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Pathology in Relation to Psychiatry and Clinical Psychology

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Concepts of pathology, as treated by the traditions of clinical psychology and psychiatry, define what is “normal” and “abnormal” in human behavior. Various psychological paradigms exist today, each emphasizing diverse ways of defining and treating psychopathology. Most commonly utilized is the medical model which is limited in many respects, criticized for reducing patients problems to a list of pathological symptoms that have a primarily biological base and which are to be treated behaviorally or pharmacologically (Schwartz & Wiggins 1999). Such reductionist positivist ways of viewing the individual maintain the medical discourse of “borderline personality”, schizoid”, “paranoid” or “clinically depressed”, often failing to address the wider socio-cultural environment of the individual. Pilgrim (1992) suggests that such diagnostic pigeon-holing does not enhance humanity, nor aid those who are dealing with the distressed individual to find meaning. It also neglects to consider life beyond the physical, failing to address the more philosophical questions that abound from our very existence.

Existential psychiatry and psychology arose in Europe in the 1940’s and 1950’s as a direct response to the dissatisfaction with prevailing efforts to gain scientific understanding in psychiatry (Binswanger 1963). Existentialism is the title of a set of philosophical ideas that emphasize the existence of the human being, the lack of meaning and purpose in life and the solitude of human existence. Existentialism stresses the jeopardy of life, the voidness of human reality and admits that the human being thrown into the world, a world in which pain, frustration, sickness, contempt, malaise and death dominates (Barnes 1962). How one positions oneself in that world becomes the focus for existential notions of pathology, a responsibility that is present for every human being, not one confined to the “mentally ill”. In this sense the human being is “response-able” to the existential predicament that is life and the necessary struggles that arise through negotiating these conditions in every lived moment.

In this essay I will give a brief outline of the history of existential thinkers, then discuss how the existential challenge emphasizes one’s freedom of choice of being-in-the-world and how ultimately one must take responsibility for how one reacts to the givens of existence. I will outline how these predicaments of life can precipitate anxiety, guilt, inertia and the loss of will; that facing the responsibilities to the “givens” and choices in existence can cause ontological anxiety, a natural reaction to living authentically, and the problems incurred when one avoids tackling these predicaments and contradictions, thus living unauthentically or choosing to withdraw into a solitary world. The existential notion of pathology will be contrasted with that of the positivist approach.

During the Second World War existentialism found its zenith of popularity, a time when Europe was in crisis, faced with mass death and destruction. Existentialism provides a moving account of the agony of being thrown into the world, perhaps appealing the times of intense confusion, despair and rootlessness caused by the War and its aftermath. In the 19th century existential thought is found in the writings of Soren Kirkegaard (1813-1855), Friederich Neitzche (1844-1900), Fyodor Dostoyevoski (182?-1881) and later Jean-Paul Satre (1905-1980), all of whom were opposed to the predominant philosophies, and scientific dogmas, of their time and committed to exploring the experience of reality in a passionate and personal manner.

The birth of modern existentialism can be attributed to Martin Heidegger (1889-1976), who’s thinking was applied to psychiatry, psychotherapy and psychoanalysis by Karl Jaspers (1883-1969), Ludwig Binswanger (1881-1966) and Medard Boss (1903- 1990). They attempted to gain a sense of the subjective phenomena of mental illness using existential concepts (Owen 1994). In America psychotherapists May and Yalom (1984) formulated their unique type of existential psychotherapy, as did Frankl (1963) in Austria with logotherapy, and also Laing (1960), working with schizophrenics, in the anti-psychiatry movement in Britain.

Ironically many of the writers celebrated as existentialists deny to be grouped together as one school of thought, agreeing wholly on all concepts, thus a diverse collection of tenets are represented under the umbrella of existentialism.

Arising from a deeply philosophical root of ideas existentialism explores the experience of existence, asking what does it mean to be in this world. Concerned with ontology, rather than aetiology, existential theorists avoid models that categorise individuals, seeking to uncover that which is universal in the human dilemma (Deurzen-Smith 1996). Scientific enquiry fails to procure a complete worldview of “human-being” by pertaining to unexamined assumptions (Jaspers 1963). Human-being is revealed in the workings of guilt, conflict, psychosis, suffering and death. Only by facing up to these contingencies can humanity be accomplished.

Bugental (1978) defines identity as a process, not a fixidity, and when one realizes this one is faced with the nothingness of being. This nothingness, the non-existence of an essence of being, is the primary source of freedom that one must face in each and every moment. Kierkegaard (1944) theorizes that such freedom brings about existential anxiety through the contemplation of choice and the realization that one’s destiny is not fixed but open to an infinitude of possibilities.

Existential anxiety differs fundamentally from psychological anxiety such that it may have no immediately perceivable cause, it seems irrational, pervades one’s whole being, may manifest as an unexplainable dread and arise only in moments when normal securities disappear. Yalom (1989) describes it as that which “whirrs continuously just beneath the membrane of life”, coming to light perhaps through personal crisis, a work of art, or a sermon. May & Yalom (1984) define this anxiety as pertaining to the threat to one’s very existence or to values that are identified with existence.

Thus there is no “cure” for such angst, it is argued, for it is an intrinsic component of the human predicament. Both the Freudian and the existential paradigm position anxiety as the central dynamic for psychopathology. Conscious and unconscious ways of dealing with this anxiety are formed, the important distinction is that whereas Freudian anxiety is “drive” based existential anxiety arises through awareness (May and Yalom 1984).

Existential anxiety manifests differently depending upon the individual’s stance toward living; work that is commonly undertaken in the process of existential psychotherapy. It can be utilized as a source of great creativity and energy (May 1969) or reveal itself as neurotic anxiety (May & Yalom 1984), paralyzing the individual. The common notion of mental health being an existence free from anxiety is thus considered absurd. Mental health is attributed to those who are able to live, as much as possible without neurotic, inhibitory anxieties but with the openness and understanding to suffer the inescapable existential anxiety of living. Psychological disturbance, it is argued, comes about when one fails to acknowledge such inherent anxiety, striving to avoid such “truth”, the consequence of which is inauthentic living (Laing 1960).

The gift of existential freedom, is not only the source of anxiety, but brings the burden of profound responsibility. If it is true that our being is actually nothing and that we are in a constant flux, then one is faced with a terrible emptiness and at the same time a miraculous freedom (Bugental 1978). May (1989) observes that freedom is how we relate to our destiny and destiny is significant only because we have freedom.

One must take this “freedom of being” and the responsibility that goes with it, including the guilt of one’s actions. Each action negates the other possible course of actions and their consequences, so that one must be accountable without excuse. As human beings are not fixed in this world, such as “things” are, one is free to realize one’s aims, to materialize one’s dreams and forge one’s own destiny (Owen 1994). The person who lives in this manner is living authentically, or in Satre’s (1951) terminology “good faith”. Consequently psychological disturbance, or pathology, is the negation of this process of authenticity – inauthentic living or bad faith, in which one moves away from the burden of responsibility, through belief in dogmas, regarding oneself as subject to outside influences, conforming to standards or roles and assuming that actions are predetermined.

Kierkegaard (1954) argues that society constantly denies the reality of nothingness and its inherent implications for living. Such inauthentic living is a world of self-deception, for one has refused to take the challenge of responsibility and confront the anxiety that comes with such freedom.

May (1969) addresses the issue of “will”, arguing against Freudian notions of determinism, as the point where one acts on one’s freedom. He highlights the crisis of will in the modern Western world. May (1969) presents a vignette, of a catatonic episode in a patient who had experienced a “crisis of will and values”, whereby he had become so acutely aware of his responsibility and actions that no movement was possible for fear of negative omnipotent consequences. In his pathological world he was caught an inner dead-lock. This case is likened to the general stupor of an apathetic society in which individuals have chosen to allow others to make their decisions, relinquishing the responsibility for their destinies, unable to make the decisions that might carry out their wishes, leading to the paralysis of will. As Laing (1960) puts it “in a hell of frenetic passivity”. We inhabit a modern world which promotes personal power and independence and yet our predicament is that the majority of human beings renounce their responsibility to will and choice, choosing to live in a culture of blame and discontent. We have the choice to choose, or not to choose, in Shakespeare’s words, “To be or not to be”.

Laing (1960) observes that some individuals do actually make the choice of withdrawing from the world of relatedness completely into their own self-made worlds. This he observed with schizophrenics when the environment, often the family, was experienced as too hostile and destructive, causing the individual to retreat into a safer inner world. Schizophrenia, he posits, is a strategy invented in order to live in an unlivable world. Frankl (1963) observed this in the Nazi concentration camps – those who had schizoid tendencies were able to survive the harsh conditions better than those in touch with an inner reality and the outer world. May (1969) has pointed towards this notion too in observing that those astronauts best suited for space travel were able to withdraw partially into their own “schizoid worlds”. In this sense the existential approach to such phenomena as schizophrenia emphasizes the importance of the subjectivity of experience for the patient, breaking away from stigmatizing labels and objectifying forms of therapy and allowing the individual to journey through their authentic experience of madness (Deurzen-Smith 1984).

Deurzen-Smith (1996) defines psychological disturbance not as that which is confined to the traditionally perceived “mentally ill” but a natural occurrence of the struggle, that each one of us must engage in, with the disturbing givens in life. Problems, therefore, are not seen as obstructions to psychological health but as challenges that must be risen to. In life it is certain that we will be confronted with new situations that challenge and undermine our evasions of the human paradox. Unexpected events, such as the death of a loved one, may expose one’s vulnerability and sense of false security in a self-deceived world. Boredom also might precipitate such an existential crisis.

Critics of the existential approach site that it is too academic and intellectual, having no practical application in the clinical setting It is often downplayed as not being empirical enough, lacking a psychotherapeutic modality that is set with techniques and interventions (Davison & Neale 1998).

Craib (1992) argues that diagnostic categories are needed in order to approach the necessary level of working knowledge of a client’s world. Pilgrim (1992) responds that the positivist categories of “pathology” are inherently power-laden, demeaning and stigmatizing. As C. S. Lewis (1943) noted, “We reduce things to mere Nature in order that we may conquer them”. When the “things” are people and their existential status is reduced to a natural category of illness, the same logic of domination applies. Existentialism may not offer a “how to” approach to the problems of living but rather a lens through which to consider each person in their world. Existential views on pathology may not give evidence of a scientific paradigm but it can offer the science of psychopathology roots much deeper and more significant to the human dilemma than other paradigms that seek mere quantification of mental illnesses. It offers a phenomenological approach to pathology, not a separation of id and ego, a reduction to pharmacological origins or recognition of maladaptive behaviors, but a holistic view of the entire being in the here and now.

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