Introduction In Chapter 1 (
Introduction), the author presents three views of the prototype of intrapsychic conflict in the individual: the
Freudian view, the
neo-Freudian view (as represented by
Harry Stack Sullivan,
Karen Horney,
Erich Fromm), and the existential view. He also offers a short review of the European tradition of
existential philosophical thinking (with brief excursions on
Søren Kierkegaard,
Martin Heidegger and others) as well as existential analytic thought (referring to the presentation in
Rollo May's book
Existence of 1958), outlining also the American field of
humanistic psychology in comparison with the existential tradition in Europe. He points out the influence of European psychoanalysts who emigrated to America as to highlighting particular aspects: the role of the will and of death anxiety (
Otto Rank, later built upon by
Ernest Becker), the future-oriented motivation of the individual (Horney), fear and freedom (Fromm), and responsibility and isolation (
H. Kaiser). Yalom also points out that he frequently refers to works of writers in his book, including
Fyodor Dostoyevsky,
Leo Tolstoy,
Franz Kafka,
Jean-Paul Sartre, and
Albert Camus. The further chapters are structured in four parts, each of which is dedicated to one of the four concerns which constitute, in Yalom's approach, the four
ultimate concerns rooted in the existence of the individual. These are: :Part I: Death (with Chapters 2–5), :Part II: Freedom (with Chapters 6 and 7), :Part III: Isolation (with Chapters 8 and 9), and :Part IV: Meaninglessness (with Chapters 10 and 11). It has been noted that Yalom uses the term
ultimate concern differently compared to Tillich and Kierkegaard: Yalom speaks of
ultimate concerns as "givens of existence" with which the individual is confronted and which form "an inescapable part, of the human being's existence in the world". In Parts I to IV, the author discusses, for each of these concerns, the changes that occur in the course of the development of the individual, his view on
psychopathology in relation to the respective concern, and proposed psychotherapeutic strategies for assisting patients in a crisis. As other books by Yalom, this book includes descriptions of numerous case studies that illustrate his arguments.
Part I: Death In
Part I, the author addresses the fear of
death and discusses theoretical and empirical findings with regard to the fear of death. He names some philosophers' views, works of literature and examples from clinical practice that assign to death awareness a role in fostering inner changes and personal growth. He offers explanations on its widespread omission in the theory and practice of psychotherapy – in particular also by
Sigmund Freud who saw it as
a mere disguise for a deeper source of concern. He then discusses the development of the fear of death in children. He presents two poles of basic defenses against this fear and possible resulting psychopathology: an orientation to personal "specialness" and inviolability, with a tendency to
individuation and "life anxiety", versus an orientation to "the ultimate rescuer" with a tendency to fusion and "
death anxiety". He outlines individuals' oscillations between these two poles and discusses how a hypertrophy of either of these defenses, or a reaction to a breakdown of either defense, can give rise to disorders (for example
schizoid and
narcissistic tendencies in the case of an extreme of individuation, or passive-dependent or masochistic tendencies in the case of an extreme of fusion, or depressive symptoms in case of a breakdown of either defense). He points out that individuation co-occurs with psychopathy less often and appears to be a more effective defense compared to fusion. Yalom sees his notion of "life anxiety" and "death anxiety" as being closely corresponding with May's earlier concept of "fear of life" and "fear of death". Furthermore, he views the dialectic of the poles of "specialness" versus "the ultimate rescuer" as being similar to that of the
cognitive styles of
field dependence versus field independence and to that of interior versus exterior
locus of control.
Part II: Freedom In
Part II, the author outlines the role of
freedom,
responsibility and the
will. According to Yalom, responsibility means authorship "of one's own self, destiny, life predicament, feelings and, if such be the case, one's own suffering". Responsibility is "a deeply frightening insight". In more illustrative terms, he states: :"To experience existence in this manner is a dizzying sensation. Nothing is as it seemed The very ground beneath one seems to open up. Indeed,
groundlessness is a commonly used term for a subjective experience of responsibility awareness. Many existential philosophers have described the anxiety of groundlessness as ″ur-anxiety″—the most fundamental anxiety, an anxiety that cuts deeper even than the anxiety associated with death." Yalom contends that: "The classical psychoneurotic syndromes have become a rarity. [...] Today's patient has to cope more with freedom than with suppressed drives. [...] the patient has to cope with the problem of choice—what he or she
wants to do" and that "at both individual and social level, we engage in a frenetic search to shield ourselves from freedom." Yalom discusses various responsibility-voiding defenses, including: "
compulsivity", displacement of responsibility to another, denial of responsibility ("innocent victim", "losing control"), avoidance of autonomous behaviour and decisional pathology.
Part III: Isolation In
Part III, he addresses three types of
isolation: interpersonal isolation (isolation from other individuals, experienced as loneliness), intrapersonal isolation (in which parts of oneself are partitioned off), and
existential isolation (an "unbridgeable gulf between oneself and any other being"). He then illustrates "what, in the best of ways, a relationship can be" in terms of
need-free love, recalling similar thoughts expressed by
Martin Buber (
Ich-Du relationship),
Abraham Maslow (
being-love, a love for the being of another person, in distinction from
deficiency-love, a selfish love which relates to others in terms of usefulness) and Fromm (
need-less love), and then addresses interpersonal psychopathology. He points out that fusion is a common escape from existential isolation and that this has a high overlap to the "ultimate rescuer" belief. He then addresses therapeutical approaches to understanding interpersonal relationships, in particular also the
therapist–patient relationship.
Part IV: Meaninglessness In
Part IV, the author discusses
meaninglessness and its role in psychotherapy. He discusses various answers related to questions around the "meaning of life", distinguishing between "cosmic" and "terrestrial" meaning, and noting that "most Western theological and atheistic existential systems agree [that]
it is good and right to immerse oneself in the stream of life", describing
hedonism and
self-actualization, which have a main focus on the self, and
altruism, dedication to a cause, and
creativity, which focus more on transcending oneself. He presents in depth Frankl's therapeutic approach,
logotherapy, that focusses on the human search for meaning. In terms of clinical research, he speaks of two psychometric instruments designed to measure purpose in life, summarizing criticism and results with regard to the "Purpose–in–Life Test" and briefly mentioning the "Life Regard Index". Yalom holds that the search for meaning is paradoxical in a similar sense as Frankl sees the search for pleasure to be paradoxical: it cannot be achieved if aimed at directly and must rather be pursued indirectly ("obliquely"). He states that, if a patient reports a lack of meaning in life, it is important for the therapist to first learn whether there are possibly other underlying issues (cultural issues, or issues relating to the concerns of death, freedom, and isolation), and addressing such issues, for example by helping the patient develop curiosity and concern for others within the framework of group therapy. Regarding "pure meaninglessness", Yalom states that the desire to engage life is "always there within the patient"—to engage in satisfying relationships, in
social or creative engagement, in satisfying work, in religious or self-transcendent strivings, and other forms of engagement. Therefore, Yalom's proposed therapeutic answer to "pure" meaninglessness is to remove obstacles that prevent the patient from wholehearted engagement. Yalom holds that the therapist's best tool for this is the therapist's own engagement with the patient. == Influence ==