Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: The Person and the Anxiety of Guilt

The anxiety of guilt can be seen as an offshoot of the anxiety of death in that the person’s actions may have consequences leading to her annihilation. It is not only the fates that determine the course of a person’s life but also her decisions, her actions. It is through the person’s actions that she becomes who she is. The peron is her life; this is the only life that person can have. Will she be able to create a life with meaning or one which she would rather have not lived? The burden of the universe is on one’s shoulders. There is more at stake than deciding on the validity of a value, it is one’s own concrete existence that is on the line.

Because life is concrete, because it is real, one may find at times that one is called upon to go against the universal norm. Life can be profoundly ambiguous, especially in those situations that matter most. In such circumstances one is never sure wether one is choosing for life and fulfillment or succumbing to some destructive influence. One may be compelled at times, in full appreciation of the ethical choice, to make an exception. There are times when rival goods make any choice result in evil. There may be so much to lose and one’s motivations so unclear that one is forced out of one’s ethical system. One is compelled to act outside the rules because they do not capture the truth about the concrete situation of oneself. One acts in an expression of pure will, fully responsible but having nothing to appeal to as a defense against condemnation. This in fact is our existential condition. It is our individual life that is at stake; it is our happiness. Perhaps the anxiety would not be as great if we didn’t know who we were, how we have acted. One’s past, if not one’s present, reveals the power one has over one’s destiny; given the ambiguity of existence, how is one to act with the totality of one’s being? It is so much easier to escape into self-righteousness or, conversely, lawlessness.

In the end who is there to convince? Who is it that one is trying to justify oneself to? Who is it that is sitting in judgement and hears the appeals to the Bible, Cosmopolitan, one’s parents or society?

The person creates his life; given the reality of ambivalence, can he ever be happy with what he, out of his circumstances, has brought into existence? Can he accept this?

The person is a paradox which is reflected in his will which drives him in separate directions. The  awareness of this condition is the experience of guilt. In affirming himself with the totality of his being, he takes on the nonbeing inherent in the act of becoming who he is. In being himself he accepts himself.

Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: The Person and the Anxiety of Meaninglessness

We are estranged from that which tells us who we are and why we are here. The anxiety of meaninglessness relates to a loss of ultimate concern which gives meaning to our activities, especially our struggles. We can endure anything when it has a purpose; without one we are unable to perform even the implest of tasks. Without a central purpose, we are driven from devotion to one object, to another  and another, as in each case we find either the meaning vanish or that what was a state of creativity, turn to indifference or aversion. The anxiety which arises, as the finite mind is met with paradox, is the result of the growing awareness of separateness and lack of universal participation.

Coming to consciousness, becoming oneself entails a self-affirming act on meeting one’s nonbeing. the encounter brings about a realization of separation; one  realizes one’s position as an individual participant within the whole. The anxiety is a barrier which, through the act of self-affirmation, is taken into oneself and thereby becomes the driving force urging the person to act heroically.

During infancy, one might imagine there being, in psychoanalytic terms, a state of primary narcissism. The person here is continuous with the larger structure and in a state of unconscious wholeness. This wholeness would be felt as good and eternal, it being an aspect of the creative self-affirmation of all existence emerging from the void. At birth the person is endowed with certain characteristics and a set of life circumstances. It is a pluripotential state from which one brings oneself into existence as one relates to what the fates bring.

The infant awakens to himself as a separate entity through hunger. His structure has to incorporate other structure be it material or psychological into itself. The psychophysiological event of anxiety that comes with hunger is the trigger and the core of the demands for food and affection.

The person develops into himself as a separate entity as he meets anxiety at each developmental level. At each stage he is met with the facts of his finitude and separation from the totality. He finds himself standing alone on his strength. Freud,Bowlby, Mahler, Klein, and many others have described what they see as occurring during the period of child development. The early history is clearly important as it forms the foundations of the personality and because one is usually never as weak and dependent on others.

 One becomes who one is, in the exercise of one’s will. The truth about oneself is revealed in one’s choices, in what one does. The choices may be limited: our freedom is finite. But it is freedom none-the- less to become what we will.

At times, in the course of one’s life, however, one may try to forge ahead heroically but is rendered impotent by the paradoxical quality of our finite existence. One’s efforts are not enough and meets oneself as weak, powerless, and insignificant. To avoid despair one is driven to find greatness in oneself or borrow it from a powerful other.

The fact of our existential position remains and emerges with the full force of anxiety and despair whenever it is reawoken by disappointment. As outlined by Self-Psychology, a fragmented, regressive state ensues as once again the illusion is seen through and the person attempts to retreat from the overpowering experience. Occurring in small increments however, the confrontation with one’s limits allows one the opportunity to overcome his condition in reality. Onecomes to a growing awareness of oneself. In one’s solitude one is also able to see the other, not as a mirror providing one with an image of oneslf, nor as a source of power and direction, not even as a twin who enables him to love and accept himself. In the end one is alone in being oneself not as an image or a role, not living on borrowed strength and love. One is the truth of one’s own will.

In terms of drives, we can understand the situation as involving the sublimation of prerational forces. There areyearnings within us that seek expression. The task in life might be seen as, not so much a refinement or redicection of these yearnings from their original aims, but rather the discovery and creation of rational objects to give them fulfillment.

Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: Nonbeing, the Family and Society

Many, if not most of us are able to get through life without extreme incapacitating episodes of anxiety and despair. Our innate abilities, our determination, the support of family, friends and society are enough that we are able to manage. We take an the reality of nonbeing, of our existential separation in small doses which we overcome and are thus able to grow.

The family and the larger social structure provide us with the opportunity to be cared for and to go on to care for ourselves and others. Religion and secular systems of belief provide us withmoral codes that guide our will in avoiding self-destructive trends. They also offer justification for self- acceptance; we feel we are right in feeling good about ourselves because we have adhered to the code that we see as defining the ultimate good and bad. The family and social stucture provide us with roles and statuses in which we gain a sense of meaning and immortality. In a healthy society the vast majority of members are made significant in their position.

Societies differ in the degree of maturity they ask of the individual. In some, the leader, like Dostoyevski’s Grand Inquisitor, takes on his subject’s guilt. In surrendering the decision- making onto him, they are relieved of the burden of freedom. He alone bears the responsibility. When the leader is deposed, the individual is left incapacitated until a successor is found. In other cultures it is a societal system, a belief or set of rules that takes the anxiety of guilt from the individual. One knows what is right and what is wrong. In acting in the accepted manner one gains self acceptance. But even social and religious systems can crumble. In defense against the possibility of freedom, the individual either becomes fanatical or turns to lawlessness. Acting without self-reflection, he feels a rush of initial pwer which dwindles as his actions bring him to a condition where his choices become ever reduced and he is led to despair. Morality after all is a description of behaviours that increase a person’s freedom. Though seemingly restrictive, moral codes allow for self-discipline which is the ultimate expression of the will; the free-est will is that which can act regardless of the barriers. Morality in this light is a set of standards which heighten power, which bring one increasing freedom. It is also a formula for avoiding hell, avoiding despair.

Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: Psychopathology and Our Existential Plight

Mental disorders are conditions that may be brought on by innumerable precipitants which reflect the complexity of the structure which we are. As we know when we attempt to formulate a case, an interplay of biological, familial, social and psychological factors is described to help understand the picture with which we are presented.

Our early experiences have a profound influence on us. At no time, except in our last moments are we usually weakest and most dependent on others. As young children, we develop our first impressions of how the world is. We are dependent on our caretakers for physical and emotional nurturance. Disruptions in these bonds, as Bowlby and others have described, have powerful repercussions within the person. Because of our limited physical abilities and understanding of the world, we may become overwhelmed by anxiety and despair by situations that in adult life might otherwise be tolerated. We may be faced with unremitting confrontations with our own weakness. As a solution, patterns of behaviour, a “character armour” develop as a means of handling the challenges, of protecting oneself from the emerging threats.

These patterns of perceiving, understanding, and acting, because they tend to be fixed, become maladaptive at times within the vagaries of life. When they begin to interfere with relationships and other aspects of the person’s life, these characterological traits are seen as psychopathological and can be classified as such under diagnostic systems like DSM III which lists them as Axis II diagnoses. Though these categories help us in conveying to one another a sense of the person we are treating, they, unfortunately also, by focussing only on certain aspects of the person, can deflect our attention away from her totality. They act as stereotypes in this way; but this too reflects the rigidity of the character that the person has become. In spite of this rigidity, the person remains unique and the behaviour patterns to which she clings so ardently and limit the fulness of her life are essentially attempts at avoiding the despair that comes with the reality of individuality.

Reviewing the different types of personality disorder we can posit some explanations of the relationships between the various presentations and the individuals’ existential positions.

Persons within this first group of Paranoid, Schizoid, and Schizotypal Personality Disorders are generally perceived as odd and eccentric. There may feel to be little connection between oneself and a person who presents in such a way.

The schizoid person seems to shun relationships. He turns to fantasy as a solution; human contact might awaken a sense of empty aloneness. In being with the other he finds himself desparately alone. So he avoids people; in order to escape from his existential position of aloneness he runs to aloneness.

Ther are other conditions of self-imposed aloneness where a bridge is maintained with the other but is constructed with hate. Perhaps this might be the case with a particular paranoid individual. Love for him is pain and humiliation; it is felt as a weakness. Unable to bear the experience of losing the other, the loss of love, and unable to stand alone, he keeps the other alive in fantasy as an object of derision and hate, alternating with fear.

Whether a person with a schizotypal personality disorder has a brain dysfunction like scihizophrenia or has developed his character in response to a particularly painful or otherwise inadequate environment, the result is someone living in a magical universe inhabited by spirits and peculiar coincidences, where others may seem deadened at times and so present at others that they appear to be within one’s head. Occult techniques are used to discern what the real world will bring. How is one to jump out of one’s private world to know the reality beyond? Clearly one cannot go beyond one’s own experience as it defines in part who one is; the horror of isolation drives the person further into his own private experience, away from others and hence into deeper isolation.

Then there is the emotional, dramatic, erratic group of personality disorders.

Here are worlds of extremes: good and bad, greatness or insignificance, elation or despair, total freedom or total restriction.

The sociopath cannot bear the burden of responsibility; it is his life but he cannot or will not see anything but how he has been treated. He relinquishes his free choice, opting for non-reflective action. He desires freedom from condemnation but frequently is left with a life of confinement and pain to others and himself.

The weakness and insignificance that is felt by the person with a narcissistic personality disorder is countered by flights into fantasy which must be mirrored by others. An inner sense of lack and smallness makes him feel entitled and causes him to disregard the rights of others. Unable to face himself as he is, he creates himself through others; he creates himself in fantasy. He doesn’t grow emotionally and spiritually as long as he fails to accept and begin from the point of who he actually is.

Likewise the pattern in the histrionic personality disorders; the person, his life feels empty so he fills it with excitement and activity. One skirts the surface in dread of nothingness. Avoiding the experience of there being nothing to life, to oneself, one dramatizes and over-reacts. In the end the shallowness that is created is the nothingness one wished to avoid.

Perhaps the most outstanding feature of the borderline personality is the attept to escape from oneself into the other. To be oneself is intolerable. The neediness is so intense that it drives others away. One is ever brought back to oneself.

Turning to the last group of scared, introverted, anxious personality disorders, we see a failure of heroic action which reinforces guilt and anxiety, thereby making the hurdle ever larger until it is mountainous.

The avoidant person cannot attempt an attack; he runs in response to his lack of strength. But life becomes increasingly impoverished thereby increasing the anxiety. He wants to live, to make real his desires but, this involves a risk. To avoid the risk, to avoid the possibility of failure, he runs to failure. In relational terms, out of fear of being unloved, one runs from the possibility of love.

The dependent person seeks the protection of others who, in turn, are all too ready to project their own weakness onto the individual presenting himself as a poor unfortunate. He may be take the form of a masochist who projects onto a complementary sadist, the terror of death and guilt. He hates his weakness as he ultimately hates the sadist, but he remains in the relationship hoping to eventually manipulate a victory from these forces of evil. The sadist too despises weakness; he overcomes his own powerlessness by subjugating his victim. Though the masochist would vanquish the sadist, he can never allow himself to succeed; to do so would entail his losing his source of borrowed power. Thus the battle continues, both seeking to escape despair into whose pit they find themselves slowly sinking as life grows ever more miserable.

The compulsive too hates weakness, especially moral weakness; there is a proper way to act. His lack of self-acceptance permeates his being in the world. He is indecisive, fearing condemnation in either direction he turns. He insists that others submit to his will in fear of giving in, surrendering , and hence seeing himself as a coward. If only life can be controlled, he reasons, he will be able to avoid death guilt and insignificance. Here again, as the individual attempts to save his life, he finds it slipping away. He becomes what he most feared.

Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: The Person and Healing

While it is difficult to tease out the degree to which psychological, social, familial, constitutional, and organic factors influence the picture we see when dealing with many personality disordered persons, in this as in other psychiatric conditions, both the physical and the mental aspects of the person are affected.”Mental”, like other illness, is both physical and psychological, and ultimately spiritual in that it shakes the person to his depths and forces him to confront himself.We as healers, attempt to effect a change in the person that comes to us for help. A complete state of health is not brought about by the alleviation of the symptom alone, nor in bringing the patient to a position where she conforms to society’s or our image of what she should be. Overcoming illness would rather seem to involve a return of the capacity to creatively affirm oneself. Health might be described as a state of wholeness of the individual in the world.There will be struggles but the patient will be able to continue and not flee from life. In health tthe person is able to be and hence express herself creatively, thereby gaining fulfillment. As Freud said, “One is able to love, work, and play.”

The healer helps by dealing with the three aspects of the person’s nature: her body, her psyche, and her spirit. The interventions range from doig something to the patient like providing medication to being a catalyst whereby she is better able to heal herself.

The importance of biological factors is quite clear in the organic brain syndromes and reasonably certain in psychotic illnesses such as schizophrenia and major affective disorders. In panic disorder as well there is some evidence of perhaps a neurochemical imbalance resulting in spontaneous anxiety states which are not precipitated by symbolic phenomena. In such cases it is clear that physical therapy in the form of medication has a role to play in the healing of the individual.

Anxiety has been thus far described as being a manifestation of our existential estrangement from ourselves and the world. In coming to know ourselves in the world we break the unconscious identification with the totality. The result is a profound sense of separation in which our dependent position is all too evident. In an attempt to avoid conditions of anxiety and despair we join one another as a society which provides us with the support to affirm ourselves. We may not have been blessed with the biological, familial, cultural, and other factors which help in the creation of these supports. In such a situation, the person faces his creatureliness, his worthlessness alone and sets about, in his own way, to evade the problem, to shield himself from the anguish inherent in existence. Torment arises out of conflict; in a no-win situation, the person is led to despair. The person becomes his own worst enemy, precipitating in the end what he most feared.

The person comes to understand himself in the psychotherapeutic situation. As the transference unfolds, the patient is able to develop a relationship with nature and its transcendent powers. In the safety of the therapeutic setting, he can begin to explore himself and the world. Though he may initially gain strenghth by using the therapist as a source of power or someone to be manipulated in a self-expansive way, as the therapy progresses his conflicts come to life within the relationship and brought to his attention.

Clearly the intervention can go only so far as to provide the patient with the therapist’s impressions. Ultimately it is the patient who changes, who becomes himself as he chooses how to react within the relationship. He attains a cohesion of self not in understanding the interpretation and not solely by his sense of being understood; rather he becomes himself by his his acts.

Psychodynamic psychotherapy is but one in a number of techniques used in our field. What may be a common thread, what may be involved in the bringing about of change is the identification of the problem which is then set in a theoretical framewok and, perhaps with the help of the therapist’s suggestions, the patient’s acting on it. The key element of all therapies: behavioural, cognitive, psychodynamic, short and long-term, what ulimately effects change is what the patient does (including introspection).   

In chronic illnesses as in other cases where we see the patient through aspects of his existential condition, there is a part of healing which involves ministering to the patient. One helps him to accept himself with the illness and adopt an attitude of thankful dependence. This would sound quite condescending if our human condition were any different; but it isn’t. We have no less trouble accepting ourselves, letting down our guard and admitting our lack of self-sufficiency. We may be even more dependent on the social structure into which we have been fortunate to forge for ourselves an enviable position. We are brothers and sisters in the human condition.

As the patient comes to the recognition of both his and the therapist’s inability to lift him above this human condition, we may see a transfer to the real source of power. He doesn’t have to please his parents, hisboss, his society, or his therapist, but rather has to find acceptance and strength in his depths, in the very power that creates and maintains him.

Abelief system won’t do; the answer has to be as real as the anxiety and despair that he is.

A lot has been said in the last forty-five minutes. What is left to say in closing? One thought that might come to mind is that mid-life crises make for unusual Grand Rounds. Perhaps we can review briefly what has been discussed.

We looked at the idea of the person and saw how she might be described as multidimensional. The person firstly exists. She does so as an individual participant within the larger universe. The fact of her existence makes her a concrete, living truth which is a creative and dynamic unity. Ultimately she becomes who she is through the free expression of her will. Through her actions she makes the potential a reality. The person participates in her creation from a universal basis which can be understood in terms of the psyche and the physical universe. The person is a psychophysiological unity which presents a paradox to our finite reason. The person is separate making her an individual participant in the world. Separateness is felt as aloneness and in the experiences of anxiety and despair. We are anxious of the possibility of, and despair of the realities of death, condemnation, and meaninglessness.

Our ills have physical, psychological, and ultimately spiritual dimensions. They are ultimately spiritual because suffering involves the totality of the person and brings him to a recognition of his existential aloneness

Healing’s aim is to re-establish the wholeness of the person in her world. Physically this means an intervention involving matter: surgery, pharmacotherapy, prosthetic devices and so on. Psychologically, it means bringing her to a recognition of her conflicts. Spiritually speaking, healing involves the development of an attiaude of acceptance and thankful dependence. In psychiatry these three separate healing roles are adopted through the administration of medication and the “talking cure” both of which are carried out in an atmosphere of understanding as two persons share their solitude.