the founder of existentialism, made an abundance of refer-
ences to the sea as a dangerous place. Luce Irigaray (1997) in her work Marine
Lover even argues that Nietzsche’s use of the sea is an indication of his fear for the
feminine. I will leave that argument aside, but indeed Nietzsche always seems to
regard the sea as a dangerous place, one to cross, in order to reach another place, yet
not a place for him to reside. Seas are dangerous indeed, and Nietzsche precisely
argues to live dangerously.
Indeed, to give up on absolute truths and values is dangerous, and it is a risk. A
society that departs from the church can go into all kinds of directions. No meaning
is guaranteed. Yet, as Nietzsche always emphasizes we need meaning, the more the
better. That does not mean we should use meaning as a crutch or scaffolding to hold
up truth. Crossing a sea, literally or metaphorically, can help us to gain new perspec-
tives in that regard.
In this light, existentialism is an exciting but dangerous philosophy. It encour-
ages us to become who we are, to break with the tradition and out of the mold that
has been provided to us: new truths, new values, new meanings. And it is for such
reasons that thinkers such as Sartre (1999) point to the responsibilities that come
with freedom. By stepping away from our daily lives, we come to reflect on it and
re-evaluate who we are and want to be. That might not be easy, and it will be a lot
easier to not challenge ourselves. If we choose not to, we will ultimately have to
confront ourselves with the question of whether we have really been living a life
worth living. When we discover the groundlessness of meaning we can either
despair or generate new ones. The latter is the path existentialism encourages.
Neowise, as any rock, cannot generate meaning, but we can. Perhaps we are as
pointless as a comet circling around the sun; yet, we can reflect on comets, on our
own existence, and on the endless possibilities our lives present to us. The comet
does not care about anything it encounters, but we do. Our existence, as a free one,
is, thus, marked by responsibility. We can sail the oceans, or look up to the sky, and
feel small and lost. Out of that feeling, we can then truly be free and generate mean-
ings that are worthwhile to dedicate ourselves to.
On the Need for Meaning 259

References

Camus, A. (1989). The stranger. Vintage.

Heidegger, M. (1962). Being and time. Harper Collins.
Irigaray, L. (1997). Marine lover of Friedrich Nietzsche. Columbia University Press.
Kant, I. (2001). Lectures on ethics. Cambridge University Press.
Kimmerer, R. W. (2020). Braiding Sweetgrass: Indigenous wisdom, scientific knowledge and the
teachings of plants.
MacArthur, D.  E. (2012). Dame Ellen MacArthur | Speaker | TED. Accessed August 7, 2020.
https://www.ted.com/speakers/ellen_macarthur.
Moitessier, B. (1975). The long way. Doubleday.
Nietzsche, F. W. (1968). Basic writings of Nietzsche. Modern Library.
Nietzsche, F.  W. (1976). On truth and lie in an extramoral sense. In The portable Nietzsche.
Penguin Books.
Nietzsche, F.  W. (1998). Beyond good and evil prelude to a philosophy of the future. Oxford
University Press.
Nietzsche, F. W. (2001). The gay science. Cambridge University Press.
Sartre, J.-P. (1999). Essays in existentialism. Carol Publication Group.
Schopenhauer, A. (2020). The world as will and representation. Cambridge University Press.
Meaninglessness, Depression
and Suicidality: A Review of the Evidence

Adrian R. Allen

Abstract  Drawing from existential philosophers, life meaning has been proposed
as an important resource to general well-being and psychological health in particu-
lar. However, the definition of life meaning has been somewhat variable. The cur-
rent chapter provides a narrative review of life meaning and its connection to
depression and suicidality. Brief review of life meaning as a construct and its work-
ing definition are provided, as well as its conceptual link to depression and suicidal-
ity. Drawing from recent research, life meaning is proposed as a state of seeing
one’s life as having purpose, coherence and significance. The current chapter pro-
poses that life meaning may be linked to these conditions, in part, through its asso-
ciation with hope. Evidence for the association between life meaning and each of
depression and suicidality is presented, drawing from cross-sectional and longitudi-
nal correlational research, mediation/moderation studies and treatment/intervention
research. Research reviewed shows that lower levels of subjective life meaning are
associated with depression, a higher depressive symptomatology and a higher sui-
cidality across samples of varying age, cultural background and psychiatric status.
Moreover, life meaning appears to play an important role in medicating, or at least
buffering, the impact of stressful life events and psychological symptom load on
depressive symptoms and levels of suicidality. That is, higher levels of life meaning
may reduce the impact of stressors upon these experiences. As such, life meaning
may be a helpful target for assessment, treatment and prevention of mental ill health.
Directions for future research are also noted throughout.

Keywords  Depression · Suicide · Suicidality · Meaning · Meaninglessness ·

Psychopathology · Mental health · Assessment · Mood · Affect · Treatment ·
Psychotherapy

A. R. Allen (*)
University of New South Wales Sydney, Sydney, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 261

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_16
262 A. R. Allen

1 Introduction

In diagnostic terms, depressive disorders are characterised by features of disturbed

affect (enduring low mood, sadness, loss of pleasure, guilt), behavioural change
(reduced motivation, withdrawal), neurovegetative features (sleep disturbance,
reduced energy, disturbed concentration, indecisiveness) and cognitive changes
(reduced hope, reduced self-esteem) (American Psychiatric Association, 2013;
World Health Organization, 2018). However, those experiencing one of the depres-
sive disorders often report additional concerns. Previous authors have noted con-
cerns around subjective deficits in life meaning as common and often central to the
subjective experience of people with depression (Fernandez, 2014), possibly causal
(Seligman et al., 2006). Indeed, clinicians are often presented with depressed clients
reporting a sense of pointlessness, futility and hopelessness, which can be associ-
ated with suicidal thinking and action in extreme cases. This prompts the question
about how central a role life meaning plays in the phenomenon of depression and
suicidality. This chapter provides a narrative review of evidence for the association
between life meaning and each of depression and suicidality. Such evidence is taken
from cross-sectional, longitudinal, moderation/mediation and treatment-based stud-
ies. In doing so, the functional role for life meaning in these phenomena is outlined
and the implications noted.

2 Conceptual Proposals for the Importance of Meaning

to Mental Health

Drawing on the work of existential philosophers, several theorists have proposed the
importance of life meaning to sound mental health and implicated its loss in psycho-
pathology. Frankl (1962/2004) placed life meaning as central to the theory on which
he based logotherapy, a meaning-centred psychotherapy. In brief, he proposed that
people are motivated by a will to meaning – a drive to find personal meaning in life.
Within the theory, such meaning is found in serving something outside the self
(such as a social cause or another person) and is referred to as ‘self-transcendence
of human existence’ (p. 89). Obstruction of this will to meaning (‘existential frustra-
tion’) can result in ‘noogenic neurosis’ and experience of the existential vacuum,
with depression as a possible outcome. As Wong (2014) noted, Frankl’s meaning-­
seeking model assumes ‘that the person is embedded within a wider context of
relationships to other human beings, to the world and to some higher power’
(p.  160). It follows that loss of access to such sources of finding meaning could
prompt depression. This accords with research showing that losses or stressful
events within these life areas can be risk factors for depression (Monroe et al., 2009).
Similar to Frankl, Yalom (1980) has drawn on proposals from existential phi-
losophers such as Sartre and Camus. In developing existential psychotherapy, he
proposed meaninglessness (in, and of, life) as one of the key existential concerns
Meaninglessness, Depression and Suicidality: A Review of the Evidence 263

that can adversely affect mental health. In his view, such meaninglessness can erode
mental health when people, born with a requirement for meaning, recognise there is
no inherent meaning in the universe. Recognising this existential concern can be
prompted by experiencing significant life stressors (which he referred to as ‘bound-
ary’ or ‘border’ situations).
More recently, Seligman (2006), Wong (2010, 2014) and Steger (2012a) have
also noted the importance of meaning in life to mental health. In developing well-­
being theory, which underpins his positive psychology approach to human flourish-
ing, Seligman (2011) included meaning as a contributing element. Likewise, and
partly drawing from Frankl and Seligman, Wong’s (2010) meaning-centred coun-
selling and therapy (MCCT) emphasises the importance of life meaning to individ-
ual well-being.
Given the above proposed conceptual importance of life meaning to depression,
and to mental health more broadly, it follows that life meaning would be negatively
affected in cases of poor mental health. To this end, subsequent sections in this
chapter review the evidence for the association between meaninglessness, depres-
sion and suicidality. Before doing so, the construct of meaning is defined.

3 Life Meaning

3.1 What Is Meant by Life Meaning?

Rather than investigating meaninglessness per se, most research on this construct
has examined life meaning. Reflecting this, the remainder of this chapter refers to
life meaning rather than meaninglessness and does so on the basis that these are
ostensibly referring to the same construct. That is, high meaninglessness is the
equivalent of low life meaning and vice versa. In general terms, life meaning is typi-
cally considered to be a subjective judgement of the importance of one’s life and
actions, embracing components of individual life purpose, a comprehension that the
events in one’s life are integrated, coherent and ‘make sense’ and that the individual
and their actions are important (Heintzelman & King, 2014). However, there is no
universal agreement on a conceptual or operational definition of life meaning, with
multiple models of the construct proposed (e.g. Antonovsky, 1993; Baumeister,
1991; Baumeister & Vohs, 2002; Martela & Steger, 2016; Reker & Wong, 1988,
2012; Steger et al., 2006; Steger, 2012b; Wong, 2010). In part, this variation may
reflect ‘definitional ambiguity’ due to the role of unconscious processes that inform
subjective judgements of life meaning, which can appear as an ‘intuitive feeling
state’ (p. 471; Heintzelman & King, 2013). Attempting to unify the field, multiple
reviews have noted convergence between models and definitions of life meaning. In
particular, they note commonality between theorists in proposing the following
components as central to life meaning: purpose, i.e. identification and pursuit of
personally important goals; coherence, i.e. a personal sense that one’s life and
264 A. R. Allen

experiences ‘make sense’, are comprehensible and characterised by regular, predict-

able patterns; and significance, i.e. appraising one’s life and experiences as impor-
tant and having value (Heintzelman & King, 2014; Hibberd, 2013; Martela &
Steger, 2016; Steger, 2012b). Understood in this light, life meaning can be defined
as ‘the extent to which people comprehend, make sense of, or see significance in
their lives, accompanied by the degree to which they perceive themselves to have a
purpose, mission, or overarching aim in life’ (p. 684; Steger, 2012b).
Finally, a distinction between presence of life meaning (recognition that one’s
life has meaning) and search for life meaning (motivation to seek life meaning) has
been noted (Steger et al., 2006). Many of the standardised measures of life meaning
noted below (see Sect. 3.2) do not have a separate subscale for search for life mean-
ing. As such, in reviewing the association between life meaning and each of depres-
sion and suicidality, this chapter focuses on subjective estimations of the presence
of life meaning. However, readers may refer to helpful reviews on search for life
meaning and its association with markers of mental health (e.g. Costanza et  al.,
2019; Park, 2010; Steger, 2012b; Wong, 2014).

3.2 Measuring Life Meaning

Studies examining the association between life meaning and each of depression and
suicidality have typically measured life meaning through use of standardised self-­
report instruments, which contain items that probe at least one of the above key
aspects of life meaning (i.e. coherence, purpose, significance). As such, instruments
with items that probe at least one of these aspects, or overall subjective life mean-
ing, are therefore considered to reflect subjective life meaning, though it is acknowl-
edged that a single measure may not necessarily tap all of the above aspects of life
meaning (Martela & Steger, 2016). The studies reviewed in this chapter have typi-
cally used at least one of the following psychometrically validated measures of life
meaning, many of which can be broken into subscales: the Meaning in Life
Questionnaire (MLQ) (Steger et al., 2006), which produces an overall score of life
meaning and contains separate subscales for presence of life meaning and search for
life meaning, with items probing coherence and purpose; the Life Attitude Profile
(LAP; Reker & Peacock, 1981), probing purpose and coherence; the Sense of
Coherence Scale (SOC; Antonovsky, 1993), probing coherence; the Purpose in Life
Test (PIL; Crumbaugh, 1968), probing purpose; the revised Life Regard Index (LRI;
Debats, 1998), probing purpose and significance; the Personal Meaning Profile
(PMP; Wong, 1998), probing purpose; the Schedule for Meaning in Life Evaluation
(SMILE; Fegg et al., 2008), providing an overall level of idiographic subjective life
meaning; the Perceived Life Significance Scale (PLSS; Hibberd & Vandenberg,
2015), probing significance; the Meaning in Life Scale (MIL; Krause, 2004), prob-
ing purpose and overall life meaning; and the Shift and Persist Questionnaire
(SAPQ) (Chen et al., 2015), with a subscale probing purpose. While these scales
contain items probing at least one of purpose, coherence and significance, they also
Meaninglessness, Depression and Suicidality: A Review of the Evidence 265

contain items probing other aspects of life meaning determined as theoretically

important by their authors. Where studies below examined life meaning utilising
other measures or means, this is noted as relevant.

4 The Association Between Life Meaning and Hope

Feldman and colleagues (Feldman et al., 2017; Feldman & Snyder, 2005) have pro-
posed a central role for hope in life meaning. They defined hope as the perceived
capacity both to develop plans to pursue goals (which they term ‘pathways thought’)
and to take action on these plans (which they term ‘agentic thinking’). So defined,
they proposed that hope underpins the planning and pursuit of personally relevant
goals – this converges with the above description of the purpose component of life
meaning. Hence, hope may be seen as supportive of life meaning through its pro-
posed role in supporting purpose. Moreover, it follows that a higher hopelessness
and a lower life meaning may be experienced when there are low estimations of the
perceived capacities of pathways thought and agentic thinking. This has been shown
empirically on both a cross-sectional (Feldman & Snyder, 2005; Hedayati &
Khazaei, 2014; Karaman et  al., 2020; Mascaro & Rosen, 2005) and longitudinal
basis (Mascaro & Rosen, 2005). Furthermore, Feldman and Snyder (2005) con-
ducted exploratory factor analysis on a measure of their conceptualisation of hope
(The Adult Hope Scale (AHS); Snyder et al., 1991) and measures of life meaning
(the SOC-S, LRI and PIL) and found that a single factor best explained variance
between their measures, suggesting hope is part of life meaning. They also found
that the positive association between each of hope and life meaning with depressive
symptoms was attenuated when statistically controlling for one in the presence of
the other.
Feldman and colleagues’ conceptualisation of hope converges partially with
Abramson’s et al. (1989) definition of hopelessness within the hopelessness theory
of depression. This theory proposed that negative inferential styles (to attribute neg-
ative events to internal, stable, global causes) are the conduit through which proxi-
mal negative life events can produce hopelessness and subsequent depression and
suicidality. He defined hopelessness as ‘(a) negative expectancy about the occur-
rence of highly valued outcomes (a negative outcome expectancy), and (b) expecta-
tions of helplessness about changing the likelihood of occurrence of these outcomes
(a helplessness expectancy)’ (p. 359). On the basis that changing the likelihood of
expected outcomes relies on adequate perceived capacity to develop and enact plans
for goal pursuit, Abramson’s helplessness expectancy converges with Feldman and
colleagues’ above definition of hope. As recently noted by Haeffel (2017), each ele-
ment of hopelessness theory has at least partial support (but see Liu (2015)). This
overlap in definitions of hope/hopelessness suggests a possible association between
life meaning and measures that probe aspects of hopelessness beyond that defined
by Feldman and colleagues, such as the Hopelessness Scale (Everson et al., 1996)
and the Beck Hopelessness Scale (BHS; Beck et al., 1974), each of which probes
266 A. R. Allen

aspects of hope about the future not related to personal action. Indeed, lower life
meaning is related to higher hopelessness in adults in the general population when
using the Hopelessness Scale (Harris & Standard, 2001). Complementing this,
Braden et al. (2017) found higher self-reported life meaning as predictive of lower
hopelessness on the BHS 4 months later in a sample of depressed military veterans.
Similar findings come from a Spanish mixed psychiatric sample in which life mean-
ing (on the PIL) was inversely associated with hopelessness on the BHS (Marco
et al., 2016). Furthermore, Marco et al. (2016) found that the meaning and life sat-
isfaction subscale of the PIL (which does not specifically probe purpose) was
inversely associated with hopelessness on the BHS. Complementing this, a recent
study found that engagement in a meaning-centred group intervention for men tran-
sitioning to retirement was associated with significant reduction in hopelessness on
the BHS (Heisel et  al., 2020). Taken together, this suggests that life meaning is
associated with aspects of hope outside of personal action.
To summarise, the above findings show not only the positive association between
hope and meaning, but the possibility that hope is central to life meaning. As deficits
in hope have been well shown to be associated with suicidality (e.g. Beck, 1986;
Beck et al., 1985, 1990; Brezo et al., 2006; Edwards & Holden, 2001; Hawton &
van Heeringen, 2009; Johns & Holden, 1997; Joiner & Rudd, 1996; Klonsky et al.,
2012; Marco et  al., 2016) and depressive symptoms (Beck et  al., 1993; Dyer &
Kreitman, 1984), it suggests that life meaning would be negatively associated with
depressive symptoms and suicidality. This proposal is addressed later in this chap-
ter. However, before proceeding, the above-noted components of life meaning are
elaborated to show their conceptual connection to depressive features and
suicidality.

5 Life Meaning’s Conceptual Link to Depression

and Suicidality

The above components of life meaning (purpose, coherence and significance) can
be understood in cognitive, motivational and affective terms. Reker and Wong
(1988) proposed a model of personal meaning with interrelated cognitive, motiva-
tional and affective faculties. The cognitive faculty is the cornerstone of the model
and captures the individual’s values and beliefs about the self and the world. This
motivates goal selection and striving (the motivational faculty), which lead to satis-
faction and fulfillment (the affective faculty). They further proposed that these fac-
ulties are mutually reinforcing. Understood in this way, coherence and significance
can be regarded as cognitive in nature, with purpose as motivational. Following
Feldman and colleagues (see Sect. 4), hope can be seen to fit within the motivational
faculty. As these faculties support the subjective sense of meaning in life and given
that individuals with depression display deficits in these faculties, it follows that
subjective life meaning would be reduced in depression. Furthermore, as deficits in
Meaninglessness, Depression and Suicidality: A Review of the Evidence 267

hope are implicated in depression and suicidality (Beck, 1986; Beck et al., 1985,
1990, 1993; Dyer & Kreitman, 1984) and hope has been proposed as integral to life
meaning as noted above, it follows that life meaning would be inversely related to
suicidality. Evidence for the association between life meaning and depression is
presented first, followed by evidence of its association with suicidality.

6 Evidence for the Association Between Life Meaning

and Depression

6.1 Evidence from Correlational and Group Difference Studies

Initial support for the association between life meaning and depressive symptoms
comes from correlational studies. Such studies with cross-sectional designs have
found an inverse relationship between self-reported life meaning and depressive
symptoms on standardised self-report measures across various age groups including
adolescents (Dulaney et al., 2018; Mascaro & Rosen, 2005; Steger et al., 2006) and
young adults up to older adults (Braden et al., 2015; Gross et al., 2019; Heisel et al.,
2015a, b; Kleiman & Beaver, 2013; Lester & Badro, 1992; Psarra & Kleftaras,
2013; Scharer & Hibberd, 2020). Though these researchers conducted studies with
Western samples, similar findings have been found in other cultural groups includ-
ing those from Asian cultural backgrounds (Chow, 2017; Datu et  al., 2019; Huo
et  al., 2019; Zhang, 2019), Middle Eastern backgrounds (Fischer et  al., 2020;
Hedayati & Khazaei, 2014), Indian backgrounds (Thakur & Basu, 2010) and Latin
American backgrounds (Schnell et al., 2018). Furthermore, meta-analytic findings
have found an inverse association between purpose in life and depressive symptoms
(Pinquart, 2002). Though the aforementioned research used samples undiagnosed
for depression, the same inverse association has been found in those with depressive
disorders. For example, Volkert et al. (2019) found a negative relationship between
self-reported life meaning (on the SMILE) and the presence of a depressive disorder
(dysthymia or major depressive disorder) in the past month.
Results from longitudinal studies provide further empirical support for a connec-
tion between depression and life meaning. For example, in a study of 797 adults (not
diagnosed for depressive disorders) from multiple countries, a higher self-reported
life meaning on the Meaning in Life Questionnaire (MLQ) predicted lower self-­
reported depressive symptoms at 3-month and 6-month follow-up (Disabato et al.,
2017). Similarly, a higher self-reported life meaning predicted lower depressive
symptoms in adolescent samples at follow-up periods of 2 months (Mascaro &
Rosen, 2005) (using PMP and the Framework subscale of the LRI) to 7 months
(Dulaney et al., 2018) (using the Persist subscale of the SAPQ). Further, in a sample
of military veterans diagnosed with a depressive disorder, there was an inverse asso-
ciation between life meaning and recovery (based on structured clinician interview)
4 months later (Braden et al., 2017). However, these latter researchers did not find
268 A. R. Allen

life meaning predictive of self-reported depressive symptoms 4 months later. As

these authors noted, life meaning may predict clinician-determined change in
depressive symptoms in clinical samples, though not change in self-reported depres-
sive symptoms. Interestingly, they found that baseline levels of depressive symp-
toms were not significantly predictive of life meaning 4 months later after accounting
for baseline levels of life meaning. That baseline life meaning was associated with
subsequent depression, but not the other way around, suggests the possibility that
levels of life meaning may be causally related to depression.
Supporting the above evidence, group difference studies have shown a lower
meaning in life in those with diagnosed depressive disorders versus those without.
Thakur and Basu (2010) found a significantly higher self-reported presence of life
meaning on the MLQ in adults diagnosed with major depressive disorder versus
those without the diagnosis. Furthermore, Seligman et al. (2006) found a signifi-
cantly lower life meaning (the measure used was not reported) in a sample of clini-
cally depressed young adults compared to non-depressed individuals with another
psychiatric diagnosis and those without any diagnosis. Similarly, another study
found that meaning in life (on the SMILE) was significantly lower in adult psychi-
atric inpatients with depressive disorders versus those without (Volkert et al., 2014).
Importantly, the findings by Seligman et al. (2006) and Volkert et al. (2014) suggest
that a low life meaning may be specific to depression rather than being a general
characteristic of psychopathology. However, none of these studies detailed how
diagnosis was determined. Thus, while these group difference studies lend prima
facie support to the above-noted correlational data for the inverse relationship
between life meaning and depression, replication would be helpful to determine the
robustness of these findings.

6.2 Evidence from Moderation/Mediation Studies

Evidence from moderation and mediation studies not only supports the inverse
association between life meaning and depression but also suggests that life meaning
may be an important link between stressful events and depressive symptoms. Life
meaning (on a standardised measure of life worth) has been shown to mediate the
connection between knowledge of stroke in elderly Chinese stroke survivors and
depressive symptoms (Chow, 2017). Life meaning (on the MLQ) has been shown
further to mediate the link between surviving sexual trauma and subsequent depres-
sive symptoms in military personnel (Gross et  al., 2019). Complementing these
mediational results, Dulaney et al. (2018) found life meaning (on the Shift subscale
of the SAPQ) moderated the impact of life stress on depressive symptoms 7 months
later in an adolescent sample. Similarly, life meaning (using a self-report measure
probing purpose) buffered the association between traumatic life events and depres-
sive symptoms in an older sample on a cross-sectional basis (Krause, 2007).
Interestingly, these latter authors reported a pattern of findings that showed that
greater life meaning was associated with reduction of depressive symptoms over
Meaninglessness, Depression and Suicidality: A Review of the Evidence 269

time, but not the other way around. Similarly, Mascaro and Rosen (2005) found that
while a higher baseline life meaning negatively predicted depressive symptoms 2
months later in a sample of undergraduate students, depressive symptoms were not
predictive of subsequent life meaning. Taken together, these findings suggest that
life meaning may be an important factor through which life stress exerts influence
over depressive symptoms and an important resource that may protect against, or at
least buffer, such an impact.

6.3 Evidence from Treatment/Intervention Studies

Evidence for an association between subjective life meaning and depression is sup-
ported further by treatment studies that have shown reduction in depressive symp-
tom with interventions that include elements that aim to enhance (at least one
element of) subjective life meaning. For example, Seligman et al. (2006) reported
two studies examining the impact of positive psychotherapy (PPT) on depressive
symptoms. In brief, PPT is a structured intervention aimed partially at enhancing
life meaning, along with life engagement and positive emotion. In one of these stud-
ies, they examined the impact on depressive symptoms from participating in a six-­
week group PPT program in mild to moderately depressed young adults. Treatment
was associated with significantly lower depressive symptoms immediately follow-
ing treatment compared to non-treatment controls, a difference preserved through
12-month follow-up. Their second study investigated the impact of individual PPT
on depressive symptoms in severely depressed young adults with diagnosed major
depressive disorder compared to medicated and non-medicated treatment-as-usual
control groups. They found that PPT produced significantly greater reduction in
depressive symptoms and more remission from depression following treatment
compared to each control group. Meta-analytic findings have further found that
positive psychology interventions are associated with reduction in depressive symp-
toms in both depressed and non-depressed individuals (Bolier et al., 2013; Chakhssi
et al., 2018; Sin & Lyubomirsky, 2009).
Complementing the above, evidence has shown that participation in acceptance
and commitment therapy (ACT) is associated with reduction in depressive symp-
toms. In part, ACT encourages engagement in actions that fit the individual’s per-
sonally held life principles as a means of living a fulfilling life, which includes goal
identification and pursuit. This fits notionally with the earlier proposed idea that
pursuing life purpose is a component of subjective life meaning. Seen this way,
ACT can be considered to target subjective life meaning. Reviewing evidence for
ACT, Hayes and co-workers (2006) found that ACT was associated with a signifi-
cant reduction in depressive symptoms when depression was the primary problem
focus and that it did so to a larger extent than other active treatment. Moreover,
evidence for the utility of ACT in reducing depressive symptoms has been repli-
cated (A-Tjak et  al., 2015; Hacker et  al., 2016), though recent meta-analytic
270 A. R. Allen

findings suggest it may have more utility for people with mild depression compared
to those with moderate or severe depression (Bai et al., 2020).
Studies examining change in life meaning and depressive symptoms from psy-
chotherapy or that have examined the impact of meaning-focused interventions on
depressive symptoms further support the connection between these constructs.
Volkert et  al. (2014) found significant increases in life meaning (on the SMILE
measure) in psychiatric inpatients (the majority of whom were diagnosed with a
depressive disorder) who self-reported reduced depressive symptom severity over
the course of mixed individual and group psychodynamic psychotherapy. Similarly,
two studies by Heisel and co-workers are relevant here. In one (Heisel et al., 2015a,
b), these researchers found that interpersonal psychotherapy was associated with a
significant improvement in clinician-rated and self-reported depressive symptoms
in a sample of older adults, along with increased life meaning (assessed with the
Perceived Meaning in Life subscale of the Geriatric Suicide Ideation Scale) (Heisel
& Flett, 2006a, b), with continued improvement in life meaning at 6-month follow-
­up. In the second (Heisel et  al., 2020), they examined the utility of a 12-week
meaning-­centred group intervention for a community sample of men around the life
stage of transitioning to retirement. They found a significant reduction in depressive
symptoms and increases in life meaning (on the Experienced Meaning in Life Scale
(Heisel & Flett, 2006a, b), which measures overall life meaning and its compo-
nents) from pre- to post-treatment. (It should be noted that neither of these studies
by Heisel’s group contained a control group, so causality of program participation
could not be determined.) Furthermore, a randomised controlled trial (RCT) of
meaning-centred group therapy (MCGT) for advanced cancer patients found sig-
nificant reductions in depressive symptoms at post-treatment and at 2-month fol-
low-­up (versus supportive group psychotherapy) (Breitbart et  al., 2015).
Complementing this, van der Spek and co-workers (2017) conducted an RCT and
found that cancer survivors participating in MCGT showed significant increases in
life meaning (on the Dutch version of the Personal Meaning Profile; (Jaarsma et al.,
2007) from post-treatment through to 6-month follow-up (compared to care as
usual), with depressive symptoms lower at 6 -month follow-up. These findings con-
verge with meta-analytic findings that engagement in meaning-centred existential
therapies is associated with significantly increased life meaning and significantly
reduced depressive symptoms with generally moderate effect size (Vos et al., 2015).
Finally, another study examined change in life meaning (based on coding responses
on a sentence completion questionnaire) following psychotherapy and its associa-
tion with depressive symptoms (Westerhof et  al., 2010). That study conducted a
randomised controlled trial (RCT) of a life review program on depressive symptoms
in older adults with depressive symptoms but not depressive disorders. It found that
depressive symptoms were significantly reduced, and life meaning significantly
increased, at post-treatment in the intervention group compared to non-treatment
controls. Further, increased life meaning predicted subsequent reduction in depres-
sive symptoms and mediated the impact of the intervention on depressive symp-
toms. This pattern of results suggests the potential of life meaning to act as a
mechanism of change in depressive symptoms from psychological intervention,
Meaninglessness, Depression and Suicidality: A Review of the Evidence 271

converging with the aforementioned studies showing a mediation/moderation role

of life meaning on depressive symptoms (Chow, 2017; Dulaney et al., 2018; Gross
et al., 2019; Krause, 2007).
To summarise, results from treatment studies further implicate an inverse con-
nection between life meaning and depressive symptoms. This is shown in reduced
depressive symptoms from participation in interventions that include meaning-­
focused components, concurrent increases in life meaning and reduction in depres-
sive symptoms from participation in various psychotherapeutic interventions and
evidence that life meaning mediates the reduction in depressive symptoms from
intervention. It is noted that these findings come from disparate study types, sam-
ples and treatment approaches. As such, well-controlled studies that examine the
impact of interventions containing meaning-focused elements in both depressed
and non-depressed samples would be helpful to robustly determine the role of life
meaning in addressing depressive symptoms. Further examination of the moderat-
ing/mediating role of life meaning would also be helpful.

6.4 Summary

Evidence from correlational and longitudinal studies in normal and clinically

depressed samples supports the proposal that life meaning is depleted in the pres-
ence of depressive symptoms. Further, clinically depressed samples have been
shown to be lower on life meaning than people without a depressive diagnosis, and
moderation/mediation studies suggest that levels of life meaning may be critical in
transmitting, or protecting against, the impact of life stressors on depressive symp-
toms. Consistent with this, treatment studies show reduction in depressive symp-
toms and increases in life meaning after intervention and suggest a possible
mediating role for life meaning, though further research is required here.

7 Evidence for the Association Between Life Meaning

and Suicidality

7.1 Evidence from Correlational and Group Difference Studies

As with the investigations on its association with depressive symptomatology, much

of the empirical work on life meaning’s association with suicidality has been cor-
relational. Findings have typically indicated that a higher subjective life meaning is
associated with a lower suicidality, though there is variation depending on the aspect
of suicidality measured. Schnell et al. (2018) found that crisis of meaning (i.e. dis-
tress at low life meaning) was associated with elevated suicidality in a sample of
Ecuadorian high school students. Similarly, Lester and Badro (1992) found that low
272 A. R. Allen

life meaning (measured on the PIL) predicted current and past suicidal ideation and
past suicidal threats in an undergraduate student sample. These findings converge
with another study of undergraduate students in which a low life meaning (on the
PIL and SOC-S) was associated with suicidal ideation and self-reported likelihood
of future suicidal behaviour (Edwards & Holden, 2001). That study also found that
a lower life meaning was associated with past suicide attempts for women in their
sample. This general pattern of low life meaning to be associated with increased
suicidality has further been found in adolescents (Aviad-Wilchek & Ne’eman-­
Haviv, 2018; Harlow et al., 1986)), Western and non-Western adults (Chan, 2018;
Chen et al., 2020; Lew et al., 2020; Liu et al., 2020) and military samples (Braden
et al., 2015; Gross et al., 2019).
Longitudinal data further indicate an association between life meaning and sui-
cidality. Bjerkeset et al. (2010) observed that low life meaning prospectively pre-
dicted later suicide in a large Norwegian sample (they did not detail how life
meaning was measured), and Kleiman and Beaver (2013) found that the presence of
life meaning (on the MLQ) predicted reduced suicidal ideation eight weeks later
and reduced lifetime odds of a past suicide attempt. However, Braden et al. (2017)
found no association between baseline life meaning (on the LRI) and suicidal ide-
ation 4 months later in a chronically depressed sample of military veterans, after
accounting for baseline depressive symptoms and hopelessness.
Group difference data further implicate life meaning in suicidality. These find-
ings come from studies noted above. In one, Aviad-Wilchek and Ne’eman-Haviv
(2018) found a significantly lower life meaning (on the PIL) and a higher suicidality
in a group of disadvantaged adolescent girls versus non-disadvantaged counterparts.
Further, in the earlier noted study by Edwards and Holden (2001), participants who
had attempted suicide showed a significantly lower life meaning (on the SOC-S)
than those who had not attempted suicide.

7.2 Evidence from Moderation/Mediation Studies

Data from moderation and mediational analyses further implicate life meaning in
experience of suicidality and suggest a possible instrumental and/or protective role.
Mediational analyses have shown that life meaning provides an explanatory con-
nection between various factors and suicidal manifestations. Life meaning has been
shown to mediate the connection between life stressors and suicidal ideation. This
has been shown for each of life event load (Schnell et al., 2018), morally injurious
events (Corona et al., 2019), sexual trauma (Gross et al., 2019) and significant work
stress (Liu et al., 2020). Moreover, life meaning also appears to mediate the link
between factors proposed as suicide risk factors (such as ostracism, thwarted
belongingness to others and perceived burdensomeness to others) and suicidal ide-
ation (Chen et al., 2020; Kleiman & Beaver, 2013). Further, life meaning has been
shown to mediate the connection between symptom load and suicidality. For exam-
ple, Sinclair et  al. (2016) found that presence of life meaning (on the MLQ)
Meaninglessness, Depression and Suicidality: A Review of the Evidence 273

explained the connection between depressive symptom severity and progress from
suicidal ideation to suicide attempts in a military sample. Similarly, Lew et  al.
(2020) showed the same role of presence of life meaning (on the MLQ) in linking
hopelessness and suicidal behaviour in a Chinese adult sample. Moderation analy-
ses complement these mediational findings to show a buffering role for life mean-
ing. For example, life meaning (on the PIL) attenuated the association between
baseline eating disorder psychopathology and suicidal ideation 7 months later in a
sample of patients with eating disorders (Marco et al., 2020). Life meaning (on the
MLQ) has also been found to similarly attenuate the connection between depressive
symptoms suicidal ideation 6 months later in HIV outpatients (Lu et al., 2019).

7.3 Evidence from Treatment/Intervention Studies

Finally, evidence from treatment studies further implicates life meaning in suicidal-
ity. For example, participation in an interpersonal therapy (IPT) intervention was
shown to significantly reduce suicidal ideation and enhance life meaning (both mea-
sured on the Geriatric Suicide Ideation Scale; Heisel & Flett, 2006a, b) in a group
of older adults with mood disorders (Heisel et al., 2015a, b). Complementing this, a
recent study (Heisel et al., 2020) found that a meaning-centred group intervention
was associated with pre- to post-treatment reduction in suicidal ideation and increase
in life meaning (on the Experienced Meaning in Life Scale, which measures overall
life meaning and component subscales and is based on Frankl’s model of meaning).
Similarly, Lapierre et al. (2007) found substantially greater reduction in past-week
suicidal ideation 6 months later in an older sample after participation in a personal
goal intervention compared to controls.

7.4 Summary

Taken together, the above findings support a role for life meaning in suicidality. The
above combination of findings from longitudinal, group difference, mediation/mod-
eration and treatment studies suggests that this role may be instrumental. It appears
that life meaning may provide a buffering or protective role in the experience of
suicidality. Importantly, it appears that this may be true for both the impact of life
stressors and the load imposed by symptoms of psychopathology. This converges
with a recent systematic review on the association between life meaning and suicid-
ality, which found presence of (though not search for) life meaning as a protective
factor against suicidal ideation, suicide attempts and death by suicide (Costanza
et al., 2019). While it is likely that other factors may also play such a role, the cur-
rent data suggest that probing life meaning may be an important component of
assessing suicidality and that enhancing life meaning may have utility in managing
274 A. R. Allen

suicidal manifestations and reducing suicide risk (Costanza et al., 2019; Gross et al.,
2019; Sinclair et al., 2016).

8 Summary and Conclusion

Life meaning has been proposed as important to human well-being and is impli-
cated in states of degraded psychological health. The evidence reviewed in this
chapter supports this proposition in general and specifically identifies its role within
depression and suicidality. Life meaning appears to be reliably lower in the presence
of depressive symptoms and heightened suicidality, across cultures, age groups and
sample types, such as civilian, military and psychiatric and non-psychiatric sam-
ples. While some have proposed a causal role for lack of life meaning in depression
(e.g. Seligman et al., 2006), further research in both clinical and non-clinical sam-
ples is warranted to confirm this and support to extant findings. Notwithstanding,
current research indicates a buffering/protective role for life meaning. Life meaning
appears to protect against the impact of life stress and symptom load on subsequent
depressive symptoms and suicidality and against other mediating factors between
depression and suicidality, such as hopelessness. As has been noted by other
researchers, probing life meaning may be a useful component of clinical assessment
and treatment planning for depression and suicidality. Life meaning may also be an
important target in psychological treatment of depression and suicidality. Indeed,
the inclusion of meaning-focused components in traditional cognitive behavioural
therapy techniques for depression has been proposed (Ameli, 2016a, b; Ameli &
Dattilio, 2013); and psychological interventions, such as acceptance and commit-
ment therapy, that ostensibly enhance the purpose component of life meaning (by
encouraging action on personally important life values) have been shown to have
utility for reducing depressive symptoms (A-Tjak et  al., 2015; Bai et  al., 2020;
Hacker et  al., 2016). Further, efforts to enhance life meaning pre-emptively may
help protect against the onset and/or advancement of depressive symptoms and sui-
cidality in response to life stressors. Indeed, the utility of building resilience to
counter depressive relapse after recovery has been noted (Waugh & Koster, 2015).
Enhancing life meaning may be a promising candidate in this regard. Further longi-
tudinal and experimental research would be helpful to elucidate this. Notwithstanding,
approaches to enhance life meaning hold promise to ease the personal and societal
impact posed by these aspects of mental ill health.

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Letting Go, Creating Meaning: The Role
of Acceptance and Commitment Therapy
in Helping People Confront Existential
Concerns and Lead a Vital Life

Joseph Ciarrochi, Louise Hayes, Gareth Quinlen, Baljinder Sahdra,

Madeleine Ferrari, and Keong Yap

Abstract  We all must confront existential crises such as sickness, death of loved
ones, loss of job, mistreatment from others, and relationship breakdown. These cri-
ses can shatter our sense of meaning. How can we face that moment with honesty
and courage, embrace the distress, and create new meaning? This chapter provides
a theory of how language and self-awareness can lead us into existential crisis and
loss of meaning. It then provides an evidence-based account of how the DNA-V
model of Acceptance and Commitment Therapy (ACT) can help people to answer
“Yes” to Camus’ most important philosophical question, “Is life worth living?”.
ACT can help people recreate coherence after a coherence-shattering event, over-
come alienation from the body, overcome inertia, overcome a sense of self that is
self-destroying or feels “empty,” and bridge the gulf between self and others and
create genuine connection.

Keywords  Existentialism · Acceptance and commitment therapy · Mindfulness ·

Acceptance · DNA-V

Each of us will experience dramatic change in our lifetime: relationship break-

downs, loss of job or career, life-threatening illness, adverse transitions (e.g., mov-
ing to a nursing home), and the finality of death. Because we are hardwired to
anticipate danger and avoid pain, we can torture ourselves not just by the experi-
ences of actual crises as they occur but by the very thoughts of having future crises.
the resourceful creatures see clearly
that we are not really at home

J. Ciarrochi (*) · G. Quinlen · B. Sahdra · M. Ferrari · K. Yap

Institute for Positive Psychology and Education, The Australian Catholic University,
North Sydney, NSW, Australia
e-mail: [email protected]
L. Hayes
The University of Melbourne, Parkville, VIC, Australia

© Springer Nature Switzerland AG 2022 283

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1_17
284 J. Ciarrochi et al.

in the interpreted world – Rilke

How can we prepare ourselves for that life defining moment, when we can no longer
pretend that everything will always be ok? This is even more difficult as we know
deep down that we ourselves and all those we love will die. What will we do in that
moment? How will we engage with this existential crisis? We could push our fear of
powerlessness away by making it external, e.g., some blame others, such as those
with different skin color or culture or different political views. Others blame the
people closest to them: partners, family, and friends. Still others try to escape exis-
tential fear through overconsumption, work, drugs, or opting out of everything risky
in life. We can also choose to live courageously in the present moment. The aware-
ness that all things pass, that we suffer and die, need not lead to avoidance, paraly-
sis, and blame, but instead can lead to a renewed focus and vitality for the things that
matter in life.
This chapter will explore how Acceptance and Commitment Therapy (ACT)
helps people to meet existential crises. ACT does not offer the promise of a stress-­
free life where we eliminate existential crises or interpret them positively; rather,
ACT helps people to acknowledge and accept the distress inherent in life. It shows
us how our ability to use language along with self-awareness can trap us in existen-
tial crises and the how we can take concrete steps to escape the trap.

1 Language, Self-Awareness, and Crisis

ACT is a behavioral approach, which means it is grounded in precise behavioral

principles such as operant and classical conditioning (Hayes et al., 2012). However,
it went beyond traditional behavioral approaches, because it has successfully tested
a behavioral theory of language and symbolic activity, Relational Frame Theory
(RFT) (Hayes et al., 2001). Therefore, it is useful to begin by explaining RFT.
RFT’s potential value for practitioners lies in its focus on the manipulable con-
text and, in particular, in how practitioners can alter context to influence complex
symbolic processes (Ciarrochi & Bailey, 2008), such as those involved in the nausea
of alienation (Sartre, 2013) and the terror of death (Yalom, 2008). Here we review
the implications of RFT for practice. If the reader is interested in exploring the sub-
stantial evidence base behind RFT, we encourage them to explore the citations that
follow (Barnes-Holmes & Barnes-Holmes, 2020; Dymond et al., 2010; Kissi et al.,
2017; Montoya-Rodríguez et al., 2017).
We explain RFT by starting with the simplest symbolic process and working our
way up to complex existential processes. In RFT, symbols (like words and thoughts)
are not “things” in the head, but “behavior” that are controlled by learning context
(Barnes-Holmes & Barnes-Holmes, 2020). People teach us to engage in symbolic
activity in our childhood. For example, a caregiver might point at a dog and say,
“dog.” If the child says “dog,” the parent reinforces with “good.” The caregiver
teaches the child to name thousands of things and to explicitly look for the thing
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 285

when the name is said out loud. Thus, the caregiver will say “dog,” and if the child
points at a dog, the caregiver will reinforce the association. In this way, the relations
between a dog, the letters “D.O.G.,” and the sound “Dog” are explicitly taught to a
child. We illustrate this in the figure below by the solid lines.
After some time of reinforcing young people to name things, something interest-
ing happens. Young people start to engage in the naming process, and the deriving,
as a matter of habit (Dermot Barnes-Holmes & Barnes-Holmes, 2000). Thus, you
can teach a young person to relate the sound, “cat” with the letters “C.A.T.” and the
letters “C.A.T.” with the visual image of a cat (bottom image, Fig. 1). The young
person will then derive all other relations. If you point at the animal, the child will
know to spontaneously say “cat,” even though the child was never explicitly taught
to say cat.
We have used a very simple example here, but the reader might imagine a child
beginning to derive or verbally relate everything to everything else. A child can even
eventually derive, “I am like a cat” or “Cats are magical” or “Cats have a secret life
underground.” Note that all this verbal behavior is based on deriving rather than on
direct experience. In this way, our symbolic life can run far from reality. Existential
crises come when we make ultra-complex derivations such as “life is meaningless”
and “God has abandoned me.”
One of the key principles of RFT is “transformation of stimulus function (Barnes-­
Holmes et al., 2004).” People teach children to respond to symbols, whether sound
or visual, as they would to the object to which the symbol points (Fig. 2).

Letters “D.O.G.

Sound “Dog”

Letters “C.A.T.

Sound “Cat”

Note: Solid lines are trained; dotted lines are derived

Fig. 1  The development of relational framing

Note: Solid lines are trained; dotted lines are derived
286 J. Ciarrochi et al.

Fig. 2  “The moon is black tonight.” People respond to symbols as if they are the “real” thing

For example, if you say “doggy” to children who love dogs, those children may
respond with excitement, even before they see the dog. They are responding to the
symbol in the same behavioral and physiological way that they would respond to an
actual dog. In the same way, adults can display emotional reactions to words like
“death.” We don’t have to experience death to experience the fear of death and dying
or the terror at having “wasted our life.” The research suggests that this process only
occurs in verbal humans, with other animals lacking the capacity to engage in trans-
formation of stimulus function. Without this ability, nonhumans will never fear the
word “death” – unless we pair the word with some painful stimulus like a shock
(Joseph Ciarrochi & Bailey, 2008).
We have focused on simple verbal relating, because simple relating is the build-
ing block for the most complex verbal behavior, including that behavior involved in
existential angst. Rule-governed behavior is one example of complex verbal behav-
ior and involves relations nested within relations (Törneke et al., 2008). For exam-
ple, some people believe, “If God is not real, then life has no meaning.” Consider
the complexity of the symbolic activity here. First the sound “God” has acquired
many stimulus functions due to a person’s particular history of relating ideas to it.
Perhaps, a person has been taught that God is equivalent to an all-loving father who
protects and cares for you and tells you what is right or wrong. Imagine a person
believes this. When this person thinks of their god, they feel life is meaningful. Now
imagine they have some experience that seems to negate the belief, e.g., the death of
their young child. In an instant the verbal relation “god is not real” powerfully trans-
forms their world. It is as if the person has lost an all-loving protector. If the verbal
conclusion is believed, then their life can be rapidly transformed from purposeful to
dead and meaningless.
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 287

Research suggests that verbal beliefs and rules can lead to rigidity and insensitiv-
ity to context (Törneke et al., 2008). Consider the rule, “if I lose my job, I will no
longer be a real man. I will have no use or purpose.” This is a rather complex rela-
tion where all meaning is caught up in a symbolic attachment to a job role. Thus, the
loss of their job can rapidly transform the person’s view of their life from meaning-
ful (“I am a provider”) to meaningless (“I am useless”). If the person believes this
verbal rule (real men provide), they will become insensitive to times when the rule
is wrong. For example, when he loses his job, he may have an increased opportunity
to participate in family functioning and child-rearing. His partner may reassure him
and describe the lost job as an opportunity. Still, he might hold on to his self-rule,
“men are providers,” and this leads to significant angst. Just like this example,
research suggests rules can make us insensitive to new contingencies of reinforce-
ment (Törneke et al., 2008).
To summarize this section: RFT is the theoretical foundation of Acceptance and
Commitment Therapy (ACT) and has shown us three basic things: (1) We relate
words to everything we touch, smell, hear, feel, and think. (2) Verbal relating trans-
forms how we experience and respond to events. Words take on the power of the
thing they point to. (3) Verbal relating, and especially self-rules, can make us insen-
sitive to context.
Verbal relating has given humans great power, but it also has a downside.
Language lies at the heart of our existential crises. There is no such thing as an exis-
tential one-year-old. Without verbal behavior, the child cannot feel the terror of
death, the anguish of responsibility, or the alienation of an indifferent world. Each
of the phrases in this sentence, so simple for us to construct and understand, has
been made possible only by years of deriving and transforming symbols. A 1-year-­
old girl inhabits the same physical world as you and I, eats the same chocolate cake,
but she experiences that cake far more purely than we will ever be able to again. Our
spontaneous verbal evaluation of the cake will transform how we experience it (e.g.,
“will I put on weight?”). Such is the downside of language.

2 The ACT Approach to Existential Crises

Let’s consider ACT, the practical application of RFT, and see how it helps people
confront and grow from existential crises. There are now over 300 clinical trials that
have examined the efficacy of ACT (ContextualScience, n.d.; Walder et al., 2019).
There is strong evidence that ACT is beneficial for chronic pain and moderate evi-
dence that ACT is beneficial for depression, mixed anxiety, obsessive-compulsive
disorder, and psychosis. There is also evidence that ACT does better than wait-list
control and treatment as usual (Bai et al., 2020; Hughes et al., 2017) and is effective
in real-world clinical settings (Pinto et al., 2017). It is, at present, uncertain whether
ACT is better than CBT or an active control (A-Tjak et al., 2015; Atkins et al., 2017;
288 J. Ciarrochi et al.

Bluett et  al., 2014; Hacker et  al., 2016; Jiménez, 2012; Lee et  al., 2015; Walder
et al., 2019).
ACT focuses on therapeutic processes to create change rather than following
standard protocols. There are many different frameworks and names for ACT pro-
cesses, such as those found in the popular “hexaflex” (Hayes et al., 1999), DNA-V
(Hayes & Ciarrochi, 2015), and “the matrix” (Polk & Schoendorff, 2014). What is
important here is the function of processes, not the particular label. Different named
processes may have similar functions (e.g., “noticing” and “mindfulness”), and
similarly named processes may have different functions (e.g., two different variants
of “mindfulness”). The use of labels for processes has become extremely complex
and confusing. To simplify things, Hayes et al. (2012) have proposed an Extended
Evolutionary Meta-model that provides a “periodic table” of processes that all
researchers, regardless of therapeutic orientation, might use.
We use the DNA-V framework here but define each process and show how we
map the processes to the hexaflex framework and the Extended Evolutionary Meta-­
model. Table 1 provides this mapping.

Table 1  Mapping ACT process labels to function

DNA-V Extended
process Hexaflex evolutionary
label process label meta-model Purpose of intervention
Discoverer Committed Overt behavior Use trial-and-error learning. Help people to
action willingly engage in new or nontypical
behavior, to develop their skills and
resources, and expand their context
Noticer Present Attention Help people notice inner and outer
moment Affect experience and have the capacity to accept
awareness; Physiological rather than avoid or cling to it. Help people
acceptance states and attend to the present context
responses
Advisor Defusion Cognition Help people to navigate their context with
language and disengage from unhelpful
language processes
Values Values Motivation Create contexts that empower people to
clarify what they value, choose value-­
consistent action, and sustain action across
time and hardship
Self-view Self-as-process. Self Help people take perspective on themselves,
Self-as-context overcome self-limiting rules or beliefs, view
self with compassion, and take actions
towards self that are self-enhancing rather
than self-destroying
Social view All six All six Help people take perspective on others, to
processes at the dimensions recognize social interdependence and the
social level above value of others, and to behave effectively in
social situations
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 289

3 A Quick DNA-V Overview

Before we link the DNA-V framework of ACT to existential concerns, we provide

a quick overview of how one might use DNA-V to understand the core goal of ACT,
which is to promote psychological flexibility, or the ability to mindfully experience
thoughts, feelings, and sensations, in the service of persisting in behavior that builds
value and changing behavior that is inconsistent with value. DNA-V seeks to build
this flexibility by helping people to shift between different psychological spaces.
The DNA-V exercise below will allow you to experience this “space shifting” rap-
idly (and perhaps you will notice that space is merely a relational frame, there is no
physical space). If you are interested in completing the exercise, we recommend
starting with A and working your way around the disk clockwise – A, N, D, and then
V (Fig. 3).
We have placed value in the center of the disk, to highlight how value is central
to all ACT processes. The core goal of ACT is to develop the ability to flexibly shift
or “pivot” (Hayes, 2019) between different spaces, always in the service of meaning
and value. “Inflexibility” occurs when a person does not pivot, for example, by

Fig. 3  An example of modelling ACT psychological flexibility

290 J. Ciarrochi et al.

staying stuck inside the advisor (e.g., ruminating, dysfunctional beliefs), noticer
(e.g., excessive focus on escaping feelings), or discoverer (e.g., impulsive acting).
The components of the DNA-V model can be viewed as varying on a continuum,
from low skill to high skill. The goal of the practitioner is to help identify skill
weakness, or presenting problems, and help people develop those weaknesses into
strengths (Hayes & Ciarrochi, 2015; Hayes et al., 2012).

4 Valuer: Crisis of Meaning

Camus argues that the most important question in philosophy is, “Is life worth liv-
ing?” or the corollary, “Should I commit suicide?” (Camus, 2013). Although ACT
doesn’t aim to answer this existential question directly, it assumes that engagement
in valued action creates meaning and makes life “worth living.” A key intervention
in ACT is helping people to choose valuing or meaningful actions. Valuing guides
us like a compass, helping us to choose what to do at any given moment. Examples
of valuing include “being a loving parent,” “being active,” “supporting disadvan-
taged youth,” “challenging myself,” and “connecting with my friends.”
Values are choices we can make without having to justify them with language.
For example, we can declare, “I love to care for animals,” and there is no need to
justify this preference. As we will see in the advisor section, the “need” to justify
with language is a verbal trap that can accelerate the existential crisis. Living things
choose without verbal justification. We might say even flowers “choose” to grow
towards the sun rather than the shadows.
That values are a choice leads to an existential dilemma: if we can choose any-
thing, why not choose evil action? This issue is illustrated in Dostoyevsky’s classic
book, Crime and Punishment (Dostoyevsky, 2017). The chief character, Raskolnikov,
murders an elderly pawnbroker, a “free choice.” What follows is Raskolnikov’s
relentless internal struggle, guilt, and anxiety about being caught. He made a “free
choice” but discovered via his verbal behavior, his own deriving, that the choice did
not bring meaning and vitality. Eventually he confesses to the crime, accepts the
punishment, and only then ends his alienation from society. Values are not abstract
or lofty ideas, but guiding principles which inform and direct ways of acting that
have consequences in the world.
The general assumption in ACT is that when we encourage people to freely
choose, they will choose prosocial actions or at least actions that won’t harm others.
We humans are, by nature, social and interdependent (see social view section). If we
were to choose to enact antisocial values, we would fail to satisfy our fundamental
need for social connection. There is now good evidence that antisocial behavior is
linked to worse mental health and lower self-esteem (Ciarrochi et al., 2019).
Generally, research suggests that helping people to choose valued action will
lead to them experiencing a higher satisfaction of their basic needs for competence,
connection, and autonomy (Chen et al., 2015; Ryan & Deci, 2017). There is also
evidence that having people affirm their values can help them overcome stereotype
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 291

or ego threat and perform at a higher academic standard (Bancroft et  al., 2017;
Cohen & Sherman, 2014).

5 Advisor: Crises Involving Incoherence and a Shattering

of “Reality”

Humans spend much of their lives inside an “interpreted” reality which can shatter
when it no longer matches physical reality. We can think we are immortal and
important, until the moment the world confronts us with death and indifference.
Our “advisor” is a label to describe our inner voice, our learned verbal behavior
that allows us to predict and plan. It is constantly shaping our symbolic and physical
reality. It is relentless and never turns off. We offer ourselves advice like “You’ve
got to try harder” and, more unhelpfully, “You are so broken that no one can ever
love you.” When the advisor is working well, it helps us to navigate our physical
environment efficiently and to avoid trial-and-error learning. An adaptive advisor
allows us to benefit from advice communicated from others’ experiences, without
us needing to suffer the consequences of a poor decision. If I say, “Avoid that tree.
There is a poisonous snake living under it,” you know what advice to give yourself
when you approach the tree: “Stay away!”
Our advisors are so useful that we use self-talk not only to interpret reality but
also to “build” preferable realities in our head. We use it to try to make all future
threats disappear (worry), to make the past seem more palatable (rumination), to
symbolically dominate another or to win their approval (resentment, reassurance
seeking), and to fix the parts of our self that the advisor has evaluated as broken (self-
criticism). We often fail to notice when our advisor strategies are failing, and our
interpreted reality is becoming more and more disconnected from physical reality.
As the figure below illustrates, there are two pathways we can take in response to
our own unhelpful advice. We can take the top pathway and respond to our advisor’s
conclusions by staying with our self-talk and engaging in problem-solving and rea-
soning. When this becomes excessive, it is termed “fusion” in the hexaflex model,
as in a fusion between words, the person, and action – they become one. Fusion
increases the impact of the unhelpful conclusions on our behavior. When fused, we
believe that “Life is meaningless” is a literal truth, and we must act accordingly.
The top pathway involves seeking “coherence” between our thinking and our
external world. We experience a shattering of coherence when the physical world
contradicts our understanding. For example, we might want to believe, perhaps
unconsciously, that “people must always have my best interests in mind.” And then,
when a lover betrays us, we may be shocked, and our world seems destroyed. “If
this person can betray me, anybody can betray me.” Then we create new self-advice,
“I must never trust anybody again.” These verbal statements cohere with each other,
to some extent, and perhaps help the person feel a sense of control, even though they
often have long-term costs.
292 J. Ciarrochi et al.

Fig. 4  The two ways of relating to the advisor

When our advisor is not being helpful, the remedy for this is to lessen such advi-
sor activity and to shape and reinforce the second path (Fig. 4). We help a person
disengage from their advisor and move into their noticer, valuer, or discoverer
space. That is, we encourage people to experience their thoughts mindfully (noticer)
or to think about what brings vitality and meaning (valuer), and/or to engage in new,
value-consistent action (discoverer). We invite people to make space for advisor
incoherence, for the possibility that our advisor has spun a story that is useless. This
opens the way for a new kind of coherence, one that is not based exclusively within
an interpreted world. Rather, it is based on functional coherence, which is a clear
link between advisor content and effective, real-world action. The question shifts
from, “Is my reasoning right?” to “Is my reasoning useful?”
Disengaging from our advisor is not always easy. Our advisor is such a constant
companion that we fail to notice it in the background restructuring our world. In
fact, the advisor is so ubiquitous that we are often completely unaware of it, and
then we believe that the contents of our thoughts are the unquestionable truth. ACT
helps to increase awareness through structured mindfulness, curious observing of
thoughts, and homework that involves noticing unhelpful thoughts as they occur in
daily life (Hayes & Ciarrochi, 2015; Hayes et al., 2012).
People are sometimes reluctant to disengage from their advisor because they are
attached to its seeming power. We worry, ruminate, judge others, and judge our-
selves because we think it helps. For example, we often value worry, because we
believe it will help us avoid problems and disastrous situations (Cartwright-Hatton
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 293

& Wells, 1997). Worry can also feed into the illusion of control and can encourage
a mistaken belief that the act of worrying is adaptive; for example, “if I worry about
every possible worst case scenario, I will be better prepared when one does occur”
(Wells, 2006). Unfortunately, our advisor is rarely helpful for existential questions
like, “What is the meaning of life?” because if we depend on reason for an answer,
we will become despondent and give up, for words are unable to solve this problem.
The advisor is not in charge of meaning, it is the servant.
Advisor attachment also occurs when we cling to an idealized version of life,
where we convince ourselves that we should always be treated fairly, be better than
others, have pleasant lasting experiences, or have a life without regrets. When real-
ity inevitably violates these false ideas, we suffer unnecessarily (Ciarrochi et al.,
2020; Ellis & Harper, 1961; Sahdra et al., 2010) and become less effective at achiev-
ing our goals (Sahdra et al., 2015). For example, imagine someone is given an unfair
job promotion and you are overlooked. You will not only experience distress at the
lost opportunity (“clean discomfort”). You might be attached to the idea that things
should have never been this way and should not be unfair. You might ruminate about
the problem, resent the coworker, and become increasingly distressed and distracted
at work (“dirty discomfort”; Hayes et al., 1999).
When we are attached to an idea about how the world “should” be, we may use
our advisor in an attempt to magically transform the world (Sartre, 2000). In the
above example, we may seek to deal with the unfair promotion by engaging in rumi-
nation: “The coworker will fall on his face eventually. The promotion was not that
good anyway.” Unfortunately, both rumination and worry only add to our distress
and rob us of the opportunity to face realities and cope with or manage them.
Magical thinking is the beginning of what Sartre calls “bad faith” or the tendency to
deceive ourselves and deny we have choices and freedom (Sartre, 1967). The ACT
solution to this problem is typically not to argue with people, or reinforce advisor
behavior, but rather help people to experience life from less verbal “spaces.”

6 Noticer: Crisis Involving Emotions and Alienation

from the Physical Body

Language allows us to create verbal labels for our emotions, like “anxiety,” “sad-
ness,” and “guilt.” Then we learn to evaluate these states as good or bad. We can
magnify the aversiveness of anxious sensations, with thinking like, “I can’t stand
feeling anxious,” “If I feel sad, something is wrong with me,” or “guilt is horrible”
(Ciarrochi & West, 2004). Once emotions are “horrible,” we use our advisor to solve
the “emotion problem” through a vast array of experiential avoidance strategies,
such as drinking, avoiding situations, and thought suppression. Most experiential
avoidance strategies are ineffective and lie at the heart of clinical disorders (Hayes
et al., 1996).
294 J. Ciarrochi et al.

Experiential avoidance alienates us from our own bodies and leads us to avoid
contact with how we are feeling from moment to moment (Lindsay & Ciarrochi,
2009). When we derive sensations as an enemy, we must, by necessity, see our bod-
ies as the enemy, because it holds and generates the sensations. We seek escape
from this “enemy” by fighting, fleeing, or freezing in the presence of the bodily
signals, just as we would in the presence of a dangerous foe. We become strangers
in our own bodies. Not only can this body alienation be a source of fear and angst
(Ciarrochi et al., 2008); it can interfere with our ability to form supportive relation-
ships (Rowsell et  al., 2016), which typically require identifying and sharing
emotions.
Noticer interventions typically involve three components: normalizing, aware-
ness, and accepting (Hayes & Ciarrochi, 2015). Concerning normalizing, ACT
practitioners help people to see that all feelings are merely signals and are not inher-
ently good nor bad. Attacking one’s body because it sometimes holds unpleasant
experiences is as misguided as attacking one’s phone because it sometimes receives
unpleasant text messages. Once people begin to view emotions as normal, they are
more willing to accept that some of their experiential control strategies have not
been working and are more willing to allow and accept bodily sensations. They
learn to notice emotion-related sensations with curiosity, without reacting to them.
Noticer interventions have much in common with those found in mindfulness
interventions and emotion-focused interventions, especially those that emphasize
observing, identifying, describing, and non-reactivity to feelings (Greenberg &
Pascual-Leone, 2006; Gu et  al., 2015; Wiebe & Johnson, 2016) and have been
shown to improve our connection with our emotions (Cooper et al., 2018). By help-
ing people to end their war with their body, we believe noticer interventions reduce
the feeling of emotional alienation and promote visceral, emotional connection to
meaning. Meaningful lives are not based merely on thought but also on feeling, on
visceral connection to gravity and other people.

7 Discoverer: Crises of Action

Low skill in recognizing and engaging with advisor, noticer, or valuer can lead to a
crisis in action. For example, low skill valuers may refuse to act because they can
find no external justification for their action, cannot make sense of their life, or can-
not generate the “right” feelings for action, such as enthusiasm or hope.
We overcome these barriers by first agreeing with Sartre (1967): existence pre-
cedes essence. We are not defined by what we think (advisor) or feel (noticer), but
rather by what we overtly do (discoverer). Indeed, it is in the doing and discovering
of life that we improve our thinking and feeling skills.
We can understand the discoverer by contrasting it with the advisor. When we are
in advisor space, we are seeking to avoid trial-and-error mistakes; when in discov-
erer space, we are seeking trial and error, monitoring consequences, and embracing
mistakes as a way of learning. Discoverer is the ultimate get-out-of-jail card. Even
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 295

when we feel completely stuck and don’t know what we feel or care about, we can
still act and see what happens next.
Many interventions, including the hexaflex versions of ACT, promote discoverer
skills, even if they don’t use this label. Positive psychology interventions also
encourage people to explore to “broaden and build” their skills, social connections,
and resources (Cohn & Fredrickson, 2010). CBT promotes behavioral activation,
even in the presence of sad feelings (Dimidjian et al., 2006), and behavioral experi-
ments to explore and experience new behaviors and evaluate beliefs (Bennett-Levy
et al., 2004). Many clinical interventions engage in functional analysis to help peo-
ple see and track the consequences of their behavior (Hurl et al., 2016). Exposure is
perhaps the most validated clinical intervention (Feske & Chambless, 1995), and
can be seen as a broadening and building, or discovery process. Through exposure,
people discover new ways to relate to their feared object and new ways of viewing
the object.

8 Self-View: Crisis of Identity

Let’s return to Sartre’s quote: “Existence precedes essence” (Sartre, 1967). This is
such a profound idea because many people believe the exact opposite: “Essence
precedes existence.” They believe that some aspect of their genes, personality, or
character dictate how they must act. This way of thinking is a trap. If we believe that
our essence dictates what we do, then we cannot develop beyond our self-beliefs.
We cling to our self-evaluations and stories, even when that story is negative.
People will defend the idea that they are really “not good enough.” We attach to
self-­stories for two reasons. First, the story seems to protect us. For example, If we
believe, “I am useless at math,” then we will not try to learn math and avoid the
disappointment of failing. If we believe “I am unlovable,” we will avoid seeking
love and risking rejection. Second, the self-story becomes equated with our essence.
We don’t think, “I’m having the evaluation that I am unlovable”; we think “I am
unlovable.” We think unlovable is our essence, in the way that ceramic is the essence
of a cup. Then, we cannot challenge “unlovable” without seeming to destroy
ourselves.
The ACT/DNA-V way of handling this issue is to encourage perspective taking
directed at the self (Foody et al., 2013) and to see that our self-evaluations are just
one aspect of us that we hold or carry. The verbal “I” which is experienced as here
learns to “look” at selfing behavior, which is experienced there. For example, “I see
that I am evaluating myself as broken.” Once “I” is experienced as an observer that
is separate from the evaluation, we are then free to listen to the evaluation or disen-
gage from it.
We help people to develop a sense of self-as context (Dermot Barnes-Holmes
et al., 2001), to see themselves as the holder of the DNA-V processes. We are notic-
ers, advisors, discoverers, and valuers at different times. We are also the ones who
shift between these spaces. Therefore, we are more than our ineffective behavior,
296 J. Ciarrochi et al.

unhelpful thoughts, or unpleasant feelings. We hold them all. To use a metaphor, we

are the sky, and our experience is the weather (Kabat-Zinn, 2013). The core idea
behind this kind of intervention is that if people can identify with their observer self
or self-as-context, they will more easily let go of unhelpful self-concepts. Self-­
concepts are not real things that define our essence.
Research supports the value of self-as-context interventions. The tendency to
experience self-as-context is linked to well-being and mindfulness (Zettle et  al.,
2018). Further, ACT creates self-as-context, and this predicts improvements in
functioning (Yu et al., 2017). Though not explicitly discussed in ACT, we might also
classify growth mindset interventions as promoting a flexible self-view (Dweck,
2008). These interventions teach people to view themselves as changing and grow-
ing and not fixed. There is reliable evidence that growth mindset interventions have
at least a small effect on well-being and performance (Burnette et al., 2020; Miller,
2019; Yeager et al., 2019). Similarly, we classify self-compassion interventions as
promoting self-view. These interventions ask people to see themselves as someone
who sometimes suffers and deserves kindness. Self-compassion interventions have
been showing promising effects (Ferrari et al., 2019; Wilson et al., 2019).

9 Social View: Crisis of Isolation and Loneliness

Humans need others as much as they need clean air. Chronic loneliness can make us
as sick as smoking ten cigarettes a day or being chronically obese (Hawkley &
Cacioppo, 2010; Heinrich & Gullone, 2006). In contrast, social connections give us
physical and emotional support, help in reaching goals, greater access to ideas and
knowledge, and the ability to accomplish things that we could not accomplish by
ourselves (Adler & Kwon, 2002; Ciarrochi et  al., 2017). If relationships are so
important to us, why is it so hard for us humans to get along? 15–30% of people
experience chronic loneliness (Hawkley & Cacioppo, 2010).
There is an existential tension between our individual needs and group needs,
between selfishness and cooperation. For example, if we give our time to helping
others, we may give them the advantage over us, or we may allow them to take
advantage of us. However, if we fail to support others, we may develop a bad reputa-
tion and lose people’s trust. Research suggests that the best social strategy often
depends on context. For example, people are less likely to cooperate in contexts
where cooperation payoff is low, where it is unclear who is cooperating and who is
cheating, or where the environment comprises a high percentage of people using
noncooperative strategies (Dal Bó & Fréchette, 2019; Grant, 2013). The solution to
this problem, if we want to increase cooperation, is to create environments in which
we reward cooperation (Biglan, 2015).
ACT undermines strategies that destroy social relationships, such as refusing to
take another’s perspective and avoidance of social situations. But why would we
avoid social situations unnecessarily?
Letting Go, Creating Meaning: The Role of Acceptance and Commitment Therapy… 297

We have argued that the advisor’s job is to keep us safe. If we look to our evolu-
tionary past, we discover that the greatest danger to humans was often not tigers or
snakes: it was other humans. War and murder were one of the most common causes
of death in prehistoric times, and our advisor adapted to this (Pinker, 2012). Thus,
our advisor has evolved to keep us safe from others. We are constantly seeking to
infer people’s intentions and assess their trustworthiness. When we are chronically
lonely, we become stressed, hypervigilant to social threat, and more likely to see
people’s behavior as negative (Hawkley & Cacioppo, 2010). Our language skills
give us the ability to verbally transform any human into an uncaring person or a
monster. If we are not careful, we will end up inside a verbally interpreted world
with nothing but monsters.
Making matters worse, we can become addicted to self-enhancing consequences
(ego; see self-view above). We see life as a zero-sum game, where the only way I
can enhance myself is by bringing you down or not letting you shine. Research sug-
gests that people who are able to let go of self-enhancing feelings and thoughts, that
is, those who are non-attached, are more likely to engage in prosocial behavior
(Sahdra et al., 2015).
All the ACT interventions described previously can be used to target ineffective
social behavior. If people are addicted to self-enhancement, we can help them to let
go of the ego (self-view), in the service of building relationships (valuer). If people
have an overactive advisor who distrusts everybody, we can help them to be aware
of this bias and to disengage from the advisor sometimes and use discovery to find
out what a certain person is like. We can also help them notice the feelings of dis-
trust without automatically reacting to them. If experience teaches us that a person
can’t be trusted, we can use discovery processes to find the best social strategy for
managing this person. Finally, we teach people to take perspective, which often has
the effect of transforming someone from an inhuman monster to a merely human
one, or perhaps no monster at all.

10 Conclusion

Humans make the same life journey. We all start in the physical world of sun, wind,
and rain and rely on safe and reliable physical contact with our caregivers. We travel
along this path for about one or two years, touching the earth with our senses and
connecting and depending on others for our needs without using words. Then, grad-
ually, we develop language. We start verbally “touching” and transforming the earth
and our relationship with others. Soon, we don’t just see sun and rain; we see
“good,” “bad,” “terrible,” “lovely,” “meaningless,” “right,” “wonderful,” “intolera-
ble,” “mine,” “theirs,” and “can’t.” We use words to gain power, to learn complex
skills from books, to build social alliances, and to persuade others. Our words are so
useful that soon we think they can solve everything. We think we can use words to
make death disappear (“I will live through my work”), to make everybody respect
us (“She knows I am better than her”), to make all those who don’t love us into
298 J. Ciarrochi et al.

villains (“They have no heart”), and to make life fair (“People deserve what they
get”). But the physical world does not care about our words. The physical world
breaks through the walls of our interpreted world when we experience loss, unfair
treatment, social exclusion, sickness, and death. If we react to these existential cri-
ses with denial, we can become lost in our verbal mazes, searching for a way out.
O waste of loss, in the hot mazes, lost, among bright stars on this most weary unbright
cinder, lost! Remembering speechlessly we seek the great forgotten language, the lost lane-­
end into heaven, a stone, a leaf, an unfound door. Where? When? – Wolfe, Thomas

Words don’t lead to the unfound door. They lead away. How far have we strayed
from that preverbal world of sun, wind, and rain and from a connection with another
person that is beyond words? Not far. This world is still here, now. Meaning is here,
now, if we awaken.
ACT seeks to promote this awakening in six ways. First, ACT helps people to
become aware of values and choose to organize their lives around them (valuer).
Second, ACT seeks to increase awareness of verbal processes (advisor) and teaches
people to use these processes when useful and disengage when not useful. Third, it
promotes present moment awareness and acceptance of all experiences, both inter-
nal and external, good and bad, so that people are no longer at war with unpleasant
sensations and their own bodies. Rather, through their body, people learn to let the
nonverbal back into their lives. Fourth, ACT helps people engage in exploratory
action. Through trial-and-error experience, people discover meaning (discoverer).
Fifth, ACT helps people to recognize self-limiting thoughts as they occur, to see that
they are the observer of these thoughts and not the same as the thoughts, and to take
a kind, compassionate view of themselves (self-view). Finally, ACT teaches us to
take perspective of others and to recognize our fundamental interdependence (social
view). Together, these processes help people to confront existential crises with cour-
age and acceptance, break through the delusion of wishful thinking, and create a life
that is meaningful and deeply connected to others.

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PFXDYn0iZEC3zfaq9FHdqtOmoKTcfIhEVDFYUZIyI236A8Y44ZZF9eWRquDOouHB
RSs
Index

A Affective faculty, 266

Acceptance, 298 Agoraphobia, 60, 61, 123
Acceptance and commitment therapy (ACT), Alcohol use disorder (AUD), 228
108, 239, 269 Amor fati, 238, 239
advisor, 291–293 Anger, 244
behavioral approach, 284 Anti-Semitic readings, 6
central aim, 28 Anxiety buffer disruption theory, 100
contextual behavioural science Anxiety buffers, 100, 101, 103, 104
approach, 27 Anxiety disorders, 123
discoverer, 294–295 agoraphobia, 61
DNA-V model, 289–290 panic disorder, 59–61
existential CBT, 26 separation, 62, 63
to existential crises, 287–289 social anxiety disorder, 61, 62
existential psychotherapy, 26 specific phobias, 58, 59
experiential techniques, 28 Appearances, 10
freedom in, 214, 215 Assessment, 274
functional contextualism, 27 Attachment, 193
general assumption, 290 Attachment behavioural system, 194
modelling ACT psychological Attachment theory, 194
flexibility, 289 Attributions, 117
noticer interventions, 293–294 Authenticity, 6, 209
philosophical assumptions, 28
psychological distress, 26
psychological disturbance and distress, 26 B
radical behavioural approach, 26 Bad faith, 12
RFT, 287 Beck Hopelessness Scale (BHS), 265, 266
self-beliefs, 295–296 Beck model, 174, 175
social view, 296–297 Behaviourism, freedom in, 213, 214
tragic sense of life, 26 Being-in-the-world, 12, 18
truth, 27 Being-toward-death and boredom, 8
values, 290–291 Beliefs, 175
ACT-based values exercises, 197 The big four, 15
Actual guilt, 217 Body scanning disorder, 60
Actual self, 170 Border situations, 10
Adult Hope Scale (AHS), 265 Borderline personality disorder (BPD), 192

© Springer Nature Switzerland AG 2022 303

R. G. Menzies et al. (eds.), Existential Concerns and Cognitive-Behavioral
Procedures, https://doi.org/10.1007/978-3-031-06932-1
304 Index

C Dasein, 18
Calmness of Gerasim, 11 Daseinsanalysis, 14
Cartesian’ perspective, 18 Death, 10, 15, 102
Causal scientific hypotheses, 20 Death anxiety, 28, 39–42, 44, 47, 58–69
CBT-oriented researchers, 20 clinical interview
CBT therapists, 14, 29, 31 emotional, cognitive and behavioural
Christianity, 155 responses, 78, 79
Christian morality, 5 establishing treatment goals, 80
Chronic loneliness, 296 life history, 79
Clinical assessment, 274 protective factors, 79, 80
Clinically depressed samples, 271 screening, 77
Cognitions, 127 interventions, 76
Cognitive appraisal models (CAMs) of measures, 80, 81
OCD, 169 mental health conditions, 76
Cognitive approaches, 117, 118 psychological interventions, 76
Cognitive barriers qualitative interviews, 76
fear of negative evaluation, 141 treatment approaches
mistrust, 140, 141 behavioural experiments, 84
stigma, 140 cognitive approaches, 81–84
Cognitive behaviour therapy (CBT), 76, 107, exposure therapy, 84–88
138, 236 imagery rescripting (ImRs), 89
conceptual and theoretical aspects, 14 psychedelic-assisted
definition, 14 psychotherapy, 89
self and, 186 uncertainty, 88
set of tools, 14 Death awareness, 37, 38, 40, 41, 46, 50
strategies, 64 Death drive, 15
technical interventions, 14 The Death of Ivan Ilyich, 11
Cognitive behavioural strategies, 136 Decision justification theory
Cognitive behavioural theory, 186, 199 (DJT), 224
Cognitive faculty, 266 Decision making, freedom and, 210
Cognitive hypothesis, 169 De Jong Gierveld scale, 117
Cognitive models, 175 Depressed/anxious self, 171
Cognitive processing, 16 Depression, 121, 122, 212, 264
Cognitive therapy, freedom in, 214 freedom, failure and, 223–225
Coherence, 263, 264 hopelessness, 265
Collectivist societies, 101 social identity approach, 174–177
Collett-Lester Fear of Death Scale–Revised and suicidality, 267
(CLFDS-R), 80, 81 traditional cognitive behavioural therapy
Compensatory Control Model, 50 techniques, 274
Constitution, 9 Depressive disorders, 262
Constructivist perspective, 25 Depressive symptoms, 266
Constructivist principles, 25 Descartes, 4
Constructivist psychotherapy, 25 Descriptive contextualism, 27
Constructivist thinking, 25 Descriptive phenomenological
Contextualism, 27 method, 20
Courage, 155, 157 Diagnostic and Statistical Manual of Mental
COVID-19, 162, 163, 253 Disorders (DSM-5), 63, 231
Creativity, 251–253, 257 Disorder-specific CBT models, 21
Disturbed affect, 262
DNA-V model, 288–290, 295
D Dominant philosophers, 4
Danger, 258 Dreaming existence, 16
Dangerous self, 171 Dualistic thinking, 4
Index 305

E and diverse identities, 158, 159

Eating disorders, 68 feminist identity and male gaze, 159
via social identity approach, 174–177 gendered identity, 160, 161
Eco-existentialism, 162 racism and, 159, 160
Embodied existence, 16 history, 4
Emotional attachment, 188 implications, 9
Emotional embodied experience, 25 influential philosophical movements, 14
Emotional loneliness, 116 issue of truth, 10
Emotionally driven behavior, 107 Philosophy of Existence, 10
Encompassing, 10 Existentialist freedom, 7
Epistemology, 24 Existentialists, 4
Ethical powers, 5 Existential issues
Evidence-based methodologies, 31 analysis and interventions, 15
Excessive existential responsibility and CBT, 15
guilt, 29 expression, 15
Existential range, 19
anxiety, 16, 99 thematic focus, 15
Boss, 16 types, 15
CBT therapists, 16 Existential Loneliness Questionnaire
competence, 29 (ELQ), 103
crisis, 284, 285, 287, 290, 298 Existential-phenomenological notions of
dimensions of existence, 29 relatedness, 19
givens, 16 Existential-phenomenological philosophy, 17
guilt, 16, 17 Existential-phenomenological principle of
Existential humanism relatedness, 18
becoming some-body, 158 Existential phenomenologists, 28
identity Existential phenomenology
as momentary, 157, 158 and ACT, 26
as reinvention, 156 and behaviourism, 27
Existential-humanistic psychotherapies, 15 CBT therapists, 20
Existential isolation and constructivism, 24
assessment measures, 103 descriptive contextualism, 27
awareness of, 97, 98 development, 24
collectivist societies, 101 existential relatedness, 18
confrontation, 98, 99 individual’s world views, 23
correlates of, 103–105 philosophical perspective, 21
in day-to-day, 100 principle of uncertainty, 17
death, 102 relational nature, 22
definition, 97 thematic focus, 21
freedom, 102 uncertainty of certainty, 17
identity, 102 Existential philosophy, 14
individualist societies, 101 ontological guilt in, 218
meaning and, 102 responsibility in, 216
out of consciousness, 100 Existential psychotherapy, 14, 17, 262
psychotherapy implications, 106 ontological guilt in, 218, 219
treatment of, 106 responsibility in, 216
Existential Isolation Scale (EIS), 103 Existential relatedness, 18, 19
Existentialism, 155, 250–252, 254, 255, 258 Existential responsibility and guilt, 29
CBT (see Cognitive behaviour Existential schemas, 23
therapy (CBT)) Existential sexuality, 16
challenge, 9 Existential thinkers, 20
definition, 3 Existential thinking, 19, 20, 26, 28
demand, 9 Existential uncertainty, 17
306 Index

Expectations, 7 Group therapy, 107

Experience of anxiety (Angst), 8 Guilt
Experienced Meaning in Life Scale, 270, 273 forms of, 217
Experiential openness, 19 actual guilt, 217
Experimental existential psychology, 21 neurotic guilt, 217
ontological guilt, 218
in existential philosophy, 218
F in existential psychotherapy, 218, 219
False consensus effect, 100
Feared-self, 170
Fear of death H
anxiety disorders (see Anxiety disorders) Health anxiety, 63, 231, 232
clinical psychology, 57 Heidegger, 3, 8, 9, 11
death anxiety, 58 Heideggerian, 8
eating disorders, 68 Herd mentality, 5, 11
mental illnesses, 57 Hierarchies of significance, 20
mood disorders, 67 Higher self-reported life meaning, 266, 267
OCD, 65, 66 History of philosophy, 4
psychotic disorders, 68, 69 History of Western philosophy, 4
PTSD, 66 Hoarding disorder, 172–174
somatic symptom-related disorders, 63–65 Homesickness, 255–257
treatment implications, 69 Hopelessness, 265
Feeling of loneliness, 116 Hopelessness Scale, 265, 266
Feminist identity and male gaze, 159 Human distress, 20
Flawed self, 171 Humanistic psychotherapies, 15
Frankl’s meaning-seeking model, 262 Humanity, 6
Freedom, 6, 9, 102, 208
in ACT, 214, 215
in behaviourism, 213, 214 I
in cognitive therapy, 214 Identity, 102
and decision making, 210 developmental considerations in, 194, 195
as existential concern and existential humanism
and connection, 210, 211 becoming some-body, 158
therapy, 211, 212 identity, as momentary, 157, 158
in existential philosophy, 209 identity, as reinvention, 156
failure and depression, 223–225 existentialism and Christianity, 155
philosophy and politics, 208, 209 existentialism and diverse identities,
in political sense, 209, 210 158, 159
responsibility, 215 feminist identity and male gaze, 159
in existential philosophy, 216 gendered identity, 160, 161
in existential psychotherapy, 216 racism and, 159, 160
Fundamental attunement, 8, 9 global dread and, 161, 162
Fundamental existential concerns, 15 eco-existentialism and sustainable
biographies, 162
self, 187–189
G synthesis, 161
Gendered identity, 160, 161 Illness Attitude Scales, 63
Geriatric Suicide Ideation Scale, 270, 273 Imagery rescripting (ImRs), 89
God’s-eye view, 24 Individualism-collectivism, 101
Good and evil ethics, 11 Individualist societies, 101
Group interventions, 136, 138 Individuals struggle, 22
Groups 4 Belonging program, 139, 142 Inference-based approach (IBA), 170
Groups 4 Health program, 138, 139 Interpersonal isolation, 96, 115
Index 307

Interpersonal psychotherapy, 270 M

Interpersonal therapy (IPT) intervention, 273 Major depressive disorder (MDD), 60
Intimate relationships, 100 Maladaptive cognition, 137
Intrapersonal isolation, 96 Materialism, 48
Maximising, 227, 236
Meaning, 102
J existentialism, 250–252, 255
Jaspers, 3, 9, 11 languages, 253
Jean-Paul Sartre, 6 perspectivism, 252
truths, 250
Meaning-centred counselling and therapy
K (MCCT), 263
Knowledge, 24 Meaning-centred group intervention, 266,
Kuperis, Gerard, 224 270, 273
Meaning-centred group therapy
(MCGT), 270
L Meaning-centred psychotherapy, 262
Language, 251–254 Meaning in Life Questionnaire (MLQ), 264,
Life, 252, 255 267, 268, 272, 273
Life Attitude Profile (LAP), 264 Meaning in Life Scale (MIL), 264
Life meaning Meaninglessness, 28, 251, 262, 263
coherence, 263 Meaning maintenance model (MMM), 49, 100
and depression, 267 Mediation/moderation, 268, 271–273
correlational and group difference Medically unexplained symptoms (MUS), 64
studies, 267–268 Mental health, 262–263
moderation and mediation studies, 268 regret and, 235, 236
treatment/intervention studies, 269–271 Metacognitive beliefs, 227
meaninglessness, 263 Mindful Self-Compassion (MSC), 241
measurement, depression and Mindfulness, 241, 292, 294, 296
suicidality, 264–265 Mindfulness-based cognitive behavioural
to mental health, 262–263 therapy (MBCT), 242
purpose, 263 Mindfulness-based intervention, 25
role for hope, 265–266 Mood disorders, 67, 273
significance, 264 Mortality, 10, 43, 45, 48, 49
and suicidality Motivational faculty, 266
correlational and group difference Multidimensional conceptualisation, 116
studies, 271–272 Multidimensional Fear of Death Scale
moderation/mediation studies, 272–273 (MFODS), 81
treatment/intervention studies, 273
Life Regard Index (LRI), 264, 265, 267, 272
Logotherapy, 262 N
Loneliness Narrative constructivist, 24
and anxiety disorders, 122, 123 Neurotic guilt, 217
cognitive approaches, 117, 118 Nietzsche, F.W., 3–5, 9, 11
combined approach, 120 existentialism, 252
conceptualisation and measurement of, 116 The Gay Science, 255
definition, 115 homesickness, 256, 257
and depression, 121, 122 meaninglessness, 251
and health, 120, 121 mind and body dualism, 252
individual therapy, 136, 137 perspectivism, 251, 252, 254
and psychosis, 124, 125 science, 250
SIA, 119, 120 use of the sea, 258
and substance use disorders, 125–127 Nihilism, 251
308 Index

Normal functioning, 25 Psychodynamic approaches, 188

Noticer interventions, 294 Psychoeducation, 22
Psychological defense, 100
Psychological disorders, 22
O Psychological flexibility, 28
Objectivist approach, 24 Psychological mainstream, 26
Objectivist vs. rationalist CBT, 25 Psychological theory, 24
Obsession, regret and, 229–231 Psychology, 168
Obsessive-compulsive disorder (OCD), 41, 65, Psychopathology, 58, 168, 262, 268, 273
66, 123, 168–171 Psychosis, 124, 125
cognitive model of, 239 Psychotherapeutic eros, 106
contemporary management of, 239 Psychotherapeutic interventions, 271
On the Genealogy of Morality, 5 Psychotherapeutic theory, 27
Ontological, 29 Psychotherapy, 9, 270
Ontological guilt, 218 Psychotic disorders, 68, 69
in existential philosophy, 218 Purpose in Life Test (PIL), 264–266
in existential psychotherapy, 218, 219
Ought self, 170
R
Racism and identity, 159, 160
P Randomised controlled trials (RCTs), 76, 270
Pandeterminism, 212 Rational correspondence with reality, 24
Perceived Life Significance Scale (PLSS), 264 Rational emotive therapy (RET), 188
Personal identity, 102, 175 Rational-logical strategies, 23
Personal Meaning Profile (PMP), 264, 267 Realities, 22
Perspectivism, 251, 252, 254 Regret, 219, 220, 227
Phenomena, 19 and mental health, 235, 236
Phenomenological equalisation, 20 and obsession, 229–231
Phenomenological listening regulation, 236
CBT therapists, 29 Rejected self, 171
client, 30 Rejectors, 244
embodied emotional experience, 30 Religious and philosophical ideas, 9
emotional experience, 30 Responsibility, 250, 254, 258
existential observations, 30 freedom, 215
participants, 30 in existential philosophy, 216
Phenomenological method, 19 in existential psychotherapy, 216
Phenomenological reduction, 19, 20 Ricoeur, Paul, 157
Phenomenology, 19 Rule of description, 20
Philosophy of Democritus, 4 Rumination, problems of, 226, 227
Philosophy of Existence, 10
Philosophy of functional contextualism, 27
Plato, 4 S
Political sense, freedom in, 209, 210 Sailing, 255, 256
Positive psychotherapy (PPT), 269 Sartre, J-P., 3, 11
Possessions as Memories (PAM), 173 existentialism, 250
Post-event rumination and social anxiety homesickness, 256
disorder, 228, 229 responsibility, 250, 254, 258
Post-rationalist cognitive therapy, 24 Sartre’s existentialist ethics, 6
Post-traumatic stress disorder (PTSD), 66, 191 Scaffolding, 251
Principle of uncertainty, 17 Schedule for Meaning in Life Evaluation
Probing coherence, 264 (SMILE), 264, 267, 268, 270
Pseudo truths, 10 Schema-focussed approaches, 22
Psychedelic-assisted psychotherapy, 89 Schema healing, 23
Psychoanalytic ideas, 15 Schema therapy
Index 309

CBT theorists, 23 Social interactions, 115, 136

degree of appreciation, 23 Social loneliness, 116
ego-syntonic, 23 Social media, 8
human experience and development, 23 Social prescribing, 143, 145
rational-logical strategies, 23 Social prescription, 143
schema healing, 23 Social provisions, 116
sense of identity, 23 Social skills, 136
standard CBT, 22 Social skills training, 136
The Second Sex, 6 Social support, 136
Self, 168 Social welfare programs, 144
and CBT, 186 Somatic symptom-related disorders, 63–65
developmental considerations, 194, 195 Standard Beckian CBT, 20–22
identity, 187–189 Standard cognitive therapy, 22
and treatment considerations, 196–198 Stoicism and principle of desire, 236–238
Self-as-context, 288, 296 Stress, 121
Self-aspects, 192 Substance use disorders (SUD), 125
Self-based interventions, 197 Suicidality, 264–266
Self-compassion, 240–242 Sustainable economy, 257
Self-concept, 122, 125
Self-construals, 198
Self-constructs, 194 T
Self-contents, 188–191 Terror management theory (TMT), 58, 98,
Self-discrepancy theory, 193 100, 103
Self-esteem, 125, 244 adult attachment styles, 41
Self-knowledge, 170 anxiety, 38, 41
Self-processes, 188, 192–194 death, 36
Self psychology, 186 death awareness, 38, 40
Self-schemas, 189–191 The Denial of Death, 36, 37
Self-structures, 188, 192–194 empirical support
Self-transcendence of human existence, 262 close relationships, 46
Sense of Coherence Scale (SOC), 264 cultural worldview defence, 45, 46
Separation anxiety disorder, 62, 63 death awareness, 48
Sexuality, 16 distal reminders of death, 44
Shift and Persist Questionnaire (SAPQ), experimental approach, 42
264, 267 mental illness, 46, 47
Simone de Beauvoir, 6, 7 proximal reminders of death, 43
Social adversity, 124 self-esteem, 44, 45
Social anxiety disorder (SAD), 61, 62, human experience, 36
123, 137 mechanisms, 39
and post-event rumination, 228, 229 mental illness, 42
Social behaviours, 127 non-death-related words, 39
Social cognitions, 118 psychological processes, 49
Social comparison, 97, 101 psychology, 40
Social constructivism, 24 psychopathology, 41
Social contact, 127 replication crisis, 48
Social engagement, 143 self-esteem, 39
Social expectations, 118 social psychological theory, 38
Social group memberships, 120 social skills, 40
Social groups, 137 stressors, 41
Social identity, 103, 120 visual arts, 36
Social identity approach (SIA), 118–120 Western and non-Western societies, 36
depression and eating disorders Therapeutic relationship, 24
via, 174–177 Third-wave CBT therapies, 26
Social identity mapping (SIM), 139 Tolstoy, 11
310 Index

Tolstoy’s The Death of Ivan Ilyich, 3 Unified Protocol for Transdiagnostic

Traditional CBT, 23 Treatment of Emotional
Tragic sense of life, 26 Disorders, 107
Transdiagnostic factors, 17, 31 Universal process, 17
Transdiagnostic issues, 15, 28 University of California Los Angeles
Trans-therapy factor, 17 Loneliness Scale, 116
Truth, 3–5, 10, 250–252, 254, 258 Unwanted psychological phenomena, 27

U V
Uncertainty, 17 Value, 3
Uncertainty Management Model, 50 Violence, 244
Uncertainty Management Theory, 49, 50
Undesired self, 170
Y
Young Schema Questionnaire, 140