Depression - An Existential View

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 (dealing with the nature of being), rather than aetiology (the cause), existentialism avoids models that categorise individuals, seeking to uncover that which is universal in the human dilemma. In contrast, the medical model fails to obtain a complete worldview of human-being, choosing instead to go with unexamined assumptions.

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. James Bugental (1978) defines identity as a process, not as fixed, and when one realises 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) theorises that such freedom brings about existential anxiety through the contemplation of choice and the realisation that ones destiny is not fixed but open to an infinitude of possibilities. Existential anxiety differs fundamentally from psychological anxiety such that it may have no immediate perceivable cause, it seems irrational, pervades ones whole being, may manifest as an unexplainable dread and arise only in moments when normal securities disappear. Yalom (1989) describes it as that which whirls 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 ones very existence or to values that are identified with existence. Thus there is no cure for such angst, 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. It can be utilised as a source of great creativity and energy (May 1969) or reveal itself as neurotic anxiety (May & Yalom 1984), paralysing 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 ones 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, one is free to realise ones aims, to materialise ones dreams and forge ones own destiny (Owen 1994). The person who lives in this manner is living authentically. 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 one as subject to outside influences, conforming to standards or roles and assuming that actions are predetermined. Kierkergaard (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 ones 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 in 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.

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. He observed this 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 suggests, is a strategy invented in order to live in an unliveable 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. In this sense the existential approach to such phenomena as schizophrenia emphasises the importance of the subjectivity of experience for the client, breaking away from stigmatising labels and allowing the individual to journey through their authentic experience of madness.

Van Deurzen-Smith (1998) 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 ones 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 and is often downplayed as not being empirical enough. Craib (1992) argues that diagnostic categories are needed in order to approach the necessary level of working knowledge of a client s world.

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 and a holistic view of the entire being in the here and now.