An EXISTENTIAL MODEL by Sister Kathleen M. Black, R. N., R. S.M.

XISTENTIALISM is a way of know- E ing and experiencing which has penetrated virtually every area of organ- ized thought throughout the Western world. In its view of the individual human being as a person rather than a member of the category “man,” it is highly compatible with our focus of con- cern in psychiatric nursing. The word “existence” in a literal sense means “standing forth” as particular. In this mode of thought a person is a being who is there, who stands out in his unique- ness. His being shines forth, and can be gathered into the awareness of an- other being who is open to the exper- ience of his presence. “Being” also car- ries the connotation of “being in process, becoming.” Each person is in the proc-

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ess of carrying out the project of his own unique existence, of becoming what he alone can become.

Existentialism does not offer a new therapeutic methodology. True to his view of each being and each situation as unique, the existentialist rejects the pos- sibility of devising a systematic concep- tual structure and labeling it “existen- tialism.” The nurse thus oriented draws upon whatever scheme of tested prin- ciples and methods she finds to be effect- ive for her in psychiatric nursing inter- vention. Existentialism does not offer a conceptualized system of role relation- ships; rather, it is a way of life. From this frame of reference, the psychiatric nurse sees her relationship with a patient as much more than a communication se-

quence, a problem solving activity, or a teacher-learner situation. Instead, she finds herself in the privileged position of participating with another in the making actual of two developing, interacting sys- tems of values which regulate the un- folding of two human existences.

Vuhes and Becoming

At any given point of his existence each person is molding his life accord- ing to the particular value to which he allots a central position in the deter- mination of his goals and the means he will use to attain them. He may place his focal value outside himself and view it as associated with religion, politics, an institution, a vocation, or a profession.

for Psychiatric Nursing

On the other hand, he may set a primary value on the fulfillment of one of his own inner needs or drives, such as that of dominance or security. Whatever his central value orientation, it provides the ground of all his experiences, the source of meaning from which all other mean- ings are derived.

Saul Bellow has given artistic expres- sion to his insight into this factor of human existence, as well as into the diverse possibilities of choice among values and the pressures they exert toward the infinite varieties of human behavior.

On Broadway it was still bright after- noon and the gassy air was almost mo- tionless under the leaden spokes of sun- light, and sawdust footprints lay about the doorways of butcher shops and fruit

stores. And the great, great crowd, the inexhaustible current of millions of every race and kind pouring out, pressing round, of every age, of every genius, pos- sessors of every human secret, antique and future, in every face the refinement of one particular motive or essence - I labor, I spend, I strive, I design, I love, I cling, I uphold, I give away, I e w y , I long, I scorn, I die, I hide, I want. Faster, much faster than any man could make the tally.’

Each person’s range of selection of his own central value is limited by the mani- fold exigencies of his circumstances. Nevertheless he chooses, and thereby he becomes, at each phase of his life, the result of the series of choices that he has thus far made. It is through his choices that he gradually shapes and forms his concrete existence. The accountability for his here-and-now-situation, or at least for the meanings he derives from it, rests with him.

The person’s responsible acceptance of this responsibility, whether conscious or unconscious, is the measure of his au- thenticity. The authentic person has com- mitted himself to integrating his values into the totality of his existence as a be- ing-in-the-world. He is participating ac- tively in his own becoming. And whether or not he is capable of verbaliz- ing his conviction, he is cognizant of the fact that in choosing for himself he is in a sense choosing for all men. “In creating the man that we want to be, there is not a single one of our acts which does not at the same time create an image of man as we think he ought to be.”2 A psychiatric nurse who has herself achieved a degree of authenticity will have similar hopes and expectations for her patient. She will realize that for him she is creating an image of man which may motivate him toward making the choices and commitments that are es- sential to further his own becoming.

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T h e Patient’s Dilemma

The psychiatric patient is a person who has failed to discover or hold to those val- ues which could give meaning to the choices which shape his being-in-the- world. The demands of existence there- fore lack validity for him, and he is over- whelmed by their apparent absurdity. Like the rest of us, he must discover that no choice is made once and for all, that each decision must be repeatedly renewed and revised in the light of newly dis- closed facets of experience. He is con- fronted with the realization that no rela- tionship with another human being is forever, that integration and reintegra- tion in affiliations occur as inevitable ele- ments of every human life. But instead of accepting these inescapable circum- stances as the conditions of life and vital- ity, with tranquility as a characteristic of stagnation and death, he has elected to abandon the struggle. He has turned away from the responsibility of the re- peatedly renewed choices that are im- posed upon each of us by life as it must be lived from one day to the next, by the inevitability of suffering, and by the ulti- macy of death.

The patient is likely to be in a state of intense ontological insecurity3 which he may consciously experience as tension or anxiety. Because he is to a greater or less extent evading his responsibility for commitment to the realities of his exist- ence, he may be in doubt as to his iden- tity as a person; he may feel that he is not quite real. In his perception of them, other people also may be lacking in reality. Dimly recognizing himself as being less than authentic, he finds it difficult to view others as possessing wholeness, completeness of identity. His experience is shot through with frustra- tion, fear, and guilt.

Frustration is a concomitant of the

inability to find meaningful gratification in one’s self and one’s world. Fear is consequent upon the view of one’s existence as being imperiled by being broken off from the rest of reality. Thus alienated, one is incessantly threatened by aspects of one’s being in one’s world which seem to be absurdly fragmented from the whole and therefore are strange and frightening. Existential guilt is more than “guilt feelings” or a “sense of guilt”: it really exists. It is the threat- ening experience of meaninglessness and emptiness which comes with the evasion of responsible choice and consequent action. It is an inevitable characteristic of the human condition which varies in degree according to the extent of one’s failure to live up to one’s possibilitie~.~

Although to himself the patient may seem to be a non-person, an alienated, uncommitted thing among things, the nurse perceives him as a person who, however deprived or despairing, still has a potential for authenticity. Aware that it is in our acts of choice that we are most distinctively human, the nurse looks upon her patient as capable of choices and therefore of becoming what he is not. She views him as much more than a collection of behaviors to be iden- tified and labeled, or a subject to be measured against theoretical criteria and influenced to calculable degrees by the use of calculated techniques.

Existential Elzcounter

Knowing that at any given point of development, human becoming oc- curs within the context of human rela- tionships, the nurse attempts to enter into existential communication with the troubled patient. She approaches him with a readiness to commit herself to his becoming. It is through commitment to another in an existential relationship that

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each of the partners in the relationship comes more and more fully into being. I become most completely myself at the moment when I go most completely out of myself and into the existential reality of another being. An authentic relation- ship between persons is an I-Thou re- lati~nship.~ The one is wholly present to the other and the other is experienced as a being who is there, a person in the process of unique becoming, of becom- ing unique.

The data of an existential relationship include all of the inner and outer realities of each that the persons concerned are able to share with one another. In an encounter of mutual presence and open- ness, of free and other-centered inter- personal transactions, the world of each will be enlarged and enriched by that of the other. Areas of construction and opaqueness will undoubtedly persist in the world-view and self-view of both. But these areas can be broadened and illuminated for each by the shining forth of the other in a genuine meeting of persons.

At any phase of development, an in- dividual grows as a person whenever he moves out of the restrictions of his cur- rent life experience into a broader con- text of space, time, and persons. The sig- nificance of his growth will be propor- tionate to the degree of his self-tran- scendence. His becoming progresses as he enters into aspects of his spatial environ- ment heretofore incompletely explored. As he emerges into places, activities, and events in which he previously has had no part, either because they lacked appeal for him or because they appeared for- bidding or frightening, he comes further into being as a person. Timewise, as he becomes more vividly present to his here- and-now experiences, his heightened awareness throws light on his past and opens up a surer way into his future. A

Perspectives in Psychiatric Care Volume V I

new openness to persons brings him into touch with new value systems, and he finds new meanings in a growing con- sciousness of related norms, problems, and institutions. For the psychiatric nurse, an existential relationship may represent a renewed coming into being for both herself and a patient, or for herself and a therapeutic group, in a hospital or clinic, in a home, or in a community organization.

An existential encounter is an ex- change of meanings between persons. It does not necessarily involve complete consensus about meanings, but it does require agreement of meaning and ex- pression, of meaning and response. It is in a real sense “telling it like it is.” The communication which takes place in such an encounter is dialogue or dis- cussion, not monologue. It is not an interrogation of one person by another, nor is it a unilateral transmission of ex- pertise. Rather, it is a mutual sharing of those convictions that are of deep sig- nificance in the lives of the persons in- volved. Its effectiveness derives from the fact that we grow most deeply as persons when we genuinely test our convictions against those of others.

In the process of testing, either we meet with affirmation of ourselves as persons, or, through the denial of the other, we are shaken into taking a new look at what we are and what we are becoming. One of the basic ontological characteristics of man is his need to af- firm himself as the unique person he is, to grasp and possess his identity.‘ One’s identity is completed and confirmed most convincingly in thi mutual response of an authentic relationship. Insofar as 1 am able to be present to others, I become most distinctively and auto- nomously “I,” and in their authentic presence to me, my reality and worth are mirrored, and thus are reaffirmed.

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Aims and MethodJ

The nurse’s therapeutic aim in an existential relationship with a patient is to help the patient to find those mean- ings in his here-and-now existence that will invite his responsible participation in his own becoming. As he succeeds in transcending the restrictions of his life space as he presently perceives it, he will create for himself new values to guide his choices and commit him to act upon them. “Awareness of the reality of the moment without misconception or delusion is reward enough for exist- t in~e .”~

Although the nurse must utilize her capacity for objectivity in observing and validating the data of her own and her patient’s feelings and behavior, she must be willing to move beyond objectivity into a shared subjectivity with the pa- tient. The therapeutic relationship may actually represent the patient’s first ex- perience with authentic human mutu- ality. If this is the case, he may respond at first in a symbiotic way, with either dependency or antipathy, to the nurse’s empathic understanding. As he gains confidence in the relationship, however, he may be expected to grow toward a mature appreciation of the unaccustomed state of solidarity it provides. While it affords warmth and security, at the same time it strongly affirms his right to and his responsibility for autonomous choice and action.

The nurse’s professional aims will lead her to examine what takes place in the relationship and attempt to organize her findings into a conceptual framework. She will realize, however, the danger that lies in permitting conceptualization to interfere with her existential presence to the patient’s immediate experience. As each person in the relationship exper- iences the other’s existence, he is enabled

to create his own. The nurse can only come into being in mutuality with her patient in so far as she can achieve the kind of openness which makes it possible for her to receive impressions, unadult- erated by her own judgments or even by her own abstractions, of the “shining forth’ of the being who is her patient. And she must be willing to take the re- ciprocal risk of disclosing her own being, of authentically sharing her meanings and values with the patient when it is clear to her that she has something of her own to offer in the segment of experience that the patient is presently undergoing.

The nurse will use whatever methods and techniques of communication her professional background has provided. The subjective content of the communi- cation between herself and the patient will be of far greater significance to both than any system of objective interpreta- tion of the process. Where the verbal content of the encounter is concerned, the primary choice will rest with the pa- tient. As is true of all relationships, however, much of the communication that occurs will be nonverbal in nature on the part of both the nurse and the patient. The complete and authentic presence of the nurse to her patient’s immediate experience will give her a heightened scnsitivity to the meanings that can be discerned in his posture, ges- tures, facial expression, collaboration or noncollaboration in the therapeutic regi- men, and so on, as well as to the patient’s reactions to the meanings inherent in her own overt behavior.

Recognizing that the core of the pa- tient’s difficulties is his inability to find acceptable meanings in his frustrating and fearful and guilt-laden existence, the nurse will begin by helping him endure these painful elements of experience when and as they become evident in the course of the relationship. This she can

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accomplish only by offering genuine human sympathy’ and by entering into the patient’s subjective experience as completely ,as possible. Tentatively at first, in order not to increase his pain and his attempts to avoid it, she will begin to share with him the meanings that she has come to associate with these inevitable limitations of the human con- dition.

Thus the patient will be furnished with new dimensions from which he may select in order to view himself and the world more realistically. The hoped for result is that he will progress in the direction of finding value in the “courage to be,” in becoming a person not in spite of, but because of, the contradictions and ambiguities posed by the very fact of being human. As these dimensions of reality become apparent to him, he will be ready to run the risk, which he has heretofore avoided, of taking a stand in situations which offer less than the cer- tainty and safety he has been demanding. The authenticity with which he then begins to experience himself will provide its own reinforcement. As he moves out into responsible participation in his own coming to be, the values which are at the center of his choices will assume vital importance for him.

The patient may not be able to put his new found convictions into words, but this is not a matter of concern. It is his existence that is in the balance, not his ability to think logically or to express himself in abstract terminology. He may need help in accepting the fact that there is a world of difference between neatly ratiocinized solutions and the living out of actual problem situations. Becoming a person with self-identity and self-unity is not synonymous with possessing un- clouded assurance about any of the cir- cumstances of life as it is given. The achievement of human authenticity is

Perspectives in Psychiatric Care Volume VI

not an arrival at a clearly defined termi- nation point. It is more in the nature of reaching a decision to shoulder a burden that is only partially identifiable and moving out with it into uncharted ter- ritory toward a goal of which only a fugitive awareness is possible. The au- thentic person has achieved a flexibly receptive attitude toward what is and a commitment to what can be.

Outcomes

To the extent that nurse and patient can be fully present to each other and to the totality of the given situation of encounter, the ingredients of growth toward self-realization will be available to both. While still within the protec- tion of the therapeutic relationship, the patient may be able to come to terms with both the satisfying and the frustrat- ing aspects of his current existential sit- uation, to view the past as necessary pro- logue and the future as holding creative possibilities. He will then understand, albeit obscurely, that his authenticity as a person will never be complete, but will continue in process as a partly agonizing, partly gratifying, wholly paradoxical coming to be.

One patient, the young mother of two children, had gradually withdrawn from her family responsibilities to the extent of spending most of her time in bed At the time of the nurse’s first encounter with her, the content of her commun- ication consisted almost exclusively of an enumeration of somatic symptoms. She described herself as useless and unde- serving of her hard-working husband and their children, whose care was added to the husband’s responsibilities as bread- winner. From the beginning the nurse was acutely aware of the many potential meanings in the situation: the patient’s distress, her own eagerness to help, the possibilities for growth inherent in the

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family situation as a whole, and the re- sources available to lend support and direction to both the family and herself. At first, however, she devoted herself to being completely present to the pa- tient, open and sensitive to the patient’s own interpretations of the barriers that were keeping her from participating in her own becoming and that of her family. As the depth of the nurse’s concern conveyed itself to her, the young mother was able to verbalize the sense of aloneness and alienation which ac- companied an overwhelming conviction of her inadequacy in the face of the responsibilities of wifehood and mother- hood.

Because she was a nurse, the thera- pist in this situation was able to imple- ment in a very practical way the prin- ciple of communicating in concrete terms with a patient thus in the grip of lone- l ines9 Together, nurse and patient ini- tiated gradually increasing household activity for the patient, with a concomi- tant decrease in external support and encouragement; later the patient’s hus- band was included in the relationship. The patient’s involvement with others and in action determined by her own free choices revealed to her new facets of herself as a person. She then began to demonstrate by her attitudes and be- havior that she was finding unexpected values in newly discovered meanings outside herself, instead of centering her concern on her own ungratified needs for self-esteem and self-confidence. Con- currently, her husband, who had previ- ously perceived himself as martyred by his wife’s incapacity, found it possible not only to relinquish the household responsibilities but also to experience an increased range of mutuality in the re- lationship between himself and his wife.

The relationship that developed be-

tween the nurse and the married couple proved to be an authentic encounter, a meeting which provided for exchange as well as identification between three persons. Both the patient and her hus- band were enabled to find and to make existential a new freedom of choice and becoming. Both discovered experientially that suffering is not defeat. The nurse, and perhaps the others as well, attained a new realization that while no life is free from limits, each person has some latitude within which to be responsible, to take a stand on living, and to accept the insecurity involved in making choices with no sure guarantee of success.

REFERENCES

lBellow, Saul, Seize the Day, New York: Viking Press, Compass Books Edition, p. 115. Sartre, Jean Paul, Existentialism and Hg- m a n Emotions, trans. Bernard Frechtman and Helen E. Barnes, New York: Philo- sophical Library, 1957, p. 17. Laing, R. D., “Ontological Insecurity,” Psy- choanalysis and Existential Philosofihy, ed. Hendrick Ruitenbeek, New York: E. P. Dutton and Co., 1962, pp. 44-45. Boss, Medard, Psychoanalysis and Daseins- analysis, trans. Ludwig B. Lefebre, New York: Basic Books, 1963, pp. 210 and 270.

“uber, Martin, I and Thou, New York: Charles Scribner’s Sons, 1958. May, Rollo, “The Context of Psychother- apy,” ed. Morris I. Stein, New York: Free Press of Glencoe, 1961, pp. 292-293. Burton, Arthur, “Schizophrenia and Exist- ence,’’ Psychiatry, 23: 385-394, November, 1960. ’ Weigert, Edith, “The Nature of Sympathy

in the Art of Psychotherapy,” Psychiatry,

Fromm-Reichmann, Frieda, “Loneliness,” Psychiatry, 22: 1-15, February, 1959.

24: 187-196, August, 1961.

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