Authenticity in existential analysis.
Article Type: Essay
Subject: Psychotherapy (Analysis)
Existential psychology (Analysis)
Author: Groth, Miles
Pub Date: 01/01/2008
Publication: Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2008 Society for Existential Analysis ISSN: 1752-5616
Issue: Date: Jan, 2008 Source Volume: 19 Source Issue: 1
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 191100066
Full Text: I. Diagnosis, Intervention, Treatment, Cure

In its brief history the goal of psychotherapy has changed dramatically several times. When only a century ago the Viennese neurologist, Sigmund Freud, first decided to intervene with words instead of available medical procedures to treat his patients' "neurotic" complaints, as a physician he still had in mind, first and foremost, the cure of a patient. A psychoneurosis was still, for Freud, a disease of the nervous system and a presumed lesion was responsible for its symptoms. More than a few steps, however, lay between the doctor's small examining room and his study in the apartment on Berggasse where psychoanalysis was first practiced at the end of the nineteenth century. While it is unclear whether Freud ever ceased to see his referrals as patients (each of them an instance of the living corpse every physician is trained to envision presenting itself to him for care) his use of words rather than scalpel and drugs (forgetting for a moment his early prescription of cocaine for "depression") marked a departure from the traditional medical model on which the physician's approach is based.

Freud wore a three-piece suit and never unbuttoned his tie in the presence of a patient. We are told he kept appropriate physical and absolute psychological distance from his patients, eventually moving entirely out of their view and the diagnostic gaze to a position seated behind the patient's body, which was stretched out comfortably on the analytic chaise longue. Like a surgeon, his work space was set up to shield from view his patient's face.

Movement of the patient's body away from the doctor's examining eyes transformed the medical patient into the analysand of classic psychoanalysis. The analysand was physically there, but the data on which Freud's treatment would be based was being gathered elsewhere, just as today the data of any primary care physician's physical examination of a patient are collected for analysis elsewhere in laboratories where the patient's blood and urine samples are scrutinized for interpretation by the physician. The data provided by Freud's analysand was gathering in that immense chamber he termed the Unbewusst, a place where consciousness could never shed its light.

Moving the site of his work with patients out of the hospital setting was decisive for Freud's invention of the prototype of the patient in psychotherapy, since it located the procedure of psychoanalysis away from an environment redolent with the ambient odors of cautery, human body products, and the chemical compounds used to cleanse wounds, induce anesthesia and maintain a hygienic institutional environment. In Freud's study, there was instead the smell of food being prepared elsewhere in the doctor's apartment, the ubiquitous, acrid odor of cigar smoke and the musty smell of heavy Victorian fabrics and upholstery. The odors produced by the patient's body--the sour breath exhaled by a dyspetic or the sweetness of acetone leaking out through a diabetic patient's pores--was overwhelmed by the smells of burning tobacco, simmering sausages, and his chow's fur. Climbing the marble stairs to Freud's apartment, an analysand might just as well have been visiting a relative or her attorney. She was entering a consulting room, not a hospital or dispensary.

Freud changed the being psychiatrists treated by changing a what to be treated to a who to be treated. Although, initially he persisted in using the language of neuropathology, Freud's conception of a psychoneurosis was soon not that of a disorder of the nervous system and therefore a disorder of the body, but a condition of a person's emotional dis-array, a dis-order of the analysand's psyche. Freud's topographic model of the intrapsychic world of the patient envisioned contents of an entity, the psyche, moving from one domain to another, between the unconscious, the preconscious and the conscious. The Freudian psyche was not the brain, yet the image was one of a thing in which energy moved from place to place. The later structural model of the "me" (Ich) and the "it" (Es) presented in The Me and the It [Das Ich und das Es] (mistranslated as The Ego and Id) included a third domain, that of an "overseer of the me" (Uberich). Still compartmentalized, the psyche was still driven by metaphoric energy in a system of dynamic transformations comparable to but utterly different from the electrochemical energy that hops between cortical neurons and courses through the nervous system.

In addition to changing the "object" of treatment, in Freud's hands the goal and purpose of treatment also changed. Treatment still implied the existence of something damaged or broken (a dysfunction) to be repaired, and the goal of treatment was still couched in the language of improved functioning, the melioration of symptoms and the possible cure of an illness, but as the Austrian clinician aged and gained in experience, his reasons for analyzing patients shifted from effecting a cure to assisting the analysand in coming to accept the vagaries of her personality. Now Freud's aim was not the curing of a disease, but rather helping the analysand tolerate being resigned with respect to the inevitability of who she was and had to be given her earlier life experiences, and by implication what she would have to go on being as she descended the stairs, walked into the street outside Berggasse 19, and went on with her life. The goal of psychoanalysis became more modest: embracing "everyday human misery." Freud also learned that the process of analysis might even entail having to feel worse for a time. Like surgery, the "psychic surgery" accomplished by psychoanalysis nearly always entailed a period of greater pain during and following the procedure than the patient had been experiencing before entering analysis.

The purpose of this paper is not to continue to review the many incarnations of "the helping profession." Instead I will focus on what I believe to be the goal of all forms of psychotherapy, one that has been in the background from the beginning (beginning with psychoanalysis) and continues to gleam (sometimes faintly) through all contemporary "mental health care": authenticity. In my view, authenticity is the unacknowledged goal of every form of psychotherapy, from Freud's "talking cure" to the current rage, cognitive-behavioural therapy (CBT). Before doing so, however, I must first examine the notion of intervention, which is implicit in all forms of psychotherapy, in order to see how it is related to the prospect of regaining authenticity.

Intervention in psychotherapy is based on the medical approach to human suffering. For a physician, unless it turns out to be "functional," a an illness indicates underlying pathology that (often literally) cries out for examination, evaluation, diagnosis and management--that is to say, some sort of intervention. (1)

As the root of the word diagnosis suggests, something wants to be known when a physician approaches an ill person. Of course, many physical disease processes are silent (asymptomatic), but the symptoms of nervous suffering are visible (anxiety, tension, agitation, tremor, paralysis, catalepsy, stereotypic movements) and often audible (crying, yelling). Outspoken like physical pain, such symptoms implore the physician to render an interpretation of the symptoms and, in psychiatry since the time of Emil Kraeplin, to classify the pattern as a disorder. Freud added to the system of medical disorders with his new nosology of nervous and mental diseases. The underlying pathology of the psychoneuroses had to be inferred, however, since there was no way of demonstrating damage to the psyche's "me," the "it" or "my overseer," as there might be of verifying damage to a heart or liver. Freud's early attempts at a scientific psychology of neurons and Q-energy were abandoned and replaced by a metapsychology of unconscious mental life that was intended to provide an explanatory scheme for justifying his diagnosis, say, of hysteria, anxiety neurosis, or obsessive-compulsive neurosis. (2)

Psychoanalytic treatment was unique in its interventional style, its almost "passive aggressive" waiting for the analysand's "free" associations. Its aim was effecting the verbalization of latent intrapsychic conflicts held to be responsible for the analysand's observable or silent (until reported) suffering. The approach attributed agency to intrapsychic structures, which were in effect personifications of the agents of the client's misery. The structural agencies were shown to be simulacra of the analysand's parents (imagos), including their own attitudes and values, and their own intrapsychic conflicts.

Unlike medical techniques, application of the fundamental rule of psychoanalysis had to be carried out by the patient herself (on her own psyche) and not by the physician. Practitioners soon realized that fluency in engaging in "free" association was, in fact, the ultimate aim of psychoanalysis. Once the uncensored association of memories was possible, analysis could be terminated, at least formally. The work of the "analytic instrument" (the personality of the analyst) had been completed, but the much desired side effect of a complete analysis was to have set into motion in the patient a habit of self-reflection that she could be expected to continue throughout her life.

Many other forms of psychotherapeutic intervention have been devised in the wake of classical psychoanalysis. It is estimated that there are currently more than 400 varieties of counseling and psychotherapy available in the United States, and this does not include the impressive array of homeopathic ("holistic") and self-help regimens on the mental illness and mental health market, or the formidable physiological and legal interventions of psychiatry (pharmacotherapy and the "milieu therapy" of mandatory hospitalization). Some plans of intervention are based on the ideological motivation and role of the counselor (e.g., medical, pastoral, forensic), while others target an area of psychological life (e.g., cognition, motivation, conation, perception) or a realm of human experience (e.g., sexuality, "ingestive behaviour"). Still others focus on a social institution (e.g., marriage, family) or lifestyle or role (e.g., gender) in which significant numbers of the population participate. Many are grounded in a formal and complex theory of personality (e.g., Jungian analytical psychology, Adlerian individual psychology). Others have a more broadly theoretical basis (e.g., client-centered, systems-based, information-processing). Still others have been developed for a specific diagnostic category (Kernberg's work with "borderline" personalities, Kohut's self psychology for work with "narcissistic" personalities). At the end of a day of consultations, however, all have common cause in having actively intervened in the lives of those who sought their counsel and help. Whether the patient or client is required by law or coerced by a family member into agreeing to work with a therapist or when it is the client's wholehearted desire to form a therapeutic alliance with a practitioner, she expects management of her life in some way through the agency of the therapist. (3)

While psychotherapy entails some degree of participation of the client, it also implies an essentially passive stance vis-a-vis the psychotherapist's interventions. Any form of treatment implies at least two players: one who takes a passive role in receiving treatment and one who take an active role in providing and effecting it. Just as medical patient gives herself permission to become less adult in the arrangement of a visit to the doctor's office by allowing (even welcoming) her physician the authority to touch and even invade her body, in psychotherapy the patient gives the therapist access to her private thoughts and feelings, and permits the therapist to manipulate that part of her world in which she makes decisions and creates her self. In doing so, she gives the therapist permission to take an authoritative, quasi-parental role to her "less adult," childlike role.

Modes of counseling and psychotherapy run the gamut from providing information, giving instruction, educating (or re-educating) and offering advice, to providing emotional support, being a surrogate ego, or accompanying the patient on an odyssey in search of insight. The goal of psychotherapy is always change. Or is it? Here we arrive at what I take to be the critical concept for a discussion of authenticity in psychotherapy.

Psychological change may be the result of outside intervention, inner self-transformation, or a shift in one's being-in-a-world. (4) In most of its incarnations, psychotherapy has been associated with one of the first two roads to change. The second also has a place in the venerable traditions of spiritual discipline. The first, outside intervention, is also ominously at home with various kinds of indoctrination (e.g., military training, mandatory schooling, religious instruction) and certain social practices that begin and end with control (e.g., conscription, institutionalization, incarceration). The methods of outside intervention are persuasion, desensitization, behaviour modification ("shaping" behaviour sequences), and sometimes even systematic punishment.

In psychoanalysis, processes of self-transformation are at work. These have not yet been well mapped, let alone understood. Psychoanalysis works as a sequence of (1) preliminary diagnosis of psychopathology, (2) considered and measured intervention (interpretations, reconstructions, and the use of so-called "parameters"), (3) inner transmutation of the analysand's psychic structure, and finally, (4) change of attitude towards her personality, way of thinking and feeling, and behaviour in the analysand. Psychoanalysis, then, is a hybrid of intervention and self-transformation.

By contrast, the means of behaviour modification are entirely interventional. They include rewarding desired behaviour ("positive reinforcement") and dissuasion with regard to undesirable behaviour by withholding rewards ("negative reinforcement," including ignoring the undesired behaviour) or judiciously using punishments. Here the therapeutic sequence is (1) identification of undesired behaviours, (2) prescription of desired behaviours, and (3) systematic elimination of the undesired behaviours through bringing about the unlearning of undesired behaviours and the learning of desired behaviours. If a cognitive dimension is taken into consideration. the series may be described as (1) recognition of ineffective ways of thinking (thought to be responsible for ways of feeling and acting) and (2) cognitive and behavioural relearning of ways of thinking that will lead to better adjustment to social norms. No assumptions about an inner life (experience) need to be made in behaviour modification since everything of psychological interest has to do solely with observable behaviour. (5) Experience, which implies the recognition of an inner life, is irrelevant, since observations of experience are impossible except by introspection and therefore cannot be confirmed or disconfirmed by a second party, in this case the therapist.

Cognitive-behavioural therapies assume that the alteration of one's judgments about the affairs of her everyday life leads to more rational responses to life's challenges, including especially the problems that press for quick solution. Ossified and inflexible ways of "thinking about things" give way to more flexible methods of "thinking about" critical issues in one's life that have generated confusion, disturbances of consciousness, and a skewed perspective on one's behaviour. From the vantage point of the patient, the therapeutic sequence here is (1) recognition of self-defeating ideas, (2) admission of confusion or irrationality or cognitive stalemate), (3) simplification of the troubling issues, (4) reformulation of problems in terms of adjustment and common sense, and (5) solving problems rationally or logically with a clear sense of what is real. Transformation of one's inner life is limited to the operations of reason (cognition), which when it is functionally optimally prevents the occurrence of disquieting or upsetting emotional reactions and behaviour that bothers the patient and others.

In psychoanalysis, an analysand's efforts to foil her admitted interest in and desire for change are termed resistance, which is understood as a way of defending the self or ego in conflict against dangers that an easing of defenses might produce.

The desire for and a way to effect change are initially provided by of the analyst. Change is unabashedly imposed on the client by the behaviourist. Cognitive therapists count on the client's willingness to reconsider her life and undertake a concerted effort to question her ways of "thinking about" what matters to her and to practice new ways of living ("homework") outside of therapeutic sessions.

Analysands and clients in cognitive therapies have agreed to their participation in treatment and they expect to be freed of external sources of control over their lives. Candidates for behaviour modification may not have agreed to being treated. In practice, they are often pressured into submitting to desensitization routines and exchange bondage to one, socially disapproved family of behaviours for bondage to other, socially approved ways of behaving. Except for trivial matters (smoking, overconsumption of alcohol) they may or may not agreed to be changed. Those in cognitive-behavioural therapies learn to think differently and, as a result, their feelings and behaviour change. In behaviour modification, change follows from submission to treatment, which is in effect a form of retraining. In cognitive-behavioural therapy, change follows from re-education.

By contrast, analysands are discouraged from making major life decisions while in treatment, but an analyst's conviction is that in spite of and ultimately thanks to resistance, the analysand will be a different kind of person as a result of accepting who she has become through the years. change in psychoanalysis amounts to acceptance of what previously had been disavowed or denied and forgotten.

Popular culture and most psychiatrists now believe that chemical agents change people's minds. That being the case, we must consider the place of psychoactive drugs in this discussion of change in psychotherapy. Many clients now entering into a psychotherapeutic contract will have been prescribed psychotropic drugs in the recent past and a significant subgroup will be taking medications while in treatment. The ready availability of these substances from busy primary care physicians and their popularization by the media have introduced a new variable in the practice of psychotherapy. With advances in psychopharmacotherapy and as a result of effective marketing strategies and lobbying by the pharmaceutical industry among physicians, the field of clinical psychology has been dramatically altered. For a time some, psychoanalysts hesitated to work with clients while they were being medicated. Now most accept the use of psychoactive medications as a form of adjunctive treatment along with psychodynamic therapy. The relevance to the present discussion of this change in outlook among psychotherapists is that the use of drugs as a form of psychotherapy or as an adjunctive form of therapy in combination with psychotherapy constitutes a form of intervention that is as potent as the most directive forms of suggestion, coercion, persuasion, and behaviour modification. Biochemical interventions are extremely powerful. (6)

Following this very brief review of the three best-known forms of psychotherapy--classical psychoanalysis, behaviour therapy, and cognitive-behavioural therapy--and the sequence of interventions leading to change that each entails, I now want to take a different perspective on the notion of change in psychotherapy and note how the therapeutic goals of these forms of psychotherapy differ from the form of human interaction termed existential analysis.

II. Situation, Encounter, Autonomy, Authenticity

Existential analysis is the therapeutic representative of existential-humanistic and existential-phenomenological psychology, both of which trace their origins to a line of philosophers leading back, respectively, to Soren Kierkegaard and Edmund Husserl. These lineages have been traced so often that they do not bear repeated here. In this section I will single out one element of the existential tradition--authenticity--and explore its place in existential analysis.

I have said that, in general, the goal of all psychotherapy is change, whether what leads to change has been imposed on the person or is self-initiated. In each form of psychotherapy discussed, some sort of outside intervention occurs, whether is it blatant and directive, or indirect, subtle and apparently nonintrusive.

But is there a form of psychotherapy and a way of construing psychotherapeutic work that bypasses intervention altogether while nevertheless providing the prospect of change? There is, if we define change as a shift in one's way of being-in-the-world. Change of this kind occurs as a result of existential analysis.

Existential analysis is a way of encountering and working with another human being in a setting of thoroughgoing mutuality where the focus of attention is the authenticity of both partners in the venture. Its uniqueness among human partnerships lies in the fact that the situation or world of one member of the pair is highlighted while that of the other remains more or less in the background, but is still visible. Here there is no place for anonymity (as in psychoanalysis) or invisible, unapproachable authority (as in behaviour modification). In existential analysis both participants retain their autonomy. Its primary goal is illuminating the "client's" way of existence or being-in-a-world with a view to the affirmation of her authenticity. (7) I sometimes think we should abandon the term client. Instead of client and existential analyst, we should speak of a therapeutic partnership. Instead of psychotherapy, we should speak of a therapeutic venture, a way of working, an approach or mode of encounter in which two human beings participate in a co-operative undertaking. The image that comes to mind is of two high-wire artists who depend each other for balance and support but who are both in a precarious place. One of two remains more or less stationary while the other changes his orientation in space. Both are performing without a net! (8)

There is nothing new about the use of the term encounter in psychotherapy, but I would stress that in my usage there is no implication of confrontation between the two participants in the therapeutic venture. I would ask the reader to recall instead the original sense of encounter as a serendipitous occasion (which Heidegger considered in his fundamental ontology under the heading of the Jeweiligkeit of Da-sein), with all of the uncertainty, surprise and unpredictability of a chance meeting.

The concept of authenticity in existential analysis may be best understood in the context of Martin Heidegger's philosophy. To be sure, the concept of authenticity in psychotherapy was not explicitly discussed by Heidegger in his analytique [Analytik] of existence [Da-sein) in Sein und Zeit (Be[-ing] and Time (1927), but authenticity played an important role in his way of thinking about existence at that time and in the following years, including the period of the Zollikon seminars with psychiatrists at the home of Medard Boss towards the end of Heidegger's life. Without his work on human be-ing [Seiende], the kind of be-ing for whom its be[-ing] [Sein] is at issue and for whom it is ever in question, it is doubtful that Kierkegaard would have been remembered as more than a critic of the Hegelian system or the author of edifying discourses on the religious way of life [Existenz]. Nor might Husserl's phenomenological psychology have been more than a part of his vast project of re-envisioning the acts of consciousness. As it is, however, the centrality of authenticity in Kierkegaard's examination of "the exister" [den Existerende] (9) runs as an undercurrent throughout Sein und Zeit and emerges vividly in the work of psychiatrists who responded strongly to Heidegger's philosophy.

While working out the categories of the unique kind of be-ing we are, Heidegger often referred to what is eigentlich (authentic). In his path-making book about the be of any kind of be-ing, his purpose was not to produce a philosophical anthropology, although many early commentators and the first psychiatrists who were influenced by Heidegger's analytique [Analytik] of existence believed they had found just that in his book. Although it is neither philosophical anthropology nor psychology, what Heidegger says about what is "most its own [eigenst]" for existence can serve as a basis for understanding authenticity in the ontic sense it has in existential analysis. In Heidegger's ontology, that is to say, with respect to possibility and what lies as yet undiscovered about any phenomenon, the notion of what is authentic [eigentlich] undergoes a process of decontamination of its metaphysical interpretations. Revealing what is "most its own" about a phenomenon first relieves it of the veneer of actuality that has settled on it and disfigured it in the course of its history and then allows the scope of its possibility to emerge, perhaps for the first time, or after a long period of having been overshadowed by distortions imposed on it by the programme of metaphysics that according to Heidegger began with classic Greek philosophy. (10)

It is well known that Heidegger was opposed to making inferences from his fundamental ontology of existence [Da-sein] to psychology and psychotherapy, but they were made nonetheless, first, in Ludwig Binswanger's approach to psychiatric practice and, later, with Heidegger's blessings, in Daseinsanalyse, the work of Medard Boss, the Swiss psychiatrist who collaborated with Heidegger over many years and convinced him that a form of therapeutic encounter could be construed in light of Heidegger's analytique of existence. (11)

I will forego discussion of the work of Binswanger, Boss and the other early existential analysts. (12) Instead, I will ask why, in spite of its academically unfashionable status, the existential approach is still so compelling, especially to the current generation of students, precisely because of its emphasis on authenticity. (13) The answer to the question is that existential analysis emphasizes the client's authenticity in a world where the attainment of uniformity by means of techniques of adjustment--whether to one's past (as in psychoanalysis) or to social norms (as in behavioural and cognitive-behavioural therapy)--is increasingly stressed. Strong rejection of this tendency among students in the first decade of the new millennium echoes the mood among students in the 1960s and 1970s when existential psychology first had an impact on undergraduate and graduate programmes in philosophy and clinical psychology. Now young people are once again challenging the abrogation of personal freedom that contemporary society seems hell-bent on forcing on them. There is increasing suspicion about the loss of control over one's body as well the surrender of freedom that pharmacotherapy entails. The is a feature of life in the 21st century that was not yet a major influence in the era of the "counter-culture" which had seen the use of psychotropic drugs only since the late 1950s.

In the approach I am describing, two worlds interpenetrate, one of which is illuminated, but thanks only to the participation of both individuals for whom their authenticity is at stake. One partner must allow himself to recede somewhat into the shadows, but without losing visibility. This is the one who retains responsible oversight of (but not authority over) the encounter, without forcing or permitting any loss of either his own or his partner's autonomy. In existential analysis the world of one becomes highly visible in a unique situation, the peculiarity of which lies in the fact that it is set up precisely to reveal what has been eclipsed for her. This state of affairs--the eclipse of existence--is what brings about the need for a therapeutic encounter in the first place. Few other life situations allow us such an opportunity for exposure. The fundamental quality of the therapeutic venture in existential analysis is its single-minded goal of illuminating possibilities that are hidden. If we define authenticity as being open to the full range of possibilities available to an individual, existential analysis is the work of providing a situation that permits the recovery of one's authenticity.

What other forms of psychotherapy term symptoms I consider to be unformulated questions. Depression, anxiety, phobic ideation, perceptual anomalies, and even bizarre and extraordinary systems of thinking are viewed as distinctive openings onto a world. The existential analyst allows questions to be asked that have been banned from articulation. Opportunities for allowing such questions to surface rarely occur in the everyday busyness of life where nearly everything is necessarily taken for granted or assumed, that is, left unquestioned. Of course, how could it be otherwise? Social life requires a wide range of relatively inflexible assumptions about space and time, place and persona, and admissible modes of interpersonal relating. Everyday interactions allow, as the Poet Robert Graves put it, "no occasion for approach or discourse." (14) We simply repeat the catch phrases the prevent us from losing our balance on the surface of that web of connections and relations that is our social life. "How are you?" "What's new?" We mime the gestures and verbal exchanges learned from our parents, peers and the media, but forget that each of these habits of talk has been acquired at the expense of a loss of freedom to speak openly. To that extent, everyday life, as Heidegger pointed out, demands inauthenticity of each of us and could not continue in its familiar way without that sacrifice.

Lapsing into routinized patterns of reaction, we necessarily forget ourselves. We find ourselves in a world of systems of communication and linguistic continuities. More and more, no matter where we are, we are never alone. Consider the cellular phone, now carried as though it were a tiny transitional object in Donald Winnicott's sense. With or without this device, we ceaselessly make small talk, mini-assertions emitted without reflection or consideration. None of this is avoidable, but it must be recognized for what it is, since we are creatures who mind what is going on, in the sense that we are reminded of it at every turn, pay attention to it, and must look after it.

Those who seek out a therapeutic partnership are at that time in their lives most sensitive to these features of everyday life and revolt against them. Often they have come to loggerheads with society, beginning with their families, in the recent past. Knowingly at stake for them is their authenticity, which contrasts so starkly with what "everyone else" does, what "people" do. (15)

Psychiatry and the major brands of psychotherapy that are based on the medical model identify discomfort with one's inauthenticity as a sign of mental illness or disorder of the functions of psychological life, including consciousness, memory, cognition, perception, affect and conation. By contrast, existential analysis understands the discomfort as a glimmering (sometimes glaring) awareness of lost authenticity.

Individuals who are uneasy in this way are usually labeled according to the classificatory scheme of psychopathology codified in the American Psychiatric Association's DSM-IV-TR (2000) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems or ICD-10 (1992). (16) For the existential analyst, however, such suffering is seen as something positive--a longing for authenticity.

III. Authenticity in Existential Analysis

Authenticity is the primary goal of existential analysis. It is understood as a realization of human freedom. (17) The aim of existential analysis is to return to an individual the primary authorship of her existence. All of us have had our existence conferred on us by the mothering figure in our life during its first weeks and months. It is validated in the ensuing years, most noticeably at turning points or what Erik Erikson called crises of the life course when the authorship of one's existence is called to account. (18) During these periods of intensified demand for self-creation, authenticity is most at stake and validation of our existence by others is crucial. For example, the "terrible twos" of early childhood is a period of vigorous creation of the self when it first becomes clear to us that we are both the artist and the work of art that constitutes a life. Again, during adolescence, the self undergoes "editing" and revision. Jung emphasized what most cultures have documented, namely, that adolescence is a time when the shape of the self of childhood may be shattered and a new figure of the self cast.

Whenever the self is revised, existence must be revalidated. Existential analysis can provide an individual with the sort of re-validation needed at such times. Revalidation is also necessary when one's existence is in the balance as a result of trauma. How can we understand this creation of the self, its critical moments, and the work of existential analysis when somenoe's existence is especially vulnerable?

Perhaps one of Jean Piaget's most enduring contributions to psychology is his having seen that during the early months of life, our first thoughts are acts that create the self. (19) These acts are internalized and become blueprints (schemata) for an increasingly complex representational network of mental relations. The representations are modified internally and, in turn, modify the dynamism that internalized them. (20) That the self begins as a series of acts seems undeniable, but for the existential analyst there is no need to assume that the creation of the self is the result of an inner dynamic system that constructs a picture of the self and a narrative of the self that later may be expressed in psychotherapy. If instead, as Heidegger suggested long ago, existence is not at all in something (for example, the mind or psyche) but rather "out there" as a world, and if in experience self and world are not distinguishable, the existential analyst has nothing to excavate or dredge up (both psychoanalytic metaphors) from the depths of the psyche and reveal to the light of day for examination by consciousness. (21)

In existential analysis the work of both partners is to see the self of one as it is being played out in and about the things in that person's world, including especially her body. Here is the key notion, it seems to me, of existential analysis: The self is already out there to be seen, but only if one is free to do so, that is, only if her existence is authentic.

As Erich Fromm pointed out many years ago, human freedom does not amount to an exoneration from constraints or a liberation from bondage, but is rather access to one's ownmost [eigenste] possibilities. (22) This is the very sort of freedom sought in existential analysis--freedom for ... in contrast to freedom from ...

As the goal of existential analysis, authenticity is the way to be that a human be-ing is as things are, or, to use Heidegger's term, "factically." Being free is what we do, first and foremost; it is what we first and foremost are (in a transitive use of the verb 'to be'). Freedom is our ontological heritage and authenticity is its existential meaning. As already pointed out, that from early childhood on we are forced to slip further and further into inauthenticity is no fault of our own; in fact, it is an inevitability of what we do, day in and day out, in becoming human. In other words, the decline into inauthenticity is part of the bargain of being human. But authenticity is implied in its absence (in-authenticity) and we yearn for it. We experience this longing as anxiety or distress [Angst], which are not signs of trouble, illness or disease, but rather a door that, when allowed to open, lets in the light of authenticity.

There are many ways back to authenticity. Psychotherapy is not the only one, nor may it be the best or most effective way. But given the absence of spirituality in modern life, most of our fellow human beings have few other ways back to existential authenticity left open to them. It is fair to say that many individuals raised in the late 20th century do not even know about their original authenticity until, in a moment of existential crisis, it dawns on them. Moreover, they do no even know about the absence of that lost freedom. As post-World War II existentialists such as Jean-Paul Sartre said, if and when they get wind of it, most flee from their freedom.

As a group, adolescents seem keenly aware that something of this kind is missing. This may be why the need for a therapeutic partnership is often so compelling at the end of adolescence and why that time in life is so notable for its existential turning points. Other moments that bring awareness of freedom lost include epiphanies such as a brush with death, the passing of a parent, or religious conversion.

What distinguishes the people who enter into therapeutic partnerships is their having sensed in some way the loss of their freedom. The point I want to make is that their complaints and suffering are welcome signs, and we must read them as such. What lies open to them but remains closed off to most is the discovery that they are not free. Inauthenticity is the felt sense of this loss. As Medard Boss's well-known reply to a patient's query "Why?" indicates, an existential analyst must affirm this loss. In response to being told about a puzzling impulse, Boss confirmed the other's recognition of the possibility of her existential freedom and how it might be turned to therapeutic advantage with his response: "Why not?"

Like authenticity, human freedom is necessarily abrogated in the process of socialization. What, if anything, can ever compensate for that loss? The obvious trade-off for freedom sacrificed on the altar of socialization is power, first in the form of independence (control over one's own body and impulses) and then in the establishment of a balance of power (relative dominance) in each relationship with another human being. Power, however, is ultimately a poor substitute for the freedom handed over to each of us with our existence.

As R.D. Laing suggested, the "mad" among us may be the most sensitive to the loss of existential freedom. The most adamantly "insane" stridently refuse to play at the game of balancing power in relationships. They may take the extreme position of omnipotence and (including magical thinking about their powers), refuse to participate in certain areas of social life, or entirely abandon independence and give in to catatonic passivity. Their suffering is surely great, but it may be the refresher course the rest of us need to be reminded of what we have given up to a greater or lesser extent in growing up.

The less "disturbed" and those labeled "delinquent" or "antisocial" have also not compromised by taking their assigned place in the social network. They protest against their loss of freedom with "neurotic" complaints or acting out. Those who have been traumatized have also had their freedom wrenched from them and comprise an important group of individuals who can perhaps benefit most by the therapeutic partnership

available in existential analysis.

But what of the more and more commonly seen individual who tells us about not being sure what "is the matter" with her? Vague feelings of content, ambivalently held goals, anomie, flat affect dominate her life-world. Her complaint is global, inchoate and nonspecific, but often tinged with anger or a general irritable uneasiness. We are tempted to say she is looking for something to be "the matter," since often such an individual is adequately positioned in a family and has a job at which she is successful. Just as she "has work" and "has what she needs," she may also "have a boyfriend (or girlfriend)" and regularly "have sex." She may even "have a family" or "have a child." Overall, however, she finds little ballast and stability in what she has. In fact, the more she has, the less she is. Most in this group typically have chronic doubts about what they "want to be" (often, "when they grow up") that are not assuaged by acquiring academic degrees or licenses, being hired into positions with "potential for advancement," or achieving recognition within their field.

By way of relating freedom as a philosophical problem to authenticity in existential analysis, I will close with a case example and a few suggestions for further discussion.

IV. The Story of "B"

This is the story of B. It illustrates how a therapeutic partnership might allow the possibility of increased existential authenticity to appear in this person's life-world.

In existential analysis, the most a therapeutic partnership can provide is recognition of possibilities that have heretofore been seen as problems. It is not a matter of re-cognition, but of seeing afresh. I saw B's so-called "disturbances" not as perturbations of some imagined "normal" state, but rather unformulated questions about how she can be, which means precisely how she already is (as B) if only she were free to be in that way and not have to create the role "B".

A therapeutic partnership in existential analysis does not have an outcome, whether it be set in terms of the short run (as adjustment) or envisioned as the culmination of a long voyage of self-rediscovery leading to insight (as in psychoanalysis). Authenticity, then, may be best understood as a new beginning in the fullness of inauthentic existence (in this case "B"). Authenticity is an option for someone only because she has embraced her inauthenticity. The story of B illustrates this especially well. The freedom that is engaged or "put in gear" is not an escape from inauthenticity but rather the reappearance of a capacity for self-authorship in the unavoidable context of inauthenticity. "B" continued to play her role, but B was granted disclosure as the underlying possibility that made had permitted "B" to be created and invested with social salience.

The therapeutic partnership affords someone the experience of this paradox of existence. The pleasure of work as an existential analyst is witnessing the unexpected emergence of human freedom.

Dr Miles Groth is a professor in the Department of Psychology, Wagner College, Staten Island, New York, 10301, USA. He can be contacted at mgroth@wagner.edu.

Notes

(1) In medicine the notion of a "functional" disturbance denotes a condition "not organic in origin; a disorder with no known detectable organic basis to explain the symptoms." This definition in an entry taken from the 26th edition (1995) of Steadman's Medical Dictionary (Baltimore: Williams and Wilkins, p. 693) refers the practitioner to neurosis, a term that is now all but absent from psychiatry (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [2000]). In turn, the second definition of neurosis in Steadman's is "a functional nervous disease, or one for which there is no evident lesion" (p. 1205).

(2) Steadman's (1995) lists thirty-two neuroses.

(3) The connections between a legal case and a case treated in medical or other therapeutic practice (casus) are fascinating and more than a matter of linguistic coincidence. The legal use of the word 'case' predates the medical. The latter, however, has the sense of something that happens to someone, which is the essential meaning of the word. Both sorts of case refer to a singular set of circumstances unique to a particular person, even though the named crime or illness (diagnosis) is said to be the same for many people. However, the delineation of a legal case has recourse to a body of law, while a case treated by a psychotherapist is defined by choosing from a selection of diagnostic features or symptoms, that is, patterns of behaviour observed to have occurred in many individuals and now conforming to a diagnostic entity. A striking coincidence of the meaning of the two kinds of case is the age-old association between illness and guilt for having done something perceived to be wrong by the individual, her family or society. Moreover, both legal counsel and a counselors (psychotherapists) may be said to manage their cases and advocate for their clients, and both are concerned with what is considered to be acceptable behaviour in their clients. Finally, both patients and potential litigants consult an expert for advice. It is therefore not surprising that we eventually adopted the term client in place of patient when psychotherapy became seemingly autonomous from its origins in medicine.

(4) Physical change is occurring continually in an individual's body as a result of environmental conditions and internal physiological processes. Many relevant stimuli responsible for such changes have been identified and some can be measured. Psychological change, however, is qualitative, although some psychologists claim to be able to measure psychological change using various psychometric instruments. Whether this is possible in principle remains an open question.

(5) The major theoretical problem for behaviour modification theory has always been the meaning of so-called intervening variables (which are not observable) in a world of independent and dependent variables (which must be observable).

(6) The popularity of pharmacotherapy as a form of treatment of psychological disorders may sooner or later make the present discussion moot--but that is the theme of another essay.

(7) I retain the term client for the paying individual in existential analysis, since it is, after all, a formal arrangement in which one person (the client) consults another (the therapist) for a fee.

(8) One of the most eloquent accounts of this approach may be found in a collection of accounts of the therapeutic venture by Ernesto Spinelli, Tales of Un-knowing. Eight Stories of Existential Therapy (New York: New York University Press, 1997). The reader may note that Spinelli has abandoned use of the term 'case'.

(9) The term 'exister' is Walter Lowrie's translation of Kierkegaard's Existierende in his Concluding Unscientific Postscript to Philosophical Fragments: A Mimical-Pathetical-Dialectical Compilation, An Existential Contribution [Afsluttende uvidenskabelig Efterskrift til de philosophiske Smuler. Mimisk-pathetisk-dialektisk Sammenskrift] (1846). For Kierkegaard, the exister is "the existing thinker," the one "who is thinking existence." See Agnes Heller, "Living with Kierkegaard," in Enrahonar 29, 1998, pp.73-74. Heidegger acknowledges the influence of Kierkegaard's ontic (existentiell) account of existence in a note to the opening section of the second major division of Sein und Zeit published. See Being and Time (New York: Harper and Row, 1962), p. 494. As we know, for Heidegger, the trail leads back via Kierkegaard to Augustine. See Martin Heidegger, The Phenomenology of Religious Experience (Indianapolis: Indiana University Press, 2004), especially the course "Augustine and Neo-Platonism" [1921]. Augustine's starting point could be that of anyone entering into existential analysis: Quaestio mihi factum sum: I have become a question to myself.

(10) See Martin Heidegger, Plato's Sophist (Bloomington: Indiana University Press, 1997), based on a lecture course at the Marburg University, Winter Semester 1924-25; The Essence of Truth. On Plato's Cave Allegory and the Theaetetus (New York: Continuum, 2002), based on a lecture course at Freiburg University, Winter Semester 1930-21; and "Plato's Doctrine of Truth," a lecture from 1940, in William Barrett and Henry D. Aiken (eds.), Philosophy in the Twentieth Century. An Anthology, Vol. 3 (New York: Random House, 1982), pp. 251-270.

(11) For Binswanger, see Being-in-the-World (New York: Basic Books, 1963). Evidence of the intellectual partnership between Boss and Heidegger is now available in Zollikon Seminars: Protocols--Seminars--Letters (Evanston: Northwestern University Press, 2001). See the forthcoming complete bibliography of Boss's work in Medard Boss and Miles Groth, "An International Bibliography of the Writings of Medard Boss 1929-2002," Review of Existential Psychology and Psychiatry (2007), and the author's "Medard Boss and Martin Heidegger. The Existential Analyst as 'a Western Kind of rishi'", also in the Review of Existential Psychology and Psychiatry (2007).

(12) The classic review of these important figures is Herbert Spiegelberg's Phenomenology in Psychology and Psychiatry, A Historical Introduction (Evanston: Northwestern University Press, 1972). The reader may also consult the author's "Existential Psychotherapy Today," in the Review of Existential Psychology and Psychiatry 25(1-3), 2000, pp. 7-27 (esp. 13-15). An interesting historical note: In the spring of 1946, Heidegger himself was treated for several weeks by Viktor von Gebsattel (1883-1974) in his clinic. See Rudiger Safranski, Martin Heidegger. Between Good and Evil (Cambridge: Harvard University Press, 1998), p.351. Regrettably, only three brief texts by von Gebsattel have been translated into English. See J.V. Welie, "Viktor Emil von Gebsattel on the Doctor-Patient Relationship," in Theoretical Medicine and Bioethics 16(1), 1995, pp. 41-58, which is followed (pp. 59-82) by a translation of Gebsattel's last paper, "Meaning of Medical Practice." In my view Gebsattel is perhaps the psychiatrist who comes closest to Heidegger's way of thinking. He was the advisor on psychology and psychiatry to the Gorres Gesellschaft, a Catholic studies organization that accepted Heidegger's first published paper, "The Problem of Reality in Modern Philosophy" (1912). See "Das Realitatsproblem in der modernen Philosophie," now in the Heidegger Gesamtausgae 1 (Early Writings), pp. 1-15. First translated in 1973, it is now available in Heidegger's Supplements. From the Earliest Essays to Being and Time and Beyond, edited by John van Buren (Albany: SUNY Press,1002), pp.39-48. Gebsattel's Catholicism, his aesthetic sensibility, and his concept of the "doctor-patient" relationship in its third "personal" stage made him the ideal therapist for Heidegger. Gebsattel's views presages my own view of the therapeutic relationship as a partnership. See von Gebsattel (1995), p, 71. Gebsattel's other translated texts are "The World of the Compulsive, "in Rollo May et al. (eds.), Existence (New York: Basic Books, 1958), pp. 170-187, and his "Foreword" to Hubert Tellenbach, Melancholia (Pittsburgh: Duquesne University Press, 1980). On von Gebsattel, see also Speigelberg, pp. 249-259.

(13) For a personal account of my encounter with existential analysis, see "The Body I Am: Lived Body and Existential Change," a contribution to Ernesto Spinelli and Sue Marshall (eds.), Embodied Theories (London: Continuum, 2001), pp. 81-97, as well a series of earlier papers: "Existential Psychotherapy Today," in Review of Existential Psychology and Psychiatry 25(1-3), 2000, pp. 7-27; "The Background of Contemporary Existential Psychotherapy," in The Humanistic Psychologist 27(1), Spring 1999, pp.15-22; "Existential Therapy on Heideggerian Principles," in Journal of the Society for Existential Analysis 8(1), 1997, pp. 57-75; "Therapeutic Revalidation in Existential Analysis," in Journal of the Society for Existential Analysis 13(1), 2002, pp. 144-158; and "Human Being and Existence. The Beginnings of and Existential Psychology," in Review of Existential Psychology and Psychiatry 22(1-3), 1990-91, pp. 116-140 (published 1995).

(14) Robert Graves, "A Former Attachment," in Collected Poems (Garden City: Doubleday, 1958), p. 133.

(15) Readers familiar with Heidegger's Sein und Zeit will be reminded of the features of existence discussed in its pages: Verfallenheit, Geworfenheit, Rede, Mitsein, Man and Sorge. Much of the presumed obscurity of Heidegger's discussion of existence and the existentials is due to faulty translations of his basic words, including how they have been "translated" into German! See the author's Translating Heidegger (Amherst, NY: Humanity Books, 2004).

(16) A fifth edition of the DSM is due in 2010. Stuart Kirk and Herb Kutchins have challenged the statistical validity of the American classificatory scheme of the DSM-III (1980) in The Selling of DSM: The Rhetoric of Science in Psychiatry (New York: Aldine de Gruyter, 1992).

(17) Whether, properly speaking, authenticity should be considered a goal of existential analysis will be addressed below.

(18) See the author's "Therapeutic Revalidation in Existential Analysis," in Journal of the Society for Existential Analysis 13(1), 2002, pp. 144-158.

(19) See, for example, Jean Piaget and Barbel Inhelder, The Psychology of the Child (New York: Basic Books, 2000).

(20) It seems to me that Heidegger also understood that the first thoughts are acts, but recognizing the inadequacy of the vocabulary and assumptions of empirical psychology, he had to find another means of saying the same thing. The closest he comes to this is in his last lecture course at the University of Freiburg (1951-52) published in 1954 as Was heisst Denken?, now Gesamtausgabe 8 (2002).

(21) One should recall that Piaget experienced psychoanalysis first-hand as an analysand and was strongly influenced by the psychoanalytic model of intrapsychic dynamics in the development of his unique method of research that first combined direct observation with the structured interview.

(22) Erich Fromm, Escape from Freedom (New York: Henry Holt, 1994), first published in 1941.
B is a 25-year-old only child who three years before we first met had
   earned her first graduate degree at an American ivy-league
   university. Encouraged by her college teachers to pursue the terminal
   degree in her field and eventually teach at the undergraduate level,
   she had completed the master's with distinction (as she had her
   bachelor's degree) but then dropped out of the programme. She worked
   for an advertising firm for a year and then pursued a career as an
   actor in Los Angeles and New York while living at home and earning
   money as a cocktail waitress.

   She complains of a variety of minor obsessions and "feeling stressed
   all the time." Her narrative of harried activity and excessive
   demands made on her time are accompanied by light-hearted laughter.
   B. seems to be talking about someone else (let us call her "B"), not
   herself.

   She says that "B" tolerates inadequate men, whom she nevertheless
   prefers to men who want to "look after" her and "take care of" her.
   "B" sees herself as "taking care of" the immature boys she dates.

   B's life is a production, a melodrama or soap opera in which "B" has
   the lead. In a sense, B already has the "part" she is pursuing with
   her portfolio, through contacts with talent agents, and in showcases
   on both coasts. Her life is something B experiences as something "B"
   "has." She does not see that she is her life, nor does she see that
   the source of her dilemma about "what she wants to be" is a search
   for authenticity. "Having" to be something, she is not free to "be"
   someone.

   Although she is still quite young, B is a candidate for a preliminary
   primary diagnosis of histrionic personality disorder (DSM-IV-TR) for
   which pharmacotherapy might be the indicated treatment. In fact, her
   mother had suggested that B seek psychiatric help to "find out" what
   she "wants to do with" her life. To her credit, B senses that her
   mother's readiness to have her daughter treated with medications is a
   direct route to forgetting that something is "the matter." She
   relates that her mother has long since forgotten just that and has
   resigned herself to an indifference in her own life that B cannot
   tolerate, let alone embrace. B is puzzled and sees what is "the
   matter" as a way into her existence, not a blockade to further
   movement.

   At the outset, B sees our therapeutic partnership as yet another
   episode in her "daytime drama" life, the life of "B". To be able to
   take the partnership seriously, B would have to be able to take
   herself seriously as a question and as a horizon of possibilities,
   not a role to play ("B") while she looked for "better parts" in the
   "real world" of a television series or a film.

   B is well-informed about psychoanalytic determinism and looks for
   "reasons" for her attitudes and motivations in early childhood
   experiences. She has little confidence in the example set for her by
   her parents, who were separated for 18 years but did not divorce, and
   recently have been living together again.

   She reports that her teachers at university disappointed her,
   although given her excellent verbal skills, she says she was able to
   "fool" them into believing she was interested in what they wanted her
   to "have": a degree, a teaching position, a career in academe, and
   tenure at an "important" college or university.

   She does not feel close to anyone, is critical of her appearance, and
   resentful of how others dictate how she should look, even while
   pursuing a "career" that is based on the creation of personae. Men
   have also disappointed her by what B perceives as their being either
   stupid and weak or exploitative and dangerous, with nothing in
   between. A woman had been interested in her sexually, but she could
   not respond. On the whole, she does not like the company of women.
   The advantages afforded B by scholarships, grants for study, and the
   privileges of an upper middle-class family income have all
   disappointed her, as have Los Angeles and New York, both of which
   she sees as merely offering her distraction and entertainment, a
   "set" or stage on which to enact her life as "B".

   The existential gap between B and "B" was a measure of the
   distance of this young woman's experience from her existential
   authenticity. Since the gap is inevitable, my stance as an
   existential analyst was fundamentally one of "no blame." Given B's
   recognition of the gap, a therapeutic partnership was both possible
   and desirable. To put it somewhat schematically and artificially: the
   partnership did not aim at intervening in "B"'s existence on behalf
   of B, but rather in allowing B's self-realization to play itself out.
   There was no lost version of B to be found, restored and reinstated,
   and no incomplete version of B to be "finished" (as the
   psychoanalytic view might propose).

   "B" was not an improperly constructed or deformed version of B in
   need of being refashioned or "straightened out" (as a behaviourist
   might see her), nor was it merely a matter of B's thinking about
   herself differently that would allow "B" and B to coincide. B was
   unacknowledged possibility.
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