The Fragility of the Mind
The Phenomenon of Anxiety: Exploring Pathology Through Medicine, Psychology, and Existentialism
The number of people suffering from mental illness, specifically anxiety, appears to have skyrocketed among millennials. This number can be attributed to Western society, the increase in conversations about mental health leading to increased diagnoses, social media, and numerous other reasons. Even though it seems as if diagnoses are continually increasing, anxiety is not a new phenomenon. French philosopher and author, Albert Camus, referred to the twentieth century as the “age of overt anxiety” (May, 1950, p. 4). According to famous philosophers like Camus, formative existentialists like Rollo May, and leading psychologists like Sigmund Freud, anxiety is a profound and pervasive phenomenon (May, 1950, p. 3). Whether anxiety is explained through existential, psychological, or neurophysiological terms, the point remains that anxiety has an impactful effect on the healthcare system. This impact comes from the prominence of anxiety as a mental health concern in modern society that, at times, depends on doctors, psychologists, and counsellors alike.
The first distinction to make regarding anxiety is the difference between feeling anxious and neurotic anxiety. May (1950) makes the distinction between the former and the latter as being a proportionate or disproportionate reaction to a threat applied to an individual: a proportionate response being normal and a disproportionate response being neurotic or pathological (p. 194). As a clear example, normal anxiety would be mild feelings of stress towards completing a final paper, whereas neurotic anxiety would be having symptoms of panic about finishing a paper. The distinction between these two anxieties is crucial for medical, psychological, and existential fields because it is the difference between anxiety as a human condition versus as a pathology. Before exploring pathological anxiety through medical, psychological, and existential fields, it is critical to examine the relevance of anxiety in Western society.
Beyond the general classification of anxiety, various reasons have been hypothesized for the increase and prominence of anxiety in Western culture. Speaking with regards to culture, May (1950) refers to the writings of R. R. Willoughby, who deemed anxiety the “most prominent mental characteristic of Occidental civilization” (p. 13). In relation to Western society, Franz Kafka’s novels, like The Metamorphosis, place connections between bourgeois culture and anxiety. This is further explored by Hermann Hesse in his writings about the increase of anxiety and isolation stemming from “the fact that the bourgeois culture in the late nineteenth and early twentieth centuries emphasized mechanical, rationalistic ‘balance’ at the price of suppression of dynamic, irrational elements of experience” (May, 1950, p. 7). Now, this was just the beginning of the debate that soon emerged and continues today in regard to the method in which Western society treats and aids those experiencing neurotic anxiety. There can be no certain cause as to anxiety’s prominence in Western culture. However, Kierkegaard, like Hesse, believed anxiety could be attributed to the “rapidly increasing mastery over physical nature” (May, 1950, p. 28).
Within the twenty-first century, there are many ways to understand and treat anxiety — the most prominent being through the medical model and the cognitive behavioural model. Alternatively, there is ample research in support of the existential model and the benefit it holds within the framework of psychology and the treatment of anxiety. Comparing and contrasting the medical model, the cognitive behavioural model, and the existential model allows one to grasp a deeper understanding of anxiety.
Since anxiety can be classified as both a human condition within the general public and as a psychiatric disorder, many people seek help from a general practitioner rather than a psychologist. This tends to lead people into a medical model treatment for anxiety (Clancy & Noyes, 1976). For this reason, it is critical to understand what this model entails. According to Wampold (1948) in his book The Great Psychotherapy Debate: Models, Methods, and Findings, the medical model is “characterized by insistence on the correct explanation of a disorder and adoption of the concomitant therapeutic actions” (p. 11). In the medical model, the doctor gives a patient a diagnosis based on the signs and symptoms they are experiencing. A valid diagnosis “predicts etiology, pathogenesis, clinical course, outcome and familial illness patterns,” all of which are used to help relieve the patient of their symptoms (Clancy & Noyes, 1976, p. 90).
Biologists explain anxiety as the body’s natural coping mechanism in response to danger. The neurophysiological aspects of anxiety are described as the sympathetic division of the autonomic nervous system (May, 1950, p. 57). Simply put, when the body undergoes a stressful situation, whether normal or neurotic, the sympathetic nervous system prepares the body to cope with perceived danger. It does so by releasing adrenaline, putting the body into the scientifically termed “fight or flight” mode (Healey, 2014, p. 16).
For those individuals who are suffering from the pathological form of anxiety, there is plenty of neuropsychological research that attests to why they are experiencing signs and symptoms. There are many biological factors that medicine considers to explain anxiety: for instance, abnormalities in the brain’s frontal, occipital, and temporal lobes can be attributed to anxiety-related symptoms. Research has also “confirmed that genetic factors play a role in the development of anxiety disorders” (Rector, Laposa, Kitchen, Bourdeau, & Joseph-Massiah, 2016, p. 18). However, the primary source of medicine’s understanding of anxiety comes from the link between anxiety and abnormal neurotransmitter regulation. The neurotransmitters affected are serotonin, norepinephrine, and gamma-aminobutyric acid (GABA) (Rector et al., 2016, p. 17). Each of these neurotransmitters is involved in cognition or behaviour associated with anxiety. For example, serotonin regulates mood and aggression, while GABA induces relaxation and sleep (Rector et al., 2016, p. 17). This explanation for anxiety is directly linked to the method of treatment for anxiety within medicine.
The treatment course for anxiety through the medical model is pharmacological. The most common treatments are with SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin and norepinephrine reuptake inhibitor), antidepressant medications that correct the amount of serotonin, dopamine, and noradrenaline being released in the brain. This form of treatment is the easiest and most effective method of treating anxiety pharmacologically, as these medications are safe for long-period use and have minimal side effects (Healey, 2014, p. 40). An alternative to SSRIs and SNRIs are Benzodiazepines, which are sedatives that should be used for short-term or intermittent use. Benzodiazepines work to increase the production of GABA which helps reduce tension. By adjusting these neurochemicals, the primary effect of this medication is relaxation (Healey, 2014, p. 42).
Medication as a source of treatment for anxiety disorders has helped many people in Western society: antidepressants being the most commonly used and the most effective form (Healey, 2014, p. 32). Patients have favourable experiences with antidepressants once the right medication is found. This process tends to be a quicker way to relieve symptoms than alternative methods. Additionally, prescribing antidepressants is an accelerated treatment plan that reduces pressure on the healthcare system from a resource perspective (Clancy & Noyes, 1976). This statement can, however, be paradoxical because quick fixes can be beneficial for resource reduction, but medication is not a long-term solution. Medication masks the problem instead of dealing directly with the anxiety.
According to Healey (2014), another issue with the sole medical treatment of anxiety is that medication may “be interfering with a process that occurs naturally […] and could possibly be causing a greater number of problems than we originally set out to treat” (p. 42). The medical model attempts to define illnesses through a defined clinical picture often found through medical testing; however, anxiety is not easily defined because it lacks precision as a physical and psychiatric illness (Clancy & Noyes, 1976, p. 91). Because of these concerns with the medical model, the most common treatment plan for anxiety is a mixture of medication and cognitive behavioural therapy (Rector et al., 2016, p. 21).
Concerning neurotic anxiety, the cognitive behavioural model of psychology intends to relieve and eliminate symptoms of anxiety. Healey (2014) explains that “research studies show that psychological therapies, i.e. CBT, are much more effective than drugs in managing anxiety disorders in the long term” (p. 35). Cognitive behavioural therapy (CBT) is a psychological treatment that recognizes a patient’s pattern of thinking (cognition) and acting (behaviour) and how that relates to anxiety (Healey, 2014, p. 38). CBT is the leading form of therapy to help those with anxiety. The goal of CBT is to change the patient’s patterns of thinking to eliminate the patient’s anxiety (Healey, 2014, p. 38).
The cognitive behavioural model looks at anxiety as a pathology and its overwhelming symptoms. Therapists work with patients to teach them how to “question and correct their tendencies to overestimate danger” (Rector et al., 2016, p. 23). Because CBT and medication are frequently used together, cognitive behavioural therapists and physicians view anxiety similarly. Psychologists in the field of cognition and behaviour see anxiety as a range of signs and symptoms that are caused by disproportionate feelings of stress towards non-threatening situations, which can be solved through the re-education of thought processes (Rector et al., 2016, p. 23).
Therapists using CBT work with clients to look at how their cognition affects their behaviour because the client’s thoughts are either “predisposing them to anxiety or keeping them from improving their anxiety” (Healey, 2014, p. 38). Supplementary to this learning of new cognitive strategies, cognitive behavioural therapists use exposure therapy. Therapists expose patients to anxiety-provoking situations that aim to show the patient that their fears are “excessive and irrational” (Rector et al., 2016, p. 22). Beyond re-educating patients and exposure therapy, CBT therapists teach relaxation training, stress management, biofeedback loops of anxiety, and meditation/breathing exercises to give patients tangible skills (Rector et al., 2016, p. 20). Since CBT helps patients through a step-by-step process of re-education, exposure, and skill acquisition, this model can be brief compared to alternative types of therapy.
Similar to the medical model, CBT is a fairly short method of treatment generally lasting about twelve to fifteen weekly sessions (Rector et al., 2016, p. 21). This, again, can be positive and negative with regards to overall effectiveness. The skill-based method of CBT is typically very effective for patients overcoming feelings of anxiety; however, existentialism is critical of CBT. The main critique that existentialism has towards CBT is that it neglects to dive below the surface to find the true root of the patient’s anxiety. The idea of existential psychotherapy and dynamic therapy is to find the root of the problem and understand the problem before dealing with physiological issues of anxiety. Therefore, existentialists feel that CBT fails to be a long-term effective form of treatment because it only deals with anxiety in basic and immediate terms. CBT barely scratches the surface of understanding the human experience (Hoffman & Cleare-Hoffman, 2011, p. 262).
Hoffman & Cleare-Hoffman (2011) critique modern psychology, and CBT as an extension of that, for focusing only on categorizing emotions as “good” or “bad” and then treating “bad” emotions as unhealthy. Therefore, unhappiness and stress would be seen as unhealthy emotions (Hoffman & Cleare-Hoffman, 2011, p. 261). They also believe that this creates “implicit value assumptions about emotions intimately tied to this process of labelling emotional stress as pathological;” therefore, critiquing psychology and its tendency to pathologize emotion (p. 262). They go on to explain that “pathologizing emotions often contributes to a barrier of accepting emotions, thus facilitating the process of emotions becoming neurotic” (p. 262). This means that the more therapists contribute to the narrative that anxiety is a “bad” emotion that must be eliminated, the more likely normal anxiety could become neurotic (Hoffman & Cleare-Hoffman, 2011, p. 262). Moreover, feminist practices and theories “explore the social construction of emotion, and systematically contest emotions as natural, universal, or biological” (Boler, 1999, p. 11). Thus, a model of therapy based around correcting anxiety does not appreciate the normalcy of emotion, nor does it adequately treat patients that are suffering.
With this critique of modern psychology, existentialism gives society an alternative therapeutic approach. Yalom (1980) defines existential psychotherapy as “a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence” (p. 3). He goes on to contrast existential psychotherapy to modern psychological therapy by saying that the ultimate driver of anxiety is based on humanity’s four ultimate concerns: isolation, freedom, meaninglessness, and death (Yalom, 1980, p. 7). To create existential psychotherapy, existential theorists began to look at mental illness and psychopathologies. Existentialists did not believe in modern psychology’s view of treatment because they believed that there was a tendency in Western culture to “regard fears and anxiety in negative light, as a result of unfortunate learning, [which] is not only an oversimplification but […] removes the possibility of constructive acceptance and calls day-to-day anxieties as specifically neurotic” (May, 1950, p. 227).
Existentialism sees anxiety in many different ways but primarily as a normal part of the human experience that should be accepted, not corrected. Therefore, therapy is used to understand why people feel anxious and to help them accept how to live with and understand anxiety in appropriate and non-harmful ways. Frankl, Crumbaugh, Gerz, & Maholick (1967) believed that anxiety may come from the “tragic triad:” suffering, guilt, and transitoriness (p. 56). In Frankl’s work as a psychologist, he takes “man’s search for meaning [as not] pathological, but rather the surest sign of being truly human” (Frankl et al., 1967, p. 72). Within this search, there comes self-awareness. May (1950) believed that anxiety is a state that happens when one confronts their freedoms, which is a result of gaining self-awareness (p. 234). The basic aim of modern psychology is to gain self-awareness, and with this comes more existential anxieties. These anxieties can only be properly discussed through existentialism because with self-awareness comes a loss of freedom that modern psychology tends to oversimplify (May, 1950, p. 35). Yalom, Kierkegaard, and May all agree that faith in modern psychology “puts a mask over” anxiety rather than facing the underlying dynamic sources of anxieties, whether they are related to freedom, isolation, meaninglessness, or death (May, 1950, p. 40).
The main difference between existential psychotherapy and modern psychological therapy (i.e. CBT) is that existential psychotherapy changes the narrative of anxiety. Rather than seeing anxiety as a pathology that must be eliminated, existentialism works with clients to change their understanding of anxiety in hopes that it will allow them to see anxiety as a part of the human condition and see how to appropriately deal with the related emotions. Where CBT and existential psychotherapy continue to differ is based on their fundamental understandings of human beings and their experiences. Psychology approaches therapy as mechanistic and technical, which is manipulative in nature (Frankl, 1969, p. 6). Psychological approaches look at “communications about ourselves and the world about us as mere symptoms of neurological functioning,” which is an epistemological approach to therapy (Szasz, 1974). Existentialism takes an ontological approach by bringing the importance of “being” to the forefront in therapeutic practice (Frankl, 1969, p. 6).
Frankl outlines his methods of therapy in his book Psychotherapy and Existentialism, which gives readers a clearer view of the practical use of existential psychotherapy. In his book, he recalls working with a client with anticipatory anxiety, which is the experience of feeling anxious about the possibility of feeling anxious in the future. In this situation, Frankl “refocused meaning and purpose, and decentered [the client] away from obsession and compulsion that [was] causing these symptoms” (Frankl et al., 1967, p. 76). Another way to use existential psychotherapy is to have the client talk about the experience of anticipatory anxiety and how it is related to a loss of freedom, feeling of isolation, the experience of meaninglessness, and/or fear of death. The keystone idea to this form of therapy is refocusing meaning and the patient’s understanding of meaning while uncovering the root of the patient’s anxieties. This differs from the cognitive behavioural model which is very strategic and intends to cure symptoms immediately rather than indefinitely.
There are benefits to existential psychotherapy because it aids clients through understanding the root of anxiety while also accepting that anxiety is a normal part of the human experience. While existential psychotherapy can work for some, there have been numerous critiques of its applicability to all individuals seeking therapy (Frankl, 1969, p. 70). However, existentialists rebut this notion because every human has the same ultimate concerns, and if implemented correctly, existential psychotherapy should work (Frankl, 1969, p. 70). Another critique of existential psychotherapy is its time-consuming nature. Existential psychotherapy requires much more time with the client than CBT. However, the difference between the two is that CBT would cure present symptoms of anxiety with a possibility of it returning or metastasizing in different ways in the future, whereas existential psychotherapy aims at relieving anxiety by completely revolutionizing the client’s understanding of anxiety (Szasz, 1974). This means that clients going to existential therapists would be able to apply what they have learned to future anxieties as all anxiety comes from the four ultimate concerns. Therefore, existentialism continues to debate that existential psychotherapy is the best way to help people suffering from pathological anxiety since anxiety cannot be properly treated until the root cause is confronted.
To be human is to be in the world (Frankl, 1969, p. 7). Humans are not machines in need of repair but rather human connection and guidance. Galileo viewed the world as a machine and a mechanism for production (Gleiser, 2005, p. 150). This idea cannot be expanded to humanity without serious complications. The existential movement fights back on science and strategy to bring therapy back to its basics: human connection. Existentialism and its forms of therapy are completely based on ontology and philosophical anthropology (Frankl, 1969, p. 10). Cognitive behavioural psychology and the medical model are grounded in science and epistemology; both are trying to retrieve knowledge from a client to learn about their condition, rather than understand the being of humanness (Szasz, 1974).
Anxiety can be understood in many different ways and examining it through the medical model, the cognitive behavioural model, and the existential psychotherapeutic model are just three ways to understand it. Everyone responds to therapy in different ways. However, Western society needs to put a greater effort into alternative methods of therapy rather than simply a “cookie-cutter” approach like antidepressants and a short-term CBT program. A more holistic view of the human experience can only help us understand ourselves more fully.
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