Empathy and the Existential in Mental Illness and Psychotherapy

May 19, 2015   •   By Jessica Hendry Nelson

MY FORAYS into the warrens of psychotherapy began in my mid-teens with Dr. T., a kindly, middle-aged woman who tended to both my family traumas and ordinary angst with equal measures of empathy and lucidity. Nearly 20 years later, all that remain are a perpetual subscription for a daily low-dose of Lexapro, refilled twice-yearly by my primary physician, and a wistful ambition to recapture that first love. The specifics of my time in Dr. T.’s office are lost to me now. I was 16, then 17, then 18 and off to college, toting the copy of Stephen King’s On Writing she had bought for me as a farewell gift. If Dr. T.’s approach fit neatly into any one therapeutic modality, I didn’t know it then and I can’t pinpoint it now. I suspect her approach was flexible. Most important, perhaps, I liked and respected Dr. T. We developed a friendship and I was disappointed when she declined the invitation to my high school graduation party.

In hindsight, it would have made for some awkward introductions.

I’ve seen a few therapists since then. I try them out occasionally like a wary suitor, only to give up within the first few sessions after I sense a bad fit. This one won’t look me in the eye, that one takes too many notes, yet another wants to know how everything “makes you feel,” from my brother’s heroin addiction to my overzealous affinity for breakfast cereal. Just yesterday, I met with a new therapist who spoke so slowly, and with such dejection in her voice, that I feared I might wind up counseling her. I went home and wrote the equivalent of the “it’s-not-you-it’s-me” email and restarted my search.

But these are paltry complaints. For most of my 20s, therapy was a luxury I couldn’t afford. I didn’t carry insurance and my wages from various odd jobs — waitress, nanny, sandwich artist in the county hospital — barely covered food and rent, let alone the $100 hourly rate that most therapists charge.

It was okay. I was okay. Meaning my mental health, while certainly not always at peak performance, is generally in basic working order. I’ve managed.

My brother, on the other hand, has not fared as well. Over 61.5 million Americans have a diagnosable mental illness. Sixty percent of them, including him, “will not receive treatment over a year’s period.” These harrowing statistics come from the National Institute of Mental Health and are recorded in the “Editor’s Note” of Same Time Next Week: True Stories of Working Through Mental Illness, edited by Lee Gutkind.

As the statistics suggest, my brother is only one of millions who suffer the slings and arrows of mental illness without consistent or beneficial therapy. From early diagnosis to misdiagnosis, he has battled bipolar disorder and addiction for 12 of his 28 years. Brief stints in rehab are cut short by insurance companies, and he exits the revolving doors of various therapists’ offices with yet another new prescription but no consistent mediation or supervision. By and large, however, he wages his wars alone. Through jail stints and rehabs and halfway houses, he is thoroughly integrated into an indifferent system.

In Same Time Next Week, Gutkind identifies a deep-rooted institutional failure, a system that “deals with patients and families in an assembly line fashion…if time, availability and resources permit treatment at all.” Health insurance companies don’t want to pay, drug companies seek to maximize profits, misdiagnoses stigmatize and harm patients, and clinicians are often underpaid and overworked. With this is mind, he’s assembled 18 personal essays written by patients, clinicians, or clinicians who have battled with mental illness themselves, each one recounting an individual tale of instability and, most often, eventual recovery. In fact, many of the patients writing in this book sought alternative paths to wellness: Gutkind’s aim is to call attention to outliers, to the success stories that occur despite institutional failures. It is a collection premised on hope and designed to offer hope, and the reader seeking to understand the front lines of mental illness without facing its many sorrowful endings will leave the book encouraged.

These essays recount desperate tales of trauma, misdiagnosis, and mistreatment, usually followed by a single clarifying event — often outside the bounds of traditional treatment — that sparks a mysterious and prescient turn. This is the nature of the beast: wherein a life’s journey is made or unmade daily, capitulated and recapitulated moment to moment, earned and not bestowed. Relapse and setbacks can be monumental events, but they can also occur in the time it takes to make a cup of coffee, answer the phone, or glimpse your reflection in the mirror. The essays in this collection are not a road map to recovery, but a reminder of recovery’s capriciousness.

And yet: if hope is a way into wellness, it is not, as this collection seems to suggest, an end unto itself. Some of the essay titles in the collection boldly espouse this credo: “Hope Nurtures the Dream,” “No Hope? Don’t Believe It,” “In Minnesota Once: On Anorexia, Masculinity and Recovery.” Many more marvel at the discovery of hope in their concluding paragraphs, a rare and priceless jewel. There is no shortage of hope here. And yet, my personal experiences prove hope to be a useful, but often illusive and ambiguous wand. Though I have hope for my brother’s recovery, I also know it will not alter his trajectory.

To wit, most of these writers struggle for years before finding the inexplicable catalyst that ushers them forward. Often, it comes from within. In “An American Boy,” Candy Schulman recounts her brother-in-law, Will’s, miraculous improvement after decades of suffering with schizophrenia. Initially, Will is considered an eccentric, an offbeat hippie in line with the 1960s counterculture ethos. He earns a PhD in neuropsychology despite a quixotic interest in spiritual enlightenment, a quest his family finds odd, but not alarming. A trained psychologist, Schulman helps the family navigate Will’s descent into schizophrenia, which begins shortly after he earns his PhD. Her research offers illuminating insights into possible causes, but the inscrutability of schizophrenia overwhelms their efforts to help Will find solace. Hospitalizations, medications, and earnest professionals do little to abate his symptoms until, without discernible motive, Will begins to improve. He gets a job. He gets a girlfriend and his own apartment. “No one can explain his sudden plunge into mental illness,” Schulman writes, “and no one could have predicted his entry back into the world.” Her elation is tempered by the possibility of relapse. “Although we are thrilled that Will is doing ‘so well,’” she writes, “we never use the words ‘recovered’ or ‘cured.’” This is hope with a caveat. We land firmly on its shores, but with a sense of the waves licking at our heels.

More often in this collection, recovery is sparked by some arcane brew of empathy, therapy, and medication, as in the case of J. Timothy Damiani’s patient, Mark, who, in “Playing Cards with Mr. Newman,” comes out of a stupefying torpor after years of institutionalization and neglect. Damiani meets Mark in a state hospital where he’d been living for years. Mark rarely talks or moves, and appears completely withdrawn. His head droops and he refuses to bathe or use the toilet, instead soaking his pants in urine. Damiani, the new psychiatrist on the ward, thinks Mark’s schizophrenia diagnosis is suspect. Mark, unlike most schizophrenics (who tend to be socially isolative), had been garrulous and romantic before he got sick. Through trial and error, Damiani slowly brings Mark back to life through a combination of empathy, friendship, and the right cocktail of medications. It’s a rocky but ultimately exultant journey. “The best my reason can do is to acknowledge that something extraordinary occurred,” Damiani concludes. The experience with Mark helps him retain hope for even his most troubled patients — but even here it is worth noting his patients are among the lucky third, not among the nearly 40 million with a diagnosable mental illness who will not receive quality care.

Tenaciously, and despite the harrowing realities illustrated in its front matter, this book highlights some of the many mental health practitioners who manage to help patients succeed despite the odds. Clinical psychologist Annita Sawyer was still a teenager when she was misdiagnosed with schizophrenia. In “What Would My Mother Say,” Sawyer recounts years of debilitating electric shock treatments that left her with hallucinations, nightmares, and memory loss. To mediate her pain, Sawyer turned to self-harm, which only affirmed her doctors’ decisions to continue this damaging course of treatment. Like many of the essays in this collection, Sawyer’s story begins with a “common diagnosis at the time” and finds closure through extraordinary bouts of good luck, hard work, willpower, and yes, hope. Eventually, she takes comfort in her work with a new psychiatrist, a man with whom she develops a relationship grounded in trust and energized by a shared sense of humor. (“‘What a pain in the neck!’ he said once, after I’d smashed my head against the wall.”) Despite the institutional vise, Sawyer’s psychiatrist manages to facilitate and bear witness to remarkable progress. Thirty-five years later, Sawyer uses her past to inform her work as a clinical psychologist. Like other accomplished practitioners, Sawyer recognizes that psychotherapy, at its best, can be an ennobling and intimate journey. Masterful clinicians foster relationships with patients founded on mutual respect and empathy. In best-case scenarios, there’s demonstrative progress. Respect and empathy are vague terms, however, and even the noblest intentions can be thwarted by cultural biases that diminish and degrade people with mental illness. Of her schizophrenia misdiagnosis, Sawyer admits, “A half century later, that stigma and shame still haunt me.”

As with any story of a life, there’s a great deal that Sawyer can’t explain. Her evolution from patient to practitioner moves swiftly (on the page, anyway) after this first serendipitous meeting with the new doctor. In four short paragraphs, we learn that Sawyer’s understanding grew “over time” and the years she lost to electric shock therapy loosened their stranglehold “gradually.” She left the mental hospital after two years, “found a husband […] and managed to complete [her] education.” These leaps in time are manifestations of the magnitude of such a recovery, however, and not lazy writing. They speak to unpredictability and tenuousness of good health and suggest that healing, if it is to occur at all, will be largely enigmatic — a repeating theme of the collection. Ultimately, mental illness doesn’t conform to the conventional arc of a short narrative about healing. (“It’s impossible to show the complexity of a narrative in a short essay,” writes therapist Jennifer Lunden in “Paradise/Lost,” “How do I do justice to Astra’s complex story?”)

In “Live a Little,” written by therapist Ellen Holtzman, we meet Ann, a girlish 40-year-old whose tremendous anxiety obstructs even her ability to drive to work. After a slow start, Holtzman worries that their time together will come to an early halt if Ann’s insurance company isn’t satisfied with her progress. “Health insurance companies might easily see twice-weekly psychotherapy […] as excessive,” she writes, “particularly if the symptoms do not subside.” Holtzman manages the pressures from Ann’s insurance company and finagles with the weekly disability forms that keep Ann financially afloat. The pair work tirelessly to overcome Ann’s crippling anxiety, but ultimately, Holtzman admits, “I cannot say for sure why Ann finally improves.” Therapy helps, but it’s not enough, this confession suggests. As with the best of these essays, Holtzman’s embraces both territories, wherein redemption is personal and idiosyncratic, and also profoundly vested in the evolution of professional treatment and the system that facilitates it.

For my brother, and countless others, institutional negligence is not the problem; it is but one part of a vast web of disadvantage: biological, situational, economic, and systematic. Both my brother and I have been aided and wounded by well-meaning mental health professionals, including the 88-year-old man who wore two different shoes to most appointments and attempted to prescribe us lithium at the ages of 12 and 14. In reality, we were just teenagers who needed to talk about our drunk daddy. Like Annita Sawyer, my brother left that office with a trendy diagnosis, ADHD, and a prescription for Ritalin — which left him with an unshakable label at school and a heavy assist toward impending addictions. “One of the villains of these tales is diagnosis,” psychiatrist Peter D. Kramer writes in the book’s introduction. “Patients accumulate labels, with little clarity gained.” Instead, this collection urges for holistic treatment that assesses people, not disease.

Additionally, Gutkind calls on our “leaders in Washington and in local and state government [to] take steps to increase funding, expand facilities, and respond to the needs not only of patients but also of the professionals who are committed to helping them.” This is only one part of a solution, however, and like any reform, only possible through the persistent war cries of the embattled. In the introduction, Kramer consents to a larger, existential predicament “where terror prevails, where stubbornness and belated good luck become critical, where the individual, hand-crafted solution is the only one we can hope to find.”

It can be both heartening and harrowing to read so many tales of recovery premised on some intangible blessing yet to grace your loved one. The remarkable stories in this collection are the exceptions, which is hard to remember (and who really wants to?) reading through this chorus of compassion, hope, and recovery. Faced with the realities of serious mental illness, it can be difficult to reconcile these phenomenal tales with your and my own experiences. My brother hasn’t gotten better. Moreover with each relapse, his chances of survival diminish. “My binges are getting shorter and shorter,” he said the last time my mother and I rushed him to yet another intake unit. That’s our reality.

But only one out of 18 essays in the collection tells this more familiar tale. Only one represents the population that comprises the statistics in the book’s “Editor’s Note,” for whom help comes too late, or not at all, or whose lives end tragically despite well-intentioned therapy. “His death wasn’t a reflection of what had failed, but of the strong hold, even if momentary, that depression and addictions can have over those who valiantly fight them on a daily basis,” writes Katharine Sheppard Carrane in “Illusions of Wellness,” referencing her patient, Ray, who ultimately commits suicide after too many gruesome relapses into addiction. As is the case for my brother, and for millions of people living with mental illness in this country, Ray’s story has a messy, discouraging, and unacceptable outcome. It defies our abiding interest in hope despite all odds. It doesn’t fit our very American desire to cap our narratives of anguish with silver linings.

Of course, we don’t want to witness yet another senseless loss — to read the less hopeful tales (or the ones where hope didn’t make a difference) — but it seems to me that these accounts are exactly why governmental reform is so pressing. For the victims of mental illness whose lives or loved ones teeter between life and death, we cry out, too. We need our stories told, our realities represented. We want to be able to hope. Mr. Gutkind writes, “The encouraging and vitally important message of the true stories collected here is that a diagnosis of mental illness […] needn’t lead to defeat.”

Absolutely not. But reform might be better achieved if we tell the whole story — even if it means fewer epiphanies, even if it leads to defeat.

If an undercurrent of death anxiety runs through this review, it is not lost on me. Nor, I suspect, would it be lost on renowned existential therapist, Irvin D. Yalom, author of Creatures of a Day: And Other Tales of Psychotherapy. In each of these 10 first-person narratives, Yalom explores his relationship with a different client, men and women who — despite a variety of backgrounds, symptoms, and circumstances — share a deeply universal struggle: how to live when we all must die. To his immense credit, Yalom has spent a good portion of his career helping patients use death anxiety as a fulcrum for change. Existential therapists take a holistic approach and use a particular lens through which they approach a variety of techniques — such as Internal Family Systems, for example, which asserts that we’re all made up of parts and the work of therapy is to help the parts work together more compatibly. In theory, the existential approach can be used with any technique, even behavior modification, which aims to modify unwanted behaviors through positive and negative reinforcements. The existential lens, then, sees crisis is an opportunity to evolve, not something to be avoided or shunned. The patient may come to the therapist seeking relief from symptoms, which is part of the process, but more critically, the existential lens has to do with finding meaning in suffering, freedom, death, and even meaninglessness — all of which is evident in the essays that comprise this collection. Like Gutkind and Kramer, Yalom eschews an overreliance on diagnosis, recognizing its limitations even while nodding to its occasional usefulness. As is so for the practitioners writing in Same Time Next Week, empathy and the relationship between therapist and patient are viewed as essential to positive treatment.

A tight focus — primarily on the dialogue between Yalom and his patients during sessions — facilitates the deep reservoirs of emotional resonance in each piece. While we are privy to some backstory, and glimpses into clients’ lives outside his purview, Yalom doggedly sticks to interactions between patient and doctor. Indeed, one of the pleasures of these essays is voyeurism, the sense of being the proverbial fly on the wall (or couch). The curtain of confidentiality is temporarily lifted, and the reader is ushered into the room with only a single responsibility: to listen.

A quick aside. I call them essays (Yalom calls them stories and a reader may choose her own label), but it is important to consider this message from Yalom’s “Note to the Reader”: “In the service of confidentiality, I have heavily disguised each patient’s identity and, on a few occasions, introduced parts of other patients’ histories or, occasionally, fictional scenes into a story.” This is important not because it invites the reader to assess the comparative truthiness of these essays, but because it reflects the ways in which these tales are constructed — in service to Yalom’s goals. His intended audience, he reveals in the “Afterword,” is anyone with a “keen interest in the human psyche and personal growth.” More specifically, though, he writes for the “novice therapist.”

“These ten stories are meant to be teaching vehicles offering graphic lessons in psychotherapy that are not generally available in contemporary curricula,” he asserts. Viewed through this lens, it is possible to see how his essays are structured to fit the rhetoric of instruction. Often, as is the case in the book’s second essay, “On Being Real,” Yalom will slip in a lesson through exposition or interior monologue and let the interaction with the patient illustrate his point. Charles, a business executive dealing with “self-doubt, recriminations, and guilt,” works with Yalom to understand and hopefully overcome deep feelings of inadequacy. After Charles loses a mentor to suicide, he’s coached to confront his grief as it relates to his own death anxiety. Existential therapists, after all, are particularly concerned with death anxiety, even when it doesn’t present itself explicitly during sessions.

After some back and forth, Charles comes to this conclusion: “I think about the pointlessness of spending all my life at work and of making more money than I need […] I feel sad about the way I’ve lived […] Thank God there’s still time.” This is exactly the conclusion Yalom was looking for, not just for Charles’s well-being, but also because it so perfectly illustrates one of the tenets of existential therapy: death anxiety can be a conduit for positive change. Right after Charles’s self-discovery, Yalom reveals to the reader, “I’ve known many who have managed to respond to grief in this positive fashion. The confrontation with the brute facts of life awakened them and catalyzed some major life changes.” For the laymen, the revelation from Charles would be enough, but for the student, such carefully constructed lessons reinforce the master’s wisdom.

In an interview for a DVD about psychotherapy called Thinking Allowed, Yalom reveals the importance of treating his patients as equals: “allies together in the therapeutic venture.” He insists that by allowing himself to be vulnerable, by revealing his own thoughts and feelings, he can imbue the patient/client relationship with a sense of spontaneity and confidence. During a later session with Charles, when he asks Yalom to share his thoughts on their recent conversation about trust, Yalom reveals to the reader:

[As] I’ve matured as a therapist, I’ve grown to trust my unconscious to behave in a professionally responsible manner, and I know full well that it is not so much what I say about my thoughts that is important but rather that I am willing to express them.

Yalom then uses Charles’s inquiry as an opportunity to espouse some of Kant’s insights into how the structure of our minds informs the experience of our reality. And as if on cue, Charles replies, “I like your speaking like this. I like your sharing your thoughts,” thereby reinforcing the doctor’s theory: it is not what he says, but that he says it at all.

Like any crafted narrative, Yalom’s use of structure informs our understanding of the experiences (or reality, in the Kantian model), and the recurring and deliberate rhetorical shaping (thesis, evidence, explanation) is only occasionally distracting to the lay reader. After all, nobody writing from life claims not to mold the raw clay of experience to achieve a desired effect and these dialogues so often read as though they are transcripts, glimpsing the artist’s hand can feel similar to conducting a science experiment from a kit. (Mix Solution A with Solution B to See the Volcano Erupt!)

What allows the book to retain its viability is Yalom, himself: his candor, intimacy, and profound insight. When the formula doesn’t work, he admits it. When he’s taken a wrong direction, he reveals the wreckage. And this, too, is instructive. For example, while working with Ellie, a cancer patient contending with imminent death, Yalom suggests she write and submit summaries of their sessions in lieu of payment. Ellie will be able to continue sessions she can’t well afford and in return, Yalom will gain a valuable learning tool. She agrees. Reading through her summaries later, Yalom encounters this admonishment about his treatment of her cancer diagnosis:

Too many people are overly respectful, braying, “You’re so brave” and Irv fell smack into that trap. After all what’s so brave about having cancer? Once we have it, what choice do we have?

Later still, trying to understand what had kept the therapeutic relationship with Ellie from developing further; he initially blames her, deciding “Ellie simply lacked the ability for deep relationships.” Revisiting her summaries after she dies, however, Yalom comes to understand that “[she] was not the problem […] I was the problem. I was protecting myself.” Treating Ellie forced Yalom to confront his own mortality, he realizes. This confession highlights his vulnerability to death anxiety, too, a theme that surges through these essays, and returns us firmly to the land of the existential, where experiences of being are sacred, but not an end unto themselves.

What separates existential therapy from existentialism is what Rollo May, Yalom’s mentor and one of the founding fathers of existential therapy, describes as the need for a patient to take a decisive stand in life. Psychotherapy must seek change at the level of our relation to existence itself — our relation to living. This kind of change requires that we actually experience the reality of ourselves. For example, think of a time when you were really relaxing; you may have started to notice things you hadn’t noticed before. Maybe you became dumbstruck by the idea of existence — that you actually exist. Or that anything exists for that matter. May called this an “I am” experience; others call it “navel gazing”; and yet, existential therapy honors these reckonings, considers them essential, but also requires more: a commitment to a way of being, living with a sense of existential decisiveness, which is what ultimately moves us toward authenticity.

When his patients avoid confronting a particular subject, Yalom pushes them to explore their behavior. In “Thank You, Molly,” Yalom practically demands that his patient Alvin examine his solitary lifestyle. When Alvin finally reveals his hoarding habits as intrinsic to his retreat from socialization, Yalom tells him that they must “face this together.” It is not enough that Alvin acknowledge his compulsion, he must also commit to change. When he can’t, Yalom isn’t particularly surprised, but his tenacious entreaties to Alvin are admirable.

“Freedom is a Man’s capacity to take a hand in his own development,” May said. The language is revealing here. “Take a hand in,” suggests that freedom (from fear, from illness, from the constrictions of a society that simultaneously promotes opposing views of personal liberty) is not a solitary venture, but requires willingness to participate in meaningful engagement. Each of the patients profiled in Creatures of a Day benefit from Yalom’s skillful facilitation of that willingness.

For the “novice therapist,” I imagine there is much to be learned about the intricacies of cultivating such an atmosphere. What’s more, Yalom’s patients like him, as he likes them, as I liked Dr. T., which may sound reductive, but it’s actually a crucial part of the process. For someone with “a keen interest in the human psyche and personal growth,” this collection is a treasure hunt of self-reflections, insights, and new perspectives. It is useful to glimpse your own biases and watch them turn. It is a relief to witness change in the seemingly incorrigible.

If Same Time Next Week describes the sets of circumstances that allow so many to flounder inside a debilitated system, Creatures of a Day is the stripped idyll, the clinician/patient relationship that our systems ought to foster. 

“The salvation of man is through love and in love,” said Viktor Frankl, another early practitioner of existential analysis. And so it does not seem a gross miscalculation that I approach potential therapists as friends, companions, or at least prospective allies. What’s more, barring extraordinary developments, such an ally could be my brother’s only hope. (And I’d give a limb to have him treated by Dr. Yalom.) My time with Dr. T., the chance meetings with likeminded professionals in Same Time Next Week, and Irv Yalom’s ceaseless wonder and empathy are proof that such miracles actually happen — and with enough persistence, they won’t always depend on luck.


Read more LARB pieces related to mental health and illness here.


Jessica Hendry Nelson is the author of If Only You People Could Follow Directions. She teaches writing at Burlington College and the low-residency MFA program at the University of Nebraska in Omaha.