The fundamental contribution of existential therapy is its understanding of man as being.

Rollo May

The problem of medicalization

One of the more controversial trends in contemporary psychiatry is the ‘medicalization’ of an increasingly broad range of human emotions and behavior. Today, for instance, a person who appears to be overly shy and withdrawn can now be diagnosed with a genuine medical condition, ‘social phobia,’ that can be effectively managed and controlled with psychiatric medications. On the medical model, mental dysfunction is interpreted as a discrete entity, an organic ‘disease’ of the brain, and it is by observing the behavior of the patient that the psychiatrist can identify the disease and apply a diagnostic label. As medicalization has grown, so have the number of psychiatric disorders and drugs to treat them. The latest incarnation of the Diagnostic and Statistical Manual of Mental Disorders, considered ‘the bible’ of psychiatric diagnosis, now contains over three hundred different disorders, three times more than the number in the first edition (DSM-I, 1952). An example of this explosion of disorders can be seen in how the broad classification of ‘anxiety neurosis,’ so central to earlier psychoanalytic models, has now been broken into seven distinct disorders: agoraphobia, panic disorder, post-traumatic stress disorder, obsessive compulsive disorder, generalized anxiety disorder, simple phobia, and social phobia. With this new diagnostic classification, the behavior of a person who is shy and introverted can now be interpreted in terms of comorbidity, where the person exhibits not just social phobia, but signs of panic disorder and agoraphobia, and requires a psychiatric cocktail of three separate medications to treat each of these discrete illnesses. Critics have argued that this pattern has created the ‘Prozac Nation’ we live in today, where we are all in search of a quick fix for every aberrant feeling or behavior without ever engaging the existential situation from which these feelings and behaviors emerge (Chodoff 2002; Lane 2007; Aho 2008). This phenomenon should not be surprising given the historical roots of psychiatry.

Modern psychology and the medical specialty of psychiatry emerged against the backdrop of the scientific revolution in the seventeenth century and developed into their own distinct disciplines in the late nineteenth and early twentieth centuries. Informed by the perspective of natural science, psychologists and psychiatrists tend to view the patient from a particular paradigm. First, because scientists adhere to a technical procedure or ‘method’ based on the subject-object model, the patient is usually regarded dispassionately as an object of investigation, and emotional and behavioral dysfunctions are viewed as discrete entities that are, like all other things in the natural world, the result of mechanistic causal interactions that can be quantified and controlled. Second, by taking a position of methodological detachment, little effort is made to contextualize the patient's experience, to understand his or her life-world. The therapist views the patient through the lens of a set of fixed determinations, restricted to the objectively observable behavior and looking for the causal mechanisms of disease (Laing 1960, 31–33). Although Freud and a number of different psychoanalytic models certainly recognize the importance of inter-human relations, they still abide largely by a mechanistic conception of human behavior and the techniques of objectification that, in the words of Heidegger, “transfer scientific causality to the psychical” (2001, 20). Psychoanalysis, as Freud confirms, “must accept the scientific Weltanschauung. … The intellect and the mind are objects for scientific research in exactly the same way as non-human things” (Freud 1964, 171; cited in Askey 2001, 309).

To be sure, the attitude of scientific detachment allows the therapist to maintain a position of alleged neutrality and objectivity and also serves as a buffer of self-protection from the exposure and vulnerability that can manifest in the therapeutic encounter. But in defending from this emotional threat, the therapist is often cut off and dissociated from the patient, making it difficult to recognize him or her as a person. “If the technical view is used dominantly in the relating to the other person,” writes existential therapist Rollo May, “the price [is] not only the isolation of himself from the other but also of radical distortion of reality [because] one does not really see the other person” (1958b, 39). R. D. Laing will go so far as to suggest that psychiatry's reduction of the human being to a complex organism and its failure to situate the patient in his or her life-world is not only dehumanizing; it's pathological. “[Psychiatry is] concerned specifically with people who experience themselves as automata, as robots, as bits of machinery,” he writes. “Yet why do we not regard a theory that seeks to transmute persons into automata or animals as equally crazy?” (1960, 23). Against the mechanistic account, existential therapists suggest that the primary aim of treatment is to relate to the patient's own lived situation. The therapist, says Laing, “must have the plasticity to transpose himself into another strange and even alien view of the world … without forgoing his sanity. Only thus can he arrive at an understanding of the patient's existential position” (34).

As we have seen, existentialists interpret human beings not in terms of psychosomatic mechanisms but in terms of existence, that is, in terms of the situated activity or way of being that is already bound up in a world. On this view, we understand ourselves only in relation to our involvement with others and the shared meanings of the public world. Thus, in order to relate to the patient, the therapist must first relate to the patient's way of being-in-the-world. Swiss psychiatrist Ludwig Binswanger describes the therapeutic aim as one that does not try to ‘explain’ the causal mechanisms of a disorder or divide the patient into distinct categories of mental and physical but, rather, attempts to ‘understand’ the patient by entering into his or her life-world.

From the existential perspective, understanding the patient has nothing to do with a scientific explanation of the causes of emotional or behavioral dysfunction. Accumulating data on hereditary or familial incidence, assessing speech or behavioral abnormalities, measuring heart rate, and examining brain scans do not help us relate to the patient's experience. The existential therapist recognizes that in coming into treatment, the patient does not just bring in a set of observable psychosomatic symptoms. He or she brings an entire existential situation, with all of the regrets, fears, traumas, and desires that accompany this existence. By attempting “to articulate what the other's world is and his [or her] way of being in it” (Laing, 1960, 25), the therapeutic encounter opens up the possibility of understanding of ‘what it means’ and ‘what it feels like’ for this particular person to suffer. Bracketing out scientific assumptions in this way, the existential therapist is able to gain insight into the patient's being, not as a diseased thing, but as an embodied existence whose pre-reflective bond with the world has been profoundly disrupted.

Anxiety, embodiment, and psychotherapy

As we saw earlier, the human body shows up differently for existentialists. It is not a causally determined physical body but a ‘lived body,’ where this is understood as the first-person experiences, feelings, and perceptions of my own body. The body, in this sense, is not a discrete object that I can examine from a perspective of scientific detachment because I am already living through it; it already belongs to me. “What I feel,” writes Marcel, “is indissolubly linked to the fact that my body is my body, not just one body among others. … Nobody who is not inside my skin can know what I feel” (1950, 104). But, from the perspective of being-in-the-world, it is a mistake to think that these feelings reside somewhere inside me as if I were a self-contained subject. As Heidegger says, “There is no longer any question about subjectivity. [Being-in-the-world] is not the ‘structure of subjectivity,’ but its abolition” (1988, 220). To be sure, my feelings are mine, but as a situated and embodied way of being, there is no clear distinction between ‘inner’ and ‘outer,’ because my emotional life is already embedded in shared contexts of meaning. Indeed, it is only on the basis of being bound up in these public contexts that I can find myself in moods – in situations that emo­tionally affect me in particular ways. As someone absorbed in the meanings of the academic world, for instance, things like books, classrooms, and lectures already matter to me in a way that is fundamentally different from a salesman, a banker, or anyone else unfamiliar with this world. In this way, the moods of the academy are always working behind my back to orient me in the world, already directing me toward the things that matter and providing a background sense of what counts in specific situations. They are, as Heidegger writes, “like an atmosphere in which we first immerse ourselves in each case and which then attunes us through and through” (1995, 67, my emphasis).

When I am mentally healthy, I am integrated and woven into the world to such an extent that my body and my feelings remain largely hidden from me. They disappear in the practical flow of my daily life because I am already geared to my situation, seamlessly living through the medium of my body without explicitly reflecting on it. In this state of everydayness, there is no separation between self and world; the world appears spontaneously to me as something that I understand, that I belong to, and am ‘at home’ in. It shows up as real, secure, and reliable, and others show up for me as equally real, secure, and reliable. In this state, I have what Laing calls “ontological security” (1960, 39, 42). Secure in my being, I can pre-reflectively move through the world, handle various situations, and affectively involve myself in the lives of others. From the perspective of existential therapy, psychopathology begins to emerge when this embodied connection breaks down, shattering my sense of self. Without the unified bond of being-in-the-world to integrate and hold my identity together, I feel as if I am losing myself, as if I am becoming nothing. Existentialists usually refer to this uncanny dissolution of the self in terms of ‘anxiety’ or Angst.

Again, anxiety is not to be reduced to a bio-chemical reaction to a perceived threat. It is not a medical condition but a structure of being human, a basic experience that discloses the nothingness that underlies my everyday being-in-the-world. Existentialists make it clear that anxiety is not to be confused with fear. Fears can be located, understood, and managed because they are always of something; they relate to external objects or things. Anxiety is a fear of nothing, and this why it is so terrifying. I have the unsettling feeling that the meaningful structure of being-in-the-world that holds my identity together is slipping away, but I cannot point to or explain what it is I am anxious about because I am the source of it. Anxiety discloses the fact that it is my identity or being itself that is nothing, that I am not a stable, substantial, and enduring thing, but a ‘being-possible,’ a ‘being-toward-death.’ This is why Heidegger says, “So if the ‘nothing’ exhibits itself as that in the face of which one has anxiety, this means that [human existence] itself is that in the face of which anxiety is anxious” (1962, 187–188). Anxiety, in other words, emerges out of my own structural nothingness, and this I why I cannot point to what is that I am anxious about; it “threatens [from] nowhere” (186).

The fact that I cannot explain or locate the source of my anxiety makes the feeling all the more horrible, creating a sense of profound helplessness that begets even more anxiety. To defend against this, most of us are able to displace it, turning the overwhelming fear of nothing into a fear of something. In this way, as Kierkegaard puts it, “the nothing which is the object of anxiety becomes, as it were, more and more a something” (1944, 55). Through this displacement, the fear of my own nothingness becomes something ordinary and manageable, transposed into a much less threatening fear of flying, fear of heights, or fear of public speaking. Such displacement allows me to be reabsorbed into the flow of the world, solidifying the illusion of my own being as something enduring and real. But for those with a diminished sense of ontological security, transforming anxiety into fear is not so easy. For such people, anxiety continually “attacks from all directions at once” (May 1950, 2256), and the self is under a constant threat of annihilation.

This experience is characterized by a collapse in the fluid synergy between my body and the world, where even the most basic tasks of everyday life – standing up and moving, reaching out and taking hold of things, and interacting with others – become difficult. Overwhelmed by anxiety, my body loses its transparent grip on the world and begins to obtrude as a brute thing or object, as something clumsy and foreign that inhibits my engagement with the world. Laing describes this experience in terms of ‘the unembodied self.’ “In this position,” he writes, “the individual experiences his self as being more or less divorced and detached from his body. The body is felt more as one object among other objects in the world than as the core of the individual's own being” (1960, 69). Dissociated from my own body and from the world in this way, I am unable to meaningfully participate in the lives of others. Their gestures, words, and actions appear as lifeless and unreal to me as my own body does. This experience can result in feelings of ‘depersonalization’ where I feel as if I am not actually there and the world is not real (see Fuchs 2005). In this state, I know there is a world out there, but I can no longer feel it. It doesn't resonate emotionally as something substantial, meaningful, or significant to me. For clinicians, patient descriptions of this experience include statements like: “This seems unreal,” “This is like a dream,” “Nothing seems to be touching me,” and “This is not happening” (Laing 1960, 78).

When the world collapses in this way, not only does my identity slip away, but also others now appear to me as a threat because they expose the frailty and uncertainty of my being. When I interact with people who seem to be integrated, substantial, and whole, I am reminded of my own fragile and vulnerable state, that I have to put on a mask when I'm in public in order to “play at being sane” (148). To protect against this, the tendency is to withdraw and isolate oneself from others. But isolation further diminishes my sense of self, exacerbating the feeling of unreality. This is because, on the existentialist view, my identity exists only insofar as it is publicly acknowledged. I can understand myself as the person that I am – as a teacher, a husband, or a father – only in relation to how others see me. In other words, who I am and how I interpret myself is constituted by my being-with-others. This is why Sartre writes, “The Other holds a secret – the secret of what I am. He makes me be and thereby possesses me” (1956, 475). Without this inter-human relation, I am cut off from the world and my publicly interpreted identity begins to die. One of the goals of existential therapy, then, is to reestablish a sense of relation with others, to reintegrate the patient back into the public world so that a stable sense of identity can emerge and ontological security can be reestablished. But the primary aim is much more than this. The existential therapist wants the patient to learn from the experience, to recognize that anxiety is not necessarily a sign of insanity or a bio-chemical disorder. It is a teacher that reveals a painful but inescapable truth about the human situation, namely, that we are nothing, that we are “not real” (see Loy 1996). This is a radical way to rethink psychopathology. From the existential perspective, the individual who is overwhelmed with anxiety and experiences the collapse of the world may not be deluded; he or she may actually be glimpsing the truth of the human situation. As Laing writes:

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.

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.

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:

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:

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:

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.