Richard Smith: The NHS needs existential psychotherapists


Existential psychotherapists help people with the existential, eternal, unsettling, and human problems of meaninglessness, isolation, and the terror of death. These are problems that are causing much suffering in Britain and yet do not respond to the drugs that are the standby of the NHS. That’s why the NHS needs existential psychotherapists. It may have some—but in disguise.

I’ve been reading about existential psychotherapy in the Worm in the Core: on the Role of Death in Life by Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski, a book that argues that responding to the terror of death has been the main driver of human culture and behaviour.

The methods of existential psychotherapy are laid out in Irvin Yalom’s book Existential Psychotherapy, and he emphasises that there is no specific set of techniques. Rather existential psychotherapists develop deep and authentic relationships with their patients in which the therapists acknowledge that they too struggle with the unavoidable existential problems—or should I call them opportunities? The therapists emphasise freedom and responsibility and that there is almost always a choice.

Authenticity seems to be the virtue of the hour. Whatever people may think of the politics of Jeremy Corbyn, the favourite to become leader of the Labour Party, they agree on his authenticity. They mean that he has a clear set of values that he lives by, says what he thinks no matter how unpopular, answers questions directly, stays away from attacking others, and—with his grizzled face, scruffy beard, and functional clothes—feels like the flawed human being we know we are. In contrast, his rivals feel somewhat manufactured, even though I know that they are not. In an age of spin, artifice, and instant messages we seem to hunger for authenticity, and existential psychotherapists offer it, no matter how uncomfortable it might be.

We all need meaning in our lives, and meaning can, write Sheldon and others, “be inadequately formed in youth or undermined in adulthood because of a host of challenges, including neurological impairment, biochemical imbalances, harsh or chaotic upbringing, traumatic experiences, awareness of alternative belief systems, discomfort with our bodies and carnal desires, economic upheaval, betrayal by or loss of loved ones, and physical ailments.” Reading that list, I wondered how any of us could hope to sustain the meaning in our lives, but we do.

Victor Frankl, who can be described as an existential psychotherapist, formed his ideas on meaning while a prisoner in Auschwitz and shared them in his book Man’s Search for Meaning, which has sold over 10 million copies. He saw three main sources of meaning: relationships, work, and overcoming suffering. People may fall into meaningless when they take what Solomon and others call a “galactic” view of life and reflect that we are short lived creatures spinning round on a dying rock at the edge of the universe. The existential psychotherapists, none of whom believe that life has inherent or ultimate meaning, help their patients by bringing them back to the everyday, their children, the lecture on death they are due to give.

Yalom writes about the ironic life of the philosopher Arthur Schopenhauer, sometimes described as the most miserable man who ever lived, who insisted that nothing matters in an absurd, indifferent, universe. He found meaning in life by writing books insisting on meaninglessness.

All of us, and certainly existential psychotherapists, recognise that we are ultimately alone, but again the therapists concentrate on the practical, helping people build new relationships, develop existing ones, and restore broken ones. The therapists put great emphasis on this part of the work, and they advise people that relationships are most effective at reducing isolation by concentrating on getting to know the other person rather than trying to meet your own needs.

Solomon and others have shown through hundreds of experiments that we have both proximal and distal defences against the universal terror of death. The proximal defence is to simply push the thought out of our minds or into the distant future or to rationalise it away. Distal defences are more unconscious and comprise strengthening our faith in our culture (whatever it might be) and boosting our self esteem.

Existential psychotherapists, following whether they know it or not the advice of Michel Montaigne, guide their patients through “a sustained contemplation of death and efforts to desensitise them to it.”

Ivan Illich, the critic of industrial society and my hero, argued that modern medicine had replaced cultural mechanisms for making sense of death with an implicit, false, undelivered, and undeliverable promise of defeating death. Atul Gawande, the Boston surgeon, seems to agree: “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.” Instead of spending billions of pounds fending off death the NHS would do better to invest in existential psychotherapists.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.