SOME PRINCIPLES OF EXISTENTIAL THERAPEUTIC WORK AND PRACTICE IN SEVERE AND PERSISTENT DISORDERS. WORKING WITH SEVERE OR PERSISTENT ANXIETY 

Digby TantamDirector, Septimus LtdEmeritus Professor, University of SheffieldHonorary Visiting Senior Research Fellow,

University of Cambridge

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WHO Europehttp://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/data-and-statistics

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 5.8Amphetamine use 15 6.2 2.4Cocaine use 16 6.0** 2.4Anorexia nervosa 17 5.9 2.3Disruptive behaviour disorder* 34

5.0*** 1.9

Methamphetamine use 35 4.7 1.8Acute and transient psychotic disorder 36

4.7 1.8

Alcohol use disorder 19 4.6 1.8Personality disorder 37 4.2 1.7Intellectual disability (moderate to profound) 39

2.8 1.1

Heavy smoking22 2.6*** 1.0Schizophrenia 1 2.5 1.0Bipolar disorder 40 2.2** 0.8Bulimia nervosa 17 1.9 0.8Eating disorder NOS 17 1.9 0.8Adults with childhood ADHD 41

1.9 0.8

Depression 25 1.6 0.6Dysthymic disorder 27 1.4 0.6Comorbid anxiety/depression 42

1.4 0.6

Cannabis use 28 1.2**,*** 0.5

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

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.

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’

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

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

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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)”

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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’

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.0116820http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0116820

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% men3.7 to 7.1% womenAnxiety disorders are often defined as qualitatively

similar to anxiety, but more persistent, more prolonged, and more disabling

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

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

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.

?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)

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Symptom disappearance at one

year22

No. seeking further therapy

No. seeing a psychiatricNo. also taking meds

50 lost to follow up

Data fromDiMauro, 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

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)

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Symptom disappearance at one

year22

No. seeking further therapy

No. seeing a psychiatricNo. 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)

Total functioningHousehold 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.

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 conditionTreatments are not particularly effectiveWe don’t really understand it

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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

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PRE-OCCUPYING CONCERN

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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 namedvon Uexküll: UmweltThe psychiatrist of Ellen West, who was examined by Kraepelin and

Hoche at his requestTranslated 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

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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 UmweltThe psychiatrist of Ellen West, who was examined by Kraepelin and

Hoche at his requestTranslated 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

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MEDARD BOSS

Worked closely with Heidegger.Influenced by, but then split, from Binswanger and

FreudOrganized the Zollikon seminarsHighlighted the importance of Gelassenheit in

recovery from psychological disorder

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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.

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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

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RONALD LAINGInfluenced by SartreDeveloped 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!

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KARL ‘KALLY’ JASPERS

Born Oldenburg (605 Km from here)Unpaid psychiatric trainee but gave psychiatry up for his parallel career

as a philosopherWrote 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 WeberBrother, Enno, committed suicide aged 42

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GENERAL PSYCHOPATHOLOGYDistinction, based on Dilthey and Weber, on (Verstehen) and those

explained (Verklaren)Form and content distinctionUnderstandable and non-understandable reactionsNone of these map onto psychosis: perhaps most onto sexual deviations

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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

THE DODO BIRD VERDICT

THE DODO BIRD VERDICT

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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.

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LIMITS TO THERAPY 2A 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.

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ANLAGEPhysical 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)AbusePrevious ‘trauma’

Culture and ideology

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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

www.nspc.org.uk

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

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

Ontological anxiety as a mood sweeps away thefamiliarity of the world: Generalized Anxiety Disorder

THE LOOKFeeling the look on one’s backCaught in a moment of private

excitementThe look is not returnedThe 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

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Titania hotel, Athens

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PRECIPITANTS

None(Interpersonal conflict)‘Stress’ e.g. imprisonment and Ganser syndromeDisappointment in love (early 19th. C) or sexual

inhibition (‘hysteria’)

..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

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PATH

Past disorder creates a pathPerhaps 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

SPECIFIC EFFECTS OF EXISTENTIAL THERAPY

What pre-occupying concern does existential therapy address?

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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).

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

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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

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3 PEOPLE

The woman who cried incestThe man who feared EasterThe dentist who suffered a chronically aching mind

(‘PTSD’)