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Psychiatria Danubina, 2009; Vol. 21, No. 4, pp 453–462 View point article
© Medicinska naklada - Zagreb, Croatia
THE EXISTENTIAL WAY TO RECOVERY
Laurie Jo Moore & Mila Goldner-Vukov
University of Auckland Faculty of Medical and Health Sciences, Auckland District Health Board
Manaaki House Community Mental Health Centre, 15 Pleasant View Rd, Panmure, Auckland, New Zealand
SUMMARY
This paper explores the essential features of recovery and the need for an
existential approach in psychiatry. The biopsychosocial model often fails to
sufficiently validate the existential suffering of patients. We review the major
principles of recovery and the philosophical and psychiatric principles of
existentialism. The ontological or intrinsic existential issues of death, isolation,
freedom and meaninglessness are described and their manifestations are explored in
clinical syndromes. When ultimate existential concerns are recognised, patients
have an opportunity to understand their life on a deeper level that is not defined as a
medical disorder but as a part of human existence. Understanding that existential
concerns underlie a great deal of human behaviour helps to free patients from the
stigma of psychiatric labels. An existential approach is a humanistic way toward
recovery.
Key words: existentialism – death – isolation – freedom – meaninglessness -
recovery
* * * * *
“The soul in its essence will say to herself: no one can build the bridge on
which you in particular will have to cross the river of life-no one but
yourself. Of course there are countless paths and bridges and demigods
ready to carry you over the river, but only at the price of your own self. In
all the world, there is one specific way that no one but you can take…”
(Nietzsche from May, 1983)
INTRODUCTION
Existentialism is important in recovery
because of the strong emphasis it places on the
individual. In psychiatry clinicians should pay
more attention to each individual’s unique
existential experiences. We found in our
experience with existential group therapy, that
existential principles resonate with the recovery
model and help clinicians and patients/consumers
transcend what they experience as the confining
aspects of the medical model. (Goldner-Vukov et
al. 2007)
The recovery model was adopted as a guiding
principle in mental health in the United States in
the 1980’s. New Zealand (MHC 2001) and
Australia followed and in 1998 New Zealand
implemented the recovery model as a national
standard of care (MHC 2001). The recovery model
has similar origins to the 12 Step Recovery Model
for Alcoholics Anonymous. Recovering alcoholics
found that traditional mental health approaches
failed to meet their needs and lacked a basic
understanding of what they were experiencing. The
recovery movement expresses the desire of those
receiving care to take ownership of their own path
toward recovery. This parallels the philosophical
and psychological ideas of existentialism. There
are ongoing debates about the principles, terms and
applications of the ideas surrounding recovery, but,
in general, it attempts to develop a social model
that moves away medical labels and empowers the
individuals going through mental health
experiences to regain control over their lives.
Recovery can be seen as a journey of healing and
transformation that enables a person with a mental
health problem to live a meaningful life and
achieve his/her full potential.
The essential elements of recovery revolve
around the individual reclaiming and redefining
their identity and defining the values important to
their retaining ownership of their own lives.
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Psychiatria Danubina, 2009; Vol. 21, No. 4, pp 453–462
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Important values include hope, having a secure
base and support system, self-empowerment, self-
determination and inclusion in the process of
engagement with the mental health system, as well
as the development of wellness recovery action
plans (WRAPS) (Copeland 1992, 1994, 1997).
WRAPS are written by the patient/consumer in
collaboration with mental health clinicians and
they include a section in which patients/consumers
describe how they would like to be treated in the
event of a relapse, who should and should not be
contacted, what medications are helpful and which
medications have not been helpful and other
advance directives for their care.
Patients/consumers who are not making
clinical progress are often stuck in existential
conflicts. Progress along the path toward recovery
is not really possible without understanding and
addressing existential concerns. We found that in
existential group therapy for bipolar patients that it
was when existential issues were addressed in the
group process and patients confronted each other
to take responsibility for their well-being and the
effect their behavior had on others, that patients
really accepted these challenges and changed their
behavior (Goldner-Vukov et al. 2007).
Individuals with psychiatric conditions
struggle with the same existential issues all human
beings confront and yet, their experiences bring
these issues to focus in unique ways. By
understanding the underlying principles of
existential thinking clinicians can assist patients in
reclaiming a sense of ownership and meaning in
their lives. It is vital for mental health profes-
sionals to recognize that patients have the freedom
of choice about how to manage their lives and that
it is only when they decide to assume respon-
sibility for their life and their treatment that they
will make any progress toward their recovery.
Clinicians can assist patients/ consumers to
establish a secure base. Housing New Zealand and
the Ministry of Health both fund low cost housing
for individuals and families. Work Income New
Zealand provides financial benefits for individuals
and families and in addition they have
implemented a Workwise Program that places
employment specialists in mental health centers to
help patients/consumers find jobs. By offering
assistance and support, skills training, socialization
and occupational activities, clinicians can help
patients/consumers deal with their feelings of
isolation and regain confidence in their ability to
form friendships and belong and participate in life
in meaningful ways. The restoration of hope is an
area that deserves special attention.
HOPE
When patients come to see clinicians they
frequently do not ask the questions that are really
on their mind nor do they talk about what really
concerns them. It is unusual for a person to go
directly to something close to their inner being
without taking a variety of paths forward while at
the same time they are asking themselves whether
or not you, their clinician, is someone who will
accept them, listen to them, be capable of
understanding their concerns and have anything of
value to offer them for the risk they take in making
themselves known. This is an essential step in
forming a collaborative relationship that supports
the self-empowerment and self-determination
important for recovery.
The archetype of a healer has been described
as a universal phenomena in human beings
(Campbell & Moyers 1991). When patients are
able to trust their clinician, feel safe and respected,
then the clinician/patient relationship allows the
activation of the patient’s internal healing belief
system. This gives patients a sense of hope. Hope
allows a relationship to develop in which the
patient and clinician are able together to
acknowledge and alleviate many of the deep issues
of suffering that people encounter in life.
Sometimes it is important to have a name for one’s
suffering. A cure is essential at times. Other times,
it is important for one’s suffering to be acknow-
ledged and for one’s courage to be recognised.
Existentialism in Philosophy
and Psychoanalysis
One of the most important values of existential
philosophy is authenticity. Authenticity is above
all a call to integrity, responsibility, and even to
heroism. It asks an individual to be true to his/her
inner self in the face of adversity no matter what
the cost. (Solomon & Higgins 1996). In the early
1900’s existential psychoanalysts began to emerge.
After a few decades without much activity,
Kierkegaard’s work was translated into other
languages and was taken up by the German Martin
Heidegger who became an exponent of
existentialism and the German psychiatrist Karl
Jaspers who coined the term “Existenzphilosophie
Laurie Jo Moore & Mila Goldner-Vukov: THE EXISTENTIAL WAY TO RECOVERY
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(philosophy of existence)”. Existential psychoana-
lysts, philosophers, writers and artists developed
across Europe and spread to America as late as
1958 (May 1983).
Existentialism might be best conceived as a
philosophical movement that includes philoso-
phers, politicians, writers, artists, psychoanalysts,
psychologists and psychiatrists. Irvin Yalom is a
contemporary psychiatrist who has continued the
work of existential psychiatry (Yalom 1980).
Existential philosophers who emerged in the
aftermath of the horrors of WWII stressed that it
was individuals who gave meaning to their lives
and not the world who gave them meaning.
Defining Characteristics of Existentialism
The human existential dilemma is something
fixed in the depths of the human character (Becker
1973). The existential nature of human existence is
ontological, i.e., it is intrinsic to being human
(Tillich 1952). Human beings are free to make
decisions about life and are responsible for the
outcome of these decisions. This creates an
intrinsic anxiety or angst about the freedom to
make choices (Yalom 1980).
The principles of existentialism can be
summarized as follows: all human beings: 1) are
centered in themselves, 2) strive to preserve and
affirm their true being, 3) have a need for and the
choice of extending themselves to others, an action
that involves risk, 4) have the capacity for self-
awareness, 5) have the capacity to know them-
selves as subjects who have a world and to know
they are being threatened, and 6) have an
ontological foundation for consciousness based on
freedom (Tillich 1952).
Existential Phenomenology
A phenomenon is that which appears and
phenomenology is the study of appearances.
Existential phenomenology is a way human beings
have of understanding themselves and the world by
means of careful descriptions of experience. The
existential philosopher Edmund Husserl empha-
sized that experience could only be studied
subjectively, that is, human life could only be
viewed from the inside instead of pretending to
view it objectively from the outside. A basic
principle of phenomenology is the concept of
intentionality, that all phenomena involve both an
intending action and an intended object. In contrast
to the cognitive approaches already discussed,
existential phenomenology focuses on under-
standing individual experience as an attempt to
capture the essential meaning of existence. This
philosophical current was inspired by Martin
Heidegger who was influenced by the existential
work of Kierkegaard who contended that existence
was absolutely unique for each individual and the
phenomenological work of Husserl (Stewart &
Mickunas 1974, Luijpen & Koren 1969).
The Need for an Existential Approach
The current approach to psychiatric problems
is biopsychosocial, cultural and spiritual. We
suggest an existential approach is needed to
comprehend the wholeness of patients. Existential
phenomenology supports the uniqueness of each
individual and helps guide clinicians in
establishing a respectful therapeutic relationship
that is supportive of the recovery approach and the
self-determination of patients. The existential
approach presents the view that there are intrinsic
conflicts that result from the awareness and
confrontation of certain ultimate concerns that are
an inescapable part of human existence. The major
existential ultimate concerns are death, mean-
inglessness, isolation, and freedom. The fear of
death, for example, is so overwhelming that human
beings would not be able to function if this fear
was totally conscious. The conflicts people
experience and the defenses they develop around
existential ultimate concerns are generally
unconscious processes. They often become
conscious through the manifestation of
psychological symptoms, disorders or patterns of
behavior. In a therapeutic relationship that
recognizes existential issues, they are an important
part of understanding the foundation and
development of each unique individual person. In
this paper, we have chosen to focus on the
importance existential issues have in the
therapeutic relationship and in assisting individuals
to find hope and meaning that may allow a
successful negotiation of recovery. Existential
conflicts and defenses become an important part of
the therapeutic process of making what is
unconscious, conscious so individuals can achieve
a greater sense of mastery and control of their
lives. This is obviously a broad and ambitious
agenda and a full discussion of this is beyond what
this paper can address. In general, confrontation of
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the intrinsic, i.e., ontological givens of existence
can be painful and challenging but ultimately
healing.
Psychopathology and Existentialism
Psychiatric problems that are reflections of
existential issues are frequently seen in primary
care and psychiatry. They include: depression,
anxiety, pain, somatization, substance abuse, and
suicidality (Yalom 1980). An existential
perspective is helpful in understanding many
psychiatric symptoms and behaviors. Anxiety
emanates from an individual’s confrontation with
the ultimate concerns of existence. The
psychopathological manifestations are a graceless,
inefficient, and ineffective defensive mode of
coping with anxiety.
There are three types of existential anxiety
(Tillich 1952). 1) The anxiety of fate or death in its
pathological expression drives inidividuals to an
unrealistic need for security. This anxiety is
compounded to the degree that a person
individuates. Unconscious pathological manifesta-
tions of the need for security include obsessive,
compulsive and dependent behavior as well as the
narcissistic preoccupation with acquiring power
and wealth that underlies modern Western society.
2) The anxiety of emptiness and meaningless is
created by doubt based on separation and isolation.
In its pathological expression this anxiety drives
individuals toward an unrealistic need for certainty
or fanaticism. Problems with separation underlie
the dynamics of all insecure attachment disorders.
3) Human beings experience an anxiety of guilt
and condemnation. Its pathological expression this
anxiety drives individuals toward an unrealistic
need for perfection. The need for perfection can be
observed in patients who are obsessed about side
effects of medication and are trying to find a
‘perfect’ cure. People with eating disorders try to
find a perfect body and the drive for perfection
may be part of people’s character structure (Tillich
1952).
When these three types of anxiety are not
mastered and they are fulfilled or manifest in the
state of despair which is a condition of no hope
(Tillich 1952).
Existential Ultimate Concerns
Conflicts arise as ultimate concerns intrinsic to
human existence. Each individual faces the core
existential ultimate concerns in a highly
individualized way: death, freedom, isolation and
meaninglessness (Yalom 1980).
Death
Death is the most obvious ultimate concern.
The core conflict is between the awareness of the
inevitability of death and the desire to continue
living (Spinoza in Elwes, 2008). Human beings
create defenses against the fear of death based on
denial. These defenses shape the human character,
influence the way individuals grow, falter, and fall
ill. There are two modes of existence: one of
forgetfulness of being ( a limited awareness of the
true nature of existential ultimate concerns
including death ) and one of mindfulness of being (
full awareness of the immences of death and
ultimate existential concerns) which is described as
authentic (Heidegger, 1996). The desire to
transcend death is so ultimate and profound that it
has been described as the source of all culture and
creativity (Becker, 1973). Humans attempt to
achieve immortality in the following ways: 1)
biologically through procreation, 2) theologically
through spiritual evolution, 3) creatively through
work and art, 4) experientially through intense life
dramas, adventures and experiences, and 5) by
immersing oneself in the forces of nature (Lifton
1973b).
Rank believed a person was thrown back and
forth in the process of individuation between the
fear of life and the fear of death (Rank 1945). That
is, between two poles of possibility: the affirmation
of one’s autonomy, emergence and potential that
leaves one feeling unprotected and lonely and 2)
the fear of loss of individuality by being dissolved
back into the whole and becoming invisible (Rank
1945). People who individuate beyond conven-
tional limits have an increased fear of death
anxiety, an increased need for fusion and an
increased need for a sense of belonging (Tillich
1952). People who suffer from mental illness are
thrown into an unconventional life style,
completely beyond their own choosing and this
intensifies their fear of death and isolation.
Fear of Death
Human beings are out of nature but hopelessly
in it. Human beings are consciously aware of the
true human condition but instead remain only
partially conscious and play all sorts social games,
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and use psychological tricks that keep them far
away from the reality of death (Becker 1973). For
example, people end up leading unbelievable lives
when they are trapped in psychotic interpretations
of reality, when they are absorbed in the madness
of gambling and addictions and when they are
completely preoccupied with forms of acting out
and harming themselves and others in order to get
revenge for their suffering. One way to cope with
the fear of death is to pull back from the full
potential of life. Mental illness provokes the fear of
death and restricts an individual’s potential for
development (Maslow 1968). Every illness
provokes the fear of death. Mental illness clearly
increases the risk of suicide as an ultimate attempt
to escape a perceived destiny or suffering.
People who do not succeed in taking upon
themselves their existential anxieties, can escape
the state of despair by developing neurotic
symptoms. Neurosis is a way of avoiding the state
of non-being by avoiding being (Tillich 1952). One
of the manifestations of death anxiety is neurosis.
Manifestations of Death Anxiety
Success neurosis is seen when people are
striving to achieve success at any cost in order to
‘prove’ their immortality. Social phobia is the
result of problems with individuation and the lack
of development of social skills leading to social
anxiety. Substance abuse is a means of achieving
an altered state of consciousness as an escape from
confronting the realities of existence. In order to
avoid death anxiety people may develop a sense of
specialness, a belief in personal omnipotence
manifested by heroism, workaholism, narcissism, a
refusal to accept necessary treatment, and
rebellious behaviour in general. The belief in an
ultimate rescuer is the need to be found, protected,
and saved without asking for help. This is
manifested by collapse when a fatal illness
appears, depression when living in someone else’s
shadow, masochism, interpersonal difficulties and
failing to separate from a relationship with aging
parents (Yalom 1980). Psychiatric patients
probably stop taking their medication and relapse
as a result of a sense of specialness and a belief
that nothing is wrong with them because they have
an omnipotent power to heal themselves. In
addition, when faced with dilemmas they can’t
resolve, they may regress to a state of believing in
an ultimate rescuer and become helpless. Patients
often give up or stop taking medication and hand
themselves over to fate as a way of refusing to face
the challenges or destiny of their lives.
Freedom, Destiny and Responsibility
Yalom assumes that freedom refers to the
absence of an inherent design in life that leaves
one responsible for all one’s choices and actions.
Freedom refers to the absence of external structure.
The human being does not enter or leave a well
structured universe that has an inherent design.
Beneath human existence there is no ground, only
a void, an abyss, nothing (Yalom 1980).
Freedom gives human beings the ability to
modify destiny. Being responsible for life at the
deepest level establishes a foundation for an
individual’s identity and existence. From the
perspective of existential thinkers the individual is
entirely responsible for creating his/her self,
destiny, life predicaments, feelings, choices,
suffering and actions (Yalom 1980). Individuals
who reject responsibility for themselves, blame
other people or phenomena for their life situations
(May 1999).
It is not possible for human beings to be
responsible for their genetic makeup, their family
of origin, the state of the world around them or
many other things. But human beings are
responsible for what they make of their lives
(Tillich 1952). Despair arises from being unwilling
to be oneself (Kierkegaard 1954). Every falling
away from ourselves is a crime against nature and
leads to sickness (Maslow 1958).
The conflict in freedom is between the
encounter with groundlessness and the desire for
foundation and structure (Yalom 1980).
Manifestations of this conflict include a variety of
ways in which people can develop a psychic world
where they do not experience a sense of freedom.
Examples include a life dominated by compulsive
fears or dominated by paranoia in which the
individual’s feelings and thoughts are attributed to
others. The conflict around freedom and
responsibility can also be acted out in the
personality. For example, a hysterical personality
may be a way of pretending to be an innocent
victim, a borderline personality may be a way of
acting out loosing control, passive behavior may be
a way of not asking for help or comfort and
abusing alcohol and drugs may be an attempt to
escape responsibility and to live in an alerted state
of consciousness (Yalom 1980).
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Isolation
Isolation refers to human being’s fundamental
separation from others and from the world. The
conflict is between absolute isolation and the
desire for protection and belonging (Yalom 1980).
Becoming an individual entails an eternal and
insurmountable loneliness (Kaiser 1965). The
major developmental task of existentialism is to
resolve the conflict between fusion and isolation.
Interpersonal and existential isolation are way
stations for each other. Human beings separate to
encounter aloneness but this allows them to return
to relationships to engage more deeply with others
(Yalom 1980).
Separation from the world, the experience of
feeling lost and lonely, is the intrinsic state of the
human condition that includes intrapsychic,
interpersonal and existential isolation. Anxiety
covers acceptance of the fact that human beings are
born alone and die alone. Manifestations of the
problem of isolation in Yaloms view include
certain manifestations of narcissism including the
Don Juan syndrome in which individuals are
unable to make a commitment to one person and
the behavior of disinhibited adolescents that may
express the child’s inability to tolerate the
separation and loneliness of adulthood (Yalom
1980). People who have been traumatized may
become trapped in their internal world of
psychological and physical pain to protect
themselves from further external trauma.
Hypochondriasis may be seen as an expression of
the fear of isolation where every physical pain
reactivates the psychological pain of having been
abandoned as an infant. As mentioned earlier, all
psychological issues related to attachment
disorders underlie the development of psychiatric
disorders including anxiety, depression, substance
use disorders and somatization. This reflects the
essential understanding of existentialists that the
negotiation of the conflict between fusion and
isolation is the major developmental task of human
beings.
Meaninglessness
Meaninglessness is the human confrontation
with an indifferent universe that compels
individuals to construct their own meaning (Yalom
1980). One solution is to cultivate a transcendental
relationship with what is divine (Buber 1965).
Secular sources of meaning include altruism,
devotion to a cause, or self-actualization (Camus
1989, Sartre 1954). Meaning falls into three
categories: 1) what one gives in creative work, 2)
what one takes in terms of experiences and 3)
one’s stand toward suffering and fate (Frankl
1969).
Meaning refers to our sense of purpose.
Meaninglessness is the chronic inability to believe
in the truth, importance, usefulness or interest
value of any of the things one is engaged in or can
imagine doing (Maddi 1970), Lack of meaning
perpetuates anxiety, isolation and despair.
Manifestations of meaninglessness include:
suicidality, alcohol or drug abuse, noogenic or
existential neurosis, depression, low self-esteem,
identity crisis, boredom, emptiness, apathy,
cynicism, and lack of direction. As a result of
being mentally unwell patients are frequently
drawn into an intense conflict about their purpose
in life. They are handicapped in their attempts to
engage in creative work and to take a stand toward
their suffering. They are hampered in finding
meaning in their experiences by the social stigma
of their illness and need intensive support to
overcome the toxic experiences of rejection they
suffer in their families and society.
How to Assess Existential Issues in Psychiatry
When assessing patients, clinicians need to
consider the presence of existential issues. It is
necessary to recognise that the biopsychosocial,
cultural and spiritual model does not sufficiently
encompass the realities of human suffering.
Clinicians need to consider existential issues in
patients who are treatment resistant and suffer, for
example, from anxiety, depression, somatization or
pain, suicidality and addiction. It should be
understood that there are layers of anxiety but that
the deepest level of anxiety is related to one’s
personal understanding of ultimate concerns.
Tillich (1952) states that underlying all anxiety is
the fear that one will not be able to preserve
oneself in the face of direct adversity. This
describes the experience of people ‘having a
nervous breakdown’, becoming overwhelmed by
depression, anxiety, mania or psychosis. Ultimate
concerns are universal and they are present in
every individual in every culture. These can be
approached by being present beside patients as
they encounter bewildering and shattering
experiences they cannot understand. In less overtly
profound situations ultimate concerns can be
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explored by listening to dreams and fantasies,
observing behaviour, and asking open-ended
questions about meaning. The goal of existential
assessment is to help patients understand and
remove or resolve obstacles to the crucial
questions of being.
Existential Approaches and Interventions
An existential approach is consistent with
good psychiatric practice and emphasizes being
empathetic and genuine. It suggests a willingness
to grasp the meaning of patients’ suffering.
Existential assessment is focused on the
dimensions of human existence in the here and
now and discourages an emphasis on the past.
Patients are encouraged to make authentic
decisions, to discover truly responsible ways of
dealing with life and the world and to think deeply
about their life situation. It is important to promote
the belief that patients can harness their anxiety
and use it constructively. For example, it is
productive for patients to see anxiety as an
opportunity to change and to achieve their full
potential. Clinicians can temper existential anxiety
by encouraging people to reach out to others, to
love and to participate actively in life (Tillich
1952).
After completing a comprehensive psychiatry
history we recommend that existential concerns be
included in the development of the psychiatric
formulation. Individuals will have different
encounters with ultimate concerns that play a role
in their vulnerability to develop psychiatric
disorders and shape the nature of their character
and their defensive structure. There is not
necessarily a 1:1 relationship between ultimate
concerns and psychiatric symptoms or disorders as
these conflicts may be experienced and expressed
in very individualized ways.
We recommend that patients identify their
most important life values and then rank their
values from the most to the least important.
Following this patients are asked to write down
their life goals linking them to their values. This
process highlights patients’ major ultimate
concerns and allows clinicians to help patients
understand their ultimate concerns and see how
they cope with their anxieties. This process allows
for therapeutic interventions when patients means
of coping are dysfunctional. For example, when a
patient ranks health as the most important value,
but does not attend to physical well-being at all
because of belief in being special. This person
could benefit from gentle confrontation and
perhaps shift to a more adaptive coping
mechanism.
Group therapy is especially helpful to teach
patients how their behavior is viewed by others,
how it makes other people feel, how it creates the
opinions others have of them and how it influences
their opinions of themselves. In addition group
therapy is especially helpful when peers confront
each other about therapy-avoiding behaviors and
behaviors that lead to the suffering of others due to
failure to assume responsibility for one’s actions
(Goldner-Vukov et al. 2007).
Clinicians need to foster an understanding in
patients that they participate in creating their own
destiny. Clinicians need to understand the role
patients play in their own dilemmas and find ways
to communicate these insights. The goal is
ultimately to support personal change by helping
patients understand that the cause of their suffering
is not always external, but may, in fact, be internal
and related to deeply human ontological concerns.
Existential Themes That Point Toward Answers
It is beyond the scope of this paper to address
the existential approach to all psychiatric
symptoms and disorders. Instead we have
attempted to give a broad overview of how
existential ultimate concerns may be involved in
the development of psychiatric symptoms and
disorders. We paid particular attention to how
existential issues apply to an effective therapeutic
relationship, and how they may be involved in
treatment resistence/ nonadherence. In this section
we will discuss themes that can help patients find
hope and meaning in their lives. These suggestions
involve atheist/ secular approaches such as that of
Yalom, naturalistic/Taoist/ mystical approaches
such as Alan Watts, the mythological approach of
Joseph Campbell and theological approaches of
religious beliefs suggested by Tillich, Buber,
O’Donohue and Frankl.
By helping patients to be honest in facing the
ultimate concerns that are causing or contributing
to their psychiatric problems, patients can first of
all begin to understand and know themselves more
deeply. The more patients are able to know
themselves and relate to their authentic true selves,
the more they are able to participate in life (Tillich
1952). In supporting patients to affirm and
preserve their own true inner beings, clinicians can
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help them find their own inner source of power. In
helping patients to develop the courage to be who
they are, to love and participate in life they can
begin to overcome their existential anxieties. The
degree of virtue people can attain in life is
determined by the degree to which they strive for
and affirm their own being (Tillich 1952). This is
not something that is beyond the grasp of people
suffering from psychiatric disorders.
Responding to the fear of death
and finding meaning
Joseph Campbell, the eminent mythologist,
says that myths are symbolic stories that reconcile
human beings to the harsh realities of life
(Campbell 1991). The first function of myths is to
point to transcendence of consciousness and the
unknown mystery of life. One universal myth
across the world is that of the hero or heroine who
is the personification of courage and strength and
undertakes a transforming vision quest. The
highest point of this quest is to confront death. The
hero or heroine is challenged to follow the wisdom
in their heart and not the contemporary
conventional wisdom that will lead them to hell.
The message of this myth is that the seat of the
soul is inside and that it is in the soul that the inner
and outer worlds meet. Each patient’s life is their
unique encounter with this myth and we need to
acknowledge and validate the courage our patients
require to follow the wisdom of their heart through
their terrifying experiences.
Campbell admonishes that if clinicians want to
help people in this world, they need to teach people
how to live in it. He says that what human beings
are seeking in life is all the experiences one can
possibly have of being alive. Myths are clues to the
spiritual potentialities of life. The spiritual and
mythological fulfillment of life is that you are here,
you exist, and you are alive (Campbell 1991).
Einstein reminds us that it was only to the
individual that the soul is given. (Einstein) Not to
the family, the church or society. It is only through
the authentic and unique true self that human
beings can discover the meaning of their lives.
Isolation and Belonging
Psychiatric patients loose connection with
their inner selves and with their environment. They
become isolated. Psychiatric symptoms per se
alienate patients from themselves and from others.
For example, people who dissociate, who shift
back and forth between devaluation and
idealization, between love and hate, loose
connection with themselves and have difficulties
establishing interpersonal relationships. The stigma
of mental illness, being unable to work and living
in poverty makes patients feel separated from their
families and society. People who are isolated and
disconnected often lack relationships that assist
them in integrating their experiences. Without
connections patients are subject to internal reality
states that become a substitute for real connections
with other people. In order to survive situations
that are overwhelmingly traumatic, patients often
develop a false self. When this false self speaks to
patients, they experience it as external and foreign.
When patients hear voices, for example, they are
listening to some part of themselves that begs for
understanding. When patients live in a false self
they search for something that can never be
obtained.
Longing and belonging are instincts of the
soul (O’Donohue 1998). In interventions with
patients clinicians need to help them belong first to
their own soul and to see that real beauty is the
light that comes from within them (O’Donohue
1998). It is the challenge of clinicians to help
patients find the connections within themselves
and to offer them a therapeutic relationship that
will allow them to discover and develop new
aspects of themselves.
One of the deepest longings of the soul is to be
seen. There is no mirror in the world where one
can glimpse the soul. The honesty and clarity of
true friendship is the truest mirror. (O’Donohue,
1998) In therapeutic alliance with patients, it is the
role of clinicians to provide patients with such a
mirror. Clinicians need to help patients understand
that what appears to be only negative also contains
an opportunity for self-knowledge and self-
mastery. By encouraging patients to adopt an
attitude of hospitality and embrace that which is
difficult and awkward clinicians can help patients
to discover the positive meaning of their symptoms
and to validate their suffering.
Acceptance, Faith and Freedom
Whereas Western society has addressed some
ultimate concerns in terms of secular or religious
faith and beliefs, Eastern approaches have
emphasized naturalistic ways of approaching life
that don’t involve conceptualizing a supreme being
or entity. These include Taoism and Buddhism.
Laurie Jo Moore & Mila Goldner-Vukov: THE EXISTENTIAL WAY TO RECOVERY
Psychiatria Danubina, 2009; Vol. 21, No. 4, pp 453–462
461
Acceptance is a basic and profound principle of
eastern philosophical and spiritual beliefs. Radical
acceptance has become one of the foundations of
psychotherapy for complex emotional states in
severe personality disorders, Bipolar Disorder,
Schizophrenia and Schizoaffective Disorder. In
addition to being oneself and finding meaning in
life, acceptance allows people an additional layer
of being that may contribute to finding happiness.
In true acceptance of the self there is a mystery that
something so apparently simple can contain so
great a treasure. Is so happens that the very things
human beings are forever struggling to get away
from, to change and to escape are the very things
that hold the much desired secret. For example,
patients frequently want to destroy or get rid of
part of themselves that is wounded when, in fact,
the sad, angry, scared or helpless parts of them
deserve compassion and understanding. One’s
present self and situation at this moment contain
the whole secret (Watts 1940). Clinicians need to
help patients accept the state of their own soul
exactly as it is instead of trying to force themselves
into some other state that they imagine to be
superior. Faith is the willingness to give oneself to
life absolutely and utterly without making
conditions of any kind (Watts 1940). In doing this,
one can begin to overcome existential dilemmas.
Human beings are always trying to interfere
with their states of mind as they appear from
moment to moment imagining that something else
is better than what they experience (Watts 1940).
Instead, clinicians need to encourage patients to
allow the moment and all it contains freedom to be
as it is, to come and go in its own time and in
allowing the moment, which is what one is now, to
set onself free (Watts 1940). In doing this one can
realize that life as it is expressed in the moment has
always been setting you free from the very
beginning but you have chosen to ignore it and
tried to achieve something else. That is why total
acceptance is actually the key to freedom (Watts
1940).
CONCLUSIONS
Existential anxieties that emanate from the
ultimate concerns of existence can interfere with
the development, relationships, creative work and
self-actualization of mental health patients. The
anxiety of death and fate can lead to a
preoccupation with security. By teaching patients
to accept their true selves and find the courage to
love and participate in life, they may be able to
overcome this anxiety and not be controlled by it.
The anxiety of meaninglessness based on the fear
of isolation may drive patients toward fanaticism.
By establishing successful therapeutic relationships
with patients, clinicians can help them feel a sense
of belonging and move in and out of their fears
toward relationships that allow them to integrate
their traumatic and difficult internal experiences.
The anxiety of guilt and condemnation is a result
of the intrinsic state of freedom and it may drive
patients toward perfectionism. If clinicians can
teach patients to accept their lives and to give
themselves to life absolutely and utterly without
restraint, patients can find the key to their freedom
and the path to recovery in this kind of total
acceptance.
Changing perspectives and behaviours in a
process that involves many conversations and
dialogue amongst colleagues. We believe an
existential approach to treatment has benefits and
we invite future dialogue around this topic.
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Correspondence:
Laurie Jo Moore, MD, ABPN, FRANZCP, Clinical Instructor
University of Auckland Faculty of Medical and Health Sciences
15 Pleasant View Rd, Panmure, Auckland, New Zealand
E-mail: LaurieJo.Moore@adhb.govt.nz
