General

o I am still haunted by my memory of the words of a survivor of the 2004 tsunami

who I met in a rural northeastern region of Sri Lanka: I lost my wife, my
daughter, my boat for fishing, and even, literally, the shirt off of my back. I have
no spirit. Life has lost its meaning. What is there? Considering prescribing
this clearly and understandably depressed man antidepressant medication
seemed especially disproportionate to these existential concerns. five
essential elementof mental health disaster response: reestablishing safety,
reducing emotional arousal, developing a positive perception of both
individual and community capacity for coping and recovery, constructive
social support, and fostering hope (Hobfoll et al., 2007).
o

All that they were missing, I desperately shut out. I was terrified of everything
because everything was from that life. Anything that excited them, I wanted
destroyed. I panicked if I saw a flower. Malli would have stuck it in my hair. I
couldnt tolerate a blade of grass. Thats where Vik would have stamped. At
dusk I shuddered when I glimpsed the thousands of bats and crows that
crisscrossed the Colombo sky. I wanted them extinct, they belonged in my old
life, that display always thrilled my boys.

Phases

Impact phase (few hours)

Rescue and Stabilization Phase (0-2d)
Early responses (0-4wks)
Return to Life

Life does not return to normal before weeks and months have
passed. Yet, within few weeks, survivors are called to regain many of
their functions, i.e., go back to work, become a nurturing parent,
resume social activities. None of this is easy or natural.Loss of
resources may be poignant. Superficial adaptation to concrete tasks
may mask ongoing grief, or shattered life. This is a time where
diseased survivors are salient,because they cant make it back. This
is also a time for definite clinical diagnoses and treatment. Cognitive
behavioral therapy (CBT) and pharmacotherapy are the two main
options (Table 11.3) but couple therapies, supportive groups, or
planned recreational activities may help. When trauma is repetitive,
classical therapies have to be modified as in the following example.
(Shalev 2003)

o existentialism

In crises brought on by, e.g., trauma, severe illness or loss of beloved ones,
the veil that usually hides our mortality from us is momentarily lifted and we
may feel strangely distanced not only from others and our own ordinary
engagement and interests in the shared, cultural world but even, in a very
fundamental way, from ourselves. Coming to terms with oneself and

understanding oneself in a situation of self-alienation are in that sense

inherent aspects of the human condition. (Grn, Arne. Self alienation)
principlesa
alienationfeelings of estrangement from some aspect of a persons
existence (nature, others, and self)results in loneliness, emptiness,
and despair and is the antithesis of Heideggers being-in-the-world.
o In the more rare occurrence of Angstbrought on by the
existential vacuum being revealedit is properly nothing (the
void, the vacuum) that makes us feel anxiety. In Angst we
dont find ourselves in fear of this or that, but we lose
ourselves to the void in our existence
o Angst reveals the nothing of our existence by stripping away
objects from us as they then toward us. Its a hard notion to
wrap ones head around. The objects dont just disappear. But
Heidegger explains that we approach these objects with a
feeling: unheimlich.
Alienation Cellphones, emails, Snap Chat, Facebook,
Twitter, Foursquare (do people still use that?) etc. etc., all fall
through ones fingers as one suddenly realizes their true
function: to keep one numb, and stupefied toward the
meaninglessness of ones life. One then slips awaya off the
grid. The white noise that once kept one connected one now
feels a stranger to.
Misanthropy Ones blood will boil at the very sight of those who
are actively absorbed in the objects (esp. those Pollyana fuckers) that
have just now evaded the frustrated individual. While others are
engaged in the drama of human existence the existentially frustrated
individual will walk around the street with a perpetual gag in the back
of his or her throat at the very sight of those drones whose canceled
face is too far-gone in their cellphones.
Self-Hatred Occurs only after the frustrated individual realizes it is
usually his or herself whose nose is only an inch away from the dull
glowing touchscreen. Please note, these gadgets exacerbate the
vacuum, theyre not the origin (dont be pissed at the gadgets).
Uncleanliness Hygiene is something most of us keep up as
courtesy for the other. If ones close relationships are seen as
meaningless, then surely impressing the pretty dentist is futile, as the
dentist will never go near that filthy mouth, so hygiene is then liable to
fall by the wayside. One is likely to redefine the word cavity to a
positive: another place to store small shit (e.g. snowcaps, wasabi
peas, and nerds).
Idleness The holiday of fools is the direct result of the inability to do
anything. Its not like one actively wants to do nothing, but most
everything by now is labeled as it truly is: purposeless. Its hard to do
things without a purpose or any end in-sight. So excessive thumb
twiddling is common during idleness (thumb twiddling lacks a telos),
or rearranging things that dont need rearranging, in which case
idleness turns into something worse: unproductive productivity.
Above are the more deeply intrinsic psychological symptoms one faces when
the existential vacuum has effectively sucked away the thin coding that is

lifes meaning. But there are other more delightfully engaging and stimulating
manifestations, for instance: increased sexual libido, drugs, and drinks.
But there is another grave potential eventuality: suicide (suicide is also a
stimulation of sorts, insofar as it is not passive).

Peter Wessel Zapffe, a Norwegian philosopher and adherent of nihilism and antinatalism,
asserted in his book, The Last Messiah, four ways that he believed all self-conscious
beings use in order to cope with their apprehension of indifference and absurdity in
existence, comprising "anchoring", "isolation", "distraction", and "sublimation" [3]:
o Anchoring is the "fixation of points within, or construction of walls around, the
liquid fray of consciousness". The anchoring mechanism provides individuals with
a value or an ideal that allows them to focus their attentions in a consistent
manner. Zapffe also applied the anchoring principle to society, and stated "God,
the Church, the State, morality, fate, the laws of life, the people, the future" are all
examples of collective primary anchoring firmaments.
o Isolation is "a fully arbitrary dismissal from consciousness of all disturbing and
destructive thought and feeling".
o Distraction occurs when "one limits attention to the critical bounds by constantly
enthralling it with impressions". Distraction focuses all of one's energy on a task
or idea to prevent the mind from turning in on itself.
o Sublimation is the refocusing of energy away from negative outlets, toward
positive ones. The individual distances him or herself and looks at his or her
existence from an aesthetic point of view (e.g. writers, poets, painters). Zapffe
himself pointed out that his written works were the product of sublimation.

Religious
o General

A most ancient and familiar story of peoples struggle with faith and meaning
in the face of disaster is the Book of Job. In the story, a righteousand
exemplary patriarch is smitten by a series of disasters, which rob him of his
property and livelihood, take his sons and daughters and families, cover him
with sores and illness, and call into question his faith. He cries out to his God
and struggles to make meaning of his suffering. His wife responds differently
and is ready to abandon faith altogether. His friends, on the other hand, urge
him, argue with him, and badger him torecognize his own sin that has
brought on these disasters. Job maintains his integrity and his relationship
with God. While the characters in the story come from a shared religious
tradition, each individual has a different faith response to this experience of
disaster. Disasters affect communities by overwhelming their capacity to
address physical and emotional needs, by destroying resources, disrupting
important attachments and relationships, threatening safety, and exceeding
individual and community capacity to make meaning of the events (Hobfoll et
al., 2007).
research in mental health, spirituality, and disaster indicates that individuals
ways of viewing the Deity and making meaning of disaster account for
different perceptions of the helpfulness of spiritual coping.

Patterns of findings in the mental health research on spirituality

andtrauma are emerging with increasing clarity. For example, in a
study of survivors of the Oklahoma City bombing in 1995
(Pargament, Smith, Koenig, & Perez, 1998) researchers found that
those accessing certain types of religious coping strategies emerged
with better mental and spiritual health. These effective religious
coping practices include viewing the Deity as benevolent,
collaborating with the Deity in problem solving, seeking spiritual
support, providing spiritual support to others, attempting to stay true
to ones faith, seeking new spiritual direction, practicing forgiveness,
and trying to develop a stronger relationship with the Divine
(Pargament, et al., 2000; Pargament et al., 1998).
On the other hand, another set of religious coping strategies were
associated with reduced coping effectiveness. These strategies
included viewing the Deity as punishing, attributing the stressor to the
work of the devil, and viewing he community of faith as unsatisfactory
(Pargament et al., 1998, 2000).
Harris et al. (2008) identified two distinct religious responses to
trauma. One type of response, called Seeking Spiritual Support was
associated with higher levels of posttraumatic growth. Seeking
spiritual support was characterized by the effective religious coping
strategies noted above, as well as engaging in prayer to stay calm, to
accept the situation, and to ask for help with coping tasks (Harris et
al., 2008). The other response, called Religious Strain, was
characterized by the ineffective religious coping strategies detailed
above, as well as high levels of religious fear and guilt, and feelings
of alienation from the Deity. Religious Strain was associated with
post-traumatic stress disorder (Harris et al., 2008).

Techniques
prayer
Hood and colleagues considered prayer as the most intensely
personal type of religious ritual (1996, p. 394) and proposed that in
prayer people seek new meanings that portend hope.
Rituals
Ritual has been defined as a ceremonial act or as an act or series of
acts regularly repeated in a set and precise manner (MerriamWebster OnLine). A more detailed definition from within the field of
psychiatry is as follows: Rituals are group methods that serve to
maintain a cultures social structure and its norms, strengthen the
bonds of individuals to their communities, assist adaptation (to
change or crises), manage fear and anxiety, and ward off threats
(Danieli & Nader, 2006).
Rituals and ceremonies, in fact, can be put to therapeutic use.
Johson et al. have written about the three effects that ceremonies can
have in helping patients with posttraumatic stress disorder (PTSD;
Johson et al., 1995). There is good reason to believe that these

effects can be generalized to traumatized populations, irrespective of

whether PTSD is at issue. First, rituals compartmentalize the trauma,
creating a safe and contained space within which to face the
emotions of the experience without flooding the rest of life. Second,
these events not only recognize the trauma but also become
metaphors for transformation and change. Third, rituals and
ceremoniesembody attachment to the family, the community, and
society at large, reflecting a shared journey away from what
happened.
What does this routine ritual have to do with flexibility? It is a teaching
that time is needed to gather together and create ceremony and ritual
in a regular way to honor the parts of us that have died or been
destroyed. When this doesnt happen, we cant gather together to tell
our stories, ritualize the moment, and connect to that which we have
lost. In my experience as a chaplain and psychotherapist, it has been
essential to clients and patients healing process to have a set ritual
of remembrance. It becomes a touchstone of their year. Without such
a time, they tend to drift in the sea. Each loss, each disaster, and
each change echoes each loss. How do we create a container
through ritual to hold this so that we as a culture can become totally
alive? What I mean by fully alive is to be connected to a larger order
of being. This differs from a psychological sense of aliveness in that
typically, although it is changing, psychological aliveness tends to be
limited to that persons specific life.
I have had the opportunity to participate in every disaster to which our
organization has responded since its founding in 1998, ranging from
aviation disasters, such as the 1998 crash of Swissair Flight 111, to
terrorist attacks like 9/11, to natural disasters, such as the 2008
Sichuan earthquake in China. I have witnessed the role of rituals and
routines across disasters, cultures, and countries and believe they
are a central aspect of the psychological and spiritual experience of
recovery.
I have had the opportunity to participate in every disaster to which our
organization has responded since its founding in 1998, ranging from
aviation disasters, such as the 1998 crash of Swissair Flight 111, to
terrorist attacks like 9/11, to natural disasters, such as the 2008
Sichuan earthquake in China. I have witnessed the role of rituals and
routines across disasters, cultures, and countries and believe they
are a central aspect of the psychological and spiritual experience of
recovery.

Delivery
For the past 16 years, we have examined the roles of clergy as de facto
mental health care providers, and the interactions between clergy and mental
health professionals, in providing care for persons with emotional needs. One
of our surprising findings was that while a majority of clergy was willing to
work with clinicians to help with mental health problems, fewer clinicians

recognized a role for collaboration with clergy. Rather, clinicians saw clergy
as one-way referral sources. In the context of disaster, clergy tend to be
viewed as leaders of commemorative rituals, as well as assets to provide
infrastructure for distributing basic needs (e.g., food, clean water, and
information semination). These actions are seen as distinct from clinical care.
This is an illogical stance as treatment must follow diagnosis. Diagnosis
begins with the recognition that a person demonstrates change from some
baseline behavior. We do not grow up under clinical care. We grow up in
communities. We raise ourselves and our children in communities. his
community context is our baseline. It is to this context that we wish to be
restored. When community clergy are full members of the disaster response
team from its inception, they can provide information to help determine if
individuals emotional well-being has changed from their normative baseline.
This information will be both biographical and cultural.
Unlike clinicians, clergy expect and hope to see their congregants as often as
possible through the course of their lives. Through their relationships with
congregants, clergy acquire comprehensive information, which (with consent)
they could share with clinicians. The clergys personal familiarity and
experience can be invaluable to facilitating appropriate and continuous
mental health care for their parishioners through contextualizing an
individuals response to disaster by sharing salient aspects of the persons
life history and cultural worldview with the treating clinician.
What follows (see Figure 16.1) is a description of a model of Clergy Outreach
and Professional Engagement (COPE)

Secular
o General
Despite this,German patients (religious) trust in a higher source of support
was rather moderate, and their (spiritual) search for meaningful support and
access to a spiritual source was moderate to low [7]. Thus, although the
intensity of engagement or the number of patients with strong
spiritual/religious convictions and beliefs might differ from more religious
countries such as the United States, many patients in secular societies such
as Germany also use their spirituality/religiosity as a strategy to cope with the
implications of their pain disease. (Bssing 2009)

CBT

Cognitivebehavioral therapy (CBT) identifies mental schemas such as

personalization, overgeneralization, and catastrophizing. These represent
patterns of distorted thinking that inhibit appropriate action. CBT is designed
to promote awareness of these distortions and positively reinforce adaptive
behaviors based on rational thought processes.
CBT is based on the Cognitive Model of Emotional Response.
Cognitive-behavioral therapy is based on the idea that our thoughts cause
our feelings and behaviors, not external things, like people, situations, and
events. The benefit of this fact is that we can change the way we think to feel
/ act better even if the situation does not change.
Buddhist psychotherapy
General
The Buddha's moethod of resolving this dilemma was to encourage
"not-knowing." "Keep that 'don't know' mind!" screams the Zen
master. Cultivate "the faith to doubt," ecnourages the contemporary
Buddhist author Stephen Batchelor.

Because there are several sub-schools of psychotherapy and Buddhism from

which to integrate, there currently is no single formalized clinical approach to
its practice. Therefore, Buddhist psychotherapy differs widely in its
presentation among diverse practitioners.
What Buddhism is concerned with is teaching us to modify our desires so we
are less likely to be in conflict with the way things are and how to remain
calm and content when they do conflict with the way things are.

Buddhist psychotherapy views our usual state of mind as significantly

underdeveloped, dysfunctional, and outside of our conscious control. In
short, we are all delusional from this perspective. Our state of dysfunction
goes unrecognized because it is so common that it is considered ordinary.
There are a number of defense mechanisms within a persons mind that
conceal the level of dysfunction from oneself and others, thus perpetuating it.
The entire range of psychological sufferingfrom mere dissatisfaction to
severe psychopathologyis a function of this untrained mind, which has
been adversely habituated away from its natural state of balance and health.

The dysfunctional mental tendencies of unconsciousness, inaccurate

perception, unrealistic cognitions, disturbing emotions, and reactive actions
are all rooted in a single, deeply ingrained misknowledge (avidya) known as
the evolutionary self-habit (atmagraha). Our state of dysfunction and its
resulting suffering are created from a causal cycle of psychological processes
originating from this self-habit, which is captured succinctly in verse 2.3 of the
Yoga Sutras of master Patanjali: avidy-asmit-rga-dves a-abhiniveah
kleh . The self is mistakenly reified (assigned ontological realness), then
erroneously experienced as a separate entity, becoming preoccupied with its
own security and identified with its own traumatic narrative. It then grasps at
external experiences and objects due to fear-based attachment, rages at
externalized threats because of entitled defensiveness, and clings
unrelentingly to its autonomy in the face of inevitable change and death.

The Buddha understood the traumas of everyday life, but he was

determined to challenge both the protective reactions of dissociation and the
underlying hoeplessness that accompanies them...They codified his pivotal
understanding that the path out of fear and dissociation depends on the
abilify to use reflective awareness to study the nature of everyday existence.
[trauma]
mindfulness practices

auto-suggestion used to induce relaxation;

meditation "to achieve a higher degree of non-attachment, of nongreed, and of non-illusion; briefly, those that serve to reach a higher
level of being" (p. 50).

Mindfulness Based Stress Reduction (MBSR)

This 'work' involves above all the regular, disciplined practice of

moment-to-moment awareness or mindfulness, the complete 'owning'
of each moment of your experience, good, bad, or ugly. This is the
essence of full catastrophe living

o Supportive-expressive group therapy (SEGT), is explicitly focused on social and

emotional support for discussions of dying and reordering life priorities in the face of
death (Spiegel, D 2015)
o

Dignity Therapy to help with psychosocial and existential distress among terminally ill
patients. (Spiegel, D 2015)

Narrative theory postulates a link between healthy mental life and a

congruous, coherent, and meaningful life story or narrative. (Shalev 2003)
Indeed,traumatized survivors do develop symptoms and changes in
temperament, arousal, and world views. (Shalev 2003)
When survivors find it impossible to narrate the event, their capacity
to create a meaningful story of the trauma, and later integrate it in
their wider life narrative, may be impaired. In contrast, being able to
tell or write a coherent story of a traumatic event may lead to
integration and better coping (Shalev 2003)

Those who develop PTSD are, infact, ill. Yet the relationship between
the traumatic hiatus on ones life narrative and the development of a
mental condition such as PTSD may also be circular, one dimension
feeding another. Thus trauma therapists may wish to address the
narrative as much as the underlying and ongoing symptoms in an
attempt to reverse the consequences of a traumatic event. (Shalev
2003)

Dignity Therapy was developed by Dr. Harvey Max Chochinov to assist

people dealing with the imminent end of their lives

This brief intervention can help conserve the dying patient's

sense of dignity by addressing sources of psychosocial and
existential distress. It gives patients a chance to record the me
aningful aspects of their lives and leave something behind that
can benefit their loved ones in the future.

During a 30 to 60 minute session, the therapist asks a series of

open-ended questions that encourage patients to talk about
their lives or what matters most to them. The conversation is
recorded, transcribed, edited and then returned within a few
days to the patient, who is given the opportunity to read the
transcript and make changes before a final version is produced.
Many choose to share the document with family and friends.

It addresses the dying patient's need to feel that life has had meaning, and to
do something for loved ones that will endure beyond the patient's own life. It
also helps the patient get in touch with the accomplishments and experiences
that have made them unique and valued human beings.

The dying patient's strong need for "generativity" and "legacy" is the basis for
the therapy. The therapy creates something that will transcend the patient's
death and extend his or her influence across time. Capturing the patient's
thoughts in written form is particularly effective because it increases the
sense that whatever is said will be preserved for the future

However, simply creating the legacy document is not enough.

Those who practice Dignity Therapy must listen to these stories
with genuine empathy, attentiveness, interest and sensitivity.
Anything less will fail to meet the patient's need for treatment
that is unconditionally positive and caring in tone.

QUESTIONS

"Tell me a little about your life history, particularly the parts that you
either remember most, or think are the most important. When did you
feel most alive?"

"Are there specific things that you would want your family to know
about you, and are there particular things you would want them to
remember?"

"What are the most important roles you have played in life (family
roles, vocational roles, community service roles, etc.)? Why were
they so important to you, and what do you think you accomplished in
those roles?"

"What are your most important accomplishments, and what do you

feel most proud of?"

"Are there particular things that you feel still need to be said to your
loved ones, or things that you would want to take the time to say
once again?"

"What are your hopes and dreams for your loved ones?"

"What have you learned about life that you would want to pass along
to others? What advice or words of guidance would you wish to pass
along to your (son, daughter, husband, wife, parents, others)?"

"Are there words or perhaps even instructions you would like to offer
your family to help prepare them for the future?"

"In creating this permanent record, are there other things that you
would like included?"

Existential psychotherapy
MCT
The issue of coping with life-threatening illness and experiences was
studied more than 35 years ago by Antonovsky [6], who introduced
the salutogenic theory. He argued that a sense of coherence or
making sense of the world is a major factor in an individuals
management of stress and illness, and staying healthy. (Antonovsky
A. Health, stress and coping. San Francisco: Jossey-Bass; 1979)
Several researchers have assessed both mood symptoms and
spirituality and existential concerns in the context of cancer and brain
tumor (Ownsworth)
Having the opportunity to express ones fears and values about life
and death in a safe and supportive context can make a profound
difference to a persons sense of inner peace and hope for the future.
(Ownsworth 2015)
examining the meaning and purpose of ones life can enhance
peoples psychological adjustment to brain tumor. Adopting a sense
of coherence framework, Strang and Strang explored how people
make sense of, cope with, and find meaning in their illness. Some
participants generated their own theories and explanations for their
illness to increase comprehensibility, and drew upon personal and
social resources to increase their sense of control and manageability.
(Ownsworth 2015)
Other qualitative studies have reported similar themes in terms of
enhanced relationships, redirecting the focus to living in the here and
now, and an increased sense of meaning and purpose in life. For
example, a patient with glioma stated: I am looking here and Im
thinking, what are we pushing for all the time? Sometimes you should
actually just sit back and enjoy what youve got and relax These
accounts reinforce existential theorists proposition that facing
mortality provides an opportunity for reconsideration of life values
(Ownsworth 2015)
Existential psychotherapy
logotherapy
o

o
o

Awareness of the world from which the person feels

alienated enables mental health professionals to know where
the pain exists so that it can be restored and reveals what
other worlds can be nurtured to facilitate survival
A) Creating a work, or doing a deed. Very Similar to Camus,
who argues that we can either commit suicide in the face of
absurdity, or create our own work of art that is our life.
B) Experiencing something or encountering someone (esp.
LOVE). Vague I know, but the people in our lives obviously

impact us a great deal. We need them and they need us, we

experience each other.
C) By the attitudes we take toward unavoidable suffering.

Frankl survived four death camps during

World War II. He experienced
incomprehensible suffering, suffering that he
identified at the time as meaningless. People
in the camps, he said, either committed
suicide in one form or another or they
continued to live despite the meaninglessness
of their suffering. If this guy could discover
meaning in Auschwitz, why cant most of us
do it in big cities where there is an abundant
supply of sushi and pizza?

Carl Rorgers Person centered therapy

o What makes person-centred therapy distinctive from some
other forms is the extent to which the power and direction is
centred in the client

o Unlike other therapies the client is responsible for improving

his or her life, not the therapist. This is a deliberate change
from both psychoanalysis and behavioral therapies where the
patient is diagnosed and treated by a doctor.

6 conditions required for therapeutic change

Therapistclient psychological contact: a

relationship between client and therapist must
exist, and it must be a relationship in which
each person's perception of the other is
important.

Client incongruence: that incongruence exists

between the client's experience and
awareness.

Therapist congruence, or genuineness: the

therapist is congruent within the therapeutic
relationship. The therapist is deeply involved
him or herself they are not "acting"and
they can draw on their own experiences (selfdisclosure) to facilitate the relationship.

Therapist unconditional positive regard (UPR):

the therapist accepts the client
unconditionally, without judgment, disapproval

or approval. This facilitates increased selfregard in the client, as they can begin to
become aware of experiences in which their
view of self-worth was distorted by others.

Therapist empathic understanding: the

therapist experiences an empathic
understanding of the client's internal frame of
reference. Accurate empathy on the part of
the therapist helps the client believe the
therapist's unconditional love for them.

Client perception: that the client perceives, to

at least a minimal degree, the therapist's UPR
and empathic understanding.

Core interrelational condtions

Congruence the willingness to transparently

relate to clients without hiding behind a
professional or personal facade.

Unconditional positive regard the therapist

offers an acceptance and prizing for their
client for who he or she is without conveying
disapproving feelings, actions or
characteristics and demonstrating a
willingness to attentively listen without
interruption, judgement or giving advice.

Empathy the therapist communicates their

desire to understand and appreciate their
client's perspective.

o Tylenol

Previous studies have shown that physical pain and social pain -- like the
pain of feeling left out of a game -- have evolved to use similar neurological
mechanisms. They activate the same regions in the brain that respond to
unpleasantness. When you take acetaminophen, MRI scans have shown,
those parts of your brain activate less and you register less pain -- be it the
pain of a sprained ankle or the pain of feeling left out.

Building off this research, scientists in Steve Heine's lab at the University of
British Columbia wanted to see if acetaminophen could also dampen those
feelings of uncomfortable uncertainty that occur when our sense of the

meaning of life is threatened -- like when we think about our death or watch a
surrealist film.

Both experiences were designed to make participants feel unpleasantly

uncomfortable, but researchers found that those who were taking Tylenol
were less affected by the experiences than those who were taking a placebo.