Existential Guilt in Cancer Patients: A Concept Analysis

1. Context

Cancer is not just one disease, there are more than 200 types, but all are due to the progressive growth of abnormal cells. Its severity ranges from non-lethal disease to life-threatening (1). It can also have emotional and psychological effects(2). Cancer can bring human life to the edge of the abyss, where one realizes that control is a myth, grief, and ambiguity replace creativity and love, and time rushes toward an end; indeed, existential concerns about health status cause challenges for patients (3). Clinically, existential issues are crucial for cancer patients (4), and existential guilt is particularly important. From a Heideggerian perspective, one could say that facing death results in existential guilt (5). Also, many existential psychotherapists believe that existential guilt is correlated with death anxiety in end-stage patients. In this regard, Frankl pointed out that the latent task in the dying process is addressing existential guilt (6).

So, what is existential guilt? The answer may be somewhat complicated. It may seem challenging to contemplate guilt existentially, because psychotherapists usually learn about guilt based on the Freudian concept of guilt (6) as a reaction to the often punishing judgment of the superego and the internalization of convention and authority of parents and, of course, social culture (7). Both Cohn (7) and van Deurzen and Adams (8) noted three sorts of guilt: (a) Neurotic guilt, which is when we imagine we have done something wrong, (b) everyday guilt, which is when we feel guilty about having done something we should not have done, and (c) existential guilt, which is when we know we have let ourselves down and failed to achieve our full potential as responsible beings. As such, it is an unavoidable part of our existence. It is ontological (7).

Definitions such as the inherent and personal nature of existential guilt, or being indebted to oneself, seem somewhat abstract. Many philosophers have provided definitions of existential guilt, and some psychologists have criticized or completed and empirically extended these definitions. That is why literature review may confront the reader with some confusion and ambiguity about existential guilt. For instance, Heidegger mysteriously defined existential guilt as: “Being-the-ground of a nullity” (9). He mentioned the 'loss of the self in they' (das Man) as the leading cause of the person’s failure to his or her potential. He believed that existential guilt is about the responsibility of the person toward himself, and ‘the call of conscience’ reminds us when we lose sight of this responsibility (10). Martin Buber, on the other hand, emphasized our relationships with others in his definition of existential or dialogical guilt: “Existential guilt occurs when someone injures an order of the human world, whose foundations he knows and recognizes as those of his existence and all common human existence” (11). Based on this definition, Friedman conceived of existential guilt as a “rupture of the dialogue that stands at the heart of human existence” (12).

In sum, it can be said that when we review the literature, especially the literature related to working with cancer patients, we realize that the concept of existential guilt, especially from a clinical perspective, is not well-clarified and seems ambiguous. It is necessary to address and resolve such ambiguity, particularly in the clinical setting, as clinical manifestations of existential guilt are obvious in patients facing death (6); on the other hand, the therapist should welcome the patient's existential guilt, so that the patient can discover his real possibilities and challenges (13). The need for a therapist's sensitivity and readiness to respond to the patient's existential guilt is to be aware of the manifestations and precise components of this concept. So, analyzing the concept of existential guilt helps therapists to follow a unified and standardized approach and efficiently use this concept in clinical settings.

2. Evidence Acquisition

Walker & Avant's approach (2019) was followed to organize the literature on the concept of existential guilt. They (14) suggested that researchers should extract as many applications of the concept as possible, and ignore any aspect of the concept that results in deprivation of valuable information, which negatively affects the concept's usefulness. For this purpose, Web of Sciences (ISI), PubMed, ProQuest, Scopus, PsycINFO databases, and Google Scholar were searched, using 'existential guilt', 'guilt', and 'cancer' keywords to identify relevant studies with no time limitation. Furthermore, Persian databases were also searched. Initially, 58 articles were identified, of which 26 were analyzed after evaluation against criteria such as validity, specificity about existential guilt, or relevancy. Furthermore, the research team reviewed valid books in the field of existential psychotherapy to collect information on various definitions and characteristics, as well as therapeutic implications of existential guilt; 5 books written in English were reviewed (e.g., those written by van Deurzen and Adam (15) and Barnett (5)).

3. Results

We analyzed the concept of existential guilt according to Walker & Avant's approach (14), which contains 8 steps, as follows:

(1) Choosing a concept

(2) Determining the aims of analysis: It was explained in the Background.

(3) Identifying all uses of the concept: It means an unlimited review of existing dictionaries, thesauruses, and available literature to identify all uses of the concept.

(4) Determining the defining attributes: Defining attributes are the main signs and characteristics of the central concept that help us to differentiate the target concept from other relevant concepts and clarify its meaning.

(5) Identifying a model case: A model case shows all determining attributes of a concept, and is an example of all illustrating attributes that determine a concept.

(6) Identifying additional cases: Include explaining cases such as borderline that contain most of the defining attributes of the concept or the contrary case that is a clear example of "not the concept."

(7) Identifying antecedents and consequences: Antecedents are events or incidents that are present before the concept occurs, and consequences occur as a result of the occurrence of the concept.

(8) Defining empirical referents: Empirical references are means, through which one can identify or measure the characteristics or attributes that determine a concept.

As Walker and Avant stated, these steps are discussed sequentially, but they are iterative. Therefore, according to the goals of this research, we did not necessarily follow the mentioned order of these steps and have made some changes.

3.1. Identifying All Uses of the Concept

Both keywords of 'guilt' and 'existential' require further explanation. Oxford Dictionary defined guilt as (1) the unhappy feelings caused by knowing or thinking that you have done something wrong; and (2) the fact that somebody has done something illegal (16). It seems that the latter is not about the personal feeling caused by understanding the responsibility, but it is a label imposed by others (the law); i.e., guilty or criminal. Cohn (1977) suggests that, from an etymology perspective, 'guilt' is an old English word with an unknown root and is related to the German word Geld (for debt). The German word for guilt is 'schuld', which refers to both guilt and debt, and this broader sense of indebtedness is closer to the existential feeling of guilt (7). Finally, there should be a terminological difference between guilt and sin; the Oxford Dictionary defines sin as “an offense against God or a religious or moral law” (17). Also, psychoanalytically, guilt is the emotionally highly charged barrier erected by the superego, indicating fear of punishment or deprivation (18). However, existential guilt cannot be understood by psychoanalytic terms such as repression, as the person is constantly reminded of it (11). It is when guilt takes on an ontological dimension (19), that it becomes existential guilt. This is Cohn’s third sort of guilt, mentioned above. Although the word existence has a precise definition and applies specifically to humans, it is a common basis for existential philosophical and therapeutic approaches. However, we rely on Oxford's definition: “the state or fact of being real or living or being present” (20). As mentioned before, existential guilt has different definitions and areas of inclusion, as well as various focuses, which all are listed below:

3.1.1. Existential (Ontological) Guilt Defined by Soren Kierkegaard and Martin Heidegger

Kierkegaard's statement that we choose ourselves shows that guilt has ontological-existential roots and is inevitable (21). The ideas intended by Heidegger and Kierkegaard are somewhat different from the English concept of guilt and are closer to responsibility. Then, existential guilt is an inevitable and ever-present issue. That is, we are always guilty because we are always responsible for ourselves (22). Existential guilt tells us that there is no external basis for our decisions and that there is no certainty in the future. It also means that a person cannot be all his possibilities. That is, choosing a thing or choosing a possibility always negates and limits the things that are possible for a person (23). Also, when we deny our agency and freedom, the call of conscience confronts us with this existential guilt or debt to ourselves. For Dasein (self) to discover itself and come into itself, it has to be jolted out of the complacency of everyday living by the ‘call of conscience’ which brings Dasein back from listening only to ‘they’ to listening to itself. The call of conscience reminds Dasein of its possibilities, it ‘calls the self of Dasein forth from its lostness in the they’ (24). If Dasein heeds the call, it is confronted with its guilt or indebtedness, that is, its failure to grasp its possibilities. Experiencing its existential guilt and the accompanying Angst, Dasein discovers its “resoluteness” and can take charge of its life authentically, recognizing its possibilities and limitations in the world, in which it lives (25). Sartre called it ‘bad faith’, and it is when we deny our freedom and responsibility. We see ourselves as being fixed and that our destiny is determined for us by circumstance (26).

3.1.2. Existential (Dialogical) Guilt Defined by Martin Buber

He focuses on interpersonal relationships. But, it is not limited to relationships. Martin Buber introduced existential guilt as: “Guilt that one has taken on oneself as a person in a personal situation”. It, therefore, does not arise from the violation of the tribal, cultural, social, or familial taboos that Freud referred to (24).

3.1.3. Existential Guilt in Psychological Theories

In a more multidimensional way, Rollo May defined existential guilt as a three-dimensional concept (i.e., three aspects of Eigenwelt, Mitwelt, and Umwelt). The Eigenwelt refers to our world and the way we do not utilize our potential. The Mitwelt refers to our social world and is about balancing our responsibility toward others with our responsibility to ourselves, and the Umwelt is about the physical world, our materiality, and our relationship with the natural world (25). Van Deurzen has added the Uberwelt, the spiritual world, which is about how we relate to the unknown and to the ideas that we use to make sense of existence. It is about our personal value system and whether or not we are acting following it. If we are not, if we say one thing and do another, we feel guilty. She talks about all of these four worlds as having a dilemma and a paradox that we have to get to grips with. And also that all four worlds can be sources of existential guilt (8).

All the above definitions have similar roots and overlaps. We can also say that the concept of existential guilt first started in the philosophical thoughts of Kierkegaard and Heidegger, and then it was taken into consideration in the theories of existential psychotherapies.

Moreover, in this review, we came across definitions of existential guilt that have the least commonality with the original definitions and, therefore, we do not consider them clinical and we exclude them from this research. Martin Hoffman, for example, talks about the guilt we experience for comparing our favorable situation to a person or population we do not even know, and we are not even the direct cause of their deprivation (27, 28). Also, the literature review showed a definition of existential guilt in psychoanalytic, which was proposed by Modell (29). Modell (1965) has raised the concept of pre-oedipus guilt on separation from their mother as the primary dynamic. In his opinion, equating the child's separation from the mother with killing the mother leads to primary guilt that occurs before the superego grows. This extended guilt results in a feeling of not having the right to a better life than his mother’s life, which in turn translates into self-destruction. According to Modell, this primary guilt is more debilitating than secondary guilt in exchange for desires arising from the oedipus complex. Therefore, the patient experiences a deep and unconscious sense of worthlessness with a feeling of guilt or violation; that is he experiences the guilt just because of being alive or just for existing. These patients conceive being alive as a factor that makes them 'bad', and their guilt roots in being alive (not because of drives) (30). Hence, this type of guilt is unrelated to our topic and can be named 'guilt for existing' rather than existential guilt.

3.2. Defining Attributes

3.2.1. Forfeiting of Potentialities

Breitbart (2017) conceived of existential guilt as the lack of sufficient success in the personal life and not having a fruitful life. Existential guilt indicates a particular implication toward the challenging task of creating a life that belongs to us, and we need and desire to live this unique life to its fullest potential. In this sense, the ability to feel “I did well enough” and “I can accept the lived life” means a lack of existential guilt (6). There is no doubt that all potential cannot be fulfilled. In this regard, Khanna (1969) conceived that the hierarchy, an essential but neglected aspect of potentials, is constantly changing so that at any time, one prefers some of these potentials more or less over others. Here, according to Khanna, unawareness about potentials and not confirming them is existential guilt (31). Therefore, it is narrow-minded and impossible to say that all potentials must be realized because there are always uncontrolled factors (e.g., the complexity of the future and the inherent unpredictability of the world). Also, in this regard, Lucas talks about existential regret that overlaps with existential guilt and anxiety (32). In Lucas's perspective, once a person abandons himself and addressed another reality at the expense of neglecting the everyday experience, needs, and choices, he feels hopeless and feels not choose at the appropriate time. Hence, it can be argued that existential regret includes a feeling of existential guilt; the guilt that one experiences when losing subjectiveness and feeling despair, or in May's view, has ruined potential.

3.2.2. A Call for Authenticity

One of the prominent features of existential guilt, which is the call of our conscience, is to release us from the clutches of others, according to Heidegger. Hence, existential guilt seems to guide us toward authenticity. Authenticity is the translation of the German word Eigentlichkeit, which means "ownedness" or "mineness". Our being can be authentic or inauthentic. In the inauthentic way of being, we conceive ourselves as 'they' or 'das Man'. In this situation, the person is in the state of 'they-self', not a responsible and distinctive mode (10). In Heidegger's view (1927), inauthentic existence and existential guilt are correlated. Existential guilt is one's accountability for oneself. That is, this "call of conscience" gives us individuality by calling us from being lost in the generality of "they" to the possession and responsibility of our existence as an individual. Stolorow (2011) believed that moving toward greater authenticity and controlling existence is often accompanied by an emotional shift from being under the control of shame (capitated by others) to accepting feelings of existential anxiety and guilt. The shift toward what matters to the person as an individual should not be equated with egocentrism or narcissism. What matters can even include love and care for others (10). There should be a balance between me and others. As existential therapists believe, there is a paradox within existence; paradoxes cause a duality that only can be addressed by accepting it (33). Adams (2013) noted the social world as one of these paradoxes. That is, only awareness of my distinction and individuality makes me understand and respect others (34).

3.2.3. Violence Against Others

According to Buber (11), particularly his dialectical philosophy (explained in I-thou (1970)), it is the relationship with others that makes us present. Indeed, our existence only becomes real in the interhuman dimension; therefore, existential guilt cannot be limited to failure to realize our potential. Buber repeatedly emphasized the qualitative difference between existential guilt and 'bugbears' of the lower conscience and the neurotic guilt that arises following suppressing taboos violation in the unconscious. Buber compared the high conscience to the legal act of confession and punishment, but they are strongly different. Because there is no doubt that, even if there is no legal guilt (e.g., cheating on the partner), the person is still fundamentally guilty of his relationship with his partner, with other women, and to humanity in general (11, 24). In this way, existential or dialogical guilt means harming, for example, our family, friends, colleagues, and social groups (12). Heard (1993) noted that neurotic guilt is what others impose on us, that is, the person is not guilty, but he experiences guilt as if it exists. This guilt can be addressed by treatment. However, existential guilt cannot be silenced, but it should be undertaken (35). Neurotic guilt prevents both accountability and recognition of existential guilt. Existential guilt is not essentially internal or neurotic, but is an event belonging to 'between' (36).

3.3. Antecedents and Consequences

3.3.1. Antecedents

3.3.1.1. The Principle of Awareness, Freedom, and Existential Responsibility

Freedom, responsibility, and awareness are the main components of existentialism. This means that if a person does not fulfill his possibilities (what should be), or recognizes that he has benefited little from the possibilities and values that life has provided him, he will somehow feel a gap in his existence that can create existential guilt (Frankl, 2017, quoted by Freitas et al. (37)). Failure to take responsibility for creating a unique life and not living the full potential of this life results in existential guilt (6). In other words, deviation from the hierarchy of values and potentials (not all potentials), and lack of awareness about them will lead to the experience of existential guilt (31). In fact, from the perspective of existentialism, guilt is necessarily related to responsibility (25). For this reason, Sartre noted 'bad faith’; that is when we deny our freedom and responsibility, which occurs when we pretend something is true when it is not, or deny that it is not true when it is. In other words, bad faith means we do not act while we know we have to, or we pretend there is nothing we can do (33). From this perspective, existential guilt means forgiving valuable things in exchange for safety, that is to say, escaping from fundamental anxiety (15).

3.3.1.2. Passivity and Following Others

In this regard, Heidegger believed that the person becomes a 'they-self' or object and lost in the whirlwind of others and things to deny oneself as a separate and responsible person (38). Indeed, the lack of subjectivity and disinterest in developmental needs, values, and beliefs, particularly when choosing, and not choosing when it is time to choose brings regret and existential guilt (32). Existential guilt is rooted in the lack of authenticity. Inauthenticity means understanding oneself and acting according to others’ interpretation, getting lost in the voice of 'them' and daily life, and in a word, the lack of individual identity (10).

3.3.1.3. Facing Boundary Situations

Exposure to finiteness, or boundary situations, such as cancer, a crisis, and existential suffering, also involves existential guilt (39). Jaspers emphasized the impact of boundary or border situations on human behavior, in which such experiences cause living in a much more authentic way or force us to give up. Heidegger also stated that only real awareness of death could lead us from an unauthentic mode of existence to a higher or authentic one (39). Facing such situations can disrupt or intervene in our expected life trajectory, in particular, facing death and realizing the lack of opportunity to complete unfinished tasks, lost possibilities, and unfulfilled potentials (6). Based on Buber's opinions, it can be argued that “the awareness of time as a torrent gives us the depth of existential guilt” (24).

3.3.1.4. Harm to Others

According to Buber, man has a high conscience, according to which we experience dialogical or existential guilt when harming relationships and the common order of existence (ourselves, the world, and other beings and individuals) and violating the common human order (11). This sense of guilt, which is personal, occurs in 'between'; i.e., neglecting obligations and responsibilities in relationships, lack of understanding and compassion among individuals (36); not participating in the world, not establishing an I-thou relationship (40), harm family, friendships, colleagues, and social groups (12). Therefore, we should take full responsibility for being in the situations we face. We strengthen conflicting situations by inconsistency and lying and allow them to control us (24).

The items mentioned above about antecedents of existential guilt are usually intertwined and interdependent; so a person who does not use freedom also does not take personal and interpersonal responsibility and, in Sartre's words, lives in bad faith; and according to Heidegger, he is lost in das Man. Such a person may harm human relationships and may have a non-I-thou relationship, and even may manipulate existential guilt and turn it into neurotic and merely a feeling.

3.3.2. Consequences

3.3.2.1. Actuating Toward Authenticity and Responsibility

As mentioned before, existential guilt is somehow the aesthetic reaction of our soul to existential defects (19) and harm to interpersonal relationships, and lack of openness to the world (11). Existential guilt is the alarm of our conscience that must be listened to. If considered, this alarm can activate the person toward a responsible life. In this sense, existential guilt can be accepted as a gift of human nature. May (1985) believed that existential guilt can lead to 'humility' and high sensitivity in relationships and can boost creativity in utilizing potential. Yalom (1980) also noted that existential guilt could be essential to our psychological well-being (25). Existential guilt is a reminder of what we owe ourselves. Once this existential challenge is accepted, we will experience a powerful sense of being responsible for our lives. Commitment to creative action brings a sense of self-control and control over life (15).

3.3.2.2. Repression and Hiddenness

Avoidance of existential guilt occurs by hiding or making it neurotic or not confronting it properly. Friedman cited several reasons for the hiddenness of existential guilt: believing that guilt is merely a feeling caused by a violation of taboos and can be addressed by psychoanalysis, or we have been prohibited from experiencing pain by ordinary conscience and our general reluctance to experience pain (24). However, existential guilt may be suppressed or hidden in a variety of ways.

3.3.2.3. Accompanied Disturbing Feeling

According to the literature, existential guilt is connected with these feelings and features: Depression, shame, anger, or severe anxiety about death (6); despair (41); soul discomfort and lack of authenticity (19); existential suffering (39); feelings of hopelessness, anger, despair, and regret, along for go to the past and changing circumstances, the ultimate rejection of past choices (32); social loneliness, alienation and self-alienation, desperation (40), depression or anxiety (33), and meaninglessness (15). It can be concluded that existential guilt, despite its painfulness, has constructive potential and requires attention and openness; otherwise, it would be suppressed or hidden and/or would be annoying.

3.4. Empirical Referents

Concerning the measurement of existential guilt, there is no questionnaire to assess it. But, it is worth mentioning that a questionnaire for existential guilt (according to Hoffman's definition) developed by Lwin, includes 12 items (42). Its items indicate the social dimension that has been emphasized (i.e., equity and equality): for instance, “I feel guilty when I overspend on luxury brands when I see kids dying of hunger”. As we noted, this definition of existential guilt that is closer to social justice is less clinical. Relevant studies investigate privileged group and their feelings for their well-being against others’ deprivation (e.g. (27, 43, 44)). While it is named existential guilt, we do not consider this scale useful for measuring the deeper and more general feeling of existential guilt.

3.5. Model Case

“A 32-year-old married man, who has a 3-year-old girl, noticed his lung cancer diagnosis last year (antecedent), which progresses over time. He never loved his job and only did it for money. Indeed, he forgave his passion for photography to earn more money (antecedent). His marital relationship got worse after his daughter’s birth, and it caused him to neglect his wife and daughter (antecedent). He felt to be alone in the home as if he was not present there. After informing of his cancer, as a boundary situation, he thinks about his nonexistence, finiteness, and defects, which makes him anxious and even angry and disappointed. He knows that he has not lived as deserved and now may never be able to make up for his mistakes. He has several dreams, their marital relationship needs to improve, and now he feels responsible for them (consequence) and he is worried about what will happen to his family after him. Even sometimes he feels guilty for disrupting contact with them (consequence). He noticed his overemphasis on unimportant issues and daily life, which distanced him from taking care of himself, his existence, and those around him, and he also realized that he has never tried to do things that were important and valuable to him (antecedent). At the same time with these thoughts, he feels guilty, failed, and angry, and when he thinks about his death and his absence, he feels apprehensive, anxious, and regretful.”

3.6. Contrary Case

“A 32-year-old married man, who has a 3-year-old girl, noticed his lung cancer diagnosis last year, which progresses over time. He is an interested professional photographer with a warm relationship with his wife and his daughter. After informing of his cancer, as a boundary situation, he thinks about his nonexistence, finiteness, and responsibilities toward family, which makes him anxious. He believes that he has lived a good and satisfying life, but still has several dreams, such as raising her daughter and feeling responsible for his family. At the same time, he feels unhappy with these thoughts, and when he thinks about death, anxiety occupies him.” It cannot be said that this patient does not experience existential guilt at all, as the expected trajectory of his life is threatened (6). That is, on the one hand, because of his history, he does not experience existential guilt, but on the other hand, due to the threat of death and the shortening of his life (loss of the future), he somehow feels existential guilt. He experiences existential guilt less intensely. And this means that our existential construction always remains incomplete and unfulfilled (22) and this need to be accepted.

4. Discussion

This research was done to analyze the concept of existential guilt to remove some unrelated definitions and make it clear or understandable, and then examine its relevance in the cancer setting. Now, we can present this conceptual definition:

Man is existentially both finite and free. He/she is free to define himself according to his/her possibilities and potentialities to become what he/she can and wants and also is limited to choosing one possibility or path in every moment and negating the rest of the known and unknown possibilities. The basis for deciding to choose any possibility and also not to choose other possibilities is the individual himself. Therefore, existential guilt tells us that to determine who we are, we exclude many people, and no one is responsible for this situation but the person himself. Therefore, making any choice implies embracing the basic amount of existential guilt. Now, when in the path of our self-definition we abandon ourselves or surrender to circumstances and others (inauthentic position), the existential guilt is intensified, and as a result, the call of personal (existential) conscience calls the person to modify his way of being and change his relationships with himself, his life, and others around him. This call confronts the individual with his debt to himself (the unfulfilled potentials, or the life he could have lived); that is, existential guilt. Facing and embracing this guilt allows the person to gain more freedom by moving toward personal conscience and inner satisfaction, that is, to live a life that is his own, or self-consistent and authentic.

It seems that existential guilt is an essential part of mental health (45); that is, similar to the painful feelings that indicate a physical problem, existential guilt indicates an injury, failure, lostness, and inauthenticity. The function of this guilt is to call the person to face existential anxiety and accept the personal responsibility for fulfilling potential (15, 25, 33). But, we should not consider this guilt limited to fulfilling potential. Both psychologists such as Van Deurzen and May, and philosophers such as Buber focus on existential or dialogical guilt. According to Buber, the I-thou relationship is cooperative and mutual, and man becomes a person through ‘thou’. Also, we do not own thou, and everything lives in the light of thou, and of course, it is thou (other), who makes us present (46). On the other hand, Heidegger emphasized that our lives should not be controlled by others (das Man). So, it seems that maintaining a balance between self and the public (others) determines the quality of existential guilt. The further away from this balance, the greater the guilt.

4.1. Clinical Implications in Cancer Setting

The final goal of this research was to extract implications for working with cancer patients from the perspective of the existential guilt concept. The patient faces a boundary situation due to the diagnosis of cancer. First of all, the patient's existential guilt should not be concealed, or even worse, the therapist leaves the patient with this feeling of guilt. Addressing existential guilt is one of the ways to help a cancer patient to focus on his priorities and what matters now. Buber introduced 3 steps for the investigation of dialogical/existential guilt (11): (1) self-illumination: A greater conscience is required to call the person toward responsibilities about oneself; a conscience that is fully personalized and does not relent to investigate the depth. This conscience is available to all those, who approach themselves to get out of the plight of guilt. Joseph K (in the trial by Kafka) is an example of a lack of illumination, who is unable to understand the necessity of confession for himself. He escapes from tolerating inner vitalizing light and insists that personal existential guilt does not exist. Nevertheless, the innermost part of his existence, with which Kafka is familiar, knows something else, but he refuses to penetrate this deep part of his existence. But, it is Kafka who understands the depth of his existential guilt (11). Here, the therapist can help the patient to face the depth of existential guilt by entering the patient's phenomenological world, and in Brooke's words, with a balanced behavior (neither skeptical nor naïve) and a moderate perspective. Credulity causes the patient to get stuck in the guilt, and suspicion also risks causing unfounded guilt (47). Then (2) the patient should show endurance and tolerance in the illumination phase and not avoid his guilt so that he can reach the main stage, which is reconciliation; and (3) we can somehow restore the harmed order actively and through devotion to the world. As each individual has a unique relationship with the human order, no one can heal the harm except the one who caused it. However, it does not apply to the harm itself. Although the person (1) we have harmed may not be alive, we can heal the harms in infinite other situations other than where we inflicted them (24). The important point is the patient's openness to harm or shortcomings that he has had about himself or others. Each patient can find his way to address the harm, and the therapist must accompany the patient to determine the personal way and implement it. According to Boszormenyi-Negi (1984), a family therapist, we must accept existential guilt, rather than removing it through treatment. The power to heal and change lies in existential guilt. If each generation benefits from support to discover the commitments and responsibilities of their current relationships, mutual understanding and compassion between generations would be strengthened (48). Hence, the therapist must first help the patient to find the source of existential guilt. For instance, existential guilt or disruption can be attributed to the patient himself, others (1), or even a group. Hopefully, a way can be found or created to relieve the patient's sense of indebtedness to himself or others through real devotion and action.

Concerning existential guilt that emerges when dealing with cancer patients, Breitbart noted the concept of forgiveness. It is not possible to correct something when we are out of time or we do not have the opportunity to address personal potentials and values in the desired way; that is when it comes to forgiveness. Breitbart conceived that self-forgiveness is the last choice to address our existential guilt (41). When the patient lives under the Damocles Sword of cancer and the illness has progressed, the therapist should help the patient to focus on his here-and-now duties, which leads to reduced existential guilt. In this case, Breitbart recommended the following interventions: completing those life tasks that can be completed; compensating for mistakes; asking for forgiveness; planning to gain a sense of security for the family; in advance allowing the partner for remarriage or recovering the happiness; write recommendations for children to accept the reality after the patient’s death. All of these strategies can be useful, and the final decision depends on the patient to forgive oneself simply for being an imperfect and vulnerable human (6). There is always imperfection and incompleteness, and death ends all half-opened or half-completed possibilities. As noted above, existential guilt means that we always have to eliminate some of our possibilities and choose one. But, this feeling of guilt intensifies when we deny our agency as if we do not have the power to choose and remove some possibilities or let the possibilities remain open until time closes them. From this point of view, existential guilt is an antidote to perfectionism (22). Therefore, this aspect of human life needs to be accepted.

In sum, the therapist can help the cancer patient, who is facing a real threat of death to achieve the feeling that he has treated his existence and those around him deservedly and appropriately, even for a short time, by doing what is important in the here and now.

4.2. Conclusions

It can be concluded that existential guilt is an inevitable component that everyone experiences with different intensities and is caused by our existential paradox: being finite and being free. Also, existential guilt indicates existential uncertainty, and cancer aggravates this uncertainty. It seems difficult to live in such a situation. What seems necessary is that the patient needs to be more open to existential guilt. The therapist or a justified person can strengthen this openness to help the patient to act and resolve existential guilt through dialogue so that he can be in relation with the world and himself fully and clearly.

Finally, as far as we know, no research has focused on existential guilt in cancer patients empirically. Therefore, it is important to know what interventions can address existential guilt in these patients, and what outcomes and achievements patients get because of addressing this guilt. The preparation of psychotherapy protocols and experimental research in this field seems very necessary.