Anticipatory grief: an existential model for spiritual care

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  • Int. J. Appl. Psychoanal. Studies 7: 143151 (2010)Copyright 2010 John Wiley & Sons, Ltd DOI: 10.1002/aps

    International Journal of Applied Psychoanalytic StudiesInt. J. Appl. Psychoanal. Studies 7(2): 143151 (2010)Published online 13 April 2010 in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/aps.237

    Anticipatory Grief: An Existential Model for Spiritual Care

    ALAN E. GATEWOOD

    ABSTRACT

    This project sought through spiritual care, demonstrated in an intentional small group process, to promote theological refl ection about meaningful living. The desired effect was to know the fact of ones death to be an impetus for life.

    Methodology entailed determination of issues the participants wanted addressed as well as delineation of the mechanics of the phenomenon of anticipatory grief. The project showed a positive correlation between a constructive sense of anticipatory grief and a sense of meaning for life. Copyright 2010 John Wiley & Sons, Ltd.

    Key words: anticipatory grief, existential model, spiritual care

    INTRODUCTION

    This project is an attempt to propose a model for Spiritual Care based on Existential Philosophy, Theology, and Psychology. It is this writers contention that this model may provide parishioners a way to get at their anxieties and work through them with a sense of meaning for life that will give them courage for their living. Anxiety is the proper starting place.

    Martin Heidegger has noted that the characteristics of everyday existence are to be described in terms of our feelings (1962, p. 108). Everyday existence is permeated by some mood: fear, anxiety, joy, tranquility. Feeling is the funda-mental mode of existence, and anxiety is the fundamental feeling for Heidegger, precisely because it is directed toward our being-in-the-world as such. That is why anxiety is more fundamental to human existence than fear. Fear is always defi nite. Anxiety, conversely, results in an existential vacuum the threat of non-being.

    Irvin Yalom asks a similar question, How can we combat anxiety? He then answers, By displacing it from nothing to something (1980, p. 43). This then is the work of anticipatory grief. By raising awareness of the dynamics of antici-patory grief, one can make something to really fear something specifi c, identifi -

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    able and therefore something to deal with at last. The alternative to this awareness of something is the dread of nothing which thrusts one into the existential vacuum. There one has no constructive work to do, no meaning or joy can be discerned for living. Nevertheless, by introducing the dynamics of anticipatory grief, one can begin to build meaningful living and dying. Viktor Frankls logotherapy assumes three senses of meaning: (1) freedom of will, (2) will to meaning, (3) meaning of life (1967, p. 2). This writer will present a case for using Frankls logotherapy for creating meaning in spiritual care.

    PSYCHOLOGY, DEATH AND EXISTENTIALISM

    Viktor Frankl

    In the sense of dramatic experience Viktor Frankl epitomizes existential psycho-therapy. Drawing on his personal experience as a prisoner in the concentration camps of Dachau and Auschwitz, Frankl has a special sensitivity to the spirits confrontation with suffering, death and meaning. It should come as no surprise that he stresses that one can transcend suffering and fi nd meaning in life beyond self. Frankl fi nds most folk are self-absorbed . . . so concerned for self that they cant see anything beyond self to give value or meaning to self (1967, p. 46). This self-absorbtion is the major obstacle to therapy. Frankl practices a special technique derefl ection to divert a patients gaze away from self. The technique is simple in principle and consists of little more than telling the patient to stop focusing on self and to search for meaning outside of self.

    Frankl is a philosopher, psychiatrist and some might say, a moralist. His logotherapy is, as the name implies, an intricate philosophy theory. Logotherapy is not indicative of any word but of the word meaning. It is based on an explicit philosophy of life. More specifi cally, it is based on three fundamental assumptions which form a chain of inter-connected links: (1) Freedom of Will

    Man is not free from conditions . . . But he is and always remains, free to stand toward these conditions; He always retains the freedom to choose his attitude toward these conditions; he always retains the freedom to choose his attitude toward them. (Frankl, 1967, p. 5)

    This ability to detach from self vis--vis ones condition is termed by Frankl the noetic (spiritual) dimension.

    (2) The Will to Meaning The more a man aims at pleasure by way of direct intention, the more he misses his aim (Frankl, 1967, p. 14).

    In this way Frankl argues against Freuds basic laws of motivation, the homeo-stasis principle. The pleasure principle acts to maintain homeostasis and has as its fundamental goal the removal of tension. Frankl believes the homeostasis theory fails to explain many central aspects of human life. What one needs, says

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    Frankl, is not a tensionless state but rather a striving and struggling for some worthy goal (1963, p. 166). The truth is, for Frankl, that the pleasure-principle view of human motivation is always self-defeating. The more one seeks happi-ness, the more it eludes one. It is to this concern Frankl says, Happiness ensues; it cannot be pursued (1967, p. 146).

    (3) The Meaning of Life While no logotherapist prescribes a meaning he may well describe it . . . in short our task is to resort to a phenomelogical inves-tigation of the immediate data of actual life experience (Frankl, 1967, p. 15). An important element of this third assumption is that even in a situation where man is deprived of both creativity and receptivity, he can still fulfi ll a meaning in his life (1967, p. 17). It is precisely when facing such a fate, when being con-fronted with a hopeless situation, that man is given a last opportunity to fulfi ll a meaning to realize even the highest value, to fulfi ll even the deepest meaning and that is the meaning of suffering.

    Frankl is aware of the many clinical issues, yet he maintains in all his work a singular accent on meaning in life. When Frankl speaks of the existential vacuum, he refers to a state of meaninglessness; and when he speaks of therapy, he refers to the process of helping a person fi nd meaning. I appreciated Irvin Yaloms articulation of Frankls will to meaning as the guiding principle of the mature adult. Yalom says, Frankl is careful to distinguish between drives (for example, sexual or aggressive) that push a person from without, and strive that pulls a person from within (1980, p. 445). Stiving indicates that one is oriented toward something outside of self (self-transcendent). Also it indicates that one is free free to accept or deny the goal that is before us. To strive is to the future as opposed to the drive from relentless forces behind one (past, present). Meaning is essential for life, Frankl claims. That is an existential decree for this man that transcended the prison camp at Auschwitz.

    Though Frankl stresses that each individual has a meaning that no on else can fulfi ll, these unique meanings fall into two categories: (1) what one accom-plishes or gives to the world in terms of ones creations, and (2) ones stand toward suffering, toward a fate that one cannot change. These meaning systems can be called creating experiential and attitudinal. Of these two, it is the second that stands as distinctive among other therapies and even among some existential psychotherapists.

    Frankls personal life experiences in Auschwitz demanded that he think deeply about the relationship of suffering and meaning. This experience gives his words special power and credibility. Survival in such extreme circumstances would seem to depend upon ones being able to discern meaning in ones suffer-ing. Frankl speaks of meaning coming from a childs photograph, the memory of a wife, a yet to be completed manuscript that could help others fi nd meaning (1963, p. 57). A common saying today is Suffering can make you bitter or better. That captures Frankls spirit. Even fi nally, when there is no hope of escape from suffering and death, Frankl says that there is meaning in demonstrating to others, to God, and to oneself that one can suffer and die with dignity (1963,

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    p. 21). There is hope against hope for meaningful living in the experience of death.

    Frankls logotherapy has two basic techniques: (1) De-refl ection, which was alluded to earlier, is intended to counteract the compulsive inclination to self-observation. Frankl cautions that such ignoring or de-refl ection can only be attained to the degree to which the patients awareness is directed toward posi-tive aspects. (2) Paradoxical intention which consists of reversal in the patients attitude toward his symptoms and enables him to detach himself from his neu-rosis. Here the patient is asked to experience and exaggerate (hyperpole and humor are essential ingredients for paradoxical intention) ones symptoms. This technique helps one detach oneself from ones symptoms; it allows one to view oneself dispassionately, even humorously; above all, it allows one to appreciate that one infl uences in fact, even creates ones symptoms.

    These two techniques are applicable even in the dread of death. For, even in the anticipation of death, life does not lose its meaning; for this meaning does not consist in preserving anything for the future, but rather storing it in the past (Frankl, 1963, p. 84).

    Again one must ask, does death then completely cancel out meaning? No. Frankl explains: As the end belongs to the story, so death belongs to life. If life is meaningful, then it is so whether it is long or short (1967, p. 128). Further pursuing Frankls metaphor, one would have to testify to the power of a short story. Also one must admit to the impotence of a meaningless voluminous work. The simple truth is life is fi nite and death is the limit of that fi neteness. It is then not the quantity but the quality of life, lived toward death, that deter-mines meaningful living.

    Death is a limit of fi nite being. One is not free from the conditions of fi ni-tude therefore, the dilemma of death. But, says Frankl, he is and always remains, free to take a stand toward these conditions; he always retains the freedom to choose his attitude toward them (1967, p. 82). One is free, for Frankl, to rise above the plane of somatic existence. At this point a new dimension can be determined one can enter the dimension of the noetic (spiri-tual). Here one becomes capable of taking a stand not only toward the world but also toward oneself. In short, writes Frankl, we interpret man in terms of a being capable of detaching himself from himself, leaving the plane of biologi-cal and psychological, passing into the space of the noological. In a stronger still statement, Frankl asserts that human existence is, in its essence, noetic. This is a crucial issue for Frankl, for transcending oneself signifi es the very act of existing. This tension between self and self-transcendence is what Frankl calls noodynamics. Noodynamics, claims Frankl, leaves to man the freedom to choose between fulfi lling or declining the meaning that awaits him. This tenet means that existence is authentic only to the extent to which it points to something that is not itself. Thus for Frankl, being human cannot be its own meaning. Frankl then concludes this case with words familiar to Scripture, One fi nds himself only to the extent to which he loses himself in

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    the fi rst place. Nevertheless, again one may ask, what of death? (Frankl, 1967, pp. 134138).

    Even through death, life does not lose its meaning for Frankl. Logotherapy centers on issues such as dying and suffering. This need not give it a pessimistic black eye, for essentially, what we deal with is an optimistic position; namely, the potentially meaningful (Frankl, 1967, p. 87). Logotherapy helps one con-front (not try to escape) pain, death and guilt the tragic triad of human existence. These three are inescapable in the human condition and the more one tries to deny them, the more one entangles oneself in additional suffering. One exercises freedom from the triad by becoming responsible (response-able) and by being open to the noological.

    What works against the will to meaning is the penultimate concern, the will to pleasure. Of this conceptual drive, developed and articulated by Freud, Frankl says, Pleasure is primarily and normally not an aim but an effect, let us say a side effect (1967, p. 146). In other words, pleasure establishes itself auto-matically as soon as one has fulfi lled a meaning or realized a value. It is upon such statements that Frankl fi nally says:

    The striving to fi nd a meaning in life is a primary motivational force in man. In logo-therapy we speak in this context of a will to meaning in contradiction to both the pleasure principle and the will to power principle. Actually pleasure is not the goal of human strivings but rather a by-product of the fulfi llment of such strivings; and power is not an end but a means to an end. (1963, p. 77)

    What of Frankl and anticipation? Though he never speaks of anticipatory grief as such, Frankl speaks of striving and searching. These two are indicative of an intense and intimate involvement initiated by the individual. For Frankl, one is not driven by some instinctive drive, but one senses the signifi cance in striving. One is not pushed by something, but pulled toward something. Whereas one might merely expect pleasure as likely to come about, Frankl would, for this writer, anticipate meaning as taking place in the present to be open to that possibility, to live life with that freedom and openness is to live an authentic life of anticipation, For striving is to the future as opposed to the drive from forces from the past (Frankl, 1967, p. 84). One must strive to take a stand (it takes intentionality and vitality), but one can merely expect pleasure.

    It is not for naught, this writer would argue, that Frankls original title, From Death-Camp to Existentialism, was changed to Mans Search for Meaning. To search (strive) is not to passively await something as likely to happen (expecta-tion), but to act on the possibility that something is in the process of coming or becoming (anticipation). For Frankl, one does not merely expect life to end, but one anticipates fi nitude and strives for meaningful living. It is the service of striving to anticipate meaning. This is the spiritual dimension. This striving anticipates meaning for living. This is opposed to the anxiety-delivered existen-tial vacuum of expecting pleasure in/of self to be meaningful.

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    Though Frankl does not speak of anticipatory grief (fear) per se, this writer would contend that the concept is served in the sense of striving and searching. To bolster this contention, the proper and necessary anlage of anticipatory grief is spoken about at length by Frankl anticipatory anxiety.

    Anticipatory anxiety is a term Frankl (1967) uses to speak of that which is the existential vacuum. Again and again it turns out that anticipatory anxiety thrives in the existential vacuum, (p. 77) he observes. Filling this vacuum prevents the patient from having a relapse. Refocusing him on meaning and purpose causes these symptoms to atrophy (p. 17). This, of course, is the task of striving for meaning. There is present here a great deal of tension between anticipatory anxiety and meaning, but Frankl is persuaded that the greater the strife, the greater the strive.

    The precursor of anticipatory anxiety, and that which is the collective neu-rosis of our time is existential frustration. Frankl gives the mood of existential anxiety a new clinical name existential frustration.

    Man is neither dominated by the will to pleasure nor by the will to power, but by what I call the will to meaning: his deep-seated striving and struggling, for a higher and ulti-mate meaning to his existence. This will to meaning can be frustrated. I call this condi-tion existential frustration. (Frankl, 1967, p. 77)

    This existential frustration is akin to the feeling of anxiety; again since one can discern no meaning one is anxious of nothing-ness. Only a sense of something-ness (meaning fullness) can fi ll the vacuum and thwart the frustration. The condition of the existential vacuum is the collective neuroses of our time (Frankl, 1967, p. 125), and that neurosis is created by existential frustration. This condition of the existential vacuum, however, is not pathological as such, rather it is the human condition.

    I do not want to give the impression that the existential vacuum in itself represents a mental disease: doubting whether ones life has a meaning is an existential despair. The search for meaning to ones existence, even the doubt whether such a meaning can be found at all, is something human and nothing pathological. (Frankl, 1967, p. 67)

    A common denominator for all persons is the stance one can take toward life conditions. One is free to take a stand. One cannot control conditions, but one can determine ones stance toward those conditions. Finitude is a condition of human living, but one can, and should, anticipate that condition and take a stand relative to ones fi nitude.

    OBJECTIVE EVALUATION

    The instrument used for both a pre-test and a post-test in the course the Purpose in Life Test developed by James Crumbaugh and Leonard Maholick (1969, see

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    appendix B). This tool was chosen because it was especially designed to compli-ment the work of Viktor Frankl.

    The Purpose in Life (PIL) Test is an attitude scale constructed from the orientation of Logotherapy. . . . This is a system of existential therapy, originated by psychiatrist Viktor E. Frankl . . . The scale is intended as a measure of Frankls basic concept existential vacuum. (Crumbaugh & Maholick, 1969, p. 1)

    In this writers research there was no indication of the test being used as a pre-test and post-test. Also, there were no available studies indicating that the Purpose in Life Test had been used in a course for anticipatory grief. The settings indicated were both individual and group. In a telephone conversation in 1985 with this writer, Dr James Crumbaugh, an author of the Purpose in Life Test, indicated a great interest and enthusiasm for the test to be used in conjunction with the issues of anticipatory grief. It was suggested by Dr Crumbaugh that statements #10, #15 and #16 of Part A in the test would be of particular interest to this work.

    The test itself is designed into three parts. Part A is the objective contin-uum pertinent to this section of the evaluation. The twenty scaled items of Part A are the only portion of the instrument which is objectively scored. The score is the simple sum of the numerical values circled for these items (Crumbaugh & Maholick, 1969, p. 1). The statements are on a continuum with number 1 representing little meaning and number 7 representing great meaning.

    These 20 items were compiled for each participant in both a pre-test and a post-test profi le. These same 20 items were also compiled for the group in both a pre-test and post-test profi le. The individual pre-test and post-test profi les resulted in the following fi nding:

    (1) Five of the seven participants scored higher on the post-test.(2) Five of the seven participants had scores that changed so signifi cantly that

    it moved them into another range on the Table of Norms and percentile Equivalents (Crumbaugh & Maholick, 1969, p. 4) (Four moved upward on the table; one moved downward):(a) Participant A moved from 108 (the indecisive range) to 115 (the pres-

    ence of defi nite meaning and purpose in life range).(b) Participant C moved from 97 (the indecisive range) to 89 (the range

    indicating the lack of clear meaning and purpose).(c) Participant D moved from 87 (the range indicating a lack of clear

    meaning and purpose) to 100 (the indecisive range).(d) Participant E moved from 100 (the indecisive range) to 113 (the range

    indicating the presence of defi nite purpose and meaning in life).(e) Participant F moved from 57 (a score not even included on the table)

    to 66 (indicating the lack of clear meaning and purpose).

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    (3) Two participants did not have scores that changed their range:(a) Participant B, though realizing a gain of fi ve points (from 106 to 111)

    did not change ranges.(b) Participant G realized a loss of one point (from 74 to 73) and did not

    change ranges.(4) In the pre-test, no participant registered in the top range indicating the

    presence of defi nite purpose and meaning in life. In the post-test, two par-ticipants ranked in this range (A and E).

    (5) In the pre-test, four participants registered in the indecisive range (A, B, C, E). In the post-test, two participants ranked in this range (B, D).

    (6) In the pre-test, three participants registered in the range indicating the lack of clear meaning and purpose (D, F, G). In the post-test, three again ranked in this percentile (C, F, G).

    According to Crumbaugh, The Purpose in Life Test raw scores from 94 through 112 are in the indecisive range; scores above 112 indicate the presence of defi nite purpose and meaning in life; scores below 92 indicate the lack of clear meaning and purpose (Crumbaugh & Maholick, 1969, p. 4).

    The group pre-test and post-test profi les resulted in the following fi ndings:

    (1) Signifi cantly, the participants moved toward greater meaning on statement #10, #15 and #16:(a) On statement #10 (If I should die today, I would feel life has been:) all

    seven participants recorded signifi cant movement toward meaning. All moved at least two points toward the response very worthwhile. The groups raw score moved from 24 to 35. The group average, correspond-ingly, moved from 3.4 to 4.5.

    (b) On statement #15 (With regard to death I am:) all seven participants recorded movement toward meaning. All moved at least two points (with the exception of participant G who moved only one point) toward the response prepared and unafraid. The group average, cor-respondingly, moved from 3.3 to 5.7.

    (c) On statement #16 (With regard to suicide, I have:) the participants either recorded movement or remained at the same point. The positive response, never given it a second thought, refl ected the groups move-ment from a raw score of 36 to 41. the groups average, correspondingly, moved from 5.1 to 6.3.

    (2) On paragraph A of the Purpose in Life Test, the group moved toward greater meaning with a combined raw score on the pre-test of 629 and an average of 4.4 to a combined raw score on the post-test of 667 and an average of 4.7. Using statement #10, #15 and #16 only, the movement toward meaning for the group was more signifi cant yet. The combined raw score on the pre-test for these three statements was 83. The combined raw score on the post-test for the same three statements was 117. The pre-test average for

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    the three statements was 3.9; the post-test average for the three statements was 5.6.

    In summary of the pastors objective evaluation, it would appear that the course did have a constructive effect in relation to developing a sense of meaning. Most signifi cantly, and specifi cally, and awareness of the dynamics of anticipatory grief seemed to affect meaning for the participants. This is, of course, a preliminary effort; but it should be an encouraging word to the further exploration of a proposed model.

    REFERENCES

    Crumbaugh, J., & Leonard Maholick, L. (1969). Manual of Instruction for the Purpose in Life Test (Munster: Psychometric Affi liates.

    Frankl, V. (1963). Mans Search for Meaning. New York: Simon and Schuster.Frankl, V. (1967). Psychotherapy and Existentialism. New York: Simon and Schuster.Heidegger, M. (1962). Being and Time, J. Macquarrie & E. Robinson (trans.). New York: Harper

    & Row.Yalom, I. (1980). Existential Psychotherapy. New York: Basic Books.

    Alan E. Gatewood, D.Min.Pastor Bethel United Church of Christ

    Concordia, MO 64020, USApcalan52@hotmail.com