Freedom, Authenticity and Crisis: Describing an Existential View of Mental Health Issues and Psychotherapy

“A man who prefers to be dead than ‘Red’ is normal. A man who says he has lost his soul is mad. A man who says men are machines may be a great scientist. A man who says he is a machine is ‘depersonalized’ in psychiatric jargon… A little girl of seventeen in a mental hospital told me she was terrified because the Atom Bomb was inside her. That is a delusion. The statesmen of the world who boast and threaten that they have Doomsday weapons are far more dangerous, and far more estranged from reality than many of the people on whom the label ‘psychotic’ is affixed.”

R.D.Laing, London, 1964 in The Divided Self Preface to the Pelican Edition.


Existential thought offers an arena for the discussion of and theoretical speculation about the most basic elements of our existence. Existential philosophy places the onus of control of our lives and how we live them onto ourselves and no other. However, they also assume that the ease with which the individual may experience the world and their existence may not be simple and at times can entail conflict, defence and crisis. Therefore, it is of as intense and keen a relevance to the study of crisis and conflict, here, in a clinical sense, as much or even more as it is to the understanding of day to day life, and the trials and tribulations of simply ‘being’.

This essay attempts to explore, as the title suggests, the existential view of mental health crisis and to describe the existential psychotherapeutic approach. I aim to give a thorough and critical account of existential psychotherapy and explanations of mental health. Firstly, I will offer a background to the development of existential psychotherapy, drawing reference from pioneering philosophers whose ideas contributed (and still contribute today) to the psychological and therapeutic existentially based paradigms. I propose to build upon this background knowledge by defining the existential understanding of mental health issues and focus on its explanation of schizophrenia, clinical depression and general anxiety disorders. I will describe existential psychotherapeutic practice - observing its therapeutic aims, practical structure, and the therapeutic relationship between the client and therapist. Alongside these key points of discussion, we also propose to examine the contribution made by the existentialist school of psychotherapy, to the ‘politics’ of psychiatry, with reference to R.D. Laing and the ‘anti-psychiatry’ movement.

In order to understand the process of existential psychotherapy and the ideology underlying it, we must first understand the philosophical background of ‘existentialism’. One of the most prolific and certainly the most well known proponent of existential philosophy is Sartre, who was the first philosopher to use the term ‘existential’, and who founded the academic and cultural movement of the ‘existentialists’ in Europe during the 1940’s and 50’s. Crowell (2004), states that Sartre’s existentialism has its roots in the earlier work of the German philosopher Heidegger, who explored and inquired into the nature of ‘being’ or dasein (the German for ‘existence’). Heidegger questioned what it is to ‘be’ and the difference between ‘existence’ and ‘consciousness’, disputing the traditional Cartesian idea of ‘Cogito, ergo sum – I think, therefore I am’. Heidegger went on to explore themes such as the discords and tensions between the ‘self’ and ‘society’ and the unconscious experiences of anxiety related to mortality and nihilism, which are tangible in existential philosophy and psychology. Sartre shared this philosophical focus and understanding of existence and defined his own philosophy of ‘existentialism’ based on human potential, free-will and transcendence.

In time, with existentialism permeating modern culture and academic consideration, there became a need for a psychotherapeutic approach which embraced an existential view of existence and experience. The link between existential concerns and the clinical understanding of human experience and pathology is highly tangible and intriguing.

The pioneering practitioners of existential psychotherapy developed their therapeutic ‘art’ in the early to mid-1900’s, embracing this new approach in response to their problems with traditional psychological and psychopathological reductionism and determinism (a reaction to Freud – as many ‘turn-of-the-century’ paradigms emerged to be). It was neo-Freudians like Rollo May, who eventually rejected the idea of biologically originated drives and instinctual predetermination, and turned to Existential thought in order to better understand human nature and experiences. Existentialist psychotherapy flourished under a larger ‘umbrella’ of psychological ideology known as Holistic, or Humanistic Psychology. However, it is clearly distinct in many ways from other Humanistic approaches to the psyche, most notably through its focus on life and how we live through and make sense of our life-experiences, rather than observing and theorising about ‘personality’. This idea leads us on to focus on the main ideological ‘goals’ of existential psychotherapy.

Deurzen-Smith summarises the aims of existential psychotherapy. She describes the ultimate goals of this psychotherapeutic approach as involving: a focus on ‘life’ and living (rather than one’s personality), the importance of self-awareness and the power to change and grow. She describes how all of life ‘makes sense’ (Deurzen-Smith, 2002) and that we only need to learn how to decipher it and make meanings, by focussing the integral parts of our individuality and experiences.

She also explicitly states the fundamental rejection, by existential psychotherapy, of the ‘medical model’ of traditional psychiatric practice. Deurzen-Smith gives an example of a client who was referred to her and was considered in great need of learning ‘social skills’. At the time of their meeting, the individual was an inpatient in a psychiatric hospital. Deurzen-Smith discovered that her client was unresponsive in social contexts, but she also found that he could cite his own valid reasons for his withdrawal, and also found that the ‘social skills’ classes that he was bound to participate in felt, to him, demeaning. Deurzen-Smith discovered that a huge amount of her client’s anxiety (at that point in his life) stemmed from institutional practices which denigrated his own sense of self and way of living. This example illustrates the importance of accepting and utilising the unique nature of humanity, and the futility (potentially even the dangers) of attempting to mould individuals into a uniform, yet inauthentic ‘self’. It also highlights the need for existential insight in the understanding of mental health issues and treatment.

I propose to explore and illustrate the ‘general’ practice of existential psychotherapy by isolating and focussing on a few key ideas in themes: death anxiety and existence tensions, the rejection of diagnostic labels, the dynamic of the therapeutic experience and individual freedom and growth.

Existential psychotherapist’s argue that ‘symptoms’ presented by individuals suffering from mental health problems are ‘responses to their individual life-experiences’ (Spinelli, 2002) and also echo the individuals perception of their interactions with the world and their place in it. Existential psychotherapists tend to reject traditional psychiatric ideas about diagnosis and pathology, maintaining (like Sartre and the existentialists) that what we are and what we experience are dependant on our own wills, inclinations and the way we respond to our experiences. Fundamentally, this idea is based in Sartre’s famous proposal that ‘existence precedes essence’. As a result, existentialist psychotherapy does not make use of diagnostic labels, and does not ‘isolate and pathologize’ (Spinelli, 2002) the responses and coping mechanisms which traditional psychiatric dogma labels ‘symptoms’, but which they instead define as ‘existence tensions’ (which we will discuss in more depth with regards to existential crisis and death anxiety at a later point in this essay). A useful illustration of the fundamental rejection of diagnostic labelling in existential therapy is the work of R.D. Laing, the Scottish existentialist and psychiatrist who revolutionised the way in which we can explain and understand psychosis. Laing focused on ‘exploring the ‘psychotic experiences’ of his clients, in order to attempt to understand their existence and their experiences. Rather than view ‘symptoms’ of psychosis as mere ‘by-products’ of a ‘sickness’, he defined them as responses to the world and the struggles of life in this world, which were illustrative of that individuals experiences – a reaction to their own reality and interrelational experiences, rather than an abstract, and unrelated ‘figment’ of an illness. Laing also highlights the pervasive existential theme which runs through severe mental health problems involving ‘depersonalization’ (Laing, 1959), with psychosis as an example. Laing (1959) describes how many mental health service users who display symptoms of psychosis or schizophrenia report beliefs that they have somehow lost, murdered or have been robbed of their ‘selves’: “Such statements are usually called delusions, but if they are delusions, they are delusions which contain existential truth.” (Laing, 1959: p.149). It is important to note here that the work of R.D. Laing, and many other clinical ‘psycho-practitioners’ has contributed greatly to the ethical and ‘political’ debates surrounding mental health, relating to diagnostic power, the use of potential abuse of psychiatric drug ‘treatments’ and institutional behaviour control and the unease (which developed amongst members of the clinical psychology and psychiatry professional communities from the 1960’s to the present day) which is now associated with the ‘depersonalizing’ of mental health service users, and their exclusion from involvement and input into their own treatment programmes.

As mentioned previously, ‘existence tensions’ are another integral part of the existential understanding of mental health issues. Yalom proposes that ‘life and death are inter-reliant’ and that the influence of mortality ‘runs simultaneously alongside and throughout life’. Yalom also emphasises that death is a “primordial source of anxiety… the primary fount of psychopathology.” (Yalom, 1980: p.29). Yalom describes how our depressions and our anxieties (both clinical and non-clinical) arise from existential angst, which taints our experiences and prompt our retreat from authenticity into defensive self-suppression. There also appears to be a link between death anxiety and schizophrenia. Searles (1961) describes how the psychotic experience could be attributed to as a ‘reality defence-mechanism’, or a weapon with which to guard oneself from the life, which in its essence presents us with the inevitability of death.

Yalom goes on to describe how an immediate and powerful reminder of our own reality – a ‘brush with death’ – can sometimes precipitate a true sense of authenticity and meaningfulness (Yalom, 1980), and the ability to realise ones true potential. Yalom cites a comment to illustrate this idea, from the author Thomas Hardy: “if a way to the Better there be, it exacts a full look at the Worst”. We wonder if, in a similar way, authenticity could in some way be ‘triggered’ by a complete mental breakdown / mental health crisis? Could it possibly take the loss of ones mind to truly find ones mind? Is there truth in the old anecdotal pseudo-theory, that the line between genius and insanity is often blurry. And if so, is this an existential/authenticity based phenomenon?

At the very beginning of this essay we described how existentialism places the locus of control in every individual’s life with that individual themselves. It is through realising this sense of man-kinds own power over their potential (a theme integral to Sartre’s existentialism) which leads us to describe a very real, almost tangible sense of the potential empowerment to be gained through existentialist therapy. Deurzen-Smith (2002) explains how existentialist therapy practitioners take the stance that individuals suffering mental health problems are struggling with life, but a valid and meaningful life in its own right – the goal of psychotherapy is to assist the individual to make sense of and interpret their anxieties and experiences in a way that helps them grasp onto the positive aspects of their lives both in the past and the potential for the future, and to learn to cope with their struggles, and the absurdities of life which may ‘bring us down’. The approach of this school of thought treats every individual as just that – an individual – but in a way which acknowledges that we are all equal, all apt to growth and change, given the chance and all struggling deep down with the same existential stressors.

Spinelli describes the existential emphasis on the importance of interpersonal interactions and relationships:

“from an existential standpoint, questions of choice, freedom and responsibility cannot be isolated and contained within some separate being… no experienced impact of choice can be mine or yours alone… no sense of personal freedom can truly avoid its interpersonal dimensions.” (Spinelli, 2001: p.16)

This basic assumption places the relationship between the client and the therapist in ‘centre-stage’ of the existential psychotherapeutic process. Spinelli describes categories of human experiences and focus in human ‘spheres of encounter’: I-focused, you-focused, we-focused and they-focused. Spinelli (2002) goes on to describe how therapists facilitate a beneficial and effectual relationship with their client through exploring their world-views through their understanding of their own view of themselves, their experiences of other people, and the view of themselves which they would attribute to other people in relation to themselves. All of these ways, in which the existential psychotherapist may explore an individual, offer insight into the individual and their interpersonal experiences of the world. The therapist gains a holistically sound picture of the individual’s world-view and is able to ‘enter’ into this world in order to begin a therapeutic interaction with the client. These assumptions ring true when we think about the isolation often experienced through mental health problems, and the sense of a breakdown in communication and understanding which can occur with regards to an individual’s relationship with the external world, and which may prolong their suffering. Bergantino (1981) describes ‘existential moments’ of communication whereby the psychotherapist ‘taps’ into a primitive and basic understanding with the client, which appears to transcend the mazes of meaning and complexities of our general social and intellectual exchanges. Bergantino describes how these moments of clarity transcend the strict social constructions of the roles of ‘psychotherapist’ and ‘client’ and allow for a purer understanding to be forged between two individuals, which is beneficial both to the client, as a way of understanding his experiences, to the therapist, in terms of conveying their own view of the situation, and is also mutually beneficial to the relationship between the two.

To conclude, we have found that existential therapy uses key (existential) philosophical assumptions with which to inform their therapeutic approach which views individuals as free and open to change and growth. They observe that throughout mental health crisis, life and existence is still meaningful and experientially valid, as the client experiences them – rather than how the analyst interprets it with regards to their own theory or rules of symbolism. Existential psychotherapy rejects the ‘pathologizing’ of individuals with mental health issues, but see clinical problems as reactions to struggles with the same mortality issues that the entirety of humanity, by their nature and definition, experience throughout life. We find that existential psychotherapy explores part of our existence and part of our very humanity, which psychotherapy has neglected previously. An existential understanding of mental health problems promotes the empowerment of individuals with mental health issues, and also highlights the importance of understanding that mental health problems are not alien experiences to the ‘norm’ of society - According to the mental health charity MIND, mental health issues are thought to effect one in every four of us in the UK at some point in our lives. Existential psychotherapy gives an explanation of mental health which acknowledges universal struggles, and reassures us of our individual strength and potential.

By Evelyn Irving

Copyright August 2006

Notes

Bergantino, L. (1981). Psychotherapy, Insight, & Style: The Existential Moment. London: Jason Aronson Inc.
Deurzen-Smith, E. (2002). Existential Counselling and Psychotherapy in Practice. London: Sage.
Laing, R. D. (1960). The Divided Self. London: Penguin Books.
Searles, H. (1961). ‘Schizophrenia and the Inevitability of Death’. Psychiatric Quarterly, 35: 631-655.
Spinelli, E. (2002). ‘The Therapeutic Relationship as Viewed by Existential Psychotherapy: Re-Embracing the World’. Journal of Contemporary Psychotherapy, 32(1).
Yalom, I. D., (1980). Existential Psychotherapy. New York: Basic Books, Inc.
Crowell, S. ‘Existentialism’. Stanford Encyclopaedia of Philosophy. As viewed 19/04/06: http://plato.stanford.edu/entries.existentialism/#5