I had reached a phase of the disorder where all sense of hope had vanished, along with the idea of futurity; my brain, in the thrall to its outlaw hormones, had become less an organ of thought than an instrument of registering minute by minute, varying degrees of suffering. … I would lie for as long as six hours, stuporous and virtually paralyzed, gazing at the ceiling and waiting for that moment of evening when, mysteriously, the crucifixion would ease up just enough to allow me to force down some food and then, like an automaton, seek an hour or two of sleep again. (1990, 58)
Styron's words are important because they reveal how out of reach the possibility of self-realization was. By referring to himself as an ‘automaton’ in ‘thrall to its outlaw hormones,’ Styron is clearly suggesting that he was in no way free to take a stand on his condition, that he was actually trapped in facticity. Whereas the existential approach insists that by confronting and accepting anxiety we can eventually break through and realize who we are, in Styron's case this interpretation seems implausible. Indeed, it could be argued that he is no longer a self at all because he does not exhibit the capacity for transcendence (see Aho 2013). And it is at these times when a medical intervention would seem most appropriate. But would this not undermine the therapeutic aim of non-interference, of freeing the patient so they can confront their own nothingness? Not necessarily.
Binswanger writes that the “existential orientation in psychiatry arose from dissatisfaction with the prevailing efforts to gain scientific understanding in psychiatry” (1956, 144). But ‘dissatisfaction’ does not entail the wholesale rejection of scientific approaches. It should entail a rejection of ‘scientism,’ a view that Heidegger describes as one where “science alone provides the objective truth. [Where] science is the new religion” (2001, 18). In his own series of seminars with psychiatrists and psychotherapists toward the end of his career, Heidegger makes it clear that mental health professionals are overly influenced by the dogmas of natural science, and this invariably makes them “blind” (59, 75) to their own prejudices as well as to the situated experience of the patient. “Science,” he writes, “is dogmatic to an almost unbelievable degree everywhere, i.e. it operates with preconceptions and prejudices [which have] not been reflected upon. There is the highest need for doctors who think and who do not wish to leave the field entirely to scientific techniques” (103). But for Heidegger, science itself is not the problem. It is the hegemony of the scientific method as the only way to interpret the human situation that is at issue because it reduces the human being to “something chemical and as something which can be affected [only] by chemical interventions” (155). Heidegger's goal in speaking to medical professionals is to liberate them from this reductive assumption so that they can encounter the patient as an existing person, not as a thing. But liberating doctors from reductivism should not preclude the use of psychiatric techniques. If a patient can be pulled out of a state of paralyzing anxiety by means of medication, electroconvulsive therapy, or hospitalization, then medical interventions do not necessarily have to be viewed as dehumanizing and repressive, but as a way of recovering the patient's capacity for transcendence. In spite of the instrumental intervention, the primary aim of existential therapy can remain intact. No longer engulfed in the ‘outlaw hormones’ of facticity, the patient can now begin the hard work of self-realization, of facing anxiety as an existential given, and of integrating an awareness of their own freedom and death into everyday life.
Of all the existentialists, Nietzsche is the most sensitive to how the determinations of one's own physiology limit the possibilities for self-realization. He insists that man “know himself physiologically,” and that “to know, e.g., that one has a nervous system (—but no ‘soul’—) is still the privilege of the best informed” (1968, 229). The suggestion, here, is that our capacity for transcendence is always mediated by the polymorphous drives and affects of the biological body. Whether I am able to freely accept anxiety and death into my life is not necessarily up to me; it is the result of the “fortunate organization” of my nature (705). This is why Nietzsche says: “[Freedom] is for the very few” (1998, 29). It is “a privilege of the strong” (1990, IX 38) who cannot help but confront themselves and accept who they are. Nietzsche understands that some of us are not so strong because we are born with a complex of inherited genes and neurochemistry that sabotages the authentic confrontation with anxiety. “It is simply impossible,” he writes, “that a person would not have his parents’ and forefathers’ qualities and preferences in his body. … If we know something about the parents, then we are allowed a stab at the child. … These things will be passed onto the child as surely as corrupted blood” (1998, 264). Our own genetic vulnerabilities or ‘corrupted blood’ invariably shape our affective response to anxiety and death. Fortified with a particular neurochemistry, confronting the experience may very well be healing, freeing us from neurotic self-deception, and opening up new possibilities for existential growth. But existential therapists need to guard against the tendency to romanticize anxiety. For some patients, there is no breakthrough or transformation. The experience can be so overwhelming that, without some medical intervention, they are destroyed. This helps us to better understand Styron's words when, in the darkest phase of his collapse, he simply asks: “Why wasn't I in a hospital?” (1990, 59).
These cautionary comments are in no way meant to diminish the importance of existential approaches to mental health. In the age of medicalization, there is more need than ever to both situate and understand the patient within his or her own context and to recognize and accept the inescapable pain of being human. By taking a position of scientific detachment and reducing the patient to an object, the therapist invariably overlooks the patient's lived experience and fails to see that ‘maladaptive’ or ‘abnormal’ behavior is, first and foremost, an expression of the patient's way of being-in-the-world. From the existential perspective, the patient does not merely want to be measured and tested for outward signs of a ‘disease.’ More than anything, he or she wants their experience “to be heard” (Laing 1960, 31). In this sense, the existential perspective offers a number of important correctives to the prevailing medical model. First, it allows the therapist to suspend objectifying judgments about the patient and the causal nature of mental illness so that they can listen to the patient as a person and enter into their experience as they feel and understand it. Second, it opens up a space for self-criticism in the ‘psy’ professions by critically engaging ‘the world,’ that is, the sociohistorical situation that has made scientific objectification and technique the default setting in modern medicine in the first place. Indeed, there are encouraging signs in recent psychiatric and psychotherapeutic theory that reflect this attitude of self-criticism by drawing directly on the insights of existentialism. They can be found, among other places, in the emergence of the ‘post-psychiatry’ movement inaugurated by Bradley Lewis (2006) and Patrick Bracken and Philip Thomas (2005), in the relational or intersubjective psychoanalysis of Robert Stolorow and George Atwood (1992), and in the social psychiatry of Dan Blazer (2005). Finally, and perhaps most importantly, the existential approach allows for a mutual recognition between therapist and patient; that the deepest forms of psychic suffering do not originate in faulty biochemistry, but emerge out of the structural frailty and insecurity of the human condition itself. In this sense, both therapist and patient are walking the same ground, both having to confront their own anxiety and death on their own terms.