How to be an Existentialist: or How to Get Real, Get a Grip and Stop Making Excuses
by Gary Cox
Continuum, 2009

This is a great introduction for anyone interested in studying the philosophy of existentialism, and as a ‘handbook’, it highlights the importance of personal freedoms, responsibility and the importance of making, and accepting, clear choices, whether they turn out to be right or wrong.

Cox — a scholar of the work of Jean-Paul Sartre — challenges today’s ‘blame and excuse culture’, where accidents, failures and life problems are explained as somebody else’s fault. He emphasises the importance of taking responsibility for our own lives and decisions and of facing the existential truths of the human condition.

Cox persuades us that existential philosophy is not pessimistic, but uplifting, with the potential to free us from the everyday restrictions and barriers we impose upon ourselves. His key themes include:

• Personal responsibility
• Freedom of choice
• Acting positively rather than simply reacting to life’s events
• The importance of avoiding bad faith (the habit of self-avoidance)
• Existence precedes essence — we exist before we have any meaning or purpose: we are physical entities before we have meaning. We must exist to have meaning or purpose
• Being-for-Others — we are not alone in this world (no man is an island)

Existentialism is not for the faint-hearted. It takes effort! It can be anxiety-provoking to realise that we make our own meaning, that there is no inherent meaning to life and that we have to be responsible for ourselves and our actions.

Cox explains how existentialism holds that we are not fixed beings but always works-in-progress striving towards our future. We are constantly changing and personally evolving. There’s a final irony in the book’s title–one can never ‘be’ an existentialist, one can merely strive to lead an existential life.

Simon Whalley, 
House Therapist

A surprise might do you good

It’s hardly surprising that if you go into therapy with a genuine hope of a positive result, you’re more likely to emerge with exactly that — and the opposite is also true. So a negative or pessimistic outlook is more likely in clients whose outcomes are poorer.

But a group of Canadian cognitive behaviour therapists wanted to know more than this; they wanted to explore clients’ expectations, and specifically, whether these expectations matched their actual experiences of therapy. And more importantly, they wanted to see if this had any link to the results and effects, after therapy was complete.

The research project

Nine ‘good-outcome’ clients and nine ‘poor-outcome’ clients were chosen for comparison. All were asked a series of questions designed to reveal in some detail what they had felt about therapy before, during and after treatment. Questions focussed on the therapist’s role, what they felt were the most and least helpful aspects of their sessions, and how comfortable they had felt. They were then asked how closely any of this matched their previous expectations.

The results

Results fell into two categories — ‘therapy was not what I expected’ and ‘therapy was what I expected’ , with categories each containing sub-sections. In the first category, where expectations are not met, therapy can bring about a ‘pleasant surprise’ feeling or a disappointed one. In the second category, therapy could match high expectations by being a good experience, or low ones by being a poor one. The most common answers showed that clients were in fact surprised by at least some of their experiences, either positively or negatively….but it was the ‘pleasant surprise’ clients that did better at the end of therapy.

Positive progress is more likely in clients who are pleasantly surprised by CBT

The results showed that ‘good-outcome’ clients were firmly in that ‘pleasantly surprised’ camp — often surprised that they were able to work with the therapist and to take the lead at times, and more comfortable with the whole process than they thought they would be. Poor-outcome clients generally reported disappointment or that low expectations were confirmed. Good-outcome clients also reported gaining more from treatment than expected.

The theory behind it

The theoretical underpinnings informing this study come from the theory of ‘expectancy violation’ which holds that surprise experiences in communications have an impact on further interactions — so if someone behaves in a way you don’t expect, it affects the way you relate to them in the future. In addition, ‘decision affect theory’ proposes that pleasantly surprising experiences are inevitably more pleasurable than the ones you knew were going to happen all along.

So it seems that you’re more likely to make the most of CBT if you keep your expectations low or neutral — and then find things are not as bad, or rather better, than you thought. Spot the implications though: does this mean that a well-informed client, who’s read something about CBT and who knows what to expect, is less likely to benefit? And that keeping clients in the dark about what happens in therapy gives the best results?

The biological basis of depression

In evolutionary terms, depression is said to be ‘adaptive’, that is, it has some sort of biological purpose in order to enable us to function more effectively in the longer term, either as individuals or as part of a social group. The discussion has given rise to a number of contrasting hypotheses. Here are just two.

Depression gives information to us and others

Let’s take the Social Navigation Hypothesis, or the SNH, first put forward some nine years ago by two biologists from the University of New Mexico. Paul Watson and Paul Andrews have suggested that depression actually helps with problem-solving, especially problems relating to social situations.

One feature of depression is ‘rumination’ — the tendency to go over and over problems and negative experiences, dwelling on them to the exclusion of other thoughts. This can, they propose, be useful, as it sensitises the individual to information they can use to understand situations better. In therapy, the content of the ruminations can be discussed as part of an awareness raising process–but why are these ruminations dominating at this time? Are they helping the individual learn something?

There are several theories on the evolutionary purpose of depression

An evolutionary cry for help

In addition, the SNH proposes that depression can act as a motivator for the other people in a relationship with, or those sharing a social network with, the depressed person–the ‘cry for help’ signal of depression could ensure help emerges in response from partners and other close contacts. This is not done in a conscious way of course–it’s not that the depression is an ‘act’ or a performance. But it does, say Watson and Andrews, give voice to feelings that indicate a need for social support.

Andrews went on to develop the notion of ‘depression as information’ with other colleagues. The theory posits that as human beings are analytical creatures, rumination is itself a form of analysis–repetitive and often not rewarding in itself, even so. The anhedonia (the technical term for the loss of pleasure in normally pleasurable experiences) that accompanies many depressive episodes is there precisely because it allows for more rumination–lack of pleasure means the brain is not ‘diverted’ by other distracting pleasures from its all-important analytical task.

Depression as a protector

A rather different hypothesis is the one put forward by psychologist Randolph Nesse, a researcher in evolutionary medicine at the University of Michigan.

Just as physical pain can be ‘normal’, alerting us to danger (such as the pain we feel with intense heat or intense cold), depression is a biological warning signal, too. A low mood stops us trying to chase after impossible goals–it tells us that now’s the time to ‘give up’ and move on to something else more achievable. Over millennia, this protective mechanism helped us identify activities or ventures we could not possibly achieve, and so permitted us to focus energy and resources on what we could do instead.

One reason for the high levels of depression in modern-day western settings is, according to this hypothesis, the pressure to succeed–the drive to achieve is not ‘healthy’ for many people, who can become at first mildly depressed, and then more chronically as they carry on ignoring the ‘warning signals’.

The accidental birth of a billion dollar industry

In 1952, scientists isolated a drug called reserpine from the dried Indian snakeroot plant (which had been used for centuries in India for the treatment of fever and snakebites). It was found to reduce levels of the monoamines in the body (serotonin, dopamine and noradrenalin) and to be pretty good at controlling high blood pressure – the only problem was that it had a tendency to make people sad.

In the same year, researchers noted that a drug given to patients for TB increased the levels of monoamines in the body and made people “inappropriately happy”.

Following this, a hypothesis was formed that depression is therefore due to decreased levels of neural monoamines; particularly serotonin. In the 60 years that followed, the idea that a chemical imbalance causes depression has been repeated like a mantra by public health authorities and become ingrained in popular culture. Pharmaceutical corporations have spent billions of dollars on researching, marketing and advertising medications that promise to cure depression by increasing neural serotonin: but are they selling us a false narrative?

Post hoc, ergo propter hoc: After it, therefore because of it

The immediate and glaring problem with the assumption underlying the development of antidepressants is that of logic: it operates on ex juvantibus reasoning (whereby an inference is made about disease causation from an observed response of the disease to a treatment): just as headaches are not caused by a lack of aspirin, the efficacy of serotonergic drugs is not in itself proof that depression is caused by a lack of serotonin.

The insidious jump was made from an association with increased positive mood, to an inference of causation of increased positive mood. These two relations are in no way the same: we cannot infer causation from correlation.

More to medication than chemicals

The chemical content of antidepressants is not their only potentially relevant variable, for they are also in themselves placebos: many people are prescribed them under the promise that they will improve their symptoms: prescribing physicians say so, the media says so, pop psychology says so… Is simply believing you are taking something which will make you happier enough to make you happier? Is this what pharmaceutical companies are actually selling us?

Kirsch et al (2002) suggest that this may be the case. They found, through analysis of all antidepressant clinical trials submitted to the FDA for approval, that the antidepressant response was matched by 80% of the placebos used. Similarly, Turner et al (2008) reviewed all published literature concerning 12 antidepressants from 1987 to 2004 and showed a 94% success rate, but in the withheld literature there was below 50% success.

Combined, all studies showed 51% efficacy; only 1% above chance, and only 2 points above placebo. There seems to be a publishing bias in which the studies that conform to the predictions of the chemical imbalance theory are most likely to be published: but what we see in journals may not be the full story.

So, the fact that ‘traditional’ antidepressants act to increase levels of serotonin in the brain may just be an accidental property, epiphenomenal to their placebo function. This is supported by several other findings:

• The latency of their chemical effects to be translated into increased positive mood (average 6 weeks): surely if depression was due to not having enough neural serotonin, we would all be happier as soon as we took an antidepressant pill, as they increase serotonin levels within minutes.
• They are not universally effective: if a chemical imbalance was the true proximal cause of depression, we would expect antidepressant efficacy to be higher than chance, which it doesn’t seem to be.
• Spontaneous remission (improvement of a condition without intervention) occurs in many diseases, including depression: how do we know that any improvements we see after antidepressant administration aren’t a result of this?
• Tianeptine, which actually reduces available neural serotonin, is clinically efficacious in the treatment of depression, with few side-effects (even alleviating comorbid anxiety without sedation). Based on the pharmaceutical industry’s story about depression, this drug should actually accentuate depressive symptoms.
• St. John’s Wort, a herbal intervention, has performed as well as or even better than antidepressants in randomised controlled studies.
• CBT: Butler et al (2006) summarised recent meta-analysis literature, demonstrating that CBT efficacy is moderately superior to that of antidepressants for the treatment of depression. Dimidjian (2006) further found that the behavioural activation component of CBT alone is as effective as antidepressant medication. CBT and antidepressants are associated with similar rates of recovery, but evidence suggests that CBT has far fewer cases of relapse.
• Group therapy: Leff (2000) found that, for people with depression living with a ‘critical partner’, couples therapy is ‘more acceptable’ than antidepressant drugs and is at least as efficacious if not more so, both in treatment and maintenance phases, and is no more expensive overall.
• Mindfulness: Kuyken et al (2008) found mindfulness to be as effective as antidepressants in preventing relapse of depression, and more effective in improving quality of life. It was also proved to be as cost-effective in helping to stay well in the long term.

Taken together, this evidence seems to suggest that, not only are antidepressants not as effective as the pharmaceutical industry would have us believe, but they may even be less effective than non-pharmaceutical interventions. Their chemical content may be secondary to the placebo effects of the industry constructed around them, which tells us that taking certain pills will make us happier. Perhaps that’s all we ever needed to hear.

Mental health in a scared — and scary — world

The MHF’s own national fear survey carried out in 2007 reveals a growing perception that the world is a frightening place, and that individuals respond, not surprisingly, by being scared of many aspects of it.

The thrust of the report is that these two phenomena — an increase in the number of people with anxiety issues, and the generally fearful perception of the world — are linked to each other. If there is a high degree of fear in our society, then a proportion of us inevitably become anxious enough to seek the help of a therapist or doctor, alongside large numbers of us who feel distressed and anxious but find it possible to cope without help.

The steps we can take

However, there’s nothing inevitable about any of this. As a society, we can take steps to counter fear, to make the world feel and crucially, be safer…and, the report argues, this is a clear and urgent public health issue, with social, economic and cultural dimensions, and one we absolutely can’t afford not to tackle.

As a society we must take steps to make the world feel and, crucially, be safer

The report lists pragmatic steps any government, of whatever hue, could take immediately, to promote good mental health. At present, only about £4 million, or less than 0.1 per cent, of the £4.5 billion adult mental health investment is directed at prevention. Business, education, media have a role to play in reducing fearfulness by increasing understanding of the way it works, and making this understanding work for us. Our culture is very good at ignoring fear and its effects — and when fear is ignored, it can rule us more easily. The report puts forward a way out of the trap.

Exploring a possible future

Can you imagine life free of emotional issues, without the concerns and problems that made you think of therapy as a way of tackling them?

What would show you your life was different?

What would you be doing instead of your current everyday activities?

What would you be thinking about, or planning for, if you weren’t preoccupied with the difficulties you’re experiencing now?

What if something miraculous happened to change your life completely? What little clues would let you know the miracle had happened?

These are possible questions put to clients by solution-focused therapists. The therapist and the client work together, with the therapist encouraging the client to use his or her imagination to really think about achievements and goals — even if the client feels they are beyond reach, or no more than a fantasy, in the initial stages of therapy at least.

The number of sessions is usually quite short — a limited number of meetings, with progress discussed, explored and assessed as soon as the next session begins.

Emphasis on the future — not the past

The focus is on what is happening now, and what could happen if things changed, in the future. Causes of problems, or events leading up to a worsening of the problems, play a minor role, if at all, in favour of imagining a solution, but always under the client’s control.

Directing thoughts towards goals and achievements

The therapist helps the client identify even the smallest changes and improvements, and aims to raise awareness of them. This builds confidence and self-esteem, often quite quickly, according to the research into this form of therapy.

Solution-focused therapy is sometimes used alongside other techniques, or as a preliminary to other therapies. It’s adaptable to a wide range of emotional and psychological concerns, and part of its success lies in the fact it can be effective with clients of all ages, including children and adolescents, and including clients who have little motivation….or who have already tried other forms of therapy and given up.

Why does it work?

There may be a neurobiological effect, on the way the brain responds to this sort of questioning and imagining. Some theorists posit that the language and dialogue of the sessions stimulate a creative, self-healing process — and other ideas are that the therapist and the client relationship is key, and that it’s likely to be ‘better’ because they can’t disagree on causes of problems (because they are not discussed).

The ‘shame’ of depression in Japan

Until relatively recently, the usual reaction to the idea of consulting 
doctors and other healthcare professionals about depression 
was one of great shame. There was very little 
understanding of what depression might be, 
and the Japanese cultural pressure to remain 
stoical and accepting, even in the face of 
great emotional suffering, meant many people 
with depression struggled on alone.

A suicide rate of twice that in the USA 
appeared to be testimony to poor mental 
health services and little recognition of the 
need for greater openness.

Now, things are different — not everywhere, 
and not completely. Rural areas, such as the 
north east where the tsunami struck, have yet to catch up with more metropolitan areas, where a huge increase in people seeking the help of doctors and therapists has shown that attitudes have undergone a genuine shift. But concerns have been expressed that the psychological fall out from the tsunami will be hard to address, if the pressure remains to suffer in silence.

Big drug companies bring the change

What made the difference in urban Japan? Why do therapists and doctors report a greater willingness to recognise and treat depression? And is this change wholly without a downside?

Pressure to remain stoical, means that many Japanese suffer depression in silence

In Crazy Like Us, researcher Ethan Watters describes how major pharmaceutical company GlaxoSmithKline became the leader in events that can only be called the ‘marketing’ of depression at the turn of the millennium.

Drug companies — like Eli Lilly, makers of Prozac — had previously by-passed Japan, on the grounds that culturally, the Japanese people and their doctors would not be interested in pills for a disorder they either ignored or denied.

Glaxo thought differently–they believed with the right approach, they could ‘sell’ depression, along with treatment for it. It became the first western drug company to target doctors and the media with an extensive, and naturally enough, expensive, campaign of public relations and education, and giving financial and academic support to the Japanese medics whose views they favoured.

The ‘buzzword’

According to the New York Times, depression–or rather ‘kokoro no kaze’, the soul catching a cold, as the new term had it–became a ‘buzzword’ in just a couple of years. Celebrities went on TV to talk openly about their experiences and how the medication had cured them. Magazines and newspapers carried articles about the phenomenon. Dozens of books were published, and doctors welcomed literally thousands of new patients.

Watters details the way in which Glaxo made the most of existing academic and political concerns, rumbling away for decades, that Japan was light years behind the USA in its grasp of mental health issues and needed to drag itself into the 21st century with new ideas.

Medicalised sadness

The downside of this, suggest critics, is that ‘ordinary’ sadness–grief and normal low mood in the face of life’s ups and downs–has become medicalised, and treated with drugs which we now know have unwelcome side effects in many, and which may only have a small chance of a cure.

Traditional community, family, and spiritual supports for emotional stress and depression have been undermined and marginalised, and opportunities for Japanese researchers to explore other means of treating depression, in a culturally sensitive way, are reduced.

As the New York Times reported, “rather than expanding options for care for those who suffer, the globalization of psychopharmacology may ultimately sow a monocrop of ideas about health and sickness.”

Love conquers all

Huston’s programme investigating coupledom and marriage, beginning with the very first date, is known as the PAIR (Processes of Adaptation in Intimate Relationships) project.

He and his team recruited 168 newly-weds in central Pennsylvania, and followed them over the course of 13 years. The team asked about many aspects of the couples’ lives together, and an analysis of the massive amount of data retrieved showed that to a large extent, the seeds for success, or failure, in marriage are already present during courtship and the very early years.

Key to a long-lasting, happy marriage? Deep and mutually-intense love, says the project. The deeper the love during courtship, the longer, and happier, the marriage. It’s love that brings couples together during courtship and which propels them towards marriage — but for the love to be enduring, it has to be there in depth before marriage takes place. If it’s not, then divorce is more likely. Lack of love, or a loss of love, does not necessarily mean divorce, but it does mean lack of happiness.

One of the very first and most revealing points for the future shows in what Huston calls ‘shared courtship reality’. Each partner was asked to plot a graph of their courtship, with the ups and downs and a note of major events including break-ups and time apart.

Enduring love must be deep and mutually intense from the beginning

Couples whose graphs diverged in several points — whose own view and memory of their courtship was different from their spouses — were far more likely to be divorced within two years. The couples whose very early views and interpretations were in close agreement were at the opposite end of the spectrum — more likely to be together, and to say they loved each other, after the end of the project 13 years later.

Early days predict

In fact, happy marriages were happy in similar ways — deep and shared affection, compatible ideas about role, similar interests from the time of first courtship were the hallmarks. In contrast, the unhappy marriages and the ones that had ended, were more disparate. Some began with problems, of varying intensity, near the surface, whereas with others, problems emerged more gradually and antagonism grew in place of affection.

A positive focus on what might be ahead

Traditionally, talking therapies for depression have involved delving into the past, unearthing painful memories and discovering how they affect us in the present. These psychoanalytic methods were overtaken in the cognitive revolution of the 1950s, which means that now, patients are commonly exposed to Cognitive Behavioural Therapy (CBT), which concentrates on altering irrational and overtly negative thoughts.

Though the move was made from analytical to cognitive, both therapies involve a great deal of hindsight. Some researchers are suggesting it’s time for a new therapeutic revolution into the age of Future-Directed Therapy (FDT), in which talking interventions for depression concentrate not on what has already happened, but on thinking about what will happen in the future in a positive way.

Cedars-Sinai, a non-profit hospital to the stars in Los Angeles, is becoming a hotbed of FDT research. Dr Pandya, interim chair of their department of Psychiatry and Behavioural Neurosciences, described FDT as “designed to reduce depression by teaching people the skills they need to think more positively about the future and take the action required to create positive future experiences.”

Scientific support

The development of this approach was informed by several important findings: Thinking positively about the future and being able to anticipate positive outcomes has been consistently related to positive well-being, but people with depression tend to have fewer of these skills, and the brain regions responsible for optimism and positive anticipation that mediate these skills show reduced functioning in the depressed too. Fortunately however, teaching people these skills can increase positive future thinking and well-being, and reduce negative emotion and hopelessness.

Focusing on a positive future

With this evidence in mind, it is understandable that setting aside an hour a week to talk only about what makes you unhappy (as per Freudian psychoanalysis) may be detrimental to the recovery of depressed patients. FDT by contrast helps people to concentrate on what they want of the future and help them develop proactive behaviours to assist them in getting there.

Comparison with CBT

Researchers at Cedars-Sinai compared 90 minute sessions of FDT administered twice a week for 10 weeks to patients with Major Depressive Disorder (MDD), with ‘treatment as usual’ (cognitive based). Both groups showed improvements in anxiety, quality of life and satisfaction with the therapy, but the FDT group showed the greatest improvements in depression. Although this was only a small pilot study involving just over 30 patients, it may be the start of a new therapeutic revolution. Considering suicidal patients have been shown to have low positive anticipations of the future, FDT may prove in time to be a life-saving intervention.

The adaptation of meditative practice to therapy

Mindfulness owes its origins to eastern religions, particularly Buddhism, and to the practice of meditation. Its more recent application in therapy owes much to those traditions, but alongside an increasing popularity, it has now gained a robust and more scientific evidence base.

Mindfulness is a therapeutic approach that focuses on ‘being’ rather than ‘doing’. It values and teaches acceptance of the moment as it is experienced now — and by extension, an acceptance of feelings and responses that may have been with us for decades.

Acceptance often involves a wholly different way of engaging with our minds and our bodies, and our own life history. When successful, the result is improved well-being and, crucially, reduced or even absent symptoms of a range of conditions and concerns, including anxiety.

There are different ‘varieties’ of mindfulness which borrow concepts and techniques from other therapies to form ‘hybrids’, but all with the common thread aim of enabling us to react less to whatever is happening to us, and to relate to experience in a new way.

Mindfulness focuses on 'being' rather than 'doing'

You might stumble across ACT (Acceptance and Commitment Therapy) or Acceptance-based Therapy; MBCT (Mindfulness-Based Cognitive Therapy) or MBSR (Mindfulness-Based Stress Reduction). These are among a half dozen or so variations and adaptations listed in The Mindful Manifesto, a recent publication by Ed Haliwell, a Guardian journalist, and Dr Jonty Heaversedge, an inner city London GP.

Paying close attention to our experience

Practicing therapists see mindfulness as a skill which gets better, and more effective, with practice. Mindfulness teaches us to pay close attention to our experience and to heighten awareness, to ignore distractions and just to ‘be’. In therapy, it aims to bring new insights and a deeper wisdom.

Neuroscientific research indicates that the positive effects of mindfulness on mental well-being may be at least partly as result of the changes it brings in the brain: the parts of the brain associated with sensory processing, together with those used in the regulation of emotions, become more developed and increase in size.

Scans on the brains of people who practise mindfulness demonstrate their greater ability to activate the sensory, sensitive, experiential or ‘being’ areas and to switch comfortably and easily from the ‘doing’ areas more concerned with thinking and which focuses on narratives and future plans and analysis of past experience…those areas which are likely to support anxieties.

Research and convincing evidence

Increasingly, the research indicates it does. A meta-analysis published in 2010 looked at a total of 39 previously-published papers with a combined number of participants of 1140, who were receiving therapy for different emotional issues or medical conditions, including generalised anxiety disorder. Results showed anxiety and other mood related issues were reduced by mindfulness therapy, and importantly, the effect was maintained over the periods of follow up.

Another study looked at two groups of patients, all with anxiety; one group was formed of patients randomised to receive immediate therapy and the other patients had no therapy (the ‘waiting list controls’). The therapy was a mindfulness-like ABBT (acceptance-based behaviour therapy). Over a period of nine months, there were significant reductions in anxiety symptoms reported by the patients in the treatment group, and by their clinicians, compared with the non-treatment group.

Heaversedge and Halliwell point out the transformation effected by mindfulness is something that can’t easily be expressed in a scientific study — if someone’s feelings about anxiety change, have their overt symptoms really reduced, or is it ‘just’ the perception that’s different, and even if it is, then is this ok?

They argue for a different kind of investigation into the therapeutic and other effects, which involves a personal and ‘mindful’ look at individual experience, to be at least an equal partner in the scientific enquiry into mindfulness as a form of therapy.