A conversation with Janeta Tansey
Rafi: Dear Janeta, thank you for agreeing to speak with me today about the intersection of existential therapy and psychiatry — two fields that often speak different languages while trying to respond to the same human suffering. Let me begin with a question in the spirit of Thomas Szasz: does mental illness really exist, and if so, in what sense?
Janeta: I think the challenge is the definition of sickness itself. When I talk to people who are concerned about a reduction to mere biological underpinnings, as the ICD and DSM often do by defining sickness as a disease of the body, I usually start to leave the word ‘sickness’ behind. In its origins, the word ‘sickness’ was much broader, encompassing various kinds of suffering. Historically, we talked about spiritual sickness, psychological sickness, and physical sickness. For those of us reluctant to see these parts in splits, the word ‘sickness’ becomes problematic, as it reinforces scientism or biological reductionism.
When I talk to my psychiatric colleagues, many of whom hold a biopsychosocial, spiritual, relational, or ecological understanding or formulation of ‘sickness,’ we tend to be on the same page. We are curious about biological, physical, or genetic contributors to this phenomenon of distress or suffering without believing in a rigid, concrete causation. These are not necessarily determinants but data points around the phenomena of suffering that might be relevant to understanding the nature of that suffering. However, when I talk to non-psychiatrists who have been harmed by scientism and reductionism, I move away from the language of sickness and disease to avoid being misunderstood and causing harm.
It’s a serious harm for people to presume that they are being reduced to a simplistic causative model, like there’s something wrong with their genes, brain, or nervous system. That’s not helpful.
Rafi: Do you believe depression is an illness in the same sense as COVID or pneumonia? Or are we dealing with something fundamentally different — something that belongs simultaneously to biology, meaning, relationship, and existence? And connected to this: what is your view of classificatory systems such as the DSM or ICD?
Janeta: In psychiatry, we don’t use the term ‘depression’ that narrowly. We take the scientific value of the DSM seriously because when we talk about specific disorders, we are referring to specific constellations of phenomena. For example, a major depressive disorder with catatonia involves a very specific set of signs and symptoms. There is some agreement in encountering patients that these signs and symptoms are reproducible and verifiable by multiple parties. We often get frustrated in talking to anti-psychiatry movement when people presume that we mean all kinds of dysphoria or grief when we use the shorthand ‘depression.’ We don’t mean that.
As a psychiatrist, I recognize that a recurrent depressive illness with specific signs and symptoms, such as catatonia or forms of melancholia with a family history and certain physiological signs, is a discrete disease state. These conditions intersect with cultural lenses and personal stories, but they also have biological variables that we can address with science and medicine.
When I take a careful history, do a neurological examination, and sometimes use laboratory findings, I look for factors that might contribute to the patient’s condition. This helps me provide tools that fall within the scope of science and medicine, while also recognizing the limitations of these tools. As a psychotherapist, I might consider other tools within my scope, negotiating with patients about what they want to work on. This approach respects the complexity of their experiences and their autonomy in the healing process.
Rafi: I sometimes feel that many psychotherapists criticize the DSM without fully understanding how it is actually used in psychiatry. At the same time, fear — like depression — affects and emerges from the whole person, not merely the body. What is your view on the use of medications such as antidepressants or anxiolytics during psychotherapy, particularly existential psychotherapy? Can medication sometimes deepen freedom rather than reduce it?
Janeta: It’s challenging to talk about the causes or correlations of experiences like fear, shame, or grief, which are often emotional but also have physiological manifestations. For example, panic attacks have specific signs and symptoms like elevated heart rate and blood pressure, which are reproducible and can significantly interfere with daily life. If a patient’s anxiety doesn’t meet the DSM criteria for panic disorder, there may be no scientific literature to predict whether medication will help. It’s important to consider both the scientific evidence and the potential benefits or harms of medication for the whole person.
As a psychiatrist, I believe in using diagnoses and medications responsibly to increase my patients’ freedom. For conditions like schizophrenia or severe bipolar disorder with psychosis, I urge my patients to consider medication because untreated, these conditions can lead to severe neurophysiological consequences. Over 25 years, I’ve seen that patients who meet the criteria for these disorders often benefit from medication, while also acknowledging that these diagnoses are not static, and that treatment is an ongoing experiment done with and for my patients. I offer any tool I can in good conscience, working with my patients to explore possibilities. I always remain open to stopping any tool that proves harmful, either by my assessment or the patient’s. Creating freedom to consent or dissent during the experiments we pursue together – that’s what is most important to me as a respectful therapeutic attitude.
Rafi: How do you distinguish between a panic attack as a bodily dysfunction and as a symbolic or existential message asking to be understood? Or perhaps the distinction itself is not always so clear?
Janeta: In humility, we can’t perfectly distinguish between these two types. When we talked previously, I shared a case with you where I believed the symptoms were due to psycho-dynamic issues, but after months with no progress, my client asked to try an antidepressant and saw significant improvement within three weeks. This reminds me that we must remain open to various explanations and treatments. For severe conditions with a strong genetic component, I’m very reluctant not to recommend medication. However, we must use all tools responsibly, considering both their benefits and harms.
I want my patients to experience more freedom, not less. Some medical or phenomenological conditions close off possibilities. I offer any tool in good conscience, provided my patient is working with me to explore options. We must always be open to the possibility that a tool is wrong or harmful and be willing to stop using it. Other tools like exercise, yoga, or meditation can be helpful, but they too can cause harm for some patients. Responsibility and humility are key in choosing the right tools for each patient.
Rafi: Thank you. I remember you once said beautifully that medications can sometimes support the defiant spirit in reaching its utmost possibilities. I found that formulation very moving. Do you think existential psychotherapists can benefit from understanding DSM criteria and psychiatric thinking more deeply, or does this risk compromising the phenomenological orientation of their work?
Janeta: I think there’s value in understanding how others make sense of suffering. Even if we don’t adopt the DSM ourselves, it helps to understand how physicians and scientists identify patterns and look for treatments. This knowledge can improve our ability to advocate for and refer our patients. For example, a psychotherapist might refer a patient for ADHD or panic disorder, but a psychiatric history might reveal a different underlying issue. Understanding DSM criteria can help us communicate more effectively with other healthcare providers and better serve our patients.
Once a psychotherapist sent a patient to me, and this patient walked through the door and said, ‘My therapist thinks that I need a stimulant.’ Now, I know that’s unlikely to happen in the existential therapy community…. But when I was talking to him, from my perspective what actually unfolded was that he had profound anxiety around the circumstances that were going on in his family at the time, which were distracting him from his ability to focus. His referring therapist was concerned with dysfunction in areas of cognitive functioning.
And so I said, ‘Well, where are you having trouble focusing? Where are you doing well focusing?’ He was having trouble focusing when he was in this very distressing and chaotic family environment. But when he would be in other places that seemed calmer and more supportive, his inattention resolved, his motivation resolved. I think it was a circumstance in which the therapist, not having some understanding of how we make a diagnosis of ADHD, resulted in a referral for medication treatment that confused both the patient..
Now, one could argue that it’s not her responsibility to do that careful evaluation, it’s mine. If I’m going to consider whether this is a pattern or phenomenon that might respond to a tool like medication, then that’s my job to do. But I think sometimes therapists who dismiss the DSM entirely but still want to intersect with the medical community miss an opportunity to refine what’s best for the patient. She had collected really good information but didn’t have the framework to ask about certain things, and the patient was then referred for a medication that was inappropriate for his situation. He was very frustrated when I said, ‘No, that’s not an appropriate treatment for what you’re experiencing. I know you’re having problems with inattention, but you do not have ADHD.’
So I would suggest that therapists, if they are going to make referrals or if they know their clients are going to self-refer to a physician, should understand how physicians think about these diagnoses. This way, they can better prepare their clients and avoid frustration when the medical community doesn’t see patients as good candidates for certain treatments. We often get referrals for patients who are said to be depressed, but good psychiatry involves understanding that they may not have depression – that is, perhaps, a diagnosis like Major Depressive Disorder – at all. Our job is to sort out the complexity and provide more clarity and shared decision-making, not just hand out medications like McDonald’s serves fast food.
I think what makes psychiatrists crazy is when we’re seen as McDonald’s, like, ‘I’d like a Big Mac, please.’ That’s bad medicine. The problem is that in the United States, there’s so much commercial pressure that some physicians make money by quick evaluations and giving the patient what they want, acting like McDonald’s. But that’s terrible, harmful, immoral medicine. It embarrasses the practice of medicine. I hope my existential therapy colleagues don’t throw out the baby with the bathwater. Not all psychiatrists practice this way, and it’s unfair to dismiss what we can offer each other by thinking psychiatrists are just pill pushers. When someone comes in saying, ‘I’m depressed,’ nobody should just hand them Prozac. Good psychiatry involves careful assessment and understanding the whole person.
Rafi: Thank you for saying this. In your view, how long should an ethical psychiatric assessment take? Fifteen minutes? An hour? More? What does a careful and responsible process of deciding whether someone suffers from depression or an anxiety disorder — and whether medication should be offered — actually look like in good practice?
Janeta: Well, we wouldn’t even consider making a diagnosis or suggesting medications until we’ve taken a careful history, which in my training was a minimum of 90 minutes. However, this has gotten shorter over time, partly because seeing people faster is financially lucrative. There’s also a belief that nuanced interviews are unnecessary for diagnosis, replaced by written assessments where patients fill out forms. But these have limitations.
For conditions like depression, anxiety, or grief, I may get a sense of what might be happening after 90 minutes and start discussing therapeutic options, including medication if appropriate. But medication might not be offered until the second, third, or fourth visit – or at all. There are other cases, like emergency psychiatry, where I might call for medication intervention within minutes of seeing the patient if they are in immediate danger. It depends on the situation.
As a psychiatrist, I often deal with emergency situations where patients are at immediate risk. These could be due to substance abuse, schizophrenia, head trauma, or severe PTSD. In such cases, the harms of not intervening with medication to stabilize the patient can be catastrophic. Some of my colleagues might say, ‘Let the neurologists handle that,’ but here in the United States, psychiatrists are usually the ones managing these crises. It’s crucial to pull patients back from the brink to make space for figuring out what’s going on. This can be a matter of minutes in some situations.
Rafi: Thank you. Let us now move toward another dimension of the question — perhaps a more philosophical or spiritual one. Do you believe in the existence of the soul, or at least in a spiritual dimension of human life that cannot be fully reduced to biology or psychology?
Janeta: I’m not sure I use the words ‘soul’ or ‘spirit’ in a strictly traditional sense. This is something I’ve wrestled with for much of my adult life. There was a time, influenced by my religious upbringing, when I thought of the soul as a special conscious witness. But now I use the word ‘soul’ to capture aspects of the human experience that are ineffable and ephemeral, like love, meaning, and beauty. These are important for understanding the whole person but are often excluded from medical formulations.
My background is that I was raised in a very religious, bicultural family. My mother is from the Midwest, and my father is from Hong Kong, bringing a mix of Confucian, Taoist, and Christian influences. I studied philosophy before going to medical school and have always been interested in theology. I earned my Ph.D. in religious studies, focusing on phenomenology and 20th-century Jewish existential thought, particularly around moral evil and idolatry.
I think of the soul as a tool – a language tool – which signals to aspects of human experience that science alone can’t capture. There are days when these ephemeral pieces seem more real to me than the body, and other days when the body seems primary. This tension and paradox are healthy. Recently, I was reading Hannah Arendt’s thesis on Augustine’s Confessions, appreciating how much paradox was in his work. This resonates with my own thinking. My religious upbringing and academic background have led me to see value in both the scientific and the spiritual aspects of human experience.
In graduate school, I had two primary things that I was obsessed with. During that time, I was also practicing as a psychiatrist, and it took me eight years to finish my Ph.D. because I was working part-time at the university in psychiatry. The two things I was very preoccupied with were: one, trying to understand the nature of evil and idolatry, especially. I was reading a lot of Paul Tillich, the Protestant theologian, and thinking about idolatry and how one might know what’s true and what’s not true. I was doing a lot of moral epistemology work at that time. The second topic, which I even wrote my dissertation on, was the power of moral emotions to give guidance to the good. One thing that came out of that for me was a much higher degree of tolerance for having subjective experiences that give clues but are not definitive.
Sometimes I do things with so much hope and care and get it wrong. This happened just this week in a very clinical way. I have a very dear patient with a long history of Bipolar Type I mood disorder, which her father also had. She was doing well after many years of hospitalization, thriving for 15 years on lithium without being hospitalized. I saw her regularly for psychotherapy, and she was doing beautifully. Unfortunately, she developed kidney disease from long-term lithium use, and we needed to take her off the lithium because continuing it, or even after discontinuing, her risk for needing dialysis had gone up significantly.
Two weeks ago, we struggled to have her feel as well as she had on the lithium. She reported feeling terribly depressed, struggling to get out of bed in the morning, not feeling joy in things that normally brought her joy like her child, feeling anxious, and unable to get her thoughts together. As a professional, she found she couldn’t make decisions. These symptoms looked like a recurrence of her mood disorder in a Bipolar depressive episode. We discussed it, got additional labs, and I suggested starting a tiny dose of an antidepressant. I knew we weren’t where we were when she was on lithium, but we couldn’t go back to it.
A week later, her labs came back and, likely as a function of her past lithium use, she has hyperparathyroidism. Her calcium levels were abnormally high. I wrote to her and suggested that her depressive symptoms might not be from her bipolar disorder but from the hyperparathyroidism. Over 50% of people with elevated calcium have the symptoms she described. I advised stopping the antidepressant (Wellbutrin) and getting the workup done for her hyperparathyroidism. I think I was wrong about the initial diagnosis of bipolar depressive episode. Time will tell if treating her hyperparathyroidism will resolve her symptoms.
I hope both psychiatrists and existential therapists practice humility and discipline in looking, listening, and trying to understand, while also having the freedom to get it wrong sometimes.
Rafi: Thank you. I like that. Last question, if you allow. Did you find the answer to your question about the nature of evil?
Janeta: I have in my possession a paper I wrote as an undergraduate college student where I tried to write an ontological argument about moral evil. My philosophy professor wrote at the end of this paper, “Sometimes a good hamburger is better than a burnt steak,” implying that I had burned the steak. It was a terrible paper. I took that to heart. Sometimes I just try to make a good hamburger. It doesn’t mean I don’t sometimes play with steak, but I am aware that smarter, more insightful, more learned people than I have been thinking about these questions for as far back as we can go.
I hope to be the kind of scholar who listens and asks good questions without burning the steak. So my answer to that question is this: you cannot tempt me to burn that steak by offering you an answer to the question of moral evil. However, I have come to believe in my own personal practices, influenced by Martin Buber and Emmanuel Levinas on the importance of the relation as the moral ground.
One of the ways I resist evil, whatever that means, is by actively practicing loving my neighbor in a very concrete way, not just in my office full of books, but with other human beings, especially those different from me. Practicing love for people can provide a kind of protection or inoculation from certain kinds of evil that plague our world.
Sometimes this relationship concerns the whole world that is mine. Beyond that, war, philosophy, theory, and criticism can sometimes be idolatry. They distract us. Our conflicts and disagreements can become a kind of moral evil when we hyper-focus on what divides us instead of practicing love.
As someone who loves those questions and thinks they matter, my hope when talking to people who are different from me, culturally or philosophically, is that we can practice kindness and maybe even love for each other as the most important grounding of all these other questions. These questions are fine, but they’re just not enough.
Rafi: Thank you very much, Janeta. It has truly been a pleasure speaking with you today.
Dr Janeta Tansey bio:
Dr. Janeta Tansey is an American psychiatrist, psychotherapist, and scholar whose work bridges psychiatry, existential analysis, phenomenology, ethics, and religious studies. She holds both an M.D. and a Ph.D. in Religious Studies from the University of Iowa and is board-certified in Psychiatry and Integrative Medicine. Alongside her clinical and teaching work, she has been actively engaged in existential and meaning-centered approaches to therapy, including Logotherapy through the Viktor Frankl Institute of Logotherapy. Her writings and teaching explore the intersections of suffering, spirituality, embodiment, moral experience, and phenomenological understanding, while advocating for a psychiatry grounded not only in science, but also in dialogue, humility, and care for the whole person.
