Most of the challenges people bring to counselling arise not because people are dysfunctional, but rather out of the confusion, difficulty, and pain that comes with being human. Life is hard. We face constant challenges and we create further ones in response. We don’t understand ourselves very well. But as difficult as our problems can be, they can also be occasions for insight and growth. Such challenges tear through our comfortable illusions and invite us to think more deeply. Struggle and suffering does not automatically make us wiser or stronger, but the way we respond to it can lead to greater wisdom and strength. Albert Camus wrote, “In the midst of winter, I found there was, within me, an invincible summer. And that makes me happy. For it says that no matter how hard the world pushes against me, within me, there’s something stronger – something better, pushing right back.” Existential therapy according to The British School aims to help us to find the clarity, insight and strength we need to face our troubles. It helps us develop richer, more meaningful lives.
During my first decade of counselling I focused intensely on existential therapy. It is actually one of the oldest forms of psychotherapy, originating with colleagues of Freud, who preferred to understand human nature and its challenges as "challenges in living" rather than through the lens of the psycho-sexual theories of psychoanalysis. Hence it takes a philosophical approach. Today existential therapy flourishes in Europe, but less so in the English-speaking countries where cognitive-behavioural therapy (CBT) dominates. There are a variety of approaches and outlooks which go under the name of existential therapy, and some of its leading representatives include Irvin Yalom, Viktor Frankl, and Emmy van Deurzen. I want to focus on van Deurzen and the tradition she represents, known as "the British school of existential therapy." While other schools tend to maintain a reliance on psychiatry and similar disciplines, in the hands of van Deurzen existential therapy is a decidedly philosophical approach, not only in outlook but in method too.
Some therapists in the British school draw on the whole history of philosophy and not just the historical movement known as existentialism. The focus is on philosophy from any era which addresses the human condition and its concrete concerns - which addresses what van Deurzen calls our "everyday mysteries." Reminiscent of Camus, the aim of this therapy is to help people face up to their realities; to become wiser and stronger about themselves, their predicaments, and life in general; and to create a life of greater meaning and value.
Emmy van Deurzen (pictured)
Existential therapy aims to be non-dogmatic and critically open-minded. Some forms of therapy, such as CBT, teach people perspectives and practices to apply to their problems. Existential therapy is less about teaching than drawing out. This is what Socrates aimed at, which is why he referred to himself as "a midwife", aiding in the birth of what was already within the other. This is why existential therapy, like the philosophy of the same name, emphasises a phenomenological approach.
Ernesto Spinelli, another leading light of the British School, places phenomenology at the heart of the practice. It is a descriptive method which attends to the details of a person’s experience and way of being. It analyses the subjective structure of a person’s world so that what is important, especially what has gone unnoticed, may show itself. People gain direction and ability through coming to see themselves and their world with greater clarity and depth.
Image: Ernesto Spinelli
The existential therapist of the British school is educated broadly - both formally and informally - in philosophy, psychotherapy, literature, psychology, anthropology, sociology, the classics and so on. They are also fellow human being who struggle with life – with its big questions and with their own challenges – just like everybody else - but who see it as their vocation to use these experiences to learn and to grow, not only for their own sake but in order to help others. They view the role of philosopher-therapist as a vocation rather than just as a profession. Mick Cooper in his book Existential Therapies sets out some of the aims for Emmy van Deurzen’s therapy. They both sum up her approach, and show the ennobling face of this work:
"[Existential therapy] can help [people] get back on top of their lives, take control, and have a sense of mastering their world rather than being at its mercy. Second, it can help them realise that they are able to take much hardship, and that they are stronger than they think. Third, it can help them to welcome, rather than fear, life’s challenges: to take life’s ups-and-downs more in their stride. Fourth, it can help them to respond to life’s challenges as constructively as possible: summoning and harnessing all their resources to find the most satisfactory ways forward. Fifth, it can help clients to experience the whole spectrum of their ways of being, rather than being stuck in rigid patterns of behaviour. Sixth, it can help them re-discover a passion for life: an aliveness, enthusiasm and sense of adventure that comes from fully engaging with the world, and meeting the challenges of life. Finally, then, for van Deurzen, existential therapy can help clients move beyond a fear of life, to a discovery that life is full of promise and ultimately worth living."
Author: Matthew Bishop
What I offer here is a moral philosophical sketch of depression. Or rather three kinds of depression, distinguished according to three moral emotions: remorse, guilt, and shame. As research shows - contrary to popular myth - the majority of depression arises from problems in living rather than from biological causes. At the heart of such problems lie ingredients such as a loss of connection, selfhood, meaning and value. Hence moral philosophy - reflection on meaning and value - is vital for understanding depression and orienting our way through it. Inventing names, I will speak first about remorse-based depression. I will write more about that another time, so I move quickly to its much more widespread cousin, which I call guilt-based depression. Following that I offer a sketch of a third sort, shame-based depression.
Before starting I would like to anticipate and address a concern of some readers. It may strike some as odd that I explore depression from a moral philosophical perspective, given that many depressed people moralistically condemn themselves or are so condemned by others. Surely we ought to banish all talk of morality? My answer is that value-neutrality is impossible in life, including in therapy. Indeed a core problem of depression regards the ways value and meaning is lost or goes awry. Furthermore I would say that the problem just mentioned is not one of morality, but of a moralistic attitude. Just as making judgements, something that we do by necessity on a constant basis, is different to being judgemental. Indeed, wisdom and compassion are forms of moral judgement! Some people have a deep difficulty distinguishing moralism from morality, often for emotional, defensive reasons which they do not clearly see. This is especially so with people suffering depression, for in many cases their problem includes the internalisation of a moralistic, judgemental voice, such that their criticism of the concept of morality is actually a confused attempt to attack on their inner-moralist. As Nietzsche said, so much philosophy - and certainly so much bad philosophy - is autobiographical, an expression of one's psychological life. Morality at its best is about goodness and truth. It is about value. We cannot do away with these and neither should we. The most important things in life are all given to distortion and corruption. To run from the danger of such corruption requires running from everything that really matters. In the case of depression what people need is not a shift from distorted values to no values - that would be nihilism (see below!) - but rather an orientation toward clear-sighted and nourishing values, or rather, a reshaping of their emotional life around those values.
When a decent person wrongs another they tend afterwards to feel remorse. Remorse is a moral emotion: it is a pained recognition of the wrong one has done another. Hence remorse is a form of lucidity, a recognition of reality through opening one's eyes to other people and the meaning of one's deeds toward them.
Sometimes depression arises from remorse as a catastrophic experience of a pained recognition of the terrible thing one has done. Imagine a person who regularly risks the safety of others while driving and who finally causes an accident which kills another; or a young bully who flippantly taunts another to kill herself and she does so; or a friend of a couple who manipulates and seduces so as to break up a marriage for the sake of a fling. Such people might later find themselves claimed - as they ought to - by a devastating or at least powerful realisation of what they have done. In response they may fall into a depression. In essence they have brought bleakness in the world, and if they are lucid that bleakness will return to them. (This is a case of where striving to be a good person means suffering more - the callous merely turn their back on reality.) Friends may try to talk such people out of their remorse, as though to feel so bad must be irrational. In effect these others are inviting the person to betray their call to moral lucidity.
Of course this lucidly remorseful depression may be mixed with unreasonable guilt, misapprehension, unjust self-condemnation, maudlin self-indulgence et cetera, but the pain of lucid remorse needs to be distinguished and answered to truthfully.
There are many moral emotions. Remorse is one. Guilt is another. We often use the concepts of 'guilt' and 'remorse' interchangeably, however guilt is unstable from a moral point of view. For while remorse is a reality principle, opening one's eyes, guilt can blind a person. It can become uncoupled from reality, becoming maudlin, misplaced, unjust or disproportionate. When guilt is not determined by truth then nothing limits it, and one easily descends in a downward cycle. Such guilt-based depression is traditionally the most common form of depression.
As I said initially, morality is about meaning and value. It is not moralism, judgementalism, nor is it merely about praise and blame. In guilt-based melancholia however, morality becomes just that: a pattern of neurotic self-blame and self-loathing. A condition for suffering guilt-based melancholia is therefore the possession of a moral sense of reality, however this fact can be obscured, because the sufferer might endorse moral relativism, such as I pointed to above. This is what is known in philosophy as a "lived contradiction": the possession of an explicit philosophical stance which is implicitly contradicted by one's way of being. The moral sense of reality is however a distorted one.
There are many reasons why the possession of guilt might turn into an entrenched depression. A critical parent during one's childhood - a parent who induces unreasonable guilt in a child - is a major cause. The child swallows the parent's voice, takes on a ghost of the critical parent within themselves. Therapy for depression often involves an exorcism so to speak, a driving out or killing of this critical inner voice.
Guilt may also become depression when a person finds themselves in a culture, whether at a micro or macro level, which fails to appreciate or even to recognise the value in their particular way of being, seeing in them only flaws or vices, and expressing that judgement to them. In his memoir Romulus, My Father the philosopher Raimond Gaita looks back at the social context for the suicide of his mother in 1958:
But for someone like my mother, highly intelligent, deeply sensuous, anarchic and unstable, this emphasis on [moral] character, given an Australian accent, provided the wrong conceptual environment for her to find herself and for others to understand her. Tom Lillie's contempt for her was common. It was also emblematic of a culture whose limitations were partly the reason she could not overcome hers.
The most common conditions for guilt-based depression appear at first to need a more psychological than moral description. Attachment theorists, who claim that personality structure is rooted in early childhood experiences of care, have shown that early loss or abuse can lead to depression in adulthood. But even such psychological-deterministic theories contain moral elements at their very core. The philosopher Simone Weil wrote: “At the bottom of the heart of every human being, from earliest infancy until the tomb, there is something that goes on indomitably expecting, in the teeth of all experience of all crimes committed, suffered, and witnessed, that good and not evil will be done to him.” It is this human need and desire which is at the core of all emotional problems. Typically a child (and later adult) will have responded to the loss of, or abuse by, a parent, by holding themselves responsible. They will instinctively blame themselves, often without recognising it. This feels much better than the feeling that the world really is this uncaring or cruel, or that the object of their love and the source of their value - their parent - really does not love them. Hence the child grows up feeling flawed and contemptible because it is the lesser evil among bad a set of options. Guilty depression is self-loathing. I hate myself because I have lost, in some deep and complex way, that which I loved and the love from them which I needed. Notice how the distinction between morality and psychology becomes blurred, as a moral language of desire for goodness, and the need to love and to be loved, is required to describe the heart of a supposedly psychological problem. The need to find oneself valuable, worthy of love, is at the heart of the childhood psychological processes described by attachment theory, including attachment theory's explanations of depression.
Guilt-based depression is the most well-known form at both a professional and popular level, as it is perhaps the most common form traditionally brought to therapy. It arises in a culture which is concerned with moral character. But as culture changes, so too does depression. We like to imagine in the first world that we are liberated beings regarding old moralities, so it may surprise people to realise that this older form of depression is being superseded by a new form, rooted in shame. This is the consequence of a materialistic age.
To be continued....
Author: Matthew Bishop
Image: Kole Berishaj, Agony
"Beware, lest in your anxiety to avoid war you obtain a master." Demosthenes, 384–322 BCE.
In 1844 the philosopher Soren Kierkegaard wrote “This is an adventure that every human being must go through – to learn to be anxious in order that he may not perish either by never having been in anxiety or by succumbing in anxiety. Whoever has learned to be anxious in the right way has learned the ultimate.” According to Kierkegaard, succumbing to anxiety is a problem, but so too is not having been anxious. This is a radically important insight: that anxiety is an essential ingredient for living a good life. Why that is so is the subject of this reflection.
The existential therapist Emmy van Deurzen wrote of Kierkegaard’s view on anxiety, “This is a remarkable insight, which is of great relevance to twenty-first century psychotherapy. Most forms of psychotherapy have the objective of relieving people of anxiety and reducing this experience to its lowest possible level. In fact, psychotherapy is often deemed necessary precisely because levels of anxiety are high in a person. Kierkegaard seems to suggest a rather different approach to mental health as he considers anxiety to be crucial to spiritual life and a sign that the struggle with human paradox is taken seriously. Anxiety indeed should be the starting point of therapy, not in order to alleviate it, but rather because anxiety must be considered the starting point of a well-lived life.” Such a way of viewing anxiety differs greatly from the dominant perspective in our culture, which is known as ‘the medical model.’ I am speaking of the perspective held by many psychiatrists and marketed by organisations like Beyond Blue. This model presents anxiety as a disorder, a mental illness which ought to be cured by psychological and pharmaceutical technology. This technical conception of anxiety makes tempting promises, however if we limit ourselves to it then we run the risk, in van Deurzen’s words, that “we will be simply insensitive to existence and unable to truly live.” For anxiety cannot be reduced to a disorder, like some physical illness with a peripheral relationship to our inner lives. Anxiety goes to the heart of our inner lives, how we deal with anxiety impacts directly on the quality of our soul, so to speak - on our inner life, our way of being, our lucidity and vision with respect to life, our character as a wise and courageous person. To understand why this is so we need to consider the nature of anxiety and why we experience it.
The essence of Kierkegaard's claim is that to live is to be anxious. For anxiety is the shuddering recognition, sometimes forced upon us, of what it means to be alive, of what it is to be human. To be human is to be mortal. To be human is to suffer. Of course to be human is also to love and be happy, life can be wonderful, but at other times, or with respect to other possibilities, life is hard, and sometimes it is terrible. This is the human condition. It is tempting to blind ourselves to this, like the ancient Greek hero Oedipus who put out his eyes when confronted with the terror of his situation. This image of Oedipus is an image of human kind. It is hard for us to look with open eyes at what terrible thing has happened. It is also hard to look at what might, or will, happen to us - our potential suffering, humiliation, loss and certainly death. As la Rochefoucauld said, “You cannot stare straight into the face of the sun, or death.” The more deeply we love life and each other, the deeper our capacity for suffering. As a matter of self-protective instinct we find ways of blinding ourselves to these harder truths of the human condition. We distract ourselves from the anxiety that registers these truths, and we lose ourselves in fantasies of control. This is why anxiety is so important. It constitutes a test which is a possibility to grow. You can blind yourself and retreat, or you can face your fears, wrestling and overcoming your anxiety, to become more wise and courageous. The nature of our character depends, among other things, on our response to our anxieties.
To put these matters another way, here are two universal truths:
Notice that there is an emotional and moral contradiction between these two statements, between the sometimes infinite value another has for us, such as in unconditional love for one's infant, and the fact that this child's existence is not infinite - that an infinitely precious being has a finite existence and can be the object of crimes that deny that infinite value. And it is the source of our deepest anxieties. The above two truths are universal, which is to say essential to the human condition, hence we call them existential truths. Hence they result in existential anxiety. Existential anxiety underlies much of the anxiety that people bring to therapy.
There are a range of elements of the human condition which feed existential anxiety, such as the element of chance in life, and the fact that action and time lead to ever increasing finitude, on a pathway toward our ultimate finitude in death. For example:
As the ancient Greek tragedians so wisely recognised, much about happiness is a matter of luck. So long as we are alive, we can lose that which gives our life meaning - our loved ones, our sanity, an able and pain-free body, political freedom, assets, our marriage, the respect of others, and so on.
Again, a client once described to me a disturbing dream. She was "invited to make some important choices", which "tricked" her into dying. At first we could not make sense of why these choices were presented in the dream as a trick. Further exploration revealed that when she makes choices in her waking life she often experiences anxiety, because choosing is an experience of excluding other possible choices. By choosing to exclude other possibilities, one's life becomes more fixed, more rigid. Rigamortis slowly sets in - because we equate life with possibility, the experience of choosing is, implicitly, of moving toward death. This client's dream expressed her anxieties about ageing and death and invited her, by roundabout means, to come to terms with what she had been avoiding: the big choices she needed to make, but avoided making because of her existential anxiety.
I quoted Demosthenes at the beginning of this reflection. We are often desperate to avoid the war, the anxiety-provoking recognition of our vulnerability. We do this through strategies such as distracting or numbing ourselves, or by becoming angry, or depressed, or by other means (here is a reflection on OCD as a response to existential vulnerability and its anxiety). By avoiding a war we gain many masters. But fortunately, as one therapist used to say, "You can run but you cannot hide". Life will repeatedly, painfully, 'invite' us to recognise our evasions and face our fears. Something fundamental in our nature always calls us to do better.
People typically come to therapy when their anxiety seems overwhelming. At such times they are at a cross-roads. They can choose to retreat from the challenges of life (and there are superficial professionals who will collude with such temptation) or they can choose to face their anxiety and grow.
Of course, nobody likes pain. The first thing I do with a client, after supporting them to deal with immediate crises and find a surer footing for the present moment, is help them distinguish between necessary and unnecessary anxiety. We create a lot of unnecessary anxiety for ourselves, and we can learn to distinguish and gradually do away with it. This I refer to as neurotic anxiety. Existential anxiety on the other hand is necessary; it comes with being human. We remove unnecessary or neurotic anxiety, and then get to work on how we might live well with necessary anxiety.
Your particular existential anxiety teaches you about your particular fears, which reveals your particular loves and values. It will teach you, if you will listen. It will teach you about your distinct way of being, about what really matters to you, about the reality of the human condition, about what really matters in life. Dealing with anxiety properly is the path to wisdom. Of course this requires courage, it demands that you find greater courage within you and draw it up, so in dealing with anxiety you become more courageous as a habit. You develop a character of courage. When I help somebody with their anxiety, I am looking beyond 'symptom reduction', beyond their acquisition of psychological techniques and skills, to the point where they face anxiety well, in some respects overcoming it, in others accepting it, though growth in wisdom and courage. Growth, that is, in wisdom and courage regarding anxiety, but ultimately growth in wisdom and courage about life. Existential wisdom - lived wisdom. Existential courage. I am helping them become a wiser, more courageous person. That is what this therapy is ultimately about.
Lars von Trier's film Melancholia offers a powerful portrayal of the affliction traditionally known as melancholia, which is today called depression. The opening sequence involves a set of slow-moving ‘stills’, of deadened scenes where lethargy infects the body like heavy vines clinging to a walker's legs, and life is without purpose - for the future is annihilated. Today I will reflect on this malady from the perspective of various existential philosophers and therapists, including Martin Heidegger, Jean-Paul Sartre, Ludwig Biswanger, and Viktor Frankl.
Many existential therapists eschew the medical model, and any associated notion that melancholia or depression is one thing. Freud saw it this way too: "Melancholia, the definition of which fluctuates even in descriptive psychiatry, appears in various different clinical forms; these do not seem amenable to being grouped together into a single entity." To put the point in terms inspired by the philosopher Ludwig Wittgenstein, we are easily deceived by language: because "depression" is one word, we imagine that it refers to one thing, describes one problem with one nature, which reveals one cause and solution. Or perhaps one set of problems with one set of causes and solutions. This is what Wittgenstein referred to as "the bewitchment of our intelligence by means of language." Instead, when we look at actual experiences, we see that the single word refers to a multitude of phenomena which hang together in related but differing ways. Existential therapy takes a descriptive approach which assumes differences, but also that there are universal human concerns present in this malady. What follows is a discussion of some such universal themes which inform existential therapeutic theory and practice.
Time shows itself as a major, if implicit, theme in depression, just as it does in von Trier's film. The character Justine is a prophet and she sees the future destroyed, which equates to the annihilation of hope. Hence she lives in a state of anticipatory mourning as well as anger and even hate. Depression is often described as a mourning for I-know-not-what. A loss of the future, of hope. The melancholic person appears like one in grief, but without a lost object.
Probably the most important philosopher for thinking about time in human experience, including in depression, is Martin Heidegger. His existential-phenomenology helps us in many ways to think about this malady. For example melancholia can be described as a mood, and as Heidegger's analysis of our human way of being suggests, we all stand, always, in a certain mood. Our particular mood expresses our relation to the world, to life. It discloses that relation. The mood we are in shows how we are with the world. (See Heidegger's essay, What is Metaphysics?)
It is important to understand that a mood, for Heidegger, is not located inside person, but rather it expresses their interaction with the world. It is the relation, the in-between. This is what it discloses. This is why approaches such as cognitive-behavioral therapy (CBT) which view depression as a consequence of faulty thinking - as an intra-psychic disorder, as per the medical model in general - is sometimes be too limited. CBT can be very effective in individual cases, but it often fails to see how deeply depression is a problem of relationship with: others, the world, time, with the meaning of things.
Moving from Heidegger to the second greatest phenomenological-existentialist, Jean-Paul Sartre wrote in his novel Nausea, “Nothing happens while you live. The scenery changes, people come in and go out, that's all. There are no beginnings. Days are tacked on to days without rhyme or reason, an interminable, monotonous addition.” This captures an essential experience of many cases of depression. In my early 20s I suffered this malady, and I remember shaving one morning, and being overcome by a sense of the many, many days stretching out ahead, when I would repeat this activity. It was a feeling of overwhelmed exhaustion at the pointlessness of the exercise, of everything I did, a sense of life stripped of quality and reduced to quantity. That is not a neutral experience, rather it is painful when it is an expression of depression or despair.
Sartres' long essay which is often published as a book - Sketch for a Theory of the Emotions - is highly worth reading. It contains, on my reading, the seeds of a therapeutically powerful theory of melancholia: depression as a defense against loss and the associated pain. I mentioned loss and mourning a moment ago. Ludwig Biswanger notes this connection of depression with time and loss too. He writes of depression that “Everything that is possible has already happened. Life is ruled by the shadow of loss – a loss which is not just anticipated but is already fact.” Again consider Justine. Biswanger says of depression that it is “the break-up of the experience of time’s continuous flow.”
How does a person move out of depression, from an existential viewpoint? Biswanger writes that “the goal of psychotherapy [for depression] is to bring the patient safely back ‘down to earth’ [...]. Only from this point is any new departure and ascent possible.” I sometimes put this by saying that a person has been drawn out of the stream of life and needs to re-enter it. In their dislocation they cannot see how the world is from within the stream - a Heideggerian point referencing moods - and their melancholic perception obstructs any re-entry. They believe in what they see from their stand-point, from their disconnected attunement to the world, and their current experience becomes an obstruction to seeing another possibility and entering it. As one therapist put it, "Depression is a prison where you are both the suffering prisoner and the cruel jailer." There is an implicit appeal in many melancholic clients: "Remind me that I am wrong, that this perception is not the truth." But there is also the pull and push, a desperate desire to escape depression, and a deep resistance to doing so.
Viktor Frankl, the existential therapist, may be our best guide here. ( I recommend his book, Man's Search for Meaning.) Note that his thoughts were tested in the laboratory of the Holocaust. He survived three years in Nazi concentration camps and his whole family, including his pregnant wife, was murdered in those same camps. He agrees that depression is an effect of a loss of meaning especially with regard to the future, and claims that meaning must be found if change is to occur. Frankl's solution seems brilliant in its theoretical simplicity and common sense. In fact he is simply repeating an age-old philosophical insight which connects existential philosophy and therapy with classical philosophical traditions like Stoicism. His solution is that the meaning currently available to the depressed resides in the attitude they take to the depression. By gradations one can eventually find themselves outside their depression through constant re-interpretation, or to put it another way, by repeated habituation of a new interpretation. Philosophical reflection within therapy serves as both a search for this better and truer perspective and also, importantly, as the practice of habituating through repetition of the new perspective, applying it to the variations of one's experiences and responses, and repeating that application until it sets down strong roots within oneself. These two aspects are the core of a therapeutic response as I practice it. Counselling is not a mere consultation, thought sometimes it is that, but rather it is a practice of inhabiting the something better. It is a return to the connected, meaningful world by inhabiting a perspective which opens our being to the (ongoing) event of this connection.
The themes of loss of the future which renders the present meaningless, and depression as a mourning of that loss, are certainly common among people who come to me with depression, although most do not at first realise this. I analyse depression as expressing varying levels of affliction in life. For example I speak here of its moral variations. At one deeper level depression reflects the challenge we each face, of coming to terms with life - to terms with the human condition as one of vulnerability. We are vulnerable to loss and violation, and so to profound suffering. There is a potential bleakness just beyond the everyday veil, and it haunts some people. The person whose depression is rooted in this, feels this potential bleakness in their bones. They are disturbed, even shattered. They feel it within them as an anxiety - which is an often unremarked but very common feature of depression - and as anticipatory mourning. Their challenge, as with everybody, but in their case through the challenge of melancholia, is to come to terms with life, to find life meaningful and good in a way that can absorb the suffering, absorb the risk. So there is a task of understanding, a task of interpreting, a task of finding deeper meaning, a task of courage in the face of our vulnerability, a task of coming to love life in a way that can absorb its darker realities too. There is the possibility here to return to life wiser than before the depression.
It is natural to grieve after a relationship ends. And this grief can take a while. But sometimes it takes too long: a person feels that the time has come to move forward with life and yet they cannot. I want to tell the story of Michael*, who struggled with this problem. His relationship with Anna was short-term, and had been over for a year before he came to see me, but his grief was unending. This problem formed a recurring pattern in his life. Michael's story suggests that when one becomes stuck in romantic grief there may be more involved than the sorrow of lost love.
Ludwig Wittgenstein characterised philosophy is an art of paying attention, captured with the words “Don’t think. Look!” The same goes for therapy. In the second session with Michael I asked questions that were designed to take him into his pain so that he could look closer and describe what he saw. Of course I needed these descriptions if I was to understand his problem, but I hoped that Michael might pay better attention to his own experience and come to his own insight with minimal prompting from me. That’s where the real work happens in philosophical therapy. The dialogues below are paraphrases which capture moments from our work together over several months.
ME: So when you imagine her not loving you anymore – say, you imagine her kissing somebody else – you get this pain in your heart?
MICHAEL: Yes, this sadness, as it has done for a year now, just aches all through my chest. That’s the pain that won’t go away.
ME: Just in your chest?
MICHAEL: The pain reaches down into my stomach too, kind of.
ME: In what way – what does it feel like in your stomach?
I expected Michael to say that he experienced a weight or some other sensation that typically goes with loss, but I was surprised.
MICHAEL: It feels like tension. Like churning, boiling.
ME: Really? What else do you feel as you imagine her falling in love with somebody else?
MICHAEL: It’s strange, but I feel like I'm falling backwards.
ME: What is your heart doing?
MICHAEL: It’s really racing!
Often we are so alienated from our own experience that we form misconceptions about it. This was true of Michael.
ME: I wonder whether you’ve got your labels wrong?
MICHAEL: What do you mean?
ME: A racing heart, a churning stomach, a feeling of falling …that doesn’t sound like sadness. Or rather, not in a straightforward way. It sounds more like anxiety.
Michael thought for a moment.
MICHAEL: But it’s over with Anna, there’s no going back, so I’m not anxious about what might happen, but rather I’m sad that nothing more will happen.
ME: Is it sadness you feel? You keep calling it pain.
MICHAEL: Well, yes, it’s very much pain.
ME: And this pain has the physical qualities not of sadness, but of anxiety?
Michael agreed with me, but after a year of telling himself that he was simply sad when he felt this way it was hard for him to interpret his experience differently. Fortunately he was willing to entertain other possibilities.
MICHAEL: Perhaps it is anxiety. If so then what do I do?
ME: I said in our last session that an emotion is like a compass. Why don’t we follow the anxiety where it leads and see what it shows?
We spent the following sessions doing just that, and as we did so Michael's inner life came increasingly into view for him. As a disciplined act of attention therapy performs the function which Kafka ascribed to a good book: it becomes an axe for the frozen sea within. Emotions and feelings show themselves, they are seen, insight happens. Dreams become lucid. This happened with Michael, and sometime later he began a session by reporting a dream.
MICHAEL: You know, it’s rare for me to dream. I only do it a couple of times a year, and now I’ve had four in the last month! But this one really got to me. And I felt like I understood its meaning.
ME: What happened?
MICHAEL: It all took place in one room, in an old, decrepit house. Throughout the dream the house continued to crumble and rain poured in through the roof, soiling the mattresses. Oh yes, the floor was covered in dirty old mattresses. I sat, and slept, on one of them. There was no toilet so I had no choice but to urinate on one of the other mattresses.
ME: What did you feel as you did that?
MICHAEL: I was on my own in the room, but it was like I was seeing myself through another’s eyes – I felt dirty, ashamed, humiliated by my act. But I had no choice.
ME: What else happened?
MICHAEL: There was dirt everywhere from the crumbling of the house. I walked over to the fireplace and found a pair of glasses. This is what I remember most; standing there looking at these glasses and knowing that their owner was dead. Long dead. I got the sense that this…intimate possession of theirs should make me feel care for them, or at least interest me or something. But it didn’t. Instead I found the glasses ugly. So I just felt nothing. But this lack of feeling disturbed me and made me sad. I realised that there were other possessions like the glasses in the room, belonging to other dead people. But I felt the same neutral way about them. Again I was saddened by this. Then suddenly there was something horrible – I don’t know what - coming for me down the chimney. I rushed to the other end of the room and put my back to the wall to protect myself, but strange holes materialised behind me like mist and dead spirits within them grabbed at me from behind, trying to drag me backwards into the holes.
What else happened?
MICHAEL: Well there were two other parts to the same dream. One of them took place in the same room, but I don’t know when. I was trying to teach the piano to Anna’s young son. I thought that she would really like this. But his father came and took him away, so it was all a waste of time. In the other part, I was at my old high school in the concert hall, playing an impressive piano solo just like I did when I was young. People liked me because of it. But as strange as this sounds, I was also located elsewhere at the same time. It is hard to describe: my step-father Daniel wanted to video-record the solo, but I had started before he arrived so he was running up a hallway to get to it in time. The perspective in this part of the dream was from that of the video recorder – I was seeing and hearing everything from the perspective of the recorder. The sound of my solo could not be heard because Daniel was still running up the long hallway. He didn’t get to the performance in time. Nothing was recorded, and I had this strong feeling that it would all be forgotten…and, that I would have nothing to show of who I was.
Michael’s dream was striking. One of the things that was so powerful about it was that he awoke not only with a vivid memory of it, but with an immediate interpretation which became more clear as the day wore on.
MICHAEL: Last time you suggested that I was very frightened of death.
MICHAEL: And I disagreed with you. In fact I felt a bit angry with you. But I kept thinking about it and two nights later I had that dream.
ME: You think the dream is about death?
MICHAEL: Yeah. I used to work in the nursing home section of a private hospital. The old people would often soil themselves. The nurses were very busy and could be so cold with them when this happened. I felt like my job was to shove these people around – I soon quit because of that. But while I was there I would make a point of looking these people in the eye whenever I had to do something "to" them. Some of them looked permanently humiliated. I think that peeing on the mattress was symbolic of this, of the fear I now have of old age: of its poverty and humiliation.
ME: And its impending death?
MICHAEL: Yes, that’s the main meaning of the dream. The crumbling house. The dead people’s belongings. The malevolent vague thing coming for me. The dead spirits trying to pull me backwards into the void – into death.
ME: These are striking images, and it appears that you and I interpret them in the same way. What about values in the dream? I sense that value was an important theme.
MICHAEL: Yes, you’ve spoken about my need to feel special. To rescue others such as Anna, even after she and I split. So I thought about that too. Nobody cared for the dead person who owned those glasses. It made me sad. It will be like that with me one day; nobody will remember - or care about - me. My possessions, the ones that mean a lot, and even my clothes which have accompanied my life and which smell of me, these will all be thrown away without care or even in disgust. I tried to be special to people with my piano solo but nobody heard it – it was lost, as though it never happened. As though I never happened.
ME: Being special won’t save you from annihilation?
Michael paused and was thoughtful.
MICHAEL: No…it seems not.
We paused some more. I don’t know what Michael was thinking, but he was absorbed and I did not need to know - it was more important that he do his own work. I sat quietly and privately with my own impressions of the dream. After a time Michael came back to the present and we continued the conversation.
MICHAEL: So that's my dream.
ME: And what about the part with Anna’s son?
MICHAEL: I don’t know.
ME: It sounds like you tried to make yourself valuable to Anna through teaching him, but it did not work. He was taken away by his father and you were left alone in the decaying room, so the love of Anna did not come and save you from dying and being forgotten.
The corners of Michael’s eyes were wet. These things hurt, but precisely for this reason we had to push on. As I said before, an emotion is a compass.
ME: You resisted my suggestion last week that you are deeply afraid of death. Actually I spoke of a tangle of death, aloneness, and meaninglessness. You say that you felt angry at the suggestion. I could tell this at the time and it did not surprise me – you were angry when I pointed out such fears because you work hard at avoiding your own awareness of them. You try push them out of consciousness, and when they rise as physical sensations then you try a second strategy: you deceive yourself about their nature. What I mean is that when you first came to me you said you were grieving endlessly for lost love, but it seems to me that you are not suffering from sadness alone but also, very much, you are suffering from anxiety. From what some people call existential anxiety.
MICHAEL: Anxiety over death, loneliness, and meaninglessness?
ME: Yes. Each of us has this fate: we live for a time and then we die. That is the human condition. We hope that our lives have meaning but secretly we fear they might not, especially in the face of death. This secretly terrifies us and so we try to keep it secret even from ourselves.
MICHAEL: So I’m not grieving Anna? Instead I'm using grief to avoid the true nature of my pain – my anxiety about my own death, about not mattering to anyone.
ME: Perhaps grief is less dangerous for you than such anxiety, and so you apply the wrong label to your anxiety, pretending that it is grief. Your grief over Anna is real, wouldn't you say, but it also seems to function as a self-protective distraction. In this sense, perhaps it’s wrong of you to say that you cannot get free of your grief; rather it is something you refuse to let go of.
MICHAEL: Yes, perhaps I am scared of dying. I’m certainly scared of being unloved, of not mattering to anybody. Of getting old that way. Of being dead and forgotten that way.
Although the above words were spoken slowly, with pauses between each point so that we might digest their meaning, we had said a lot. We sat in silence for a time, and then Michael spoke.
MICHAEL: How does a person deal with this?
The rest of the conversation is a topic for another day.
Socrates said that to do philosophy is to prepare for death. This is because to do philosophy is to strive to live well. If we can face death as the fundamental limit of our life then we may find the courage to live a life of meaning rather than of mere self-protection during this short time that we have. On the other hand when we simply run from anxiety over death then we also lose out on living. Such running also affects our way of being with or toward others: we reduce them to performing the function of defending us against our fears. This was the lesson that Michael learnt, and the substance of our work aimed at helping him face his anxiety rather than him trading the quality of his life for respite from his fears. My purpose was not to convince Michael of a philosophical thesis about himself. I used the notion of "a tangle of death, aloneness and meaninglessness" because I wanted to point in the direction of his fundamental fears rather than specify their exact nature. These fears showed themselves through careful exploration. Irvin Yalom wrote that the physical fact of death destroys, but the idea of death can save us, and this was the case for Michael when he finally came to terms with it.
Author: Matthew Bishop
Image: Max Klinger, Isle of the Dead
*'Michael' is a pseudonym. This story is of a true experience, but all identifying details have been changed to ensure anonymity.
In my work I am concerned with the use that can be made of suffering, alongside the attempt to diminish it. Today I specifically discuss the use a person can make of their mental illness. I focus on Obsessive Compulsive Disorder (OCD). I have supported people in this way while they also undertook specialist psychological treatment for the disorder.
If a person cannot change a hateful truth then what else might they do, insofar as they can do something? They might simply distract themselves from it. Or they might engage in the fantasy ofcontrolling it. OCD performs these functions of avoidance and fantasised control. In a discussion of death-anxiety, existential therapist Irvin Yalom writes about this avoidant and controlling function: “[Research] reports that over 70 percent of patients with a severe obsessional neurosis [OCD] had, at the onset of illness, a security-disturbing death experience. As the syndrome develops, patients are increasingly concerned about controlling their world and preventing the unexpected or accidental. Patients shun disorder or uncleanliness and develop rituals to ward off evil and danger. Erwin Strauss notes that the obsessional patient's disgust at decay, illness, germs, and dirt was intimately related to fear of personal annihilation.” Many people who suffer OCD fail to recognise that they are anxious, or that there is a connection between 1) their anxiety, 2) its existential roots such as the fear of death, and 3) their OCD. All they can see are the OCD “symptoms” which baffle them.
OCD is avoidance. It is magical thinking. It is an attempt to control the uncontrollable. As Yalom suggests it functions (at least in part) as a set of rituals to ward off danger and the associated anxiety. From the outside it is easy to assume that people with OCD are irrational compared to the rest of us, but that is untrue. People with OCD vary in intelligence and sanity to the same degree as the rest of the population. Indeed a part of what pains many OCD sufferers is their sense of the irrationality of their compulsions and obsessions. They do not reflectively believe that they are warding off danger, rather they experience OCD as an overwhelming compulsion linked to what they consider an irrational fear. This is why OCD can feel so humiliating.
But here's the thing. Everybody has a tendency for magical thinking, regardless of how rational and scientific they otherwise are. Once upon a time when faced with life’s dangers we would make a magic potion - perhaps a combination of three herbs - to ward off threats. Our brains are very slow to evolve and this magical urge has not gone away. The potions which people concoct these days use different herbs: instead of rosemary, sage and thyme, people mix together a spouse, career, and mortgage; or cynicism, detachment, and criticism; or some other concoction. The magical ingredients may be fine things in themselves or not. Neoliberalism is a striking example of the latter: “If I am a hard worker then I will do well, I will be safe, and in order to believe this I will also believe that people who have not done well must be lazy or bad.” Or to take a left-wing version, "If I do what is considered compassionate then I will be valued and treated well in life." We all engage in magical thinking, each in our own way. Because many people’s favoured potions are socially-approved - consider the mortgage example above - therefore neither they nor others notice their magical thinking. OCD on the other hand gets noticed. It stands out and is disapproved of, therefore it is seen as a problem requiring pathological explanation even while socially lauded forms of magical thinking are praised.
I am building a picture of OCD as a particular example of a universal problem. The universal problem is that we all suffer anxiety, which occurs in the face of our human vulnerability, and we all find ways of avoiding it and warding it off. With respect to particular ways of achieving this universal tendency different people engage in particular - non-universal - strategies. For example some people give over to conventionality, some become bitter, some greedy, some depressed, some obsessive-compulsive. Every person has an arsenal of particular strategies, which differ from their neighbour’s methods, for engaging in the universal act of avoiding anxiety. I will unpack this some more.
I noted before that Yalom suggests that OCD functions, at least in part, as a set of rituals to ward off the danger which evokes anxiety. There are three elements here: the obsessions or compulsions (OCD), the danger, and the anxiety. The existential picture of OCD which I have painted is structured around these three elements, and if we set them out in order we can say that each is a response to the one below it:
1. OCD is an avoidance and control of
2. anxiety, and anxiety is a response to
3. the vulnerability (danger) of our human condition.
Through avoidance and magical thinking OCD is an attempt to be ignorant of, and to control, the anxiety we experience, in response to the danger we face as human beings in the form of the vulnerability of the human condition. From the existential viewpoint that I am setting out, this is how OCD arises in a person.
To picture the three steps another way, if we were to peel an onion, so to speak, the structure of OCD might look like this:
There are various psychological ways of responding therapeutically to OCD. The most common approach takes a medical, cognitive-behavioural, and often neuroscientific, approach. This is captured in Jeffrey Schwartz's Brain Lock. There are also psychodynamic/psychoanalytic approaches, and Nancy McWilliams' Psychoanalytic Diagnosis exemplifies this, while a more detailed discussion can be found in H.P. Laughlin's 1967 book The Neuroses. The essence of existential therapeutic support for OCD is that we need to come to terms with life. The challenge is to face reality and accept it. And by acceptance I mean, ultimately, that we need to learn to love life. To love this life with full emotional recognition of the painful truths from which we instinctively withdraw.
Readers who are waiting for something more clever, a technical intervention, a psychological strategy, might assume that the above is a first step. But as Kierkegaard said, “Whoever has learned to be anxious in the right way has learned the ultimate.” This recognition and acceptance of reality is itself the greatest challenge in life, and its achievement is harder than we realise. Strategies fall by the wayside by comparison.
This is not a matter of heroics, but it does require courage. Many who suffer OCD are particularly sensitive to the painful truths of the human condition, so they may need more courage on a day to day basis than those with a talent for blindness. The way forward is demanding, but it is worth it. My concern with the medical model, which reduces OCD to a meaningless mental illness, is that unless we struggle with the valleys and peaks of our inner life, then we become passive. We need to be active, to be agents in our lives. We cannot hand over our recognition of, and struggle with, the human condition to technical experts who will 'treat us'. It is an abdication of the self to forgo both attention to one's inner life and the need to craft it. To forgo is to reduce oneself to an object, to being inauthentic in the existential sense - failing to author one's life. It is the land of the mechanical, the functional. In Kierkegaard's words, we have then lost "the ultimate." This is why van Deurzen writes that "anxiety should be the starting point of therapy, not in order to alleviate it, but rather because anxiety must be considered the starting point of a well-lived life."
Just as OCD is a particular expression of a universal challenge, so too it can be a particularinvitation, and means, for facing the anxiety of the human condition. We need to find a use for OCD rather than simply a cure. To use Kierkegaard’s wonderful word again, we have realised “the ultimate” when both pleasure and suffering are secondary to the pursuit of genuinely good living. Of course this runs counter to our tendency to believe that pleasure equals good and pain equals bad, that pain is something with a negative value only which must be done away with. If you suffer OCD then, as strange as this sounds, although you suffer, you may be more fortunate than the person who engages in evasion and magical control through pleasurable or socially-approved means. For in your case you cannot fly under the radar, you are confronted with your behaviour, confronted with “the starting point of a well-lived life” (van Deurzen). Normal forms of evasion and magic do not involve the pain, and neither do they attract the sort of criticism, which invites change. OCD can be a pathway, for becoming more attentive to life in its depths, including its universal vulnerabilities and the pain attached, and more courage and loving.
I am not saying that you shouldn't try to diminish your OCD, but rather that you might also take this different attitude, holding on to your desire for a cure while also putting your problem to a higher use. Perhaps this approach will make more sense to those who have tried to cure OCD by conventional means and found that it does not go away so easily. Of course the distinction between a cure and a use fades in reality. OCD is something that you do, and to use OCD in this way is to do the opposite of OCD: facing the fear rather than avoiding it, courageously loving life with all its danger. Therefore this use weakens the obsessions and compulsions at their root. However to maintain the important distinction, such a cure is not my main point. Indeed, such a paradoxical ‘cure’ only works if one values the use of OCD above the desire to cure it. This requires that one accept that they may always have a tendency to OCD as their instinctive strategy for reacting to life’s anxieties. This does not mean they cannot largely overcome it. How do I know? I grew up with pronounced OCD and I took this approach to it. Nobody would guess that OCD sits in the back of my mind like a subtle white noise, for I no longer act of the compulsions. I faced them in the way I have described.
So I am suggesting something more daring than an alternative cure for OCD. I am saying that one ought to consider consenting to the existence in your life of OCD, and doing so in each moment, as a consent to, or perhaps lucidity about, that which it avoids. What it avoids is no less than our humanity, the human condition, which is a dangerous situation. To consent to this reality is a work of wisdom and love.
I have set out a proposal to treat OCD as a means, on reflection not unlike those spiritual exercises which ancient Stoic philosophers and medieval monks engaged in, to grow in lucidity regarding our human condition. To grow in your capacity to bear well the anxiety which courageous living arouses. And to hone a capacity to love life. I welcome your comments and questions.
Author: Matthew Bishop
Art work: Michael Kerbow
He went like one that
hath been stunned,
And is of sense forlorn:
A sadder and a wiser man,
He rose the morrow morn.
These lines conclude Coleridge’s poem, The Rime of the Ancient Mariner. They describe the man to whom The Mariner has just told his tale. The Mariner is compelled to travel the land, telling his tale to those whose faces declare their need of it. His ability to read the soul of another reminds me of these words by Freud:
"When I set myself the task of bringing to light what human beings keep hidden within them . . . I thought the task was a harder one than it really is. He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his finger-tips; betrayal oozes out of him at every pore."
The Ancient Mariner seeks out people who, like him in his earlier days, will sacrifice anything for their own happiness. He is a kind of therapist, but his 'client' has just left as "a sadder and a wiser man." What kind of therapy is this?
Therapy aims to help people "become better." Sometimes what that means is taken for granted, but perhaps it should be less clear.
The assumption that is readily made is that therapy should help people feel better. This makes sense. Our emotions tell us when something is wrong. They register the meaning of events. They are like a compass, pointing out what we need to attend to and where we need to go. So when people feel better it can be for a good reason, and can register that things are good in certain respects, including that good changes have happened. And feeling good can give us the energy we need to do better. However we need to ask, What is made invisible, or traded in, when we demand to feel better above all else? Is there a risk that therapy can amount to a training in hedonism?
A man comes to mind whose marriage had ended, after his wife discovered he was paying women for sex. What struck me most were his subtle demands and accusations toward me. His unacknowledged but strongest demand was that I make him feel good about his losses. His implicit accusation was that if I did not acquiesce then I was a cruel person and bad counsellor. Rather than face up to the loss of his family with all the pain involved, rather than facing what he needed to do now as a father, rather than attending to what he had done in betraying his wife, he ignored all this and simply treated me as somebody he could pay to make him feel better, like an emotional prostitute. He had learnt no lessons.
Ideally the result of therapy is to become a happier and wiser person. And certainly that is a common outcome of successful therapy. But wisdom and happiness do not always correlate. Good therapy can lead to becoming a wiser person with the same emotional struggles as before. Importantly, I think we need to leave space for the idea that sometimes a person will, after therapy, find themselves to be “a sadder and a wiser man." Perhaps the man I spoke of above needed to become sadder and wiser first if he was to be a good father and to achieve a happiness worth having.
There are forms of happiness that are not worth having. And suffering that is good. The philosopher and novelist Iris Murdoch wrote, "Man is a creature who makes pictures of himself, and then comes to resemble the picture." What sort of people do we become when we only value good feelings? Most of us want to feel better, but not at the cost of becoming selfish or superficial. True happiness is a by-product of living meaningfully; of living, say, with depth and kindness. The ancient Greeks often said "Call no man happy until he is dead." They meant that the possession of happiness is a matter of luck, and some people get very unlucky. What matters is living well rather than feeling good no matter what. There is more to therapy, because there is more to life, than quick-fix happiness and pleasure. The Rime of the Ancient Mariner points to the deeper goals of living, and so the deeper point of therapy.
“I feel empty most of the time.” Janet* stretched awkwardly on the couch and eyed me with discomfort. “I don’t know that you can help me.”
“What led you to book in and see me?”
She pulled a paperback from her bag.
“It’s Sartre’s novel, Nausea. Have you read it?”
“It expresses how I constantly feel. I’ve done a lot of reading about this issue, but I can’t find an adequate answer to my problem.”
“Of feeling empty?”
“Yes. Everything is meaninglessness to me.”
“Tell me more.”
“I am 30 now. When I was in my early twenties I was angry at people’s complacency - at their naive belief that their lives have meaning. Then for a while I think I was depressed from seeing things this way. But in the last few years I haven't gotten angry or depressed as much. I just feel bored, detached, empty....”
When I teach philosophy I am fascinated by the emotions which accompany a person's philosophical position. I say 'accompany', but it goes far deeper than that. A major if understandable blindness in academic philosophy is its failure to attend to how people hold philosophical outlooks. Nietzsche wrote, “every great philosophy so far has been … the personal confession of its author and a kind of involuntary and unconscious memoir.” Existential therapy is a philosophical practice, but it differs from academic philosophy in precisely this respect. It attends to the emotional life involved in a person’s possession of an outlook. What is the felt world a person inhabits, which underlies their statements about the world out there? Consider Janet's nihilism, her sense that everything is meaningless. Some nihilists are on an angry mission. But why anger? The reasons vary. In certain cases, so it appears to me, the anger is a protest against the nihilism itself. The person secretly fears they are right, and hopes they are wrong. In other cases it is an attempt to get on top of, rather than sink under (say in a wave of depression) the nihilistic world.
Sometimes anger expresses itself in gleefulness and scorn. Surely that is strange; why these emotions rather than resignation, disappointment or sorrow? During the years before I studied philosophy I volunteered with an organisation that visited elderly people in poverty. In this role I once sat with a homeless man as he slowly died one evening in hospital. There were no family or friends to call, and when after several hours I had to leave it was painful to think that he would die alone, which he did in the early hours of the following morning. If philosophy speaks truth then it must speak to real life. If I had thought that life was meaningless as I sat with that alcoholic as he lay dying, I could not have thought it in a tone of glee or scorn. Perhaps those strange emotions are how one evades their vulnerability - through contempt. These days I am convinced that nihilistic glee and scorn are a luxury. The same is true even of the anger. I think there is room for such emotions only when nihilism has not penetrated too deeply. When it goes in further, when a sense of meaninglessness has entered more fully into a person’s psyche, then such triumphalism rings hollow and there is only painful despair.
I continued the conversation: “So you used to get angry, then depressed, but now you feel nothing, just detachment and apathy?”
“That’s right. And for that reason I've done nothing about this for too long. My life is on stand-still.”
“This is an example of why it is sometimes better to suffer.”
“What do you mean?”
“When a person is in pain they are usually motivated to find a way out of the problem. When the pain goes and apathy replaces it, they lose motivation and enter stand-still.”
“Yes, that’s how it is with me. It’s the monotony that Sartre writes about. But what do I do?”
“I think we need to look deeper into the problem.”
"That's precisely my worry - I've looked too deeply. I over-think things."
"Yes, but often our thinking, as clever as it might be, is of the wrong kind. Let's look again anyway, exploring how you got to this place of emptiness and meaninglessness."
"You mean, how did I reason my way to this position? I think it just makes sense, from the point of view of cold, hard logic, to admit that everything is meaningless."
“What if reason did not get you here?”
Janet seemed puzzled, “I thought when I booked in that we would have a rational debate about what life means, and perhaps you would tell me to read something.”
“Not necessarily” I grinned. Janet returned my smile. But where was I going with this? To be honest oftentimes I simply feel my way forward. This is an intelligent guessing however, or more often a descriptive following of threads. I was tuning into Janet's world. In considering where to go next, I reflected on the fact that the first thing which struck me about Janet was how ill-at-ease she seemed with me. Most people are a little nervous in their first counselling session, but I sensed that there was more to it in her case.
“I'm interested in what it’s like for you to talk to me right now?”
Janet paused for a moment. “If you want me to be honest, I feel wary.”
“I don’t know.”
“Hmmm. Is there a question in it for me?”
Janet paused, seeming to meditate on her wariness, and asked, “What use are you going to make of me?”
“Why do you think I want to use you?”
“I don’t know, it just came to mind.”
“Is that a common question for you?”
“People use one another?”
“Sometimes. Often. But importantly: not always. I think....”
“Everybody uses everybody, that’s how human beings relate.”
Later conversations with Janet revealed that those relationships in which she should have been most valued for herself in her autonomy, were ones in which she was often reduced to a use that the other made of her. In response to these experiences she had withdrawn from life – from relationships, from her hopes for them – such that life had slowly, inevitably, drained of meaning. This influenced her philosophical outlook. I was reminded of Ludwig Wittgenstein's claim that "The solution of the problem of life is seen in the vanishing of the problem." Her nihilism expressed the truth of her existential, felt world, but there was a wider truth - wider possibilities - to which she had become insensible. She needed to let that desire breath again and to find a reciprocal place for it in the world.
Author: Matthew Bishop
* = 'Janet' is a pseudonym. This story is of a true experience, but all identifying details have been changed to ensure anonymity.
Art work: Brandt Lewis
What does it tell you when it tells you now you grow up?
What does it tell you when it tells you now you be a man?
Tidy your thinking up, finish your drinking up?
Be the Tom, be the Jack, beat the beaten track,
Die the slow death your forefathers died, in fact
Be ever lonely and angry inside of that
Maze of rage and inchoate affection.
Those words are from Melbourne band Augie March. The song ends with: “After the fall, after the crack up, Nothing then? Nothing then.” Nothing, it is true. There is no reward for going through shattering and hell. Not that it is nothing to go through it - it can be all-consuming - but the experience itself is a negation, a destruction. One which exposes a nothingness in us. So what then?
“Emotional breakdown.” That’s not a technical term, but I am writing of an experience, not a diagnosis. I want to speak of its inside, of the fear, the desperation. Many people will suffer a point – or several – in their life where they come apart at the seams. All of us are prone to this, and it is a matter of luck whether the crack up comes to you or not. Perhaps the more emotionally alive we are, the more we are at risk.
Such a breaking down is usually a combination of two things: internal and external stresses. Relationship catastrophes, bullying, job loss, traumatic experiences, these are the external contexts of a breakdown. But not everybody reacts in the same way to the same events, and here is where the internal dimension comes in. Different people possess different psychological structures, and walk in varying worlds of meaning. We possess different architectures, with different strengths and pressure points and can weather different kinds of storms. One person handles relationship break-up well but goes to pieces when they lose their job, and for another it is the opposite. Certain events at certain times will come together like a “perfect storm” for an individual. Certain events constitute psychological bombs for certain people. This explains suicides, but also breakdowns. Many people will not recognise their bomb before it hits. It is only after being shattered that we can look back and begin to make sense. To imagine that you are strong and so free of this danger is to be deluded and arrogant.
To break down is traumatic. To experience one's being succumbing to pressures that break it apart is immensly frightening. To feel that you cannot hold your mind or your life together is terrifying. First you fear for your material survival. Will I lose my job? My home? And perhaps even, will I take my life? Secondly you fear you may lose love and esteem. For human beings secretly hate the sick or broken, even though they deny this to themselves. (The hate is a defence; people want to believe they will not suffer the same fate as others, and so they unconsciously locate the source of the problem in the sufferer, blaming the individual rather than our shared, vulnerable condition as human beings.) Of course human beings are divided souls, and so we are also compassionate. For this reason we disavow our secret contempt, because we would be ashamed to admit it to ourselves. Nonetheless the afflicted can perceive it. To break down is humiliating. And because every person has a degree of that secret contempt in them, and the broken one is guilty of exercising it toward others in the past, they turn it on themselves when they come apart. They hate themselves. Such a person may recognise that they are doing this to themselves, or they might imagine that it is coming purely from others. They feel rejected by the tribe. They fear they may never again function or be loved or respected as they were. They may fear becoming a loathed, broken object. And that takes us to the devastating core of a breakdown with respect to the issue of love and esteem. You may feel ugly as a person. Fundamentally bad. Like an utter failure.
What people need most at all times, but especially when they are coming apart, is others who will help hold them together. A person can repair themselves with the help of others, but the container for that healing is the love and esteem and reassurance which they are temporarily unable to find for themselves. Love is the contrary of the negation. After the crack up? We lay our hands on one another. "You are not alone."
This reflection is based on a paper which I presented at a conference yesterday. The main theme of the conference was evidence-based practice in counselling, with a sub-theme being recent changes to psychiatry’s diagnostic manual. I began with some words from Australian philosopher, Raimond Gaita:
"Our sense of the preciousness of other people is connected with their power to affect us in ways we cannot fathom and in ways against which we can protect ourselves only at the cost of becoming shallow. There is nothing reasonable in the fact that another person's absence can make our lives seem empty. The power of human beings to affect one another in ways beyond reason and beyond merit has offended rationalists and moralists since the dawn of thought, but it is partly what yields to us that sense of human individuality which we express when we say that human beings are unique and irreplaceable. Such attachments, and the joy and the grief which they may cause, condition our sense of the preciousness of human beings."
Previous editions of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, have included a "bereavement exclusion" in the case of depression. This was a direction in the manual that when diagnosing a possible case of major depression, if the symptoms can be properly interpreted instead as a case of bereavement, then bereavement rather than depression should be the diagnosis. This is because depression and bereavement can look like one another in certain aspects, but they are different in important ways and it is inappropriate to treat bereavement as a mental illness.
It was proposed that this bereavement exclusion be removed from the new DSM-5. As a result a debate emerged while the new edition was being drafted based on the concern that this removal would lead to grief being increasingly viewed as a mental illness. It seemed to me that there were no meta-analyses of the controversy which adequately surveyed the arguments pro and contra the removal, so as a philosopher and counsellor I engaged in this analysis.
The key argument against the removal of the bereavement exclusion was that it would likely lead to "the pathologisation of grief". That is, grief and bereavement – a natural, meaningful experience – would become re-described in our cultural practices as a medical problem, something to be treated by GPs and psychiatrists and drugs. Beyond the obvious problem that some clinicians see everything in medical terms and will be very happy to prescribe antidepressants for grief, it was also suggested that many more time-pressured clinicians would opt to treat bereavement as depression out of compassion - misguided compassion - as a means of increasing client access to psychological help and dulling their pain. It was noted that profiteering pharmaceutical companies would probably become very active in ‘raising awareness’ of the supposed biological roots of our bereavement and how their products can treat it.
These arguments certainly resonate with the widespread criticism that we currently pathologise many forms of anguish, visiting physicians and popping pills rather than looking at the real roots of our despair and anxiety. Psychological technologies often serve as culturally approved yet nonetheless superficial evasions of life's deeper challenges. This has already happened in the case of anxiety and melancholia, and with the latest edition of the DSM it appears that this distortion is spreading to grief and bereavement.
Grief – a pained response to a significant loss - can be terrible, but it is also a vital good in our lives. It is a condition for experiencing others as valuable. The value we can have in each other's lives means that death can occasion profound suffering - our suffering is an expression of that value. It is not a medical condition.A reduction of grief and bereavement to a medical pathology would surely obscure and threaten its vital, meaning-filled - and meaning-bestowing - place in our lives. I am reminded of Gaita's words above about rationalists and moralists - this time around of the medical sort. I am reminded of what he says in the second part of that sentence. The pathologisation of grief may reduce our pain, but it will rob us of our sense of the profound meaning and value that we have in one another's lives. And that is too great a cost.
My name is Matthew Bishop. I am a counsellor, with a background in philosophy. I have spent years exploring how philosophy enters into therapy, both theoretically and practically. One of my big influences is existential therapy. Although uploaded here recently, these are reflections written at different times over the last ten years.