If a man tells us he is “an unreal man,” and if he is not lying, or joking, or equivocating in some subtle way, there is no doubt that he will be regarded as deluded. But, existentially, what does this delusion mean? Indeed, he is not joking or pretending. On the contrary, he goes on to say that he has been pretending for years to have been a real person but can maintain the deception no longer. (1960, 36)
This interpretation exposes the limitations of the medical model. The existential therapist knows that psychiatric techniques may help the patient function, sleep better, and cope with the various stresses of life, but they can never fill the void lying at the core of the human condition. Social psychiatrist Dan Blazer offers his patient Tom as a case in point.
Tom, a law student at a local university, felt the bottom had dropped out of his life three months prior to consulting a psychiatrist. He could not sleep, he had difficulty eating, and his energy was ‘just gone.’ Everything seemed meaningless. Going on seemed useless. … Tom took an antidepressant medication for about six weeks. The antidepressant helped him sleep better and maintain his weight. … When asked in therapy what situations led him to experience [his] symptoms, he answered he felt anxious, lonely, and dislocated when he thought about his life. When asked, ‘What about your life led to these feelings?’ he answered, ‘Everything yet nothing in particular.’ (2005, 136–137)
In addition to medication, Tom began sessions of cognitive behavioral therapy with a psychologist to learn how to better manage his distorted thoughts. The pills and cognitive techniques helped him ‘feel better,’ but they could not get at the root of the problem. He continued to describe his experience as “empty” and “meaningless,” as if “the bottom dropped out” of his life, and that “maybe there never was a bottom” (137). This case presents a serious problem for the psychiatrist, because what Tom is going through is not a medical episode, but an ‘existential crisis,’ the all-too-human experience that occurs when “the defenses used to forestall existential anxiety are breached, allowing one to become truly aware of one's basic situation” (138; Yalom 1980, 207). This is where existential therapy breaks with the medical model because it does not seek to diminish or eradicate anxiety, but to confront it, dwell in it, and even increase it.
Because existence itself is the source of the crisis, existential anxiety should not be displaced or repressed. It should be fully experienced and accepted so that the patient can learn from it and become aware of who he or she is. Psychiatrists, of course, generally avoid this kind of exercise in self-awareness not only because it is discomfiting to them but also because it would aggravate the patient's already unstable condition. Their aim as medical professionals is to turn the inchoate experience of anxiety into something objective that can be managed and controlled, if not eliminated altogether. But the existential therapist knows that this is impossible because anxiety belongs to the human situation. As Paul Tillich writes, all “attempts to transform anxiety into fear are in vain. The basic anxiety, the anxiety of a finite being about the threat of nonbeing, cannot be eliminated. It belongs to existence itself” (2005, 333). Unless there is a genuine confrontation with one's own nothingness, anxiety will continue to emerge again and again, often with greater degrees of intensity. So, instead of defensively recoiling from the experience or trying to blunt it with medication, the aim of therapy is to “plunge into the roots of one's anxiety, for a period of time, experiencing heightened anxiousness” (Yalom 1980, 206). In the safety of a clinical setting, the therapist would encourage the patient to invite anxiety to come forth and dwell in it so that he or she can feel it, recognize it, and come to grips with its sources. It is only then that anxiety begins to lose its terrible power because the patient learns how to confront and integrate anxiety and death into everyday life. This is why Kierkegaard claims that “only that man who has gone through the anxiety of possibility is educated to have no anxiety” (1944, 141, my emphasis). In this case, the patient becomes aware that the world is fundamentally insecure and that he or she is not and has never been an enduring and substantial thing. With this acceptance the patient can be opened up to ways of living that are no longer mired in the neurotic and self-deceptive need for control and certainty, and life takes on a transformative sense of urgency, poignancy, and depth that was missing before the confrontation. Tolstoy's The Death of Ivan Ilych offers the classic example of this kind of transformation.
Absorbed in the trivialities of everyday life, Ivan has a strong sense of ontological security. He has normal fears about money, vocational success, and social appearance, but because these fears are of something they can be easily managed. It is not until he is stricken with the possibility of his own annihilation from a terminal illness that his world begins to collapse. Initially, Ivan can't face the fact that he himself is the source of his anxiety, referring to his impending death as ‘It,’ as if it were an object that was separate and distinct from him. “It would come and stand before him and look at him,” writes Tolstoy, “and he would be petrified and the light would die out of his eyes, and he would again begin asking himself whether It alone was true” (1960, 133). But his anxiety persists, and the more he denies and represses it the more intense it becomes, eventually swallowing him completely. “From that moment the screaming began that continued for three days and was so terrible that one could not hear it … without horror” (154). Experiencing the full force of anxiety, Ivan's identity as a judge, a husband, and a father is destroyed, yet in this dissolution he suddenly realizes, “Maybe I did not live as I ought to have done” (148). This is the power of the existential crisis. It shakes us out of the false security of everyday life and makes us stand before the ultimate questions: ‘Who am I?’ and ‘How should I live?’ In his last moments, Ivan finally accepts his death and is transformed. He is flooded with an awareness of the poignancy and fleetingness of life and of the depth of his feelings for his wife and children. Tolstoy's story reveals that anxiety is a threat to existence because it shatters the meanings that hold our identity together. But it also opens up possibilities for existential growth and change by revealing who we are as vulnerable and finite beings and by forcing us to confront the self-defining choices and actions that made us who we are.