Does a Philosophical Grounding in an Existential Ontology Make for a Better Psychotherapist?

Let me begin by summarizing my understanding of some of Hersch’s main points. He proposes 1) that “the use of existential themes and concepts” and “an existential ontology provides a more suitable philosophical grounding for psychotherapeutic theories and practices”(presumably more suitable than other philosophical groundings); and 2) that “an existential version of the mental status examination… can provide us with a more in-depth understanding of…an individual’s experiential world” (2015, 107).

According to Hersch, an existential perspective directs our attention to the existential guilt and anxiety “present inherently in the human situation” (p. 109). The former, “existential guilt,” “is a kind of guilt which is always present as our guilt about having chosen one option over another” (p. 109). “The existential therapist might help the patient to face and accept this inevitability…” (p. 110). As for existential anxiety, it is concerned with the “radical finitude, indefiniteness, and temporariness for human life” (p. 110)—an anxiety with which the existential therapist may help the patient deal. Hersch then goes on to discuss self-deception and bad faith as “existential defense[s]” (p. 110), including their presence “in some of our psychiatric theorizing” and “objectivistic approaches where diagnostic labels and constructs tend to become inappropriately reified” (p. 112).

This is then followed by a discussion of the implications of a Heideggerian existential ontology for psychiatric and psychological thinking. And finally, the author suggests the usefulness of “an existential mental status examination” that focuses on “six key features of human experience” (p. 115) (e.g., relatedness to a world, temporality, interpretiveness and perspective, etc.).

What do I, a psychodynamically oriented psychologist and psychotherapist, make of all this? I have a number of comments and reactions with regard to some of the issues discussed.

Hersch argues that existential writings have called our attention to existential guilt and existential anxiety that are “often neglected” (p. 109), that “are part of the universal human condition” (p. 109), and that, as such, need to be addressed in any meaningful psychotherapy. Hersch defines existential guilt in terms of “our guilt about having chosen one option over another” (p. 109). Based on his philosophical convictions, Hersch suggests that, for all patients and in some form, existential guilt and existential anxiety will be at the center of their suffering and concerns. However, even if one accepts the idea that existential guilt and anxiety are universal aspects of the human condition, it does not follow that they will necessarily be a given patient’s central concerns. After all, there are many issues in one’s life that may be central to a given individual and that may underlie the patient’s concerns, sufferings, and strivings.

Although the content may not be the same, the focus on existential guilt and anxiety does not seem to be different in structure from, say, Freudian theorists being certain that, for all patients, oedipal conflicts will be central to their suffering and concerns. In both cases, there is the real risk that an a priori theoretical position will be imposed on a living, feeling person whose primary concerns may be different from those that are central in the therapist’s theoretical or philosophical presuppositions. The therapist’s job is to be open to the patient’s living experiences and concerns, not to decide beforehand what those experiences and concerns are going to be.

It is, of course possible—perhaps likely—that sensitivity to and concerns with issues of existential anxiety and guilt will enrich the clinical work of any therapist. This is what Hersch may have in mind when he suggests that an existential ontology is a suitable philosophical grounding for psychotherapists. However, such background sensitivity and concerns may not necessarily translate into the centrality of these issues in the clinical work itself.

As a separate incidental point, even within Hersch’s own framework, it is not clear to me why one would necessarily experience guilt about having chosen one option over another. Why not regret or a sense of loss? As Hersch...