Adlerian and Existential Theories in Clinical Diagnosis

Introduction

Clinicians have always been expected to examine mental disorders and draw diagnoses from objective factors, such as observable symptoms. Recent studies have shown, however, that despite this traditional outlook and persistent professional reminders, clinicians still rely on their personal theories when examining and diagnosing patients with mental disorders. Among the personal theories in popular use are Alfred Adler's individual psychology and existential theory. Adler's theory draws from an inherent motivation toward self-perfection and social interest, while existential theory works to restore patients' lost, damaged, or unrecognized autonomy, freedom, and responsibility for their own actions, lives, and destinies.

The influence of clinicians' personal theories on their diagnosis of mental disorders was the subject of a study conducted by two researchers working with 35 clinicians and 25 clinical trainees (Holmes, 2002). Dr. Woo-kyoung Ahn of Vanderbilt University and Nancy Kim of Wesleyan University asked the subjects to perform four basic tasks: draw the relationship between the symptoms of certain disorders; identify the relative importance of those symptoms to the disorders; diagnose some hypothetical cases; and then test the participants' recall of the symptoms several hours after diagnosis. The study showed that, despite considerable efforts by leaders in clinical psychology to keep diagnosis objective, clinicians' theoretical beliefs still exert major influence on diagnosis. The findings were published in the December 2002 issue of the Journal of Experimental Psychology: General (Holmes, 2002).

Clinical psychologists have always been expected to base their diagnoses on a checklist of symptoms, but the findings revealed that clinicians' diagnoses draw heavily from their individual theories (Holmes, 2002). Clinicians are more likely to diagnose a mental disorder when a person displays symptoms central to the clinician's own theory of that disorder than when the patient's symptoms are peripheral to it. Furthermore, all study subjects — both practicing clinicians and graduate students — held different and complicated theories about mental disorders ranging from schizophrenia, major depression, and anorexia to diverse personality disorders, and those individual theories had little in common. There was no basic shared understanding of causes, and clinicians' theorizing could be erratic or lead to conflicting diagnoses. Clinicians' recall of symptoms was also influenced by the theories they held: if symptoms were peripheral to their theory, clinicians tended to forget them more readily (Holmes, 2002).

Personal Theories: Adler and Existentialism

Among the personal theories used by clinicians are those derived from Alfred Adler's individual psychology and from existentialism. The sections below examine each theory in terms of its origins, core concepts, therapeutic approach, and clinical relevance.

Adler's Individual Psychology

Adler was born in Vienna, Austria, on February 7, 1870 (Boeree, 1997). He could not walk until he was four years old because of rickets and nearly died of pneumonia at age five. His physical difficulties motivated him to pursue a medical degree from the University of Vienna, which he obtained in 1895. He began his career as an ophthalmologist and later switched to general practice in a lower-class district of Vienna. Many of his patients were circus performers who suffered from organ inferiorities, which led to his early interest in organ deformities and compensation — an interest that clearly also reflected his own childhood experience of physical disability. He later shifted to psychiatry and joined the discussion group led by Sigmund Freud, contributing papers on organic inferiority, an aggression instinct, and children's feelings of inferiority.

Adler proposed that the single motivating force behind human behavior and experience is the striving for perfection (Boeree, 1997). This is the desire to fulfill one's potential or move closer to one's ideal — similar to, and a precursor of, the modern concept of self-actualization. He initially called this an aggression drive: the reaction that arises when other drives — the need to eat, to achieve sexual satisfaction, to accomplish something, or to be loved — are thwarted or frustrated.

Adler also described this basic motivation as compensation, or the striving to overcome (Boeree, 1997). He believed that personalities are structured so as to compensate for or overcome problems, shortcomings, and inferiorities of all kinds. One of his earliest formulations was the concept of masculine protest, by which boys were expected to be strong, aggressive, and in control, while girls were expected to be weak, passive, and dependent. Boys and men were viewed as superior to girls and women and were therefore accorded power, education, talent, and motivation that girls and women were denied. Adler did not view this difference as innate, however; he saw boys as merely encouraged to be assertive while girls were discouraged from doing so, and he held that both sexes possess the same capacity for protest.

His final phase before arriving at the concept of striving for perfection was the striving for superiority (Boeree, 1997; Stein, 1991), which parallels Friedrich Nietzsche's philosophy of the will to power as the basic motive in human life. Adler believed that this striving was not only for superiority but also for being better than others, and he connected it primarily with unhealthy or neurotic behavior. Rather than adopting Freud's reductionistic model, which breaks a person down into the concepts of superego, ego, and id, Adler adhered to the holistic theory of Jan Smuts — a South African philosopher and statesman — who saw a person as a unified whole within his physical and social environment. Adler labeled his approach individual psychology and, rather than perceiving personality as a complex of internal traits, structures, dynamics, and conflicts, he spoke of life style: the way one lives, handles problems, and manages relationships. In Adler's view, individuality expresses and molds itself within its own environment and against a background of other, different environments, with its own life pattern that is not a merely mechanical reaction to circumstances (Boeree, 1997).

Alongside the striving for perfection, Adler held that the human person naturally pursues social interest (Boeree, 1997; Stein, 1991). Under his holistic approach, a person pursues perfection within a community and out of a sense of community feeling. Social interest is both inborn and learned, but parents and culture must teach empathy. Adler interpreted social interest broadly as caring for family, community, society, humanity, and all life — in short, being useful to others. He regarded a lack of concern for others as both the cause and the defining characteristic of mental ill health, and he traced all personal failures — neurosis, psychosis, criminal behavior, alcoholism, problem behavior in children, suicide, perversion — to that absence. In his view, such individuals suffer precisely because they lack social interest, and whatever personal triumphs they achieve are meaningful only to themselves.

Adler enumerated four psychological types: ruling, learning, avoiding, and socially useful (Boeree, 1997). The ruling type is aggressive and dominant; bullies and sadists fall here. The learning type is sensitive, with a low energy level and dependent tendencies, and easily develops phobias, obsessions, compulsions, general anxiety, or hysteria, depending on life style. The avoiding type has the lowest energy level and survives by withdrawing from life itself; when pushed to the limit, this person may turn psychotic and retreat into a purely private world. The socially useful type is healthy, with a life style characterized by social interest and high energy.

Childhood plays a large role in Adler's theory (Boeree, 1997; Stein, 1991). He identified three basic childhood situations that can lead to a faulty lifestyle: organ inferiorities, pampering, and neglect. A child with organ inferiorities is often overburdened and harbors a strong sense of inferiority, which may be compensated through a superiority complex. Pampering is self-defeating because the child does not learn to act independently or to deal with others. Neglect breeds both a sense of inferiority and selfishness. Birth order is another factor: the only child is often pampered and assertive; the first child is similar to an only child until siblings arrive; and middle children tend to be more passive than either the eldest or youngest.

In diagnosing mental disorder, Adler's approach seeks out the patient's birth order, serious childhood illnesses, childhood habits, dreams, and forms of self-expression (Boeree, 1997; Stein, 1991). His approach to therapy differs from Freud's: Adler had everyone seated and speaking face-to-face. Patient resistance is recognized as another sign of a lack of courage to relinquish a neurotic lifestyle. The patient must be helped to understand how his lifestyle and self-centered fictions account for his mental condition, and the objective of therapy is to bring him to a state in which he is willing to listen and to understand. He can then be influenced to live according to what he now understands but has not yet put into practice. The therapist must encourage the patient, awaken his social interest, and raise his energy level accordingly. By developing a genuine human relationship, the therapist can re-establish the basic form of social interest that the patient can then transfer to others. Both therapist and patient must recognize that the ultimate cure can come only from the patient himself.

Adler's approach shares similarities with that of Socrates (Stein, 1991). Whereas Socrates exhorted others to "know thyself," Adler urged people to think for themselves (Meyer, 1980, as cited in Stein, 1991). Like Socrates, he would lead a person through a series of questions to a contradiction revealed by that person's own answers. Both were committed to the search for truth through reason, both helped the troubled person understand his own values and beliefs, and both practiced tact, wisdom, humility, eloquence, and patience. They both valued freedom, courage, responsibility, and inner integrity (Stein, 1991).

Adler's theory may seem less dramatic than Freud's or Carl Jung's, but it is arguably the most sensible and accessible (Boeree, 1997). Its clear description of complaints, straightforward and common-sense interpretation of problems, simple theoretical structure, and genuine trust and affection for the ordinary person make it comfortable, credible, and very influential (Stein, 1991).

Adler's therapy encourages a patient to overcome feelings of insecurity, develop deeper feelings of connectedness, and redirect striving for significance into more socially acceptable and satisfying goals (Adler, 1932). Through carefully planned dialogue, the patient is led and challenged to correct mistaken assumptions, attitudes, behaviors, and feelings about himself, others, and the world. Through constant encouragement, the patient becomes stimulated to do what he always believed he could not. The outcome is growth in self-confidence, pride, and gratification, which can generate a greater desire to cooperate with the therapist. The goal is to replace exaggerated, false, and damaging patterns of self-protection, self-enhancement, and self-indulgence with courage and a healthy, balanced social interest (Adler, 1932).

Adler believed that treatment should not focus on a single symptom or expression but on the mistake embedded in the patient's entire lifestyle and in the way his mind has interpreted his experiences — the meaning he has given to life in the past and in his actions through which he has responded to impressions from the environment (Adler, 1932). These are the data that reveal something about the patient's psychology, providing evidence of the life style. Life styles are the proper subject of psychology and the proper material for investigation. Individual psychology deals with the psyche itself — the unified human mind — and examines the meanings a patient has assigned to himself and his world, his goals, the direction and quality of his strivings, and the means he has used to address or solve his problems (Adler, 1932).

Conclusion

Because individuals possess complete freedom to make their own decisions and bear full responsibility for the outcomes of those decisions, they experience a characteristic anxiety — or angst — about their choices (Wikipedia, 2005). Therapists draw on existential philosophy to explain the anxiety experienced by patients, proceeding from the belief that patients can confront that anxiety and use it positively. By facing and accepting anxiety as something inevitable, the patient can pursue and attain his fullest potential. Irvin Yalom (1980, as cited in Center for Existential Depth Psychology, 2004) offered an organizational structure for understanding existential theory through four main themes: death, freedom, isolation, and meaninglessness. His existential psychotherapy is, however, too broad to summarize comprehensively, and it is more useful to consider several individual theoretical strands.

One major distinction among existential theorists concerns whether the fundamental questions of existence can ultimately be answered (Center for Existential Depth Psychology, 2004). In general, theorists agree that such questions cannot be answered from within a finite frame of reference. Some philosophers and psychologists — including Sartre and Yalom — believe there are no final answers. Many have come to associate existentialism with atheism, nihilism, and pessimism, but this characterization does not accurately represent many existential thinkers. Existentialists generally hold an optimistic view of the potential for human goodness and growth. Some ground this optimism in a spiritual or religious foundation; others do not. Yet even optimistic existential thinkers do not deny the reality of the challenges and potential horrors of human existence. Among those who have given voice to that horror are the philosopher Søren Kierkegaard, Christian theologian Paul Tillich, Jewish theologian Martin Buber, and psychologist Rollo May. These two groups — the spiritual and the non-spiritual — represent the central split within existential thought. The spiritual existential approach is not necessarily religious in the conventional sense of affirming belief in God, although it can be so interpreted; it offers a transcendent or embodied answer to the major existential questions. The non-spiritual approach holds that no such answers are available (Center for Existential Depth Psychology, 2004).

The existential theory places deep emphasis on respect for the individual person (Park, n.d.). It holds that human beings are in a state of constant transition and evolution, and it affirms total and independent choice, freedom, personal responsibility, and self-determination. A person controls his own life and must therefore accept responsibility for his own actions. Loneliness is understood as a natural and inevitable experience; it is the individual alone who creates meaning in his life by answering questions about who he is, where he has been, and where he is going. He must also confront, sooner or later, the reality of death and non-being (Park, n.d.).

The key concepts behind existential theory are: the capacity for self-awareness; freedom and responsibility; the striving for identity and relationship with others; the search for meaning; anxiety as a condition of living; and awareness of death and non-being (Park, n.d.). Clients or patients with mental disorders retain that built-in capacity for self-awareness, and it becomes their choice alone to expand it. They choose to live freely and fully, or they choose to restrict themselves.

Every person is a free being who must accept the reality and responsibility of that freedom (Park, n.d.). He is responsible for the choices that shape his own destiny, and he exercises that responsibility by freely choosing among available alternatives. Responsibility for his acts lies within him, not outside him or with other persons. A client also has an intrinsic concern to preserve his uniqueness and identity. He learns about himself through relationships and interactions with others. Although the development of a personal identity requires courage, struggle, and a significant price, it is an essential task. Loneliness is built into human existence, and a person gains strength from confronting it. At the same time, he depends on his relationships with others — a paradox, since the ability to relate meaningfully to others requires the capacity to stand alone.

The fourth key concept is the search for meaning (Park, n.d.), wherein a person's existence is never complete or final but evolves through goals. Life's meaning can be discovered only through engagement in activities such as commitment to creating, loving, working, and building. That search is a never-ending struggle. A state of meaninglessness can produce an existential vacuum — a hollow, empty feeling. Associated with this is the concept of existential guilt, which arises from a progressing sense of incompleteness. This condition is addressed through logotherapy, which focuses on finding meaning in life.

The existential theory proposes that anxiety is an integral part of the human condition but also a potential source of growth (Park, n.d.). It is neurotic anxiety that handicaps a person, whereas normal anxiety arises when a person confronts a situation or reality honestly and is the consequence of genuine freedom and of the acceptance or rejection of one's choices. The theory also holds that death is an eminent part of living, and that awareness of death is precisely what gives life its significance. Death is not viewed as something negative; rather, it is considered a motivating factor for the living. A person who commits to living fully can be at peace when he approaches the end of his life (Park, n.d.).

Existential therapy differs from other approaches in the way it addresses how patients are failing to live full and authentic lives (Park, n.d.). It helps the person make choices that can lead to recovery and to a realization of what he is able to become or overcome. The existential therapist shares his reactions with the patient in a spirit of genuine empathy. The sharing can be confrontational, but the therapist must remain in touch with her own world as she works to cultivate in the patient that essential awareness of death — so that she can help him make free choices in his life (Park, n.d.).

The goals of existential therapy are to enable the client to accept the inherent freedom and responsibility that accompany action; to help him recognize that he is genuinely free and can become aware of his possibilities; and to help him identify what factors block his freedom and understand that there is a price to pay for increased awareness (Park, n.d.). Existential therapy places primary emphasis on understanding the subjective nature of the patient's experience through empathy. There are no specific techniques considered essential; rather, it is the therapist who invites and leads the patient to recognize and explore how he has allowed others to make decisions for him and has emboldened them to assert influence over his inherent autonomy. A patient with a mental disorder often has limited self-awareness or a restricted sense of existence, and may feel vague about the nature of his difficulties.

In existential therapy, the patient is encouraged to take his own subjective experience seriously (Park, n.d.). Many people see psychotherapy as frightening, but the existential approach can help a patient become aware of what he has been and who he is now, enabling him to decide more clearly what kind of future he wants. If he continues to persuade himself of the powerlessness of his situation, the therapist should remind him of his freedom and of the choice he must make to engage with therapy. Major themes of existential therapy include anxiety, freedom, responsibility, isolation, alienation, and death and its implications for the living (Park, n.d.).

This approach lacks a systematic statement of principles and specific practices of therapy (Park, n.d.). Existential writers tend to use vague, universal terms and abstract principles that can be difficult to grasp. The approach has not been extensively validated through scientific research, and in the meantime therapists must evolve their own techniques or adapt suitable ones from other schools of therapy. It has limited effect for low-functioning patients who experience extreme distress, who need clear direction, or who are nonverbal (Park, n.d.).

Nonetheless, the existential approach is fundamentally person-to-person, which reduces the dehumanizing effect of clinical encounters (Park, n.d.). It emphasizes self-determination and personal responsibility as inseparable from making choices, and it impresses upon the patient that he is the author of his own life. It also provides a useful framework for confronting and understanding anxiety and guilt. Death is treated as a vital reality and a motivating force for the living, and the experience of being alone is acknowledged as a natural feeling. Its special emphasis on anxiety and death can make a positive contribution regardless of the type of therapy employed. The patient who finds the courage to confront himself will benefit greatly from this approach, though one who is in a stage of denial may struggle with it. The life skills that can be gained from existential engagement can help him move forward (Park, n.d.).

Ultimately, the patient must alter his view of his own life and stop seeing himself as a victim (Park, n.d.). He must come to understand that no one can act upon him or take control of his life from him, because he alone is responsible for the choices he makes. This therapy enables him to examine the extent to which he has allowed social and cultural conditioning to govern him, and to reclaim his freedom and responsibility to make genuine choices.

Recent findings have shown that, despite the emphasis on objective diagnosis of mental disorders based on patients' symptoms, clinicians still draw heavily on their personal theories when examining patients. Two of the most widely used personal theories are Adler's individual psychology and existential theory. Adler's theory focuses on the striving for perfection and social interest. The existential theory, by contrast, places the patient in full control of his choices, thereby empowering him to take responsibility for his own recovery.

Adler stresses the striving for personal perfection within a social community. Existential theory, on the other hand, foregrounds death as a motivator and as a test of authentic living. Under both theories, the patient recovers damaged or absent autonomy, self-awareness, and identity. Both challenge the patient to show courage and to accept difficult realities such as loneliness, anxiety, and mortality. A significant barrier remains, however, in the stereotyped belief that people with mental disorders are incapable of full functioning — a belief that has itself deterred patients from overcoming their limitations and reaching their greatest potential (Park, n.d.).