Anxiety and existential therapy

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Anxiety and existential therapy

  1. 1. Anxiety and existential therapy Digby Tantam New School of Psychotherapy and Counselling Universities of Sheffield and Cambridge
  2. 2. Anxiety and Depression Association of America http://www.adaa.org/about-adaa/ press-room/facts-statistics •  Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older (18% of U.S. population). •  Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country's $148 billion total mental health bill, according to "The Economic Burden of Anxiety Disorders," a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999). •  More than $22.84 billion of those costs are associated with the repeated use of health care services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses. •  People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders.
  3. 3. Age-standardized rates for one anxiety disorder (GAD) in Denmark, Finland, Norway and Sweden from Munk-Jørgensen P, Allgulander C, Dahl AA, Foldager L, Holm M, Rasmussen I, Virta A, Huuhtanen MT, Wittchen HU. •  The age-standardized rates for generalized anxiety disorder using general practice sample •  4.1 to 6.0% men •  3.7 to 7.1% women •  Anxiety disorders are often defined as qualitatively similar to anxiety, but more persistent, more prolonged, and more disabling
  4. 4. Bereza, B. G., Machado, M., Ravindran, A. V., & Einarson, T. R. (2012). Evidence-based review of clinical outcomes of guideline- recommended pharmacotherapies for generalized anxiety disorder. Can J Psychiatry, 57(8), 470-478. al
  5. 5. Fig 4 Probabilistic analysis showing percentage probability of each treatment being ranked first by outcome measure. Baldwin D et al. BMJ 2011;342:bmj.d1199 ©2011 by British Medical Journal Publishing Group
  6. 6. Fig 5 Individual rankings for outcomes for response, remission, and withdrawals because of adverse events for each of treatments considered. Baldwin D et al. BMJ 2011;342:bmj.d1199 ©2011 by British Medical Journal Publishing Group
  7. 7. Kjernberg et al
  8. 8. Bereza, B. G., Machado, M., Ravindran, A. V., & Einarson, T. R. (2012). Evidence-based review of clinical outcomes of guideline- recommended pharmacotherapies for generalized anxiety disorder. Can J Psychiatry, 57(8), 470-478.
  9. 9. ?N 181 completed CBT Symptom improvement at end of average of 14 session treatment (minimum 3) 87 Symptom improvement at one year 83 Symptom disappearance at end of average of 14 session treatment (minimum 3) 26 Symptom disappearance at one year 22 No. seeking further therapy No. seeing a psychiatric No. also taking meds 50 lost to follow up Data from DiMauro, J., Domingues, J., Fernandez, G., & Tolin, D. F. (2013). Long-term effectiveness of CBT for anxiety disorders in an adult outpatient clinic sample: A follow-up study. Behaviour Research And Therapy, 51(2), 82-86. doi: http://dx.doi.org/10.1016/j.brat. 2012.10.003
  10. 10. 754 181 completed CBT Symptom improvement at end of average of 14 session treatment (minimum 3) 87 Symptom improvement at one year 83 Symptom disappearance at end of average of 14 session treatment (minimum 3) 26 Symptom disappearance at one year 22 No. seeking further therapy No. seeing a psychiatric No. also taking meds 50 lost to follow up DiMauro et al Extrapolation based on attrition rate in IAPT project in Doncaster of 76% (Glenys Parry, personal communication)
  11. 11. Total functioning Household functioning Work functioning Interpersonal functioning Figures from: Iancu, S. C., Batelaan, N. M., Zweekhorst, M. B. M., Bunders, J. F. G., Veltman, D. J., Penninx, B. W. J. H., & van Balkom, A. J. L. M. (2014). Trajectories of functioning after remission from anxiety disorders: 2-year course and outcome predictors. Psychological Medicine, 44(03), 593-605.
  12. 12. •  Of those entering CBT, 45.9% are improved or have remitted at one year, 12.2% have remitted •  Of those entering drug treatment, 29.9% are remitted at end of treatment •  529 people with anxiety who are referred for specialist help, 16% are improved or recovered at one year, and 3% are recovered. Many will also have been treated with antidepressants •  Anxiety disorder is a chronic condition •  Treatments are not particularly effective •  We don’t really understand it
  13. 13. Fear syndrome, common to all anxiety disorders •  Restlessness •  Fatigue •  Muscle tension •  Irritability •  Difficulty concentrating •  Sleep disturbance •  (Other specific disorders of somatic function linked to autonomic changes) •  (Dysphoria, sometimes reported as depression)
  14. 14. Le Doux http://www.scholarpedia.org/article/Amygdala
  15. 15. Donatella Marazziti, Marianna Abelli, Stefano Baroni, Barbara Carpita, Carla E. Ramacciotti and Liliana Dell'Osso Neurobiological correlates of social anxiety disorder: an update . CNS Spectrums, Available on CJO 2014 doi:10.1017/ S109285291400008X
  16. 16. From Feinstein, J. S., Adolphs, R., Damasio, A., & Tranel, D. (2011). The human amygdala and the induction and experience of fear. Curr Biol, 21(1), 34-38. doi: 10.1016/j.cub.2010.11.042
  17. 17. From Feinstein, J. S., Adolphs, R., Damasio, A., & Tranel, D. (2011). The human amygdala and the induction and experience of fear. Curr Biol, 21(1), 34-38. doi: 10.1016/j.cub.2010.11.042 SM’s lack of reaction to feared objects: a snake, a spider and a haunted house
  18. 18. •  Difference between anxiety and fear is one of persistence, and absence of overt conditioned or unconditioned stimulus •  Anxiety is described as ‘object-less’ fear –  Fear ‘of’, but anxiety ‘about, ‘to’, or ‘for’ –  Object is to change the world to a more satisfactory state (Sartre: Sketch for a Theory of the Emotions) –  Evaluation of the world •  Disorder is when arousal is discrepant with ‘reality’
  19. 19. Jeffrey Gray’s hypothesis •  Septo-hippocampal structures are involved in anxiety and not fear •  Anxiety is a failure in these structures to resolve conflict (e.g. approach/ avoidance conflicts) leading to a lack of a ‘map’ of the path to take
  20. 20. Figure 1. Encoding of Contextual Fear Memory in the Dentate Gyrus Granule Cells and Optogentic Dissection of Dorsal and Ventral Hippocampus (A) Sagittal section of mouse brain showing dorsal and ventral dentate gyrus (DG) (yellow). (B) Schematic of the activation pattern (in red) of DG-GCs in response to exploring a novel environment during fear conditioning, which activates a discrete population of granule cells (GCs) that are thought to encode unique aspects of the contextual environment. (C and D) In dorsal DG, contextual learning is impaired by either optogenetic inhibition (eNpNR3.0) via inhibition of encoding GCs (eNpHR2) or excessive stimulation (ChR2) of both encoding and non-encoding GCs that causes interference of neurotransmission. (E) Optical stimulation of the ventral hippocampal DG decreases innate anxiety but does not impair contextual learning. Neil M. Fournier , Ronald S. Duman Illuminating Hippocampal Control of Fear Memory and Anxiety Neuron, Volume 77, Issue 5, 2013, 803 – 806 Derived from Kheirbek et al
  21. 21. Sketch for a theory of the emotions
  22. 22. Rejects psychoanalytic idea •  One could thus account for this essential characteristic of emotion -that it is 'suffered', that it surprises, develops of itself according to its own laws, and that conscious efforts cannot modify its course to any very appreciable extent. •  Better still, they will say, in the majority of cases we are struggling, in our conscious spontaneity, against the development of emotional manifestations; we are trying to master our fear, to calm our anger, to restrain our weeping. Thus we have not only no consciousness of any finality of emotion, we are also rejecting emotion with all our strength and it invades us in spite of ourselves. A phenomenological description of emotion ought to resolve these contradictions. •  Emotional consciousness is, at first, consciousness of the world. It is not even necessary to bring up the whole theory in order clearly to understand this principle At present, we can conceive of what an emotion is. It is a transformation of the world. When the paths traced out become too difficult, or when we see no path, we can no longer live in so urgent and difficult a world. All the ways are barred. However, we must act. So we try to change the world, that is, to live as if the connection between things and their potentialities were not ruled by deterministic processes, but by magic.
  23. 23. •  One could thus account for this essential characteristic of emotion -that it is 'suffered', that it surprises, develops of itself according to its own laws, and that conscious efforts cannot modify its course to any very appreciable extent. This dissociation between the organized character of emotion -the organizing theme being relegated to the unconscious- and its ineluctable character, which it would not have for the consciousness of the subject, would render something like the same service in the psychological domain as the Kantian distinction between the empirical and the noumenal does in the domain of metaphysic. •  Better still, they will say, in the majority of cases we are struggling, in our conscious spontaneity, against the development of emotional manifestations; we are trying to master our fear, to calm our anger, to restrain our weeping. Thus we have not only no consciousness of any finality of emotion, we are also rejecting emotion with all our strength and it invades us in spite of ourselves. A phenomenological description of emotion ought to resolve these contradictions. •  Emotional consciousness is, at first, consciousness of the world. It is not even necessary to bring up the whole theory in order clearly to understand this principle. A few simple observations may suffice, and it is remarkable that the psychologists of emotion have never thought of making them. It is evident, in effect, that the man who is afraid is afraid of something. Even if it is a matter of one of those indefinite anxieties which one experiences in the dark, in a sinister and deserted passageway, etc., one is afraid of certain aspects of the night, of the world. And doubtless, all psychologists have noted that emotion is set in motion by a perception, a representation-signal, etc. But it seems that for them the emotion then withdraws from the object in order to be absorbed into itself. Not much reflection is needed to understand that, on the contrary, the emotion returns to the object at every moment and is fed there. For example, flight in a state of fear is described as if the object were not, before anything else, a flight from a certain object, as if the object fled did not remain present in the flight itself, as its theme, its reason for being, that from which one flees. And how can one talk about anger, in which one strikes, injures, and threatens, without mentioning the person who represents the objective unity of these insults, threats, and blows? In short, the affected subject and the affective object are bound in an indissoluble synthesis. Emotion is a certain way of apprehending the world.... The subject who seeks the solution of a practical problem is outside in the world; he perceives the world every moment through his acts. If he fails in his attempts, if he gets irritated, his very irritation is still a way in which the world appears to him. And, between the action which miscarries and the anger, it is not necessary for the subject to reflect back upon his behavior, to intercalate [[= insert]] a reflexive consciousness. There can be a continuous passage from the unreflective consciousness "world-acted" (action) to the unreflective consciousness "world- hateful" (anger). The second is a transformation of the other. •  At present, we can conceive of what an emotion is. It is a transformation of the world. When the paths traced out become too difficult, or when we see no path, we can no longer live in so urgent and difficult a world. All the ways are barred. However, we must act. So we try to change the world, that is, to live as if the connection between things and their potentialities were not ruled by deterministic processes, but by magic.
  24. 24. 6/12/2011 28NSPC teaching Kurt Lewin’s hodology from which Sartre may have borrowed
  25. 25. Downloaded from http://www.ediblegeography.com/sensory-maps/ 2 May 2014
  26. 26. •  Scent maps •  Emotional flavour maps •  The ‘hodology’ of emotions
  27. 27. Independent route of emotional processing summarized in LeDoux’ Emotional Brain, and also by Damasio in several books •  Claparede effect 10-11 April 2008, Pre-conference workshop
  28. 28. •  Emotional flavour •  Preoccupying concern •  Value congruity
  29. 29. •  Emotional flavour –  Respectful but not fearful attitude to anxiety •  Preoccupying concern –  Experience of anxiety (‘phenomenology’) •  Value congruity –  Emotions might be right: I should listen (‘existential’ approach)
  30. 30. Conroy, S. A. (2003). A pathway for interpretive phenomenology. International Journal of Qualitative Methods, 2(3). Article 4. Retrieved 2 May 2014 from http:// www.ualberta.ca/~iiqm/backissues/2_3final/html/conroy.html
  31. 31. Conroy, S. A. (2003). A pathway for interpretive phenomenology. International Journal of Qualitative Methods, 2(3). Article 4. Retrieved 2 May 2014 from http://www.ualberta.ca/~iiqm/backissues/2_3final/ html/conroy.html
  32. 32. Quotes from Kierkegaard, S. Concept of anxiety •  og da ængstes jeg for det Mulige og det Tilkommende. Saaledes ere vi atter komne hen, hvor vi vare i Cap. I. Angest er den psychologiske Tilstan, der gaaer forud for Synden, kommer den saa nær som mulig, saa ængstende som mulig, uden dog at forklare Synden, der først i det qualitative Spring bryder frem. •  The history of the individual life proceeds in a movement from state to state. Every state is posited by a leap. As sin entered into the world, so it continues to enter into the world if it is not halted. Nevertheless, every such repetition is not a simple consequence but a new leap. Every such leap is preceded by a state as the closest psychological approximation. This state is the object of psychology. To the extent that in every state possibility is present, anxiety is also present. Such is the case after sin is posited, for only in the good is there a unity of state and transition. P. 113
  33. 33. Two ways to approach psychotherapy: What does it feel like to be you? How are you trying to make the best of your life? •  Emotions are not merely symptoms •  They are qualia, like flavours or colours: feelings •  They have directedness
  34. 34. Phenomenology of anxiety disorders •  Using the writings and the lives of some key philosophers in the existential tradition •  Imagine the fear syndrome, but persistent, and according to Jeffrey Grey leaving people irresolute, planless, and therefore stewing plus…
  35. 35. •  Lost father when young •  Long period in hospital with TB, and could not play semi- pro football thereafter •  Moved to France •  Married but many relationships •  Died in car accident going home from holiday in a sport’s car, while his family were travelling by train
  36. 36. Separation anxiety •  Newly added to DSM-5 •  Fear of being alone or unsupported •  Meursault murders the Arab in L’Etranger: “I waited. The heat was beginning to scorch my cheeks; beads of sweat were gathering in my eyebrows. It was just the same sort of heat as at my mother’s funeral, and I had the same disagreeable sensations—especially in my forehead, where all the veins seemed to be bursting through the skin”
  37. 37. •  Lost father when young •  Long period in hospital with TB, and could not play semi- pro football thereafter •  Moved to France •  Married but many relationships •  Died in car accident going home from holiday in a sport’s car, while his family were travelling by train Key theme: absurdity What clients say: “I disappear when I am alone, I feel nothing” “What if something goes wrong when you are here” “Can’t settle” “insecure”
  38. 38. “A world that can be explained (. . .) is a familiar world. But, on the other hand, in a universe suddenly divested of illusions and lights, man feels an alien, a stranger. His exile is without remedy since he is deprived of the memory of a lost home or the hope of a promised land. This divorce between man and his life, the actor and his setting, is properly the feeling of absurdity.” Camus, A. (2000). The Myth of Sisyphus London: Penguin Classics. . p. 13)
  39. 39. Maps of separation anxiety •  Anxiety reducing –  Clinging –  Checking up on another person –  Jealousy •  Anxiety denying –  ‘Foot loose and fancy free’ •  ‘Magical transformations’ (Brain-based behavioural repertoire) –  Depersonalization: a consequence of ‘disorganized attachment’– although this may be attention deficit hyperactivity disorder/ hyperkinetic syndrome (ADHD)
  40. 40. Depersonalization, absurdity, and knowing oneself Mantovani A1, Simeon D, Urban N, Bulow P, Allart A, Lisanby S. (2011) Temporo-parietal junction stimulation in the treatment of depersonalization disorder. Psychiatry Res. 2011 Mar 30;186(1): 138-40. doi: 10.1016/j.psychres.2010.08.022. Epub 2010 Sep 15 Abstract This is the first clinical trial of repetitive Transcranial Magnetic Stimulation (rTMS) in depersonalization disorder (DPD). After 3weeks of right temporo-parietal junction (TPJ) rTMS, 6/12 patients responded. Five responders received 3 more weeks of right TPJ rTMS showing 68% DPD symptoms improvement. Right TPJ rTMS was safe and effective.
  41. 41. •  We may consider these maps self-deceptive even unhelpful •  This morning just focus on what they can tell the psychotherapist about the lived experience of their emotion, which includes what Sartre calls their transformation of the world •  I will come back to what they might be aiming at this pm
  42. 42. Generalized anxiety disorder •  Attended seminary as child but had to leave because of functional heart disorder •  Enthusiastic espousal of Volkisch movement linked to Nazism •  Regular references to coming death •  Like Kierkegaard believed in importance of embracing ‘ontological anxiety’ •  Lots of stressful events: planned gas attacks in WWI, wife’s second son was not his, sacked from Rectorship of Freiberg, banned from teaching by Denatzification Commission
  43. 43. One of the cartoons on the ‘Being and Tim blog’
  44. 44. One of the cartoons on the ‘Being and Tim blog’ Ontological anxiety as a mood sweeps away the Familiarity of the world
  45. 45. Heidegger’s autochthonous perception of generalized anxiety disorder “anxiety in the face of death must not be confused with fear in the face of one’s demise. This anxiety is not an accidental or random mood of ‘weakness’ in some individual but a basic state of mind of Dasein, it amounts to the disclosedness of the fact the Dasein exists as thrown towards the end” Quoted in Deurzen, E. van “Everyday Mysteries” •  NB ‘Thrown’ in Heidegger, ‘Leap’ in Kierkegaard
  46. 46. Maps of Generalized Anxiety Disorder •  Anxiety reducing –  Worry and irresolution –  Conflict avoidance –  Risk avoidance –  Reassurance seeking •  Anxiety denying –  Risk-taking –  Aggression •  ‘Magical transformations’ (Brain-based behavioural repertoire) –  Increasing negative flavour of semantic and perhaps other memory –  Not just ‘divorce’ is a threat, but ‘marriage’ or ‘relationship’, too
  47. 47. www.existentiala cademy.com 53 Tantam, D. (2003). The flavour of emotions. " Psychol Psychoth er. 76(Pt 1): 23-45. Sacco, T. and B. Sacchetti (2010). "Role of Secondary Sensory Cortices in Emotional Memory Storage and Retrieval in Rats." Science 329(5992): 649-656.
  48. 48. www.existentiala cademy.com 54 Sacco, T. and B. Sacchetti (2010). "Role of Secondary Sensory Cortices in Emotional Memory Storage and Retrieval in Rats." Science 329(5992): 649-656.
  49. 49. www.existentiala cademy.com 55 Sacco, T. and B. Sacchetti (2010). "Role of Secondary Sensory Cortices in Emotional Memory Storage and Retrieval in Rats." Science 329(5992): 649-656. Sacco, T. and B. Sacchetti (2010). "Role of Secondary Sensory Cortices in Emotional Memory Storage and Retrieval in Rats." Science 329(5992): 649-656.
  50. 50. Figures from Reinecke, A., Rinck, M., Becker, E. S., & Hoyer, J. (2013). Cognitive-behavior therapy resolves implicit fear associations in generalized anxiety disorder. Behaviour Research And Therapy, 51(1), 15-23.
  51. 51. Not all ‘magical transformations’ are magical •  Predicaments •  Bullying
  52. 52. Pupils with AS make fewer steps than neurotypical pupils and spend less time in the playground Mean number of steps per hour: AS group = 902, control group = 1312 (t = -2.645, p = .027) From Wainscot, J., Naylor, P., Sutcliffe, P., Tantam, D., & Williams, J. (2008). Relationships with peers and use of the school environment of mainstream secondary school pupils with Asperger Syndrome (High-Functioning Autism): A case- control study. International Journal of Psychology and Psychological Therapy, 8, 1-25
  53. 53. Where were people with AS in Sheffield? •  Most living at home, even above 30. •  Most had difficulties coping with changes in everyday environments •  Difficulties moving between places (for example using public transport) •  Most common places frequented were libraries and cinemas Seeing the light – or ticking the box?
  54. 54. •  Father cursed God, and married the maid after his wife died, but before she was cold •  "(Merciful God, alas, how my father, in his melancholia, has wronged me quite terribly--an old man places the entire burden of his melancholia on a poor child, to say nothing of what was even more dreadful, and yet, for all that, he was the best of fathers.)" •  Phobia of fire, and rituals lighting matches (family evacuated because of fire when he was aged 12; great fires in Kobenhaven in 1728, 1795, abd 1806 (following British bombardment) •  Collected tea cups and walking sticks •  “all of existence makes me anxious from the least little fly to the mysteries of the incarnation” •  5 out of 7 of his sibs died •  The surviving brother suffered anxiety disorder, and eventually had to give up his bishopric because of depression •  Kierkgaard had intense anxiety attacks
  55. 55. “All existence makes me anxious, from the smallest fly to the mysteries of the Incarnation; the whole thing is inexplicable, I most of all; to me all existence is infected, I most of all. My distress is enormous, boundless; no one knows it except God in heaven, and he will not console me….”
  56. 56. Map of obsessive –compulsive disorder •  Nostalgia for what might have been •  Repetition and undoing •  Increased reactivity to threat leading to increased need for control •  Not being able to let go of objects, or ideas (Kierkegaard needed many identities to partly deal with this) •  Magical transformation –  Lack of suppression of weaker conflicting stimulus or impulse by caudate
  57. 57. Ambitendency of OCD •  “Anxiety may be compared with dizziness. He whose eye happens to look down into the yawning abyss becomes dizzy. But what is the reason for this? It is just as much in his own eyes as in the abyss . . . Hence, anxiety is the dizziness of freedom.” (in Concept of Anxiety) •  "Anxiety is neither a category of necessity nor a category of freedom; it is entangled freedom, where freedom is not free in itself but entangled, not by necessity, but in itself" (ibid.)
  58. 58. •  Father a lawyer who wanted to be an actor gradually lost his money •  She shared a private language with her younger sister, and played sado-masochistic games with her, in which she was the tortured saint •  Her father started to call her ugly in adolescence when she developed acne •  Her mother disapproved of her giving up her Catholic faith. •  She had difficulty in making friends, and had no boyfriends as an adolescent •  In love with but always second to Sartre •  (Most famous book Le Deuxième Sexe) •  Looked after Sartre, but probably no sexual relations with him after 40 •  Many lovers, including Nelson Algren
  59. 59. Hélène de Beauvoir’s home
  60. 60. Henriette-Hélène de Beauvoir (6 June 1910, Paris – 1 July 2001, Goxwiller) was the younger sister of Simone de Beauvoir. Her art was exhibited in Europe, Japan, and the US. She married Lionel de Roulet, a pupil of Sartre when he taught school, and they were married for 48 years. He became a representative at the Council of Europe, and they moved to Goxwiller, a village near Strasbourg, where she founded a shelter for battered women. She continued painting until she was 85. Her paintings were related to feminist philosophy and women's issues
  61. 61. Map of panic disorder •  Suffocating, drowning •  "There was the feeling of panic at being cut off from the world. . . . I felt I had been put under a curse: I was never going to get away from here. . . . This continent was a great net from which we were never going to escape." Flying with Sartre to Amazonia •  on reaching her 50th birthday. She describes waking from a dream: “ “Sometimes, too, just before I come back to reality, a giant beast settles on my breast: ‘It’s true. It’s my nightmare of being more than fifty that’s come true!’. How is it that time, which has not form or substance, can crush me with so huge a weight that I can no longer breathe?” •  Magical transformation –  Hyperventilation to hypocapnia leading to chest pain (‘effort syndrome’
  62. 62. Poulou as a boy: falling from graceBullied at school, and few friends Mother remarried when he was 12 to an engineer and the family moved to La Rochelle where his step father had been put in charge of the dockyard. Untreated squint when his hair was cut “ugliness” was disclosed Poor school results but then average Ecole Normale Superieure (ENS—think of en soi), aggregé de philosophie, 1929 failed, 1930 (1st. place, Simone de Beauvoir second) 12 Mar 11 Titania hotel, Athens
  63. 63. Sartre the celebrity Memberships: American Academy of Arts and Sciences, Modern Language Association of America (honorary fellow). Lived in hotels or with his mother for most of adult life. Awarded Nobel Prize for Literature in 1964 but refused to attend ceremony. Also refused to be Academicien . 12 Mar 11 Titania hotel, Athens
  64. 64. Map of social phobia (shame) •  Internal focus on unacceptability to others •  Hiding away from other’s gaze •  Fear of contaminating others with shame (hikikomori) •  Magical transformation –  Self-disgust and nausea –  Blushing –  Tremor
  65. 65. “The faces of others have some sense, some direction. Not mine. I cannot even decide whether it is handsome or ugly. I think it is ugly because I have been told so. But it doesn’t strike me. At heart, I am even shocked that anyone can attribute qualities of this kind to it, as if you called a clod of earth or a block of stone beautiful or ugly. People who live in society have learned how to see themselves in mirrors as they appear to their friends. I have no friends. Is that why my flesh is so naked? You might say—yes you might say, nature without humanity.” La Nausée Titania hotel, Athens
  66. 66. •  ..a gap in the road •  ..what should I do? •  Let God decide, or my family, or the state, or my neighbours? •  Decide myself…but I want to the right thing… •  …this is what Sartre (and indeed all ‘existential’ philosophers have addressed Titania hotel, Athens 12 Mar 11
  67. 67. The Look •  Feeling the look on one’s back •  Caught in a moment of private excitement •  The look is not returned •  The other is not a person with a particular reaction e.g. a facial expression, but the Other, a totalization •  The name of the father, the Master, the State, authority, grandfather Schweitzer 12 Mar 11 Titania hotel, Athens
  68. 68. •  “..I persevere in it [in looking through the key-hole], I shall feel my heart beat fast, at the slightest creaking of the stairs. Far from disappearing with my first alarm, the Other is present everywhere, below me, above me, in the neighbouring rooms, and I continue to feel profoundly my being- for-others” (B & N p.277). Titania hotel, Athens Etre pour autrui: being for others 12 Mar 11
  69. 69. •  Sartre’s ‘project’ was to escape from the look of the other, and to overcome what Kierkegaard, Heidegger, and he himself all discovered: that without being anxious to please, we are anxious because we are potential but not actuality as we look into the future, and falling short and not perfection if we look into, project ourselves into, throw ourselves into, or leap into the past. Whether we call this ‘sin’, or ‘existential guilt’, or ‘nausea’
  70. 70. Heide Klumpp*, David Post, Mike Angstadt, Daniel A Fitzgerald and K Luan Phan (2013) Anterior cingulate cortex and insula response during indirect and direct processing of emotional faces in generalized social anxiety disorder. Biology of Mood & Anxiety Disorders 2013, 3:7 A priori region of interest: Anterior insula. A) Voxel-wise main effect of group for the contrast Match Faces  >   Match Shapes, along with Match Angry  >  Match Shapes, Match Fear  >  Match Shapes, and Match Happy  >   Match Shapes, showing bilateral anterior insula (aINS) displayed on statistical F-map at p  <  0.05; cluster size >10 contiguous voxels (family-wise error corrected for multiple comparisons across small volumes of interest). Color scale reflects F-score. B) Bar graphs depicting extracted parameter estimates of activation from the aINS ROI within each group showing Generalized Social Anxiety Disorder exhibited greater bilateral anterior insula activation than Healthy Controls (p  <  0.05). fMRI study
  71. 71. •  Some predetermined, or sensitized biological pathways, but focus is not on what causes these disorders but on what the subjective experience is •  Phenomenological approach paramount in this •  Next step: what we do with the emotions –  Win the Nobel prize? –  Kickstart feminism? –  Become a national hero? –  Something more modest: find the path that anxiety is uncovering
  72. 72. Case history of the little monkey George Williams first presented to his general practitioner complaining of poor sleep. This was of particular concern to him because he was a window cleaner. When he had a bad night, his coordination was affected and he was afraid that he would fall of his ladder. He had already lost his job as a computer programmer because he could not concentrate. Mr. Williams lived with Sara who had children by a previous relationship. Mr. Williams said that he and Sara got on well, but that she had begun to sleep in another room as he kept her awake with his not sleeping. He was afraid that the relationship was going to breakdown His general practitioner established that Mr. Williams had difficulty in getting off to sleep, and often woke in a panic in the night; that he was having trouble with his memory and with his concentration, and that he often felt his heart pounding. The general practitioner prescribed a beta blocker for the heart pounding, and explained to Mr. Williams that a tablet to help him sleep would only be of short-term value. He would quickly become tolerant of it, and would therefore be of little help for his long-term sleep problem. There was also a risk of dependence. His GP thought that Mr. Williams would benefit from anxiety management, gave Mr. Williams some self-help books and referred him to the community psychiatric nurse. She noted that Mr. Williams had not improved, and attributed this to his disturbed childhood. She thought that he had a post-traumatic stress disorder and that he would need specialist help. Mr. Williams was therefore referred to the local psychiatrist. As the local service did not have a community mental health team, Mr. Williams was referred personally to a consultant psychiatrist, and seen by a trainee who took a history before discussing the case with the consultant. Mr. Williams confirmed the account of his anxiety symptoms that he had given to the GP He could have attacks up to 8 times in a night, and sometimes had to give up trying to sleep because of them. His shortness of breath could get so bad that he had once or twice gone to Casualty to get checked out in case he was having a heart attack. Mr. Williams said that his parents were both alive and well, and that he had three younger sisters. He thought that his parents were closer to his sisters than to him. His mother had rejected him, he thought, when his younger brother had died of a cot death at the age of four weeks, when Mr. Williams was only two. After that his mother had not really coped well with the children. The family were frequently seen by psychologists and psychiatrists, and the children placed in temporary care by social services. Mr. Williams had developed enuresis and encopresis, for which his mother would punish him physically, sometimes by locking him into his bedroom with a bucket for a toilet. He was sometimes banned from toilets in other parts of the house. There were two investigations of physical abuse, but no action was taken until he was nine, the year that his mother did not celebrate his birthday, when he was placed in foster care. He was physically punished in the first foster family, too, but was then fostered by another, kinder, couple. His encopresis had resolved long before he was fostered, and his enuresis stopped, never to return, shortly after he joined his second foster family, when he was 12. From Tantam, D. Brijesh, S. Existential supervision and the NHS, in Existential Perspectives on Supervision (eds. Deurzen, E. van and Young, S.) Palgrave Macmillan, London, 2009)
  73. 73. What anxiety would reach out to if it were not baffled (what might we anxious about, or for)
  74. 74. •  “We must imagine Sisyphus happy” •  i.e. not trying to hold on to death and stasis, but owning both his life and therefore his death •  Being a member of a football team was his greatest happiness •  Courage to live with what life brings, and not repine or wait for respite, or God Aanxiety points to absurdity
  75. 75. Clears the ground •  Resoluteness •  Embracing being finite
  76. 76. •  Life is never simple: best to long for it to be more difficult •  Predicaments provoke a leap in understanding that is emotional and not rational (contra Hegel) •  Write, think, reflect until the leap is made •  Sin—falling short—is inevitable. To imagine it is not is to fall short of God, who knows
  77. 77. •  What a suffocating life a woman has? How smothering Sartre must have been? •  Do not seek a solution for yourself, but for those who come after who can go beyond •  Contain anxiety not to die oneself but to give birth to other’s freedom •  (Some sinning can sweeten the pill if one can face up to it)
  78. 78. •  Anxiety (shame) is a sign that we being unmade •  Only if we are unmade can we be free •  Each time we think we are free, we choose a path that will take us forward but we must be prepared to leave it if we see it curving away •  And then we will feel anxiety again, which is good •  (but a bit of alcohol, amphetamines, or sexual incontinence helps too) •  Anxiety, or at least terror, enables us to be close to other people if we accept it and not run away from it
  79. 79. 05/05/201 4 86 Final thoughts •  Facing up •  Not crying out for relief •  Digging down to what one is anxious for, or about •  Choosing to live with this, or to change •  Revealing the truth •  Accepting that the leap leads to new ‘sin’ i.e. the possibility of criticism, rejection, or shunning

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