Why understanding and explanation are not exclusive: what Jaspers really wrote

1. SOME PRINCIPLES OF EXISTENTIAL THERAPEUTIC
WORK AND PRACTICE IN SEVERE AND PERSISTENT
DISORDERS. WORKING WITH SEVERE OR PERSISTENT
ANXIETY
Digby Tantam
Director, Septimus Ltd
Emeritus Professor, University of Sheffield
Honorary Visiting Senior Research Fellow,
University of Cambridge

2. Click to edit Master title
2
WHO Europe
http://www.euro.who.int/e
n/health-
topics/noncommunicable
-diseases/mental-
health/data-and-statistics

3. Diagnosis All-cause mortality (risk
compared with the general
population)
Prevalence ratio (risk
compared with that for heavy
smoking)
Post-partum psychiatric
admission (at 1 year) 33
19.5 7.7
Opioid use 6 14.7 5.8
Amphetamine use 15 6.2 2.4
Cocaine use 16 6.0
**
2.4
Anorexia nervosa 17 5.9 2.3
Disruptive behaviour
disorder
*
34
5.0
***
1.9
Methamphetamine use 35 4.7 1.8
Acute and transient
psychotic disorder 36
4.7 1.8
Alcohol use disorder 19 4.6 1.8
Personality disorder 37 4.2 1.7
Intellectual disability
(moderate to profound) 39
2.8 1.1
Heavy smoking22 2.6
***
1.0
Schizophrenia 1 2.5 1.0
Bipolar disorder 40 2.2
**
0.8
Bulimia nervosa 17 1.9 0.8
Chesney, E., et al. (2014). "Risks of all-cause and suicide
mortality in mental disorders: a meta-review.”
World Psychiatry 13(2): 153-160.
ASD

4. The dose–effect relationship in psychotherapy.
By Howard, Kenneth I.; Kopta, S. Mark; Krause, Merton S.; Orlinsky, David E.
American Psychologist, Vol 41(2), Feb 1986, 159-164.

5. The dose–effect relationship in psychotherapy.
By Howard, Kenneth I.; Kopta, S. Mark; Krause, Merton S.; Orlinsky, David E.
American Psychologist, Vol 41(2), Feb 1986, 159-164.
Remoralization
Symptom change
Improvement in ‘life-functioning’

6. THE EFFECTS OF PSYCHOTHERAPY: AN EVALUATION.
EYSENCK, H. J.
JOURNAL OF CONSULTING PSYCHOLOGY, VOL 16(5), OCT 1952, 319-324.
HTTP://DX.DOI.ORG/10.1037/H0063633

7. Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial Severity and
Antidepressant Benefits:
A Meta-Analysis of Data Submitted to the Food and Drug Administration. PLoS Med, 5(2), e45. doi:
10.1371/journal.pmed.0050045

8. HTTP://WWW.APA.ORG/ABOUT/POLICY/RESOLUTION-PSYCHOTHERAPY.ASPX
“These large effects of psychotherapy are quite constant
across most diagnostic conditions, with variations being
more influenced by general severity than by particular
diagnoses—That is, variations in outcome are more
heavily influenced by patient characteristics e.g.,
chronicity, complexity, social support, and intensity—and
by clinician and context factors than by particular
diagnoses or specific treatment "brands" (Beutler, 2009;
Beutler & Malik, 2002a, 2002b; Malik & Beutler, 2002;
Wampold, 2001)”
8

9. Imel, Zac E; Wampold, Bruce E (2008). "The importance of treatment and the science of common factors
in psychotherapy". In Brown, Steven D; Lent, Robert W. Handbook of counseling psychology (4th
ed.). Hoboken, NJ: John Wiley & Sons. pp. 249–262.
Up to 70% of the variance of the effects of psychotherapy
Jerome Frank. Persuasion and healing
First attempt to formulate universal therapeutic factors for combatting
‘demoralization’
9

10. Fig 2. Age-Standardized DALY Rates Attributable to Individual Mental, Neurological, and
Substance Use Disorders, by Gender, 2010.
Whiteford HA, Ferrari AJ, Degenhardt L, Feigin V, Vos T (2015) The Global Burden of Mental, Neurological and Substance Use Disorders: An
Analysis from the Global Burden of Disease Study 2010. PLoS ONE 10(2): e0116820. doi:10.1371/journal.pone.0116820
http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0116820

11. 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

12. 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

13. 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

15. 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.

16. ?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

17. 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)

18. 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.

19. 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
Of 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

20. 20

21. Click to edit Master title
People persist in therapy if it addresses their
preoccupying concern
Therapists who are effective in the area of
preoccupying concern will have better
outcomes because:
a. Their clients will stick with them;
b. They will receive more of any specific effect
21
PRE-OCCUPYING CONCERN

22. THE EARLY EXISTENTIAL PSYCHOTHERAPISTS WERE
PSYCHIATRISTS OR PSYCHIATRIC TRAINEES
Ludwig Binswanger
Coincidentally the nephew of Nietszche’s psychiatrist, Otto, for whom
Binswanger’s disease (sub-cortical vascular dementia) is named
von Uexküll: Umwelt
The psychiatrist of Ellen West, who was examined by Kraepelin and
Hoche at his request
Translated into French by Michel Foucault who wrote a preface to
Binswanger’s Traum und Existenz in which he considered Ellen West
and Simone Weil’s belief that the body was a weight holding back the
spirit
22

23. LUDWIG BINSWANGER
Coincidentally the nephew of Nietszche’s psychiatrist, Otto, for whom
Binswanger’s disease (sub-cortical vascular dementia) is named
(Nietszche may have been one of his cases)
Influenced by von Uexküll and Heidegger’s conception of the Umwelt
The psychiatrist of Ellen West, who was examined by Kraepelin and
Hoche at his request
Translated into French by Michel Foucault who wrote a preface to
Binswanger’s Traum und Existenz in which he considered Ellen West
and Simone Weil’s belief that the body was a weight holding back the
spirit
Originated the term Daseinsanalysis
23

24. MEDARD BOSS
Worked closely with Heidegger.
Influenced by, but then split, from Binswanger and
Freud
Organized the Zollikon seminars
Highlighted the importance of Gelassenheit in
recovery from psychological disorder
24

25. INTERNATIONAL FEDERATION OF
DASEINSANALYSIS
“Daseinsanalysis proceeds phenomenologically; it
does without causal-genetic interpretations and,
instead, inquires more intensely into the meaning
and meaning-content of the observed phenomena.
The concem of Daseinsanalysis is to see (sehen),
not to explain (erklären). The importance and
meaning of this "Seeing" becomes manifest in the
theory of neuroses and psychosomatic diseases”
http://www.daseinsanalyse.com/ifda/daseinsanalysis.
html.
25

26. VIKTOR FRANKL
A noted suicidologist who survived concentrations
camps partly through his informal or formal status
as a camp doctor
Emphasized the importance of living life with
‘meaning’ and linked suicide to losing meaning
26

27. RONALD LAING
Influenced by Sartre
Developed a complex theory of social
interrelatedness, partly based on social psychiatry
ideas
Considered schizophrenia to be an individual
reaction to disturbed social relations that ultimately
because a repudiation of the medical concept of
mental illness
Inspired Emmy van Deurzen to come to UK!
27

28. KARL ‘KALLY’ JASPERS
Born Oldenburg (605 Km from here)
Unpaid psychiatric trainee but gave psychiatry up for his parallel career
as a philosopher
Wrote Allgemeine Psychopathologie in 1913 and then revised it
repeatedly until the 4th edition in 1946 (a further 3 editions were
issued, and it was the 7th. that was translated into English
Friend and support of Max and Marianne Weber
Brother, Enno, committed suicide aged 42
28

29. GENERAL PSYCHOPATHOLOGY
Distinction, based on Dilthey and Weber, on (Verstehen) and those
explained (Verklaren)
Form and content distinction
Understandable and non-understandable reactions
None of these map onto psychosis: perhaps most onto sexual deviations
29

30. The fact of the psychoses is a puzzle to us. They are
the unsolved problem of human life as such. The
fact that they exist is the concern of everyone.
That they are there and that the world and human
life is such as to make them possible and
inevitable not only gives us pause but makes us
shudder. This concern is one of the mainsprings of
our desire for psychopathological knowledge. (p.
778)
But that did not make the un-understandable
30

31. THE DODO BIRD VERDICT

32. THE DODO BIRD VERDICT

33. LIMITS TO THERAPY 1
Therapy cannot be a substitute for something that only life itself
can bring. For instance, we can only become transparently
ourselves through a life time of loving communication in the
course of a destiny shared with others. On the other hand
such clarification as is brought about by psychotherapeutic
means always remains something limited, objective,
theoretical and restricted by authority. A professional
performance constantly repeated on behalf of many never
reaches the goal which only engagement in mutuality can
attain. Further, life brings responsible tasks, perforce, and
there are the real demands of work which no therapy
however artful can contrive.
33

34. LIMITS TO THERAPY 2
A person is originally thus and no other and therapy
finds itself con fronted with this factor which it cannot
alter. I in my freedom may confront this fact that I am
thus and no other, confront it as something I may
change or at least transform through acceptance, but
any therapy of others has to reckon with unalterable
elements, the mark of some lasting essence,
something inborn. It is true we cannot say what this is
in any given case but it is a basic experience of every
doctor that where this 'being thus and no other' is the
cause of the patient's distress, it provides an
insurmountable obstacle which will frustrate every
therapeutic attempt. 34

35. 09/12/
www.nspc.org.uk

36. ANLAGE
Physical habitus (his own bronchiectasis?)
Genetics e.g. serotonin receptor allele, Enno’s lack
of foresight (ADHD)
Tuning e.g. pCO2 receptor
socio-economic deprivation in childhood
Experience
(Attachment)
Abuse
Previous ‘trauma’
Culture and ideology
36

37. 09/12/
www.nspc.org.uk

38. 09/12/
www.nspc.org.uk

39. MITCHELL, C.,
HOBCRAFT, J.,
MCLANAHAN, S. S.,
SIEGEL, S. R., BERG,
A., BROOKS-GUNN, J.,
NOTTERMAN, D. (2014).
SOCIAL
DISADVANTAGE,
GENETIC SENSITIVITY,
AND CHILDREN’S
TELOMERE LENGTH.
PROCEEDINGS OF THE
NATIONAL ACADEMY
OF SCIENCES, 111(16),
5944-5949
09/12/
www.nspc.org.uk

41. One of the cartoons on the
‘Being and Tim blog’

42. One of the cartoons on the
‘Being and Tim blog’
Ontological anxiety as a mood sweeps away the
familiarity of the world: Generalized Anxiety Disorder

43. 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
Titania hotel, Athens

44. PRECIPITANTS
None
(Interpersonal conflict)
‘Stress’ e.g. imprisonment and Ganser syndrome
Disappointment in love (early 19th. C) or sexual
inhibition (‘hysteria’)
44

45. ..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

46. PATH
Past disorder creates a path
Perhaps he was here thinking of his hero, Max
Weber for whom a path of anxiety was created by
childhood meningitis, and his extreme mood
change following the death of his father
46

48. SPECIFIC EFFECTS OF EXISTENTIAL
THERAPY
What pre-occupying concern does existential therapy
address?

51. 51

52. 1) People possess orienting systems (global meaning) that provide them with
cognitive tools to interpret their experiences and motivate their functioning in
the world.
2) People appraise the situations that they encounter, assigning a meaning to
them.
3) The extent to which that appraised meaning is discrepant with their global
meaning determines the extent to which they experience distress.
4) The distress caused by discrepancy initiates a process of meaning making.
5) There are many ways to make meaning.
6) Through meaning making, individuals reduce the discrepancy between
appraised and global meaning and restore a sense of the world as
meaningful and their own lives as worthwhile.
7) Meaning making, when successful, leads to better adjustment to the
stressful event
PARK, C. L. (2013). TRAUMA AND MEANING MAKING: CONVERGING CONCEPTUALIZATIONS AND
EMERGING EVIDENCE THE EXPERIENCE OF MEANING IN LIFE: CLASSICAL PERSPECTIVES, EMERGING
THEMES, AND CONTROVERSIES (VOL. 9789400765276, PP. 61-76).

53. Click to edit Master title
53
Frequency of expressions of fear or anger correlate with ‘stress’ parameters i.e. strain
Lerner, J. S., et al. Facial Expressions of Emotion Reveal Neuroendocrine and Cardiovascular
Stress Responses. Biological Psychiatry, 61(2), 253-260.

54. Click to edit Master title
www.existentialacademy.com 54

55. In relation to the individual himself and his potential true
Existence, the doctor can only act within the concrete,
historical situation, where the patient is no longer just
a case but a human destiny that unfolds in the light of
its own self-illumination. Once the individual has
turned into an object, he can be treated by technical
means, nursing care and skill…
The whole treatment is thus absorbed and defined within
a community of two selves who live out the
possibilities of Existence itself, as reasonable beings.
One questions and gropes from one freedom to another
within the concreteness of the actual situation, taking
no responsibity for the other nor making any abstract
demands pp 797-8 55

56. 3 PEOPLE
The woman who cried incest
The man who feared Easter
The dentist who suffered a chronically aching mind
(‘PTSD’)
56