Psychotherapy in a Death Conscious east
Mohammad San’ati, MD, FRCPsych
Head of the Unit for Individual and Group Psychotherapy
Associate Professor of Psychiatry
Academic Department of Psychiatry
Tehran University of Medical Sciences
Published on 20 September 2004
Introduction: The problem
In this paper, a very deep cultural difference existing between death conscious people of the east and Western modern man with denial of death is in focus. This is a cultural difference, which has been there for centuries, recognized by Schopenhauer in 19th century, as “the denial of the will to life” which was “more fully developed, more comprehensively expressed, and more vividly presented in the ancient Sanskrit writings than could be done in Christian church and the Western world.”  Schopenhauer was just fascinated by the peace and inward joy of a Hindu mystic, Christian or Buddhist monk, or a Tibetan Lama with total renunciation of all self-love, abstinence from all pleasures and rejection of all possessions, forsaking of his home and family, choosing a deep unbroken solitude spent in silent contemplation, with voluntary penance and terrible slow self-torture for the absolute mortification of the will, and torturing himself to the point of voluntary death by starvation, being buried alive, exposing himself to crocodiles or throwing himself beneath the wheels of a huge wagon in a state filled with unshakeable peace and profound tranquility, a state which Schopenhauer looks at with greatest longing and envy. This is perhaps similar to the heroic state of mind praised by the founder of self-psychology, Heinz Kohut in his essay On Courage, some two centuries later (1970’s). 
These are of course extreme cases of “the denial of the will” in the transition from virtue to asceticism. If they are compared with the extremes of “will to life” in western world, in particular “will to power” in Nazi Germany leading to War, concentration camps and nuclear holocaust, they would be less destructive to human life and perhaps more desirable, because of the tension free state they can produce; a state full of inward joy, serenity and true peace of heaven.
Then, what is in focus here, is not these two extremes in human understanding of life and death which still exist in our age, both in eastern and Western societies, and they have been the object of psychological and psychoanalytic studies, in order to help authors to understand the nature of these different life styles, or extreme ideologies. But they never been a problem for psychotherapy, as such, as those who live in these cultures, seldom get into trouble, because of their conflict with these world views or life-styles, to seek psychiatric help, and if so, their case would not be a great dilemma for psychotherapy as the point in question is rather clear and understandable for both side. But our dilemma in psychotherapy is with a less extreme, intermediate group in a more widespread culture, particularly among people of more traditional societies, living with technological achievements of the new civilization. they are prepared to use modern psychotherapies as modern cures, but they have been nurtured with a culture of death which is there, at least, in the back of their mind, challenging therapeutic attempts for change! and this is where we, as therapists, are faced with a serious, but perhaps not easily recognizable culturally bound problem, that is indeed, the most fundamental cultural difference between traditional eastern and modern Western cultures.
Two modles of Man and two kinds of mind
Modern psychotherapies developed to cure or change the mind and behavior of the modern man, a man of free will with conscious mind who under the control of reason, steer towards a future of unlimited progress. A rational human animal with a developed individual ego and a strong desire for life, power and pleasure. This was the ideal model of man Freud first had in mind, at the turn of 20th century when he introduced his theory and practice of psychoanalysis, aiming to cure and change the primitive, irrational and archaic part of human mind, i.e. the unconscious which was to become conscious and rational, through the process of psychoanalysis in accordance with Western understanding of ideal modern man and his values. That is why he started to build his theory on self-preservation and procreative instincts, which later became life trieb (or Eros) in his Three Essays on the Theory of Sexuality in 1905.
This was a model of an ideal modern man during renaissance and enlightment introduced by influential thinkers such as Abelard, Michel de Montaigne, and Spinoza, Descartes, Kant etc, who strongly opposed death conscious western philosophical tradition; began with Plato’s Phaedon which was continued most vigorously by Epicureans and Stoics, and later during Mediaeval, by Christian Church. And this ideal modern man which was unaffected by early 19th century philosophical teachings, particularly some of Schopenhauer’s writings i.e. The denial of the will, but actually was similar to his theory of the will to life which had a deep impact on significant and influential thinkers such as Nietzsche who echoed this anti-Christian attitude that “It makes me happy that men do not want at all to think the thought of death. I should like very much to do something that would make the thought of life even a thousand times more appealing to them.” and that was this Renaissance idea reaching 20th century which was picked up by Freud to formulate the first phase of his theory of instinct; a dualist instinct theory without Thanathos. This was, perhaps, western culture that almost had forgotten any conscious desire for death; a desire which was perhaps, introduced to the mind of civilized man by philosophical and religious teachings, through out the history of mankind.
Fear of death v Denial of fear of death
As we learn from mythological, anthropological and psychological studies, there had been no desire for death either in primitive man or in children. The oldest mythological epic available to us; the Epic of Gilgamesh is mostly about devastating fear of death and a quest for immortality. In his voyage of many dangers, Gilgamesh is accompanied by Enkidu; his close friend who is in fact his double. And when this friend-double is overwhelmed by ‘the fate of mankind’ and experienced a very sad death, Gilgamesh mourned over his loss most violently, as if mourning over his own loss. Then he cried out that he was frightened by death’ struggling to find a way out of man’s inevitable fate, he sailed through ‘the waters of death’ till finally he found ‘the spiny bush’ of immortality which he called it ‘the antidote to the fear of death’(pp196). Among Persian myth, we find ‘the myth of Alexander and The Water of Life’, which is similar to the Epic of Gilgamesh. But Alexander’s voyage is into The Darkness, accompanied by his to ministers one of which; The Prophet Khizr finally found the water of life, drunk it and became immortal, but Alexander, the king was deprived. It is not only Gilgamesh or Alexander, but perhaps all mankind have been frightened by death and were longing for immortality, one way and the other. Not only all religions and most philosophies are promising eternal world and immortal life after death, but they also, teach their followers not to fear death. There are many examples of this human desire in the world mythology; from Egyptian myth of Osiris, Sumerian Ishtar to Greek Oedysseus who went down to the underworld to return alive to the earth; challenging the inevitability of death. The voyage of Odysseus is in fact a voyage through the Waters of Death and perhaps the first western war against the symbols of death. There are also other examples such as appeal of Etana to Shamas (or Ishtar) to be shown the plant of birth (J.Campbell’s Oriental mythology pp136) and the Zoroastrian Elixir of Hom (made of the plant of immortal life), and many other well-known Greek, Mesopotamian, Roman myths which are all symbols, either for fear of death or man’s desire for immortality. We, also, know that many religions apart from promising eternal life; they also, strongly oppose any attempt of man against his life such as suicide which is considered to be a sin
But, contrary to the above world view, there is a world view coming mainly from philosophy, Gnostic teachings and mysticism, disappointed with mortal life and longing for immortality, introducing a desire for death, or a wish for a shorter life. We also learn from Plato’s Phaedon; not fearing death, and that death is the final aim of life. And a Buddhist looks at Nirvana as ultimate truth. Hindus, particularly Lingayats worship Shiva: the god of destruction. In Manichean teachings, we find that the whole life is a preparation for death, and the good Manichean is the one who wishes an early death to enter The Gardens of Lights, as soon as possible. In Iranian Gnosticism and Sufism, we find similar teachings, even the concept of “voluntary death”. A quotation ‘die before your own death’ has had great impact in Iranian Islamic culture and its recent revival is well known. Japanese hara-kiri is another example. But this is a kind of human mind manufactured by some cultures against man’s natural will to life, to overcome man’s overwhelming fear of death, particularly, at the time of inevitable disasters. And this is the very same teaching that early thinkers of modernity strongly opposed.
Therefore, Freud being brought up in modern culture had no place for death in his early theories. Then it took him so long to be able to face frightening reality of death! And that was when facing this reality was inevitable. That was in 1915, when the world War was taking numerous lives all over the Europe, when he, surprisingly, quoted Plato’s saying that ‘the final aim of life is death’ in his paper ‘some thoughts for the time of war and death’! A paper that was to be a kind of introduction for his seminal paper ‘beyond pleasure principle’. And that was. After experiencing the whole War, the loss of a favorite daughter, a beloved grandson and a close friend as well as a threat to his own life by cancer, till he managed to balance his theory with its other end: “the death trieb”. But even then, he knew that it was speculative, while strongly opposed authors such as Otto Rank and Stanly Hall who emphasized fear of death as being fundamental to all human anxieties, but Freud, still believed that castration anxiety was the basic and ultimate one. Freud writes , ‘The high sounding phrase, ‘every fear is ultimately the fear of death’۱ has hardly any meaning , and at any rate cannot be justified. It seems to me, on the contrary, perfectly correct to distinguish the fear of death from dread of an object ( realistic anxiety)… It represents a difficult problem to psychoanalysis, for death is an abstract concept with a negative content for which no unconscious correlative can be found. It would seem that the mechanism of the fear of death can only be that the ego relinquishes its narcissistic libidinal cathexis in a very large measure – that is, that it gives up itself, just as it gives up some external object in other cases in which it feels anxiety. I believe that the fear of death is something that occurs between the ego and the super-ego.(the ego and the Id pp400). And again he says at the end of the paper that:‘ ‘ These considerations make it possible to regard fear of death, like the fear of conscience, as a development of the fear of castration ( the id and the ego pp 4000 when western modern world had, perhaps forgotten old Platonic ideas regarding death;//// i.. Socratic philosophical principles in phaidon which instructed members of Academy to remember that philosophy was practicing dying and therefore not fearing death; a principle which influenced western philosophy as well as every western wise man, perhaps till the dawn of Renaissance, when philosophers such as Abelard, de Montaigne and Spinoza taught otherwise. Thus Western modern culture was lacking any conscious desire for death, although experiencing two great wars; including Napoleonic wars, forced Freud to turn to the East to borrow the concept of Nirvana from Buddhism, a tension free state similar to death as seen by Freud, but disagreeable to modern idea of man. That is why death drive has been so controversial, as the modern man has no desire for death, particularly with the insight received through Darwin’s survival theory, whereas in the east, although there is a very deep seated fear of death in human mind, but it should be kept hidden at least from the public, as there is a culture of death consciousness, widespread; in the eastern cultures from Buddhism and Hinduism to Christian monasticism, and in particular eastern Gnostic attitude towards life and death which makes one appears foolish if desiring life on earth. Therefore, one is inclined to have a skeptical, negative attitude towards life, which is indifferent, almost melancholic, mortifying the will to life and devaluing all the earthly living and whatever is mortal; desiring eternal life through death. And just because of the overwhelming power of death, which man has no control over it, makes a fatalist attitude inevitable. The death conscious man is content with whatever happens to him, knowing that this is his deserved destiny, which cannot be changed; and this fatalist attitude has motivational implications which together with a belief that this mortal life is so absurd which is not worth living, makes every psychotherapeutic effort somewhat meaningless and futile, as the respectful, mature man should not have any love or desire for anything in this world to make him dependent upon this life so that he can not depart at ease, particularly when the death is too terrifying. Thus the eastern culture finds solution in the denial of fear of death, just like what Socrates did and advised Greek philosophers to do. Then western philosophers from Greek antiquity all the way through Middle Ages believed in the same solution to the problem of death as the Wiseman of the east did: denying fear of death.
As we know Socrates drunk hemlock without any fear believing that “to philosophize is to practice dying.” Diogenes too, actually put an end to his life, and most of Lucretius book On the nature of universe is an attempt to counter fear of death.
Thus as Freud in Thoughts on war and death (1915) wrote “death was the necessary outcome of life,” but “in reality, however, we showed an unmistakable tendency to put death on one side, to eliminate it from life,” and “that in the unconscious everyone of us is convinced of his own immortality.” Then it may be acceptable that these opposites, i.e. the idea of immortality and fear of death coexist in the unconscious.
Philosophers Schopenhauer (1935) and Max Scheeler (1926) suggested “that we have an intuitive knowledge of death despite a deep-seated tendency to deny it” (Hans Jurgen Wirth 2003). But idea of immortality is not in the unconscious, at least in Jews, Christian & Muslim believers as well as Gnostics who consciously believe that immortality of the soul is the reality of human existence. But they denied the fear of death just like western philosophers suggested since Socrates up to renaissance, making that unconscious.
Importance of Fear of Death
Ernest Becker a distinguished Anthropologist in his book The denial of death introduces “one of the great rediscoveries of modern thought that of all things that move man, one of the principal ones is his terror of death” (P II). He also writes: “the idea of death, the fear of it, haunts the human animal like nothing else, it is a mainspring of human activity – activity designed largely to avoid the fatality of death, to overcoming it by denying in some way that it is the final destiny for man” (P XVII). Becker was inspired by a brilliant disciple of Freud, Otto Ronk who broke his Father’s law, by bringing “fear of death” to the centre of psychoanalysis, replacing Oedipus Complex and castration anxiety which was rejected by Freud who was denying existence of the meaning of death in the unconscious. Irvin Yalom examined Freud’s case histories and concluded that “only by a supreme effort of inattention could Freud have omitted [death] from his discussion of precipitating Traumas” (1989).  Freud denies the knowledge of death even in children (1900).  But Anna Freud who knew about children better than her father writes that “all the children who were over two years realized the house will fall down when bombed and that people are often killed.”  Ernest Becker in his book on the bases of data from several disciplines of human sciences tries to show that the fear of death is a universal and according to Otto Rank’s ideas, human culture was created as a response to fear of death.  But universality of fear of death may be questionable.
Freud said once “This attitude of ours towards death has a powerful effect on our lives, life is impoverished, it loses in interest, when the highest stake in the game of living, life itself may not be risked.” He clearly stated very important point that “The tendency to exclude death from our calculations in life brings in its train many other renunciations and exclusions” (Thoughts on war).  Then he wrote in “beyond pleasure principle” that “The aim of all life is death” when introducing death drive or Thanathos; a concept rejected by many.
Point of departure
Perhaps one can see from what has been said that western man’s attitude towards life and death was not very much different from eastern cultures in the written history of ancient past. Human being from his childhood has knowledge of death & dying which made him fearing death, and desiring immortality that is still apparent in human behavior and his production of art as well as his neurotic, and psychotic symptoms in reaction to traumas and stressful events, threatening human life. Not only eastern religious teachings and Gnostic, Mystic sects emphasized the immortality of the soul to counter fear of death and reduce pains of dying, but great philosophers of ancient Greece had similar way of life. Although their thinking was not so much polluted with mythical material, as one finds in eastern cultures.
It was perhaps from Renaissance & enlightment that western man began to depart from main stream of traditional civilizations, first, by departing from cultures dominated by mythical thinking and pre-modern cultural structures. The newborn man was in fact a newborn individual, with a new identity; emerging from his self-incurred immaturity with an independent self in relation to the other. A man who can use his own understanding and consciousness, motivated to change himself and the world around him; capable of overcoming his own problems in everyday life with hopes of progress in the future.
This was a man who had enough courage and integrity to face his own fear of death, following Michel de Montaigne who first unmasked philosophers of the past for their denial of fear of death (1580) to follow by one of his contemporaries; Francis Bacon (1595) who saw universality of this fear. Some 50 year later Thomas Hobbes put fear of death at the centre of his political thoughts (1651) saying that in “a state of war of every man against everyman,” and a “continual fear and danger of violent death one has to surrender oneself to a sovereign power, the Leviathan!” It is interesting that most writings about death were produced at the time, or just after the wars. Freud mentions this in his essay: “It is evident that war is bound to sweep away this conventional treatment of death. Death will no longer be denied; we are forced to believe in it.” Even novels about death; crime novel, Gothic stories, ghost novels produced after Napoleonic wars or during 20th century.
From mid-seventeenth century, western thinkers rarely wrote about death. Death was suppressed or denied, as much as sexuality & love. It was just about early 19th century and just after Napoleonic wars that Hegel and Schopenhauer wrote about death. Hegel takes fear of death into the dialectic of “Master & Slave” relationship; which is history as class struggle and Schopenhauer sees human being as the “will to life”. In his theory, birth and death belong in like manner to life and hold the balance as reciprocal conditions of each other. He finds Siva, in Indian mythology the best example of this balance. The very God who symbolizes destruction and death is given not only the necklace of skulls, but also the lingam, the symbol of procreation. Then he goes on to explain the fear of death and felt consciousness of immortality which does not prevent the individual from living seized with the fear of death. And this is very true even in death conscious cultures. Where except for the extreme examples of Gnostic renunciation of life, belief in immortality coexists with terror and pains of dying. As there would be pain and punishment awaiting the sinner. Schopenhauer says “what we fear in death is the eclipse of the individual” and the possibility of nothingness. To overcome the terror of death, a person accepting that his life should endure forever or repeat itself over anew. Such a person, theoretically has nothing to fear. This is what Nietzsche would call “The optimism that is the basis of western culture.” Schopenhauer calls this the “affirmation of the will to life”, and is opposite is “the denial of the will to life”. The most obvious example of that is Christianity, the ethics of which is entirely in this spirit and lead not only to the highest degrees of philanthropy, but also renunciation of life and pleasure, to endure all possible insults without resistance, to practice abstemiousness in eating and drinking, to suppress passion and what is the first stages of asceticism.
This is a style of life modernity resists, but it is a widespread culture in the more traditional eastern societies, resisting will to life. They have brought death from the end to the beginning. Whereas still in post-modern west, experiencing 2 world wars, with its horror of nuclear Holocaust, and a terrifying cold war, fear of Aids, terrorism, military invasions, September the 11th and after, followed by numerous human disasters; like Bam Earthquake. But still Jacques Derrida, talking about death, he sees it as an impossible possibility, and Jean Baudrillard writes about “the illusion of the end”!
But in my view, western modern culture, despite its skeptical attitude towards death, has brought fear of death from the back to the fore, turning it into a creative and productive tool, defending survival of human community against destructive forces.
Death Consciousness and Renunciation of Life: A cultural inertia
In the east, from old Vedas, Upanishads, Bhagavad-Gita and Hindu religions such as Siva religion to Buddhism, Christian monasticism, Persian Gnostic religions, i.e. Manichean teachings and Sufism are mostly death conscious way of life. Yama (Jam), the king of the dead said:
“The wise one is neither born, nor does he die. He is unborn, constant. Eternal, primeval”. 
It can be seen that there is a denial of death together with acceptance of its reality in eastern cultures. For Krishna, death is not something to be grieved over, but to be accepted as the natural course of events. There is no escape from it. In the second place, there is no such thing as death. There is something eternal in man that is not destructible. For Gita there is endless series of births and deaths. For Buddha immediate concern was suffering and how to overcome it. The first Noble Truth is the existence of pain, which includes despair, disease and death, and at the root of all suffering was desire stemming from ignorance.
Then, asceticism, and renunciation of desire, pleasure and self-love is the aim for those who strive for perfection. Among other things, rejection of all possessions, genuine unconcern, and indifference to all worldly things are prescribed.
Mani, the prophet, taught his followers not to marry, not to work, not wash; just to live on charity! Withdrawing from life to have enough time for prayer and asceticism, one should have his back to life, desiring death; it is the only path to eternal life in gardens of lights.
In some ways the Sufi conception of passing away (Fana) of individual self is Manichean and Upanishadic, but Fana is not the same as Nirvana. Though both terms imply the passing away, Fana involves the extinction of all passions and desires, the holding back of the senses; it is to possess nothing and to be possessed by nothing. Sufism, like the Upanishads, calls for the giving up of desires as a means to attain god. This calls for the eradication of self-will.
Although Sufism and other Gnostic sects have limited followers, but Gnostic ideas and Sufi’s way of life and their teaching have been there since Mongols and Turkmen’s invasion of Iran, and the centuries of experiencing death, genocide, terror, destruction and horrifying disasters. When there was no feeling of security, hope and safety, renunciation of such a dreadful life by Sufis seemed attractive that is why it became part of day to day life for some people in Iran. The whole Persian poetry is filled with such ideas and teachings, which could be called the culture of death consciousness, or just the culture of death. Where there is very little will to life, life is worthless, corrupt, and decaying; and one has to look into death as the only way to salvation and eternity. Therefore, respectful man should not have any love or desire for anything in this world which can make death difficult for him. This obviously brings about a cultural inertia. The death conscious man, should be aware that, from his birth, death is there awaiting him, and he should be prepared to surrender himself to it. Sufis “Chele-Neshini” (a recluse-sitting) with very little food and stimulation is, in fact, a practice for dying.
This is where problem of modern psychotherapy in a death conscious society appears. Methods and techniques based on will, life drive or life skills, could be meaningless to those being brought up in such cultures, whether one should go along with their world view, or impose ideals of modernity, is a very important question to be answered.
My clinical experience in the group
My clinical experience with death consciousness is mostly coming from single-sex groups which I’ve been running during past 18 years, with a population over 2500 patients attending these groups. The pile of data gathered, shows a spectrum of personality structures, dominated by death-consciousness and its consequences. The patients’ resistances did not allow any change unless the problem of death conscious attitude was dealt with appropriately.
Presented at the Asian Congress of Psychotherapy in Tehran 2004
 Schopenhauer, A. (1935). The World as Will and Idea. Trans. J Berman. The Everyman Library. 1995. p 243.
 ibid. p 243.
 Kohut, H. (1985). Self-psychology and Humanities. WW Norton & Co Inc. p 5-50.
 Yalom, Irvin (1989). Existential psychotherapy. N.Y. Basic books. p 62.
 Freud, S. (1900). Interpretation of Dreams. S.E. p 260.
 Freud Anna (1936). Quoted in Yalom. 1989. p 88.
 Becker, Ernest (1973). he denial of Death. Free press. p xvii.
 Freud, S. (1915). Thoughts on war and death. Sec. iv. p 241.
 Kamath MV. The Philosophy of Life and Death. Taico Pub. p 9.