From this discussion, we see that existential therapy is not a scientific or technical procedure that seeks to eradicate anxiety. The aim, rather, is to understand the human situation, to bring to the surface fundamental experiences and questions of being human, and to free the patient from self-deception by accepting and integrating anxiety and death into life. The scientific framework of medical psychiatry cannot address these kinds of concerns because it fails to see the patient from the perspective of existence. This raises the question of whether or not existential therapy is opposed to any kind of medical intervention that objectifies and dehumanizes the patient, even if these interventions would protect the patient from self-harm or from hurting others. From a clinician's standpoint, is it naïve or even dangerous to encourage existential anxiety to come forth?
Is existentialism anti-psychiatry?
Although its philosophical roots can be traced back to Kierkegaard and Nietzsche in the nineteenth century, the acceptance of an existential approach as an alternative to the medical model in psychiatry is a more recent development. Austrian psychoanalyst Otto Rank (1884–1939) first began to incorporate existential interpretations of selfhood and anxiety in his clinical practice after breaking with Freud in the late 1920s. And Rank's contemporaries in Switzerland, Ludwig Binswanger and Medard Boss, drew on Heidegger's conception of Dasein to pioneer new forms of treatment in the 1940s and 1950s by framing the nature of psychopathology, not in terms of biological dysfunctions or unconscious Oedipal conflicts, but in terms of the structural breakdown of being-in-the-world (May 1958a). And, in the United States, clinicians such as Rollo May and Irvin Yalom played a similar role in applying the insights of existentialism to psychotherapy. But it was in Britain in 1960s and 1970s that existential therapy gained the most widespread acceptance among mental health professionals, largely through the work of psychiatrists such as David Cooper (1931–1986) and R. D. Laing. The reenvisioning of psychiatry offered by Cooper and Laing resonated with the anti-authoritarian ideals of the 1960s by challenging prevailing psychiatric practices, where the patient was diagnosed and labeled as ‘insane,’ controlled with drugs and/or electroconvulsive therapy, or hospitalized against his or her will. These practices, famously satirized in Ken Kesey's One Flew over the Cuckoo's Nest (1962), were criticized for representing the attitudes of an overly rationalized and repressive society, where any behavior that broke with the status quo was considered a threat to the social order, and psychiatrists were viewed as enforcers of the order in the same way police or prison guards were. Indeed, on their view, mental illness was seen as a ‘healthy’ reaction to these dehumanizing social conditions (Kennard 1998, 104).
In response to these conditions, Cooper and Laing established a new kind of therapeutic community where the aim was not to label, objectify, and control patients, but to understand them as people, relating to their existential situation and giving them a safe space to confront their anxiety and discover who they were. In these communities, residents were not diagnosed as ‘mentally ill’ but given freedom to participate in community activities as they saw fit. Staff and residents were regarded as equals, and medications were largely unavailable. Although a number of communities were established in the 1960s, the most famous and controversial was Kingsley Hall in London. A psychiatrist who lived and worked there described the conditions in the following way:
People who were psychotic were given space, they were given company if they wished, or not, and they were given a great deal of physical support if necessary. It was a feature about life at Kingsley Hall that as people were not considered ill, they did not have to be treated. No drugs were to be given to anybody. There were no staff and no patients, and there was no formal structure of doing things around the Hall, yet things got done. There were people who were “up” and people who were “down.” The people who were “up” or capable of functioning in a more usual social sense look after the Hall. (106)
Following Heidegger's notion of ‘liberating solicitude,’ the aim of treatment at Kingsley Hall was to release or free the patients from dehumanizing interventions so that they could face anxiety on their own terms and create their own identity without the reflexive need to conform to what society deemed ‘normal.’ On this view, medication and hospitalization were rejected because they would deny the patient the freedom for this authentic confrontation, to break through the anxiety and ‘become who they are.’
The obvious problem with this approach is that it runs the risk of romanticizing or glorifying anxiety as a “healing experience” and a necessary path to self-realization and personal growth (Barnes and Berke 1971, 86). This is a recurring theme in existentialism, one suggesting that those who suffer the most are the most self-aware and live with increased intensity and passion. They are more artistic, creative, and authentic than others because they fully experience the chaotic anguish of the human situation. Nietzsche famously expresses this romantic sentiment in an oft-quoted line from Thus Spoke Zarathustra: “I tell you: one must still have chaos within oneself, to give birth to a dancing star. I tell you: you still have chaos within you” (2006, I, 5). Or, consider this compelling passage from the Russian existentialist Nikolai Berdyaev:
Not the worst but the best of mankind suffer the most. The intensity with which suffering is felt may be considered an index of a man's depth. The more the intellect is developed and the soul refined … the more sensitive does one become to pain, not only the pains of the soul but physical pains as well. … But for pain and suffering the animal in man would be victorious. (cited in Olson 1962, 28)
There is certainly therapeutic value in recognizing the inescapable pain of being human. But it is questionable whether or not this pain is a sign of a person's creative depth and sensitivity, and whether or not it is always transformative. There are clearly instances of psychic suffering that are so overwhelming, so dangerous, that a medical intervention is necessary. Indeed, Mary Barnes, arguably the most famous patient at Kingsley Hall, nearly died because of the therapeutic attitude of non-interference. In the process of ‘going down’ to confront her anxiety, she would repeatedly cover herself with her own feces, attack her doctors, and eventually stopped eating altogether. Her own psychiatrist, Joseph Berke, “was horrified to see how thin she was, almost like one of those half-alive cadavers the army liberated from Auschwitz” (Barnes and Berke 1971, 228). But Berke and Laing, believing that this was her choice and part of her own process of personal growth, let it go on for some time. The situation eventually reached a point of crisis, where Barnes became “so thin that [they] felt she couldn't even be sent to a hospital, [and that they] might be prosecuted for keeping [her] like that” (Kennard 1998, 107). The staff was forced to intervene and feed her like a baby with milk from a bottle. Barnes survived but her experience exposed the danger of the non-interference aspect of existential therapy.
We can appreciate this problem by going back to the existentialist configuration of the self as a tension between facticity and transcendence. Laing and his colleagues do not deny that there are determinate ‘facts’ about being human, that I am, for instance, a living organism with a unique biochemical signature that shapes my emotional vulnerability. But what distinguishes us from non-human organisms is that we do not simply react to biochemical impulses; we can transcend them by choosing to interpret them in particular ways. I can, for instance, choose to flee from anxiety by taking tranquilizers or by trying to displace it with some objective fear, or I can face it, accept it, and try to integrate it into my life. In either case, the existentialist position makes it clear that I make myself who I am through my free, meaning-giving choices. But the case of Mary Barnes suggests that existential therapists may be overplaying their hand when it comes to transcendence. Indeed, in instances of extreme psychosis, the ability to self-consciously reflect on and give meaning to my emotional state is diminished to such an extent that the very notion of selfhood can be called into question. Consider William Styron's famous description of his own depressive breakdown in his memoir Darkness Visible: