Demoralization and the Loss of Transcendence: What is the Clinician's Role?
John Peteet, M.D., Associate Professor of Psychiatry, Harvard Medical School
Demoralization is a form of existential distress marked by discouragement and futility, at times so severe that life does not seem worth living. Demoralization overlaps with but indistinguishable from depression, and is a frequent reason for both psychiatry consultation in the general hospital, and requests for assisted suicide.
The flattening of a demoralized individual’s experience of the world gives clinicians reason to assess their spirituality, understood as a relationship to something larger than the self which gives their lives meaning. Yet physicians and other clinicians are often unsure how to help individuals who have lost a sense of transcendence. In this paper I suggest approaches based on what form of transcendence has been lost – aesthetic, moral or relational.
Many individuals describe themselves as spiritual in being connected to nature, or beauty. Some, like the Romantic poets, find personal meaning in being part of a cosmic order that pre-existed and will continue after them. Others, like Kierkegaard’s Don Giovanni live for the beauty of the moment, comforted in difficult times by memories of better ones.
Individuals who experience transcendence primarily in moral terms value having been a good person, or leaving a legacy of integrity and generosity. A life review can often help them to clarify and consolidate the narrative by which they have lived, and to find ways to forgive themselves for their shortcomings.
For many (arguably most) individuals, transcendence has a relational dimension: life viewed in relation to important others, whether ancestors, loved ones, or God. Not surprisingly, the conflicted nature of these relationships and the expectations that often attend them can leave individuals vulnerable to losses such as a life-threatening illness. In his book A Secular Age, Charles Taylor describes the "immanent frame" of the West which is due less to scientific progress than to less conscious, more emotional factors. Clinicians encounter a number of these when they ask patients if they are spiritual or religious. Some patients indicate that they cannot relate to a God who has hurt, disappointed or offended them. Others, like those who display negative religious coping described by Pargament, feel distant from a God who seems to be punishing them. Exploration of the history of the relationship is required to understand what might be necessary to restore, or revise it. Still other, practically minded individuals have a concept of God (as Rizutto has argued every person does), but find a transcendent being incidental to their purposes. Mindfulness, or other forms of meditation may help them to develop their capacity to reflect. And others, like Freud, describe themselves as too rational, or scientific to be religious. They may find meaning in the beauty or integrity of science, while also benefitting from attention to the ways their interpersonal lives can be deepened, or enriched.
Transcendence, whether aesthetic, moral or relational, involves perspective taking, identification, and inspiration. Clinicians and other spiritual care providers can help demoralized patients by attending to specific obstacles presented by their individual stories and ways of experiencing the world.
Demoralization is a form of existential distress marked by discouragement and futility, at times so severe that life does not seem worth living. Demoralization overlaps with but indistinguishable from depression, and is a frequent reason for both psychiatry consultation in the general hospital, and requests for assisted suicide.
The flattening of a demoralized individual’s experience of the world gives clinicians reason to assess their spirituality, understood as a relationship to something larger than the self which gives their lives meaning. Yet physicians and other clinicians are often unsure how to help individuals who have lost a sense of transcendence. In this paper I suggest approaches based on what form of transcendence has been lost – aesthetic, moral or relational.
Many individuals describe themselves as spiritual in being connected to nature, or beauty. Some, like the Romantic poets, find personal meaning in being part of a cosmic order that pre-existed and will continue after them. Others, like Kierkegaard’s Don Giovanni live for the beauty of the moment, comforted in difficult times by memories of better ones.
Individuals who experience transcendence primarily in moral terms value having been a good person, or leaving a legacy of integrity and generosity. A life review can often help them to clarify and consolidate the narrative by which they have lived, and to find ways to forgive themselves for their shortcomings.
For many (arguably most) individuals, transcendence has a relational dimension: life viewed in relation to important others, whether ancestors, loved ones, or God. Not surprisingly, the conflicted nature of these relationships and the expectations that often attend them can leave individuals vulnerable to losses such as a life-threatening illness. In his book A Secular Age, Charles Taylor describes the "immanent frame" of the West which is due less to scientific progress than to less conscious, more emotional factors. Clinicians encounter a number of these when they ask patients if they are spiritual or religious. Some patients indicate that they cannot relate to a God who has hurt, disappointed or offended them. Others, like those who display negative religious coping described by Pargament, feel distant from a God who seems to be punishing them. Exploration of the history of the relationship is required to understand what might be necessary to restore, or revise it. Still other, practically minded individuals have a concept of God (as Rizutto has argued every person does), but find a transcendent being incidental to their purposes. Mindfulness, or other forms of meditation may help them to develop their capacity to reflect. And others, like Freud, describe themselves as too rational, or scientific to be religious. They may find meaning in the beauty or integrity of science, while also benefitting from attention to the ways their interpersonal lives can be deepened, or enriched.
Transcendence, whether aesthetic, moral or relational, involves perspective taking, identification, and inspiration. Clinicians and other spiritual care providers can help demoralized patients by attending to specific obstacles presented by their individual stories and ways of experiencing the world.