Existential Psychotherapy Part 1: Death

Preston: [00:00:00] In a survey of several hundred people, why be afraid of dying? Seven common answers are, are what came up. 

Margaret: It's like the least fun version of Family Feud. 

Preston: Yeah. 

Margaret: Ding. 

Preston: Show me. Show me seats Show. Show me Ovi. Ding. 55 people how to be.

And welcome back to How Do We Patient the podcast where we don't do a lot of how to, but do a lot of yapping and so you will have to be patient at some point about 

Margaret: death, you know? 

Preston: Yeah, yeah. 

Margaret: To the podcast about death. 

Preston: Just 

Margaret: kidding. There's enough of those. 

Preston: This is the, this is the Death podcast. I was trying to be light introducing that a little bit, but yes, so.

This is a topic that I think about all the time, actually, so I figured why not use the podcast to discuss this? 

Margaret: Why not us here for four? Just kidding. 

Preston: Yeah, so it, it's, it's interesting this, [00:01:00] this came up to me because, um, like some of my mentors in therapy are very interested in existential psychotherapy, which is ultimately what this is kind of all related to.

So I originally wanted to actually do a single episode covering all the ex existential psychotherapy and then realized covering everything 

Margaret: in life, 

Preston: I would need to literally. Talk like Busta rhymes for 90 minutes straight to try to like scratch the surface on that. So I said, what if we broke it up into a series and talked about some of the fundamental pillars.

And so this is gonna be the first part in that series, talking about my two favorite things, existentialism and psychotherapy and them like combining a little bit. Mm-hmm. I guess 

Margaret: what, like, so your mentors have talked about this, but like what, why are you interested in this approach? 

Preston: Um. So it's, it's funny because I think as a college kid, I, so as a biochemistry major, but I always found myself attracted to like reading, like existentialist [00:02:00] authors and texts and like pondering, like why do all the things that I'm doing, you know, and that I ended up, you know, reading like.

Kafka and Kao and Play-Doh and I went to this like Play-Doh book club for all of college. So, so I just found myself very interested in, in philosophy and I, I'm gonna eat some of my words from prior episodes when I think I was critical of psychodynamic therapy. Um, because I, I think this like, maybe it was suppression or denial or something, this, this like pragmatic part of me, like wanted to, to measure something.

I felt the need that like there has to be some kind of like empirical data to it and. Like the, the frank truth that when you're dealing with those fundamental questions of existence is that you can't measure it and you, you kind of have to accept that a little bit. And I, and I, I always score 'em around that.

So anyways, when I realized that there was some therapist taking a specifically existential approach, I, I [00:03:00] naturally like, kind of ped my interest and then I, I wanted to learn more about it. So that, that's kind of how I, I found myself here and, and I guess the reason why I'm kind of tucking my tail and saying sorry to psychodynamic about criticism I've given in the past is that existential therapy is like really fundamentally like rooted in psychodynamic therapy.

Margaret: Mm-hmm. Yeah. No, that's interesting. It's interesting to hear how you like, came to be interested in, 'cause it feels like kind of different than some of your other interests that we've like talked about in the podcast and not. Like at odds with them, but just like a different sphere of your interests.

Preston: Mm-hmm. Yeah. I think I give people the impression sometimes that I'm this like. Cold neuroscience imaging obsessed person. Um, but I, I, I guess this is the other, this is the other part of me that's coming out a little bit, the, the soft side. And, and I think that leads us into today's icebreaker, which is, it's not necessarily a question, but maybe a quote that you can reflect on.

Um, and just kind of, I wanna hear your thoughts [00:04:00] on this. So the quote goes, certain truths of existence are so clear, and sure that logical argument or empirical research seems highly gratuitous. Put by Carl Lashley. If you teach a dog to play the violin, you don't need a string quartet to prove it. 

Margaret: I think that my philosophical bent is with the mystics and the romantics from my theology background.

Hmm. So I think the idea for me is that there is something at the core of truth in the statement, um, that is just known and that it cannot be explained in the way that it's known. Like you could try, but like. In some ways you'll do a disservice to it. And I guess related to existential therapy, I think one of my experiences as both someone who has been in therapy and had like a beautiful experience with therapy and been a therapist is that there are parts of it that are [00:05:00] ineffable and are kind of like.

So human and so deep that they can't be put into like a framework to submit to acap. Mm-hmm. What do, what do you think of it? 

Preston: No. So I, um, what I'm hearing is that you agree with the statement that there are all things are, 

Margaret: if they were like, let's do this with vaccines, I'd be like, probably not. Yeah. But yeah.

Yes. In gen in, in this 

Preston: topic. Yeah. I, I guess I, I sound, um. Y Yeah, I, I do agree. And, and I like the, the kind of tongue in cheek example at the end. If you teach a dog to play the violin, you don't need a string quartet. Like if, if the absurdity is self-evident that you don't need a complex explanation, or can you explain, also try to understand it, 

Margaret: what that means?

Because I kind of feel like I don't get that last part of it. 

Preston: I, I think it's like. If, if you, if you taught a dog to play the violin, like it in itself is like, it's so absurd and like clear that [00:06:00] this is like what's happening that to, to convince me of it to be reality. I don't need these extra levels to the performance.

I don't need to add like support cast, I guess is how I see it. Um, and. This isn't, uh, I guess a, a fundamental concern of existential psychotherapy, but I do think about justice with like some of these topics. So, and, and this, this comes up a lot in, in Plato's work, and shout out to Texas a and m who just banned Plato from their philosophy 1 0 1.

Um, hope you, hope you guys get outta the cave soon anyways. Um, why'd they do that? I, I guess it had like gender topics in it. 

Margaret: Oh, 

Preston: in. I don't remember public covering a lot of that, but anyways, go back to 

Margaret: ancient texts and want them to not say things 

Preston: about gender. Yeah. Know. I, I think it's funny, like no matter what, Socrates is always just getting flack for poisoning minds of the youth.

Like it's how he goes. Um, but like a lot of that discussion is around uncovering justice and it's like seeking [00:07:00] the definition of justice that we know intuitively to be true as humans yet. It's so hard for us to find the right words to capture it, nor as you said, it's ineffable yet, you know it deep inside you.

You know it. And I, I, and while this kind of sounds like, um. You know, boundless, almost like Phil philosophy talk, this is actually through the basis of what brings us into existential psychotherapy, which is it's really the posture that there are these truths that we know intuitively, and no matter how much we try to wrestle with them, um, they don't go away.

Margaret: Yeah. 

Preston: And, and, and the, the art author of, of this book. It's existential psychotherapy. Irvin yell, shout to Sky's awesome. 

Margaret: Also, author of letters or whatever the like gift of the gift of therapy. That is a wild read if you're not familiar with analysis, but is a good book regardless. 

Preston: Yeah, it is. So, so he basically says that like [00:08:00] this.

These like fundamental problems of, of existence are kind of like the secret sauce that live under all therapies. Like whether you're doing cognitive behavioral therapy or psychodynamic therapy that like, you're always coming back to these like fundamental questions and, and, and ultimately they, they're the concerns of death being that we are all inevitably unequivocally going to die.

There's nothing we can do to stop it. And as, um, an insightful being, we are aware of our own death, so we must, we must address it in some way the next being. Yeah. Address me, the, the elf in the room going address me. Let's, let's put that on screen listeners. That'll, we'll, we'll, we'll have Jason put it up.

Um, and then isolation. So ultimately. We are all alone. No matter how close you try to get to someone, you are still destined to your own personal, private experience of the [00:09:00] world. No one can ever experience anything for you, including death. And, and that's a hard concern to address, 

Margaret: which is Yeah, the, this particular existentialist view of the truths of the world.

Yeah. 

Preston: Correct. Yeah. So, so these are. These are postulates that you, I, I guess, have to accept for the purpose of like further discussion. Mm-hmm. Though one could argue like these postulates themselves can be like up for debate. Um, and that, that's probably gonna go for, um, your opinion of this next one, which is freedom.

So ultimately we all have freedom will and we are all capable of making of our own decisions and are therefore responsible for all of our own decisions. And that, um, also torments people. 

Margaret: Do, do you think we have free will? 

Preston: I don't know, 

Margaret: because I feel like I'm remembering that episode with Allison and Stone when we talked about free will at the end there.

Preston: Yeah, I, I think, uh, I guess to step aside from this for a second, I think [00:10:00] scientifically, um, it's hard for me to picture how we could possibly have free will yet, despite. All of my, like, understanding of quantum mechanics and entropy and chemical reactions and everything that's governing what must be going on in my brain.

I still feel as though I have a choice. And so, I mean, some people argue like whether or not you do have free will or not, it almost like doesn't matter because you, you still have to decide at the moment and whether or not someone could predict it or not makes, makes it almost irrelevant. Um, 

sorry, 

Preston: that is an aside.

Yeah, I'm not sure. I, I, so, so it's like simultaneously, like, I think it's like scientifically, I don't believe I have free will yet. I get, I still feel like I have the ability to make a choice, so I, I don't know how to, what to make of that and that I'm still responsible for my choices. So, so freedom. It's still relevant to me, I guess.

No, no, [00:11:00] I saw, I saw the eyebrows go. You have a thought. 

Margaret: I'm gonna hold the thought. Keep going. 

Preston: Okay. And, and the last one is meaninglessness. So this is the concern that there is no preordained meaning to life in that we have to, um, find or construct our own meanings within life. And otherwise we're like destin to meaninglessness or despair.

So, so ultimately all these like four concerns, death, isolation, freedom, and meaninglessness are kind of like at cores, like what's, um, addressed in existential psychotherapy and, and didactically We'll, we'll talk about them all kind of individually. So this episode's primarily gonna be about death. But I think the best way to think about them is almost like a coil or like a cable where they're all wrapped together.

Mm-hmm. And they're all kind of traveling in unison at the same time. 

Margaret: What a perfect season to be taught. Well, when we're filming this listeners, it's early [00:12:00] January. It's winter where I am. 

Preston: Yeah. 

Margaret: We are in the season of like death and. Quiet and silence. So what a, what a good time. And we can, I don't know, I guess, I don't know what month meaninglessness is, but maybe March.

Preston: Yeah, we'll find it. Uh, maybe July. 

Margaret: Maybe July. 

Preston: Yeah. We, we have to find our meeting. Well, we are gonna take a quick break and then when we come back, we will dive more into how we think about death and other, and other fun light topics.

Margaret: So in 2026, my goal is to open a very small private practice as a post-grad psychiatrist. And one of the tools that has helped me do it is Simple practice. Preston, have you heard of Simple Practice? 

Preston: Yeah, I have heard of Simple Practice. Actually. I use it as a patient, well I guess my therapist technically uses Simple Practice 

Margaret: and is it in fact simple?

Preston: It's very simple. It's, it's convenient. Um. I [00:13:00] would recommend. 

Margaret: Yeah, well, from from the therapist side, simple Practice is an all-in-one EHR that is HIPAA compliant, high trust certified, and it is built specifically for therapists. So it brings scheduling, billing, insurance, and client communication. Into one place so that you are not juggling multiple systems just to run your practice.

Or if you're Preston's therapist to see him, 

Preston: I, I mean, I'm enough to handle as is. She doesn't need to worry about other complicated things. 

Margaret: And if you're just starting out or growing your practice, there's also credentialing service that takes the headache out of insurance enrollment, which honestly can be a huge lift and something that I was a little scared of.

Preston: So if you're ready to start the business side of your practice, now is the perfect time to try simple practice, do it with us. Well, I guess me in the future. And Margaret now. So start with a seven day free trial, then get 50% off your first three months. Just go to simple practice.com to claim the offer.

That's simple practice.com.

Margaret: You're back with the Grim Reaper Podcast. 

Preston: Oh, yeah, welcome. [00:14:00] So, I, I wanted to start out this, this section with a quote from Twain. The fear of death follows the fear of life. A man who lives life fully is prepared to die at any time. And, and I, I think I always find myself like, like wondering about like the ways in which like life and death are like intertwined, I guess, or like this concept that life has left less meaning if, if death doesn't exist.

Do you agree with that statement? 

Margaret: I don't know. I like in theory, probably, yes. I think what I'm struck by in talking about this is like, and you know, our listeners know, you know, I come from a background that, of therapy that looks at like feminist power, dynamic, intersectional therapy. And so I don't know, this idea of living, it feels to me that like.

[00:15:00] This connection between life and death and like risk in life is for a lot of human history was part of more of day-to-day life in a lot of different societies and in particular. Mm-hmm. For like women who would die a lot in like childbirth. And so it's just, it's interesting, I'm trying to pick up the thread of your question of this like life and death as contrast and would life be as meaningful if there wasn't death?

And it's hard for me to separate them out. From each other as being separate things. 

Preston: So So you're saying that they're so intertwined you can't even separate them? 

Margaret: Yeah, I think so. 

Preston: Okay. Well, I, I guess that would, that would be because kind of what like, I guess the reason I bring that up is that there are some people that would push back on this conversation against death because death is not often brought up in like psychotherapy spaces unless the patient is directly confronting death or in some kind of way.

Margaret: Interesting way you say that. 

Preston: Um, and [00:16:00] I, I don't know, maybe I don't bring it up a lot. And then, um, and the author talks a lot about how often, like death isn't brought up. So, so I'm kind of agreeing with him there. And maybe I'll talk about death more frequently as, as I progress in therapy or, or make a point to.

But there, there are some that would respond by saying, don't scratch where it doesn't itch. This patient is coming into my office. They want to talk to me about their, their problems of life. They're concerned about living. So why bring up death? Why even, why even do any of that in the first place? And so that kinda leads into the Mark Twain quote of like, well, to live fully is to be prepared to die.

And kinda what you're saying is that life and death are so intertwined. 

Margaret: Yeah. But 

Preston: you can't separate the two. If you wanna talk about life, you have to talk about death. 

Margaret: Yeah. Well, and I think his quote reminds me of something that's like popular and has been popular for a long time. But you see like on social media.

But this idea of like, what does it mean to like live your life to the [00:17:00] fullest? And often it's like splashy or it's like about not working or not having dah, dah, dah, dah, and it's about like these, like peak moments in relationships. And so I, I think that kind of quote, I, I feel like the context I see it in is like, okay, but how?

This kind of, uh, sorry, I'm not being linear enough to your, to your, sorry. I'm recognizing as I respond to that, I'm not being, uh, directly responding to what you're saying. Um, I just find this, this quote is like setting me off for some reason in like a good way. 

Preston: Yeah. And like, it's, it's an important question to have and like, and the, the but how is like.

The of it a thousand page book. 

Margaret: Yeah. 

Preston: Is like, and, and honestly the, but how is probably the entire purpose of philosophy. I think I, i dunno the person who said this, but, um, the, the, someone once said that like, the entire art of philosophy is learning how to prepare to die. So like, like Mark Twain says, [00:18:00] to live prepared to die, to live fully and to live prepared to die.

Like master philosophy, I guess, you know, like, like the, like the philosophy is like the pursuit of, of like preparing for death in that way. So, yeah. Much easier said than done. 

Margaret: Do you think that, that, what do you think like with this like separation of life and death, like a good life, like what do you make of that quote yourself?

Preston: Um, I guess I agree with it. Um. And I, I, I'm gonna like, kind of push forward to this next quote that I think like supports and kind of helps explain why I, why I agree with it. That, um, I think in general to enjoy something more fully, you have to accept the absence of it. So let's take relationships for example.

I, I think like I am more stable in a relationship if I can accept that [00:19:00] like. We were to break up or something and not be together. Like if you can accept the concept of you not being together, it can help you being together more fully. Because if you cannot accept the idea of not being together, then that, if that's a non option to you in the sense that like that is the the worst thing that could happen, it's catastrophic and generates a ton of anxiety in you.

Then that anxiety about the possibility of breaking up. Actually starts to make mm-hmm. The relationship worse, 

Margaret: like distort things. 

Preston: Yeah. And, and the same goes for like, things like your job. You know, like if you can't accept being fired from your job, then almost your, your job will probably become worse and you're more likely to let yourself be taken advantage of and you're gonna be more stressed about constantly trying to lose your job.

Margaret: Right. 

Preston: Um, and I, I think, you know, if you were like, zoom out, the same thing applies to life. It's, if you're always afraid of, of dying, it can be harder to like, enjoy the parts of life that you do have. And that, that's not to say that like, you know, being willing to accept, like losing your job means you're gonna go outta your way to try to [00:20:00] get fired.

Just like how being prepared to die means you're gonna go do cavalier stuff and back flips off of like, helicopters flying through the Alps and, you know, put yourself at great risk of dying. But it, it does mean that you can like, enjoy those moments a lot better without like the constant fear, dread of what's happening.

I think that's kind of how I see it. 

[music]: Yeah. 

Preston: And so I guess like to tie in that the kind of almost irony there that, that death brings us to life. There's a quote from the book that although the physicality of death destroys man, the idea of death is what saves him. And I guess like as such, like insight into your awareness of death.

Death is what spurs you into a good life. 

Margaret: Yeah. That's interesting. I, I feel like I. I've talked about this in the podcast, but I feel like who I was as a person before my dad got sick, and honestly before going through like clinical years in med school and in the hospital, it's hard to imagine not being super aware of death for [00:21:00] me.

Preston: Mm-hmm. 

Margaret: Like literally anytime. I like, and it reminds me also somewhat of our episode talking about like caregiver, P ts d, which I, I do not have, but like. I was talking to my parents the other day and I was like, when is the next MRI? Because my dad gets an MRI every quarter and they're like, oh, it's actually tomorrow, like tomorrow for me right now, listening.

And so in thinking about this episode and in thinking about like this quote that you just shared, it's hard for me, like I guess I'm pushing a little bit against not your idea, but this idea that it's like, are people not thinking about death? I feel like, like the public consciousness of death after COVID is so present.

Preston: Um, I, I guess I would say yeah, people are not thinking about death 

Margaret: really. 

Preston: Yeah. 

Margaret: Huh. What makes you say that? I don't disagree with you, but I'm just curious. What makes you say that? 

Preston: I, I mean, I think the, the entire, um, 

Margaret: I'm like ruining Preston's episode, you guys. I'm sorry. [00:22:00] 

Preston: It's like the entire impetus of our society is.

Kind of like hiding death in a lot of ways. And I think a, a lot of, uh, at least in in America, in Western society, we have these hedonistic views where we see life as something where we try to maximize our pleasure and maximize the number of pleasurable experiences we have. And in, in that sense, death must be the cessation of all pleasurable experiences.

And if life's greatest good is. Pleasure and how much I can maximize it, then life's greatest evil must be the absence of all those things. And, and so I think when we do think about death, we, we try to hide it in every single way. We try to hide the ways that we age when, when our family members do age, we tuck them away in nursing homes where we don't have to look at them.

Um, and, and we like don't stare at in the face in almost. Anyway, we, and, and I think there are other cultures that have, I think a healthier relationship with death. And I kind see the intertwined here in San Antonio. So like, um. Latino culture does, [00:23:00] like they have like the Day of the Dead, for example. And like, it, it was kind of interesting to, for me to see this, the relationship that like this city has with death and the way they celebrate it, which is, I I don't think it's very common in a lot of other, I think like Western driven, like American cities.

Margaret: There's kind of like a marked absence though, in, in how you're talking of like consideration of like the function of religion. Like whether you agree with religion or not, but like the Day of the Dead is also, it's a Latino religion component, but it's also a like a Christian Catholic component. So I, I feel like that's part of also why I'm kind of like do is this is this sweeping kind of statement that people don't think I, I agree with the core thing that we like push aside aging, especially we push aside like ourselves getting ill.

Really entering towards death. And so I do think the core of it, I agree with you that like the actual thing of starting to move towards dying as we really age [00:24:00] is hidden and avoided. 

Preston: Mm-hmm. Yeah. I, I think like people like through religion, I, I think acknowledge the existence of death, but this is their own personal death and, and what they are gonna be dealing with.

And I think that is like.

Try to skirt around, try to dis that onto other things. So, um, like, like for example. The ways in which people like fear death may not be actually of like death itself, but things that are translated onto it. So the thought of like being forgotten by another person, ultimately that's, that's a fear of like ceasing to exist or dying, but, but.

It's like about like, what if they, what if they forget about me? Or, or what if I lose this? Like, what if I lose my function or like my cognitive function? What if I lose my ability to do those things? Those are, those are all like fears of ceasing to exist, but the person, when they're, when they're fearing that and they're [00:25:00] thinking about that all day, they're not thinking about, I'm gonna die some day.

This is my mortality. They're, they, it's translated onto that one specific thing, I guess. So what I'm saying is that like when people have these like conscious fears, is it, is like. Unconscious often like death, anxiety, that gets translated onto other things and that what the hope is here is to try to make that death anxiety more conscious so that it can be better accepted.

Margaret: Mm-hmm. Got it. 

Preston: And, and that's actually, and it sounds like you, from like your personal experience as you're describing it, you, you have. A lot of like conscious interaction with mortality and death and your own mortality in, in a way that maybe other people don't? 

Margaret: Yeah, I mean, I don't, I don't actually know that.

I would say other people don't, like, I would say a lot of the women I talk to who are mothers think about their kids dying every single day, and they're like more terrified of that. [00:26:00] I mean, granted, I see anxious women, but even outside of that, like, I guess. And we can move on from this, but I guess I questioned this statement that some of this is based on after, and I, I did not question the statement actually when I was first, when I like first started like learning about it a little bit at the end of med school.

But now that I've actually like worked with people, I just, I just wonder and like also just working with people who aren't in academics and like are living all sorts of different lives. In real time on this podcast. I guess I'm questioning my own basis of belief, this theory, but that's neither here nor there.

I'll question that in my own therapy. Um, but yes, my personal experience is such that I think about it quite often and also working in a hospital, working with sick people on like consults and stuff like that. [00:27:00] And then in my family situation, like I think, I do think about it probably, I do think about it probably more than the average person.

Yes. 

Preston: Yeah. And I guess like in your consult services, how much time is being spent trying to like avoid the discussion or the possibility that like someone is going to die? Like, you know what I, I think like that's, yeah, I, I think we're. Maybe, um, kind of like intersecting on the same idea, but um, like from different directions.

So I guess like what I'm saying, that like people don't like to think about death is that they don't like to think about like, confronting death and that like, like people are aware that they're gonna die, but like they're terrified that like it's ever gonna come for them and they do everything they can to try to like, run away from it and avoid it.

Then 

Margaret: the dynamics play out the way and the teams and the teams play it out that way of like running around when. They're like refusing to do a palliative care consult when it's clearly indicated E 

Preston: exactly like the, the thought of like patients skidding or patient family members, or even like primary [00:28:00] teams being like distraught or, or like caught off guard by the thought of the goals of care discussion.

That the resistance to that, that's them not wanting to talk about death. So it's, it's not that they're like not aware that people don't die. It's that Okay. It's, it's confronting that like you are going to die. Mm-hmm. And that's why palliative care needs to come in and talk to you about goals of care.

That's what you have to accept. The concept of like coming into like near death experiences can have like, almost like a paradoxical, like positive view or, or this, I guess as we're saying, like this is what's argued in the book and we can have our own opinions about it. But I, but I did find this statistic kind of interesting.

So, um, this guy, Russell Noles. He studied, uh, patients with near death experiences. Um, it was like a cohort of 200 individuals and he kind of like did qualitative research asking them about how they felt about their life before or after the accident. So these like, um, 200 individuals this cohort. [00:29:00] From a variety of like snowboarding accidents to rock climbing, um, you know, cancer.

Like they, they all had like some sort of like near death experience. And then when he kind of asked them about like how they felt after death, 23% of them, so about a quarter of people actually reported having a much better relationship with life after their accident and that they had more moments of serenity.

A higher and better awareness of the preciousness of life and a deeper drive to savor and enjoy moments in front of them. So we, and like I think that's something we also know intuitively, that like everyone talks about how, like they had that one, or like someone in a movie talks about they have that one near earth experience and how they just enjoy every moment the same way.

And, and it's, it's just strange to think that like this brush with death in a way, like improved the rest of their life. And like that, 

Margaret: it's like the ultimate exposure therapy. 

Preston: Yeah. It's, it's like that they, that confrontation that they spent so much time trying to [00:30:00] avoid ended up having this kind of like positive reaction.

And that's in a fourth of people. And another fourth of them, it actually elevated their death anxiety and, and the rest of them, it didn't really make a difference in how they felt about things. Mm-hmm. So some people have this like profound positive response to it. Um, and I guess like. Except or not that, you know, people are afraid to confront death or don't wanna think about or talk about death.

Um, I, I think the next thing we have to think about is if someone is afraid to confront death, what are they actually afraid of when they think of dying? 

Margaret: Hmm. 

Preston: Like why, why be afraid of death? 

Margaret: I mean, I think some of it is the like. Turning into nothing and ceasing to exist and not mattering, whatever mattering means to someone.

Um, I think the fear of [00:31:00] oblation is also probably something deep in us, or at least the analyst would probably say that. Uh, 

Preston: what do you mean by that Oblation? 

Margaret: Just the, the fear of becoming a total literal nothing in the universe and your kind of. Being, being glued together, coming undone, and never mattering ever again.

Almost as if you could have just never existed. And then I think in a less analytic dynamic voice, I would say like, I think there's also worries depending on what part of the lifecycle you're in of like, did I get to do this, this, and this thing? Did I get to have the life that I thought I wanted? Um. At other points, I think it's like very, really, like, I don't wanna leave behind these people who still need me.

Like, I don't, yeah. Like I think that's a huge one. 

Preston: Yeah, I think that's really good. I think you, [00:32:00] you hit all the beats that I was probably gonna to address all y'all, all the reasons why I'm scared. So 

Margaret: nos, 

Preston: um, in, in a, in a survey of, um, several hundred people. Ask that direct question, why, why be afraid of dying?

Um, seven common answers are, are what came up and 

Margaret: it's like the least 

Preston: fun 

Margaret: version of Family Feud. 

Preston: Ding, show me, show me me Show, show me ovi

55 people. Uh uh, but actually, so, um, number one was my death would cause grief to those who love me. And then, um, next was all my plans would come to an end. 

Margaret: Wait, but the fact that like, isn't that, so the first one being like, isn't that so like, it makes me wanna like tear up that the first one is that like, 

Preston: I 

Margaret: can't 

Preston: leave hurt 

Margaret: other people.

People who love me would. 

Preston: Mm-hmm. Um, the [00:33:00] next one is it the process of dying itself may be painful or might hurt to die? Um, nex is, I could no longer have experiences. Or enjoy things. So ceasing to exist, I guess. Um, next one is those who I care for would lose support. This is a common one. I also come across that, you know, they have dependences and people that they're responsible to, so what's gonna become of them?

The next one is, I'm afraid of what might happen next. And I'm afraid of what will become of my body. And, and so ultimately those. You really, I guess, address like the three things that it are kind of three, three common themes that come out of that, which are, um, the unknown or what comes next that, that fear, whether in life or outside of life, like what comes next for the people, um, that I'm leaving behind?

What's coming next for me? The event itself [00:34:00] and the, the, the idea of ceasing to be, those are like the three things that scare us the most about death. Mm-hmm. And it's weird because when I say it out loud to myself, I'm like, ceasing to be sounds scary, but like, like death sounds scarier to me. But then when I try to break down my fear of death into its component parts, each one of them feels less scary, I guess.

Margaret: Hmm. 

Preston: It's almost like, like the fears built to be greater than the sum of its parts in a way. 

Margaret: Yeah. It's like the, like three little aliens in the trench coat and space jam. 

Preston: Yeah, 

Margaret: exactly.

Preston: Yeah. The the trench coat coming, coming to take you away. So, so, so essentially like in summary, um, in, in summary of this part, we, we are all going to die dead and, and we are, we're intimately aware. That we are going to die, yet we are afraid to confront our fear of death. And then it's [00:35:00] for like these kind of several reasons and we are gonna take a quick break and when we come back we'll talk about, I guess like some of the ways that we try to cope with those fears.

And we are back to talk about the ways that we fight death, the unwinnable battle that we're all facing. 

Margaret: In Preston's view? In or in the existentialist view? 

Preston: In the existentialist view, correct. Yeah, 

Margaret: yeah, 

Preston: yeah. So like essentially, um, the existentialists, and I guess I, I shouldn't, I need to like check myself here because, because I am kind of like saying out some of this stuff, like it is gospel and it's not gospel.

It's, it's, it's a book that, and a, and a style of thinking that I'm going through and I'm kind of like regurgitating essentially. What they do, in essence say, is that like when we have this fear of death, that we kind of approach it with like several of like the denial based [00:36:00] strategies, um, so to speak. So, and then like that's kind of like how we translate our fear of death onto other things.

So like, things like repression, projection, suppression, like those are all like really functionally like our denial based strategies in that if you do them in. So to speak, like unhealthy ways that the existentialist would argue that that's like the source of psychopathology and that like the confrontation and the acceptance of death is like the healthy thing.

[music]: Mm-hmm. 

Preston: And we'll, we'll like get at these when we like look at some of the other episodes, but, or like kind of some of the other aspects of existential psychotherapy, but like ultimately each of these like pillars has like a confrontation and then like, like a challenge. And then it has like some. Some barrier you have to overcome to accept it.

So like the challenge is like, you're going to die. We squirm about it by trying [00:37:00] to kind of translate that fear of death onto something else, but then ultimately have to come around to confront it in order to like live holistically. Mm-hmm. And, um, I, I guess like reading about that makes me think about like, what are, like some of the ways that, like me, I guess like would translate my own, like fear of death onto like other things.

And like what, what, I guess what, what comes to mind for you? When, or, or, or maybe it, it doesn't translate onto other things. 

Margaret: I mean, I feel like, I think for me there's an element of thinking about like what kind of like life and values do I wanna live by? And maybe avoid thinking about death or I guess like try to like sublimate it kind of into like, do I feel like I am being helpful?

To my patients. Do I feel like I'm being like a caring like daughter and friend and person like that? And in a way that can be a type of like avoidance, like a sublimation [00:38:00] can go so far when it becomes rigid that it becomes an avoidance of death, like as a way to cope. What about you? 

Preston: So, um, this is, this is like, I guess one that like the book talks about or that, that Irvin Yam talks about that kind of resonates with me and I think I catch myself doing it.

It's, it's the idea that you can shirk death or deny death by finding other ways to become immortal. So I, I think a lot of people approach this, that, that if I can generate something that people will always care about me writing about, in a way I'll never truly die. Like, then I can kind of convince myself in some way that I, I'll become a mortal.

[music]: Mm-hmm. 

Preston: Not physically, like, I'm aware that my body will physically die, but you know, my, my children will remember me. 

[music]: Mm-hmm. 

Preston: I'll be remember for my work, my legacy or X, Y and Z. And, and, and I think it's kind of interesting too that like, even in like Erickson stages for example, this becomes like a [00:39:00] primary like preoccupation or fear of people, like as they start to like approach death and then things become like more legacy, like motivated.

Yeah. So like those are, are like still in a, in a way, like not confronting. That initial fear we talked about before, the break of ceasing to be right, because if I'm ultimately afraid of ceasing to be, yet I'm determined to cope with that by generating my legacy. Like I'm still, I'm running from that, if that kind makes sense.

Mm-hmm. Or I guess that's like, I guess I agree with that, um, argument. 

Margaret: Yeah. Yeah. Is there a way in which like that can be healthy? 

Preston: Um, 

Margaret: I guess is there like, because part of me thinks like. That's like a positive way somewhat to deal with it. But like, like is it, is it, to quote the internet, is it always a cope or is like, at what point is it just like functional behavior versus like coping to the existentialists?

Preston: Mm-hmm. [00:40:00] I guess, uh, um, I kind of agree with you. Or, or, or, or actually. I don't say, I don't mean kind of, I do agree with you that there are healthy things about building a legacy or that even maybe building a legacy in of itself might be healthy, high lilac. Um, I guess like the existentialists would argue that you are still not letting yourself live life fully and like, I guess clear eyes wide, o wide open.

If you are trying to shirk or not confront the things that mm-hmm. That scare you about death. So I I I, I'm sure there's like a both and in there where you can build a legacy but also have easily come to terms with that you will cease to be, and at some point you legacy in of itself will also cease to be.

And like ev you know, like everyone who's ever lived that might remember your da, your name might also die someday. And so will everyone who's [00:41:00] ever read your book. And, and so like at that point, you know, you'll completely disappear from the universe. Well, what happens then? Is that okay with you? You know, like, oh yeah, fine.

You know, like, I, I just wanna help for like, the next generation or something else. But maybe some people are like, no, I'll go find a way. Like, you know, and then, and then the next civilization will come back and they'll discover me and I'll, and I'll live again. You know, like, I think that's, that's kind of, um, the, the nuance between that.

Because there, there's obviously positives in building like lasting work. 

Margaret: Yeah. Yeah. I mean, I feel like also you hear people talk about this with like a legacy just of like, oh, like my, my family and my children or whatever, like my family home will be or the like, even sometimes like, not hoarding, but like people who can't, like, don't, won't look at the fact as they get older that like.

Maybe they need to like downsize or like there's a lot of things in their house that like they're not gonna ever use again in their lifetime. [00:42:00] And kind of this idea of like, well, no, these things are gonna matter after me. That's probably also combined with like a little bit of a different way of coping, but Which is maybe denial.

Preston: Yeah. 

Margaret: Another one I'm sure. 

Preston: Yeah. I mean like de denial is, it's incredibly powerful and really effective. And I guess it took me to PGY three of Psycho of Psychiatry residency to like, I think appreciate denial for what it is is like, like an S tier defense. And, and it was funny because I think I would always get.

Upset or irked in, in like my friends when they like showed evidence of denial. I'm like, come, come on. You know, like, like confront the issue head on. Like I try to confront my issues head on, but like, obviously I don't like, that's probably why denial irks me so much because there's like my own things that I'm denying and, [00:43:00] and like it's, it's ubiquitous and, and I think.

Ultimately, like when, when people are thinking about your, like the ego defenses that people put up against like the threat of death, they all kind of start pointing their way back to denial. You know, like, uh, and, and, and these are all like when you say like, oh, maybe they're cos maybe they're not, they, they're different ways of kind of denying those like three primary fears.

Like, my body will deteriorate, but I won't cease to be because I'll have a legacy. Right. I, if I do die, it's gonna be peacefully in my sleep and it won't even feel anything. And then therefore, the event won't be bad at all. Or, or if I, if I do die, like there, there must be an afterlife and I have faith in the afterlife, and therefore there's no unknown that I have to confront or be afraid of.

I, I, you, so, um, well, I also don't necessarily agree with like, all of these, um, propositions put forward. Those would be in and of themselves, like ways to [00:44:00] deny the like. Existential fears of death or, or like avoid them rather than confronting them. And I, and I guess like I, I, I come across all three of those fears in like different places.

I mean, we, it's obvious like people fear the event and we see that in the hospital a lot. How do, like, is there a way, like, or like of those three fears or like the three are kind of like subsets of a fear of death. Like what do you see coming up in patients? 

Margaret: I mean, I think it's hard for me to say. With, because some of the kids I'm seeing are dying.

Um, but it depends, I think developmentally for people to be able to understand or they're, I'm seeing kids and their parents are dying. Um, I think with adults, I think there can be an avoidance of it and avoidance of the emotions around it in kind of. Sinking into like, let me just go into this cognitive logistical mode [00:45:00] around like if I'm Ill, whether that's like I'm terminally and acutely ill, or it's like I have an illness that like limits me over the next 30 years of my life.

Mm-hmm. And so it can kind of be like, well let's just focus on, you know, having this perfect routine and doing these things and like, almost like pushing off the feeling of the worry, but also the like pre grief of death. So I feel like that is one I would see quite a bit. Um, and then I think it's interesting to think about working with like adolescents and young adults who were being raised around the time of COVID and developing during COVID.

And in this current like political slash like economic time point where. Sometimes like the word failure to launch is thrown around glibly, but I actually feel like it's also kind of like a death shadow where it's like they're worried at the beginning that their life is never gonna be what they want it to be or [00:46:00] matter enough anyway.

So why try? Like why live? Um, and so it's almost like a defensiveness of life. But I, again, I think that's like part of this death thing. Like I won't confront the fact that my life will end. By just saying like, my life will never matter anyway, and my life will never be good. So like why even kind of start it?

Preston: Yeah. It's, it's, it, it's interesting that like suicide or like suicidal ideation is also often running from something. 

[music]: Mm-hmm. Yeah. 

Preston: Like it's not, it's not usually conceptualized as running towards death, but rather running away from life. 

[music]: Mm-hmm. 

Preston: So, so maybe I, I guess like. The core of this is that, like, maybe to sound like too, too simple as I'm like paraphrasing, existential thought, but that like confrontation is the goal and that like avoidance [00:47:00] is like what will lead to more psychopathology.

Mm. Ultimately. 

Margaret: Mm-hmm. 

Preston: Yeah. And, and it's, and it's hard to do. Like, I, I struggle a lot with like helping my patients like confront things and, and. I don't know if I've ever like, frankly brought this up to a patient where essentially, I guess you would just say like, are you afraid to die? 

Margaret: Yeah. I think that's probably good that you that way.

Preston: Why? Why would it be bad? I guess I'm, and then it, it might be bad, honestly. I'm just kinda think thinking openly, like, and, and, and this isn't like in a hospice situation where like someone's actually gonna die, like, you know, like, like a 30-year-old client who's coming in like. Just discussing like what might seem like average things.

Like what? Like tell me about your thoughts about death. Like does it, does, does it cause you fear? 

Margaret: Well, I think it's just like, um, a little, like on the nose. Like I think it would be like someone coming in and being like, it's our second session, and you maybe have a hypothesis that they're really [00:48:00] coming in because they've like been in an abusive relationship or something, or like an abusive family situation.

And then you say like. Why do you let your family treat you that way? Or like your family's obviously abusing you, what are you gonna do about it? Like, it's just like a little bit too confronting to be metabolized and digested. 

[music]: Mm. 

Margaret: I think that we can talk about death and certainly sometimes that means like often, actually, I feel like it means getting to actually talk about death and grief and something that people are either afraid of or have already experienced, but.

I do think the, like, avoidance isn't necessarily overcome by forcing the door, like wide open. Like you don't take someone who's suffering with agoraphobia and be like, we're gonna the mall today. Mm-hmm. Appointment one. 

Preston: Yeah. 

Margaret: Like, it's just, yeah. 

Preston: And, and if, if denial is your primary motive of coping, then like that's the worst way to [00:49:00] go about it.

Margaret: Yeah. Well, and you have to ask, you always have to ask, I mean, what the. What often we talk about in dynamics is like, defenses exist for a reason, right? Like they're functioning, they're doing something for people. So if you just like rip the defense away, then you kind of are like blowing over a house of cards sometimes.

Preston: Mm-hmm. Yeah. Like the, the defenses are there for a reason. The, the other part of that coin, um, that, um. Yam argues is that when the therapist doesn't bring up death and the patient doesn't bring up death, both of your like avoidance of the topic starts to collude together, and then you just never discuss death.

And that was like ultimately, like one of his like main criticisms of Freud is like Freud's, like deliberate inattention to death in like many of his writings and, and relating them ultimately to a lot of like childhood anxieties. But then like. I guess Yala would argue that underneath those childhood anxieties is the primordial [00:50:00] fear of death that, that he was like shirking or, or avoiding talking about.

So, um, I guess as, as we kind of wrap up right now, um, we don't have any good solutions to this problem. We gonna solve that. We're all gonna die. I think we can talk a lot about like, the things that make us afraid and, and how we translate it and just the thought of bringing it up to patients. But, um, we appreciate you kind of.

Joining, I guess, me, on my pet project in this series. And, and then the next one we'll kind of continue with the other, like, concerns of, of existentialism. So I just wanna say thank you so much for listening. Um, I know some of you guys have been leaving some voice notes and somebody left us one. Um. In response to all of the, like, the food, um, episodes that we did of like the frustration of, um, dealing with like yogurt and macros and how when you try to eat right and help your body, it turns you into a Jimbo a [00:51:00] little bit.

And, and I kind of feel you there. It can be hard to strike the balance between, um, gym row and whimsically enjoying food and also eating for your mental health. Um, 

Margaret: true. 

Preston: I do check out the Patreon. I'm, I included a cooking video. I'll try to make like a non jimbo, uh, yogurt video for you guys as well or something there.

Um, but otherwise, like, if you like the existential stuff, we want to hear about it. If you don't like the religion philosophy, discussion, also want to hear about it, but you can always let us know on Instagram and TikTok at Human Content Pods. You can also contact the team, the team directly at how to be patient pod.com.

You can see more of me at it's prerow or Preez on TikTok, wherever you. Scroll on your reels, and you can always find Margaret at Badar every day. She's on Substack and TikTok and Instagram. Full episodes are on Spotify and YouTube on video, but honestly, anywhere you get your podcast, you can just hear us yap in your ears, in your car, or on your long run or in the gym.

Thanks again for listening. We're your hosts, Preston, Russia, [00:52:00] Margaret Duncan, our executive producers are. Me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aron Korney, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Bizzo. Our music is Bio Benz V. To learn more about our program, disc displayer and ethics policy submission verification in licensing terms and our HIPAA release terms, go to howie patient pod.com.

Or reach out to us at how a patient@humancontent.com with any questions or concerns how a patient is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear [00:53:00] they're there. They, they probably exist for real, but in the meantime, I'm just gonna pet lilac and then.

I'm gonna go dance in the background.