Psychiatry 72(2) Summer 2009

154

Particpation-Engagement
Shahar and Davidson

Participation-Engagement: A Philosophically
Based Heuristic for Prioritizing Clinical Interventions in the Treatment of Comorbid, Complex,
and Chronic Psychiatric Conditions
Golan Shahar and Larry Davidson

We propose Participation-Engagement (PAR-EN) as a philosophically based heuristic for prioritizing interventions in comorbid, complex, and chronic psychiatric
conditions. Drawing from 1) the sociologist Talcott Parsons, 2) the continentalphilosophical tradition, and 3) our own previous work (Davidson & Shahar,
2009; Shahar, 2004, 2006), we argue that participation in personally meaningful
life goals represents a hallmark of mental health. Symptoms and vulnerabilities
that impede such participation should therefore be targeted vigorously, whereas
others which do not pose such imminent threats should assume a secondary focus,
if at all. Winnicotts (1987) notion of the spontaneous gesture, the importance of
daily activities as reflecting patients participation, and the dialectics of interpersonal relatedness and self-definition, are introduced as guidelines for implementing PAR-EN. Implications for clinical assessment and the therapeutic relationship
are discussed.

The medical faculty needs a doctrine of

man in order to fulfill its theoretical task;
and it cannot have a doctrine of man
without the permanent cooperation of
all these faculties whose central object
is man. The medical profession has the
purpose of helping man in some of his
existential problems, those which usually
are called diseases. But it cannot help
man without the permanent cooperation
of all other professions whose purpose is
to help man as man. Both the doctrines
about man and the help given to man
are a matter of cooperation from many

points of view. Only in this way it is

possible to understand and to actualize mans power of being, his essential
self-affirmation, his courage to be. (Paul
Tillich, 1952, pp. 71-72)

Where do I begin? one of us (GS) reflected as he reviewed findings obtained from

evaluating a 22-year-old male referred for
psychotherapy by an experienced psychiatrist. Jonathan, an ambitious, bright, and extremely articulate philosophy undergraduate
had been experiencing severe, recurrent, and

Golan Shahar, PhD, is Professor of Psychology, Department of Psychology, Ben-Gurion University of the Negev,
Israel. Visiting Associate Professor of Psychiatry, Yale University Medical School. Larry Davidson, PhD, is Director
of the Program for Recovery and Community Health, Yale University Medical School.
Corresponding author: Golan Shahar, Ph.D. Department of Psychology and the Stress & Personality (StreP) Lab,
Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel. E-mail: shaharg@bgu.ac.il, Golan.shahar@yale.edu

Shahar and Davidson

quite debilitating panic attacks for the past

three years.1 These attacks began shortly after his girlfriend had broken up with him and
were accompanied by low grade, but quite
pronounced, depressive symptoms (sad and
agitated affect, anhedonia, negative cognitions, poor concentration, difficulties sleeping and weight loss, and suicidal ideation,
albeit with no clear plans), meeting criteria
for Dysthymic Disorder (DSM-IV, 300.04).
In fact, Jonathan reported experiencing these
debilitating depressive symptoms since his
early adolescence. At the time of the evaluation, Jonathan was already taking antidepressant medications (Sertraline, 75mg), but
these had brought about only partial relief.
His family history was replete with cases of
unipolar depression and anxiety disorders
(particularly Generalized Anxiety Disorder
[GAD] and Obsessive-Compulsive Disorder
[OCD]). His mother had committed suicide
when he was seven years old.
Jonathans passion for philosophy was
obvious andto usdeeply endearing. His
long-term goal was to become an academic
philosopher. To accomplish this, he intended
to excel at his undergraduate studies and to
apply to several world-class departments of
philosophy for graduate training. However,
he experienced his symptoms as a major impediment to his goals. In particular, he was
bothered by his sleep problems. I function
at my best when I sleep well, he said, and I
need an enormous amount of sleep. Not to be
able to fall asleep and to wake up anxiously
several times a nightthat is a killer. I cannot
concentrate in school, cannot do homework
assignments, and I feel like my life is going
down the drain. He further noted that his
panic attacks, occurring mainly while he was
out of the house, propelled him to stay in, in
what appeared to evolve as a comorbid classic panic disorder with agoraphobia. This
is ridiculous, he said. I want to go out. I

155

want to meet someone, have a relationship. I

cant. I am afraid to leave the house.
This clinical picture was further complicated by Jonathans interpersonal style. As
part of the evaluation, he was administered
both objective symptom measures (the Brief
Symptom Inventory [BSI]; the Beck Depression Inventory [BDI] and the Beck Anxiety Inventory [BAI]; and the Hamilton Depression
Rating Scale [HDRS]), and projective tests
(The Thematic Apperception Test [TAT], and
the Object Relations Inventory [ORI, Blatt,
Auerbach, & Levy, 1997]). As expected, he
scored above cutoff on the BDI, BAI, and
HDRS. His BSI scores exhibited, alongside
the expected high levels of depression and
anxiety, also elevated levels of suspiciousness
and interpersonal sensitivity. The latter patterns were clearly evident in his past romantic relationships, as well as in his current relationships with family members (at the time
of the evaluation, he had no friends). In these
relationships, Jonathan frequently oscillated
between strong dependency on the one hand
and anger and quarrelsomeness on the other.
Relationships with his therapists were no exception. His psychiatrist constantly felt enraged by Jonathans tendency to show up late
for appointments, forget to pay on time, and
put his extensive knowledge of pharmacology, as well as his brilliant rhetorical skills,
to use in challenging the physicians medical
advice. Likewise, his psychotherapist (GS)
constantly felt frustrated by Jonathans repeated cancellations, and overwhelmed by
his suspiciousness (Youre going to have me
hospitalized, right?) and accusations (You
really despise me, dont you?).
A determination of paranoid personality disorder was readily made by the therapist (GS), but was of little help, and actually
seemed to be more an expression of hidden,
counter-transferential aggression than an enhanced understanding of Jonathans predica-

1. Jonathan is not a real individual. Rather, he is a composite of several patients of ours, all of whom presented with
comorbidity, chronicity, and treatment resistance, and for all of whom PAR-EN was found to be helpful. In fact,
these patients are the real originators of PAR-EN, and we wish to thank them for that.

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Particpation-Engagement

ments. Such an understanding was eventually gained through a close look at the link
between Jonathans interpersonal style and
transference-counter-transference exchanges,
as well as through findings from the projective tests. These suggested that Jonathan experienced significant others as domineering
and punitive, and himself as largely feeble
and weak. Also evident, was his tendency to
utilize defensive projection, projective identification, and turning against the self, while in
interpersonal confrontations, many of which
he himself generated.
What was a psychotherapist to do,
then? This is a frequently asked question
in commonly occurring situations in which
patients present comorbid, complex, and
chronic clinical conditions. The purpose
of this article is to address this problem by
proposing Participation-Engagement (henceforth, PAR-EN) as a philosophically based
heuristic for prioritizing clinical interventions in such cases. In what follows we 1)
briefly describe the role of comorbidity, case
complexity, and chronicity in psychiatric
practice; 2) define PAR-EN and present its
philosophical and clinical rationale; and 3)
locate PAR-EN within the broader context
of clinical assessment and the therapeutic relationship.
Comorbidity, case
complexity, and chronicity:
The unholy trinity of
psychiatric practice

The prevalence of psychiatric comorbidity is overwhelming (e.g., Angold, Costello, & Erkanli, 1999; Clark, Watson, &
Reynolds, 1995; Kendall & Clarkin, 1992;
Kessler et al., 1994; Kessler et al., 1996;
Reiger et al., 1990; Swendsen & Merikangas, 2000; Watson & Clark, 1998; for an
excellent overarching treatment of this issue,
see Maser & Cloninger, 1990, as well as the
special issue on comorbidity and treatment
implications of the 60[6] issue of the Journal

of Consulting and Clinical Psychology). The

evidence is so compelling that, with respect to
depressive and anxiety disorders, comorbidity is actually the rule rather than the exception (Brown, Schullberg, Madonia, & Shear,
1996; Seligman & Ollendick, 1998). Indeed,
depressive disorders are highly comorbid
with eating, somatization, conduct, substance use, and personality disorders (Casper,
1990; Godart et al., 2007; Hirschfeld, Hasin,
Keller, Endicott, & Wunder, 1990; Kazdin,
1990; Widiger, Mullins-Sweat, & Anderson,
2006). Also notable are comorbid psychosis and substance use (Mauser, Bellack, &
Blanchard, 1992).
Because basic research on psychiatric comorbidity is still at a very preliminary
stage, there is no consensual definition of this
term, and researchers still debate comorbiditys mechanisms, course, and causes (e.g.,
Piotrowski, 2007; Swendsen & Merikangas, 2000; Watson & clark, 1998). What is
agreed upon is that the challenges posed by
comorbidity are formidable. Among these,
one may count increased illness severity,
chronicity, treatment resistance (Hirschfeld,
Hasin, Keller, Endicott, & Wunder, 1990;
Kessler, 1995; Kessler et al., 1996; Murphy,
1990), andwhen co-occurring with physical
illness premature mortality (Felker, Yazel, & Short, 1996; Hser, Hoffman, Grella,
& Anglin, 2001; Johnson, Fontana, Lubin,
Corn, & Rosenheck, 2004). It is most probable that this led to Kendall and Clarkins
(1992) conclusion that the study of comorbidity is the premier challenge facing mental
health professionals in the 1990s (p. 833).
Intimately related to the construct of
comorbidity is case complexity (Abramowitz, 2006; Addis, Wade, & Hughes, 1999;
Haas & Clopton, 2003; Kazdin & Whitley,
2006; Stirman, DeRubeis, Crits-Christoph,
& Brody, 2003; Westen & Morrison, 2001;
Westen, Novotny, & Thompson-Brenner,
2004). The term is variably defined, but we
take it to pertain to the presence of a host
of risk factors, including cognitive-personality vulnerability, interpersonal difficulties,
and financial strain, in an already comorbid

Shahar and Davidson

psychiatric picture. Similar to psychiatric comorbidity, case complexity has been shown
to seriously impede the delivery of evidencebased pharmacological and psychotherapeutic treatments (e.g., Blatt & Zuroff, 2005;
Westen et al., 2004; but see Kazdin & Whitley, 2006, for evidence that comorbidity and
case complexity do not impede outcome for
evidence based treatment of child disruptive
behavior).
Chronicity is a third participant in an
unholy trinity of obstacles for evidencebased psychiatric treatments. For obvious
reasons, personality disorders are, by definition, chronic conditions. However, many
DSM-IV Axis I disorders assume a chronic
course (e.g., Joiner, 2000; Leahy, 2007; Pettit
& Joiner, 2006; Strober, 2004), and chronicity is associated with poorer outcome (e.g.,
Fenton & McGlashan, 1987).2 What needs
to be appreciated is the fact that chronic
psychiatric cases are deeply embedded in patients social contexts and life situations. For
instance, personality disorders are likely to
generate interpersonal stress (Daley, Hammen, Davila, & Burge, 1998), and chronic
depression is likely to erode social support
(Joiner, 2000). Thus, the chronicity of caseness, which might be caused by comorbidity
and case complexity, is also likely to give rise
to these complications. Moreover, because
of previous treatment failures, people with
chronic psychiatric disorders are likely to be
demoralized, and are less likely to assume an
active role vis--vis their medical care.
It is probably clear from the above that
Jonathan constitutes an exemplar for the unholy trinity of psychiatric practice, namely,
comorbidity, case complexity, and chronicity. Specifically, this young man presents a
clinical picture that meets criteria for Panic
Disorder with Agoraphobia, Dysthemic Disorder, and a Paranoid Personality Disorder.
Such comorbidity is further complicated by
case complexity, namely, by the presence
of several risk factors, both contextual (the

157

absence of social support and positive life

events) and intrapsychic (maladaptive representations of self and others [object relations] and excessive use of low level defense
mechanisms). Finally, at least two of his diagnosesDysthemic Disorder and Paranoid
Personality Disorderare chronic, dating
back to his early adolescence.
PAR-EN: Demarcation,
definition, and rationale

Thus, the questions remain: What to

do with cases such as Jonathans? Where to
begin? How to address this multifaceted clinical presentation? This is where we summon
PAR-EN, the aim of which is to address the
above unholy trinity in clinical practice. Yet,
prior to defining PAR-EN and explicating its
rationale, it is important for us to demarcate
our overarching approach to psychotherapy,
which serves as the theoretical umbrella under which PAR-EN is employed.
In essence, we see our approach as
philosophically informed, evidence-based,
and integrative. By philosophically informed
we mean that we strategize treatment on the
basis of our notion of the basic nature of
psychopathology and mental health, which
are in turn predicated upon a philosophical
understanding of human behavior. By evidence-based we mean that we take clinical
science seriously, and incorporate assessment
and intervention procedures that have been
shown repeatedly and robustly to be effective with certain problems and populations
(e.g., exposure and response prevention for
obsessive-compulsive symptoms; Abramowitz, 2006). By integrative we mean that we
are not confined to a clinical practice governed by a single school of thought (e.g.,
psychodynamic or cognitive-behavioral), but
rather expect ourselves to transcend these
schools and customize treatment based on

2. In the present article we treat recurrent disorders as tantamount to chronic ones (e.g., Leahy, 2007).

158

each patients particular makeupboth their

personality and psychopathologyand their
social contexts.
The role of philosophy in our approach should be emphasized further. Because clinical science is usually conducted
with narrowly defined populations, and
because, often times, randomized clinical
trials are conducted with pure, rather than
complex, cases, the application of empirically validated treatment protocols in the
real world is far from straightforward.
Moreover, the presence of comorbid conditions further complicates the employment
of empirically validated treatment protocols
because it is not clear which protocol to apply first. Take, for instance, the frequently
occurring comorbidity of OCD and Major
Depressive Disorder (Abramowitz, 2006).
While both conditions could benefit from SSRIs, evidence-based psychotherapy with the
former condition relies heavily on exposure
techniques, whereas that of the latter draws
from behavioral activation. Which to do
first? And how to coordinate and negotiate
the two protocols? These are tough enough
questions to answer. But then, of course, the
frequent presence of personality pathology
in depression (e.g., Shahar, Blatt, Zuroff, &
Pilkonis, 2003), and/or OCD (Wu, Clark, &
Watson, 2006) complicates the matter even
further.
What is needed, then, is an approach
that can cut across several distinct syndromes
and vulnerabilities in identifying the hallmark of psychopathology and mental health,
as well as identify conditions under which
symptoms and vulnerabilities may then be
prioritized in terms of their impact. Once
such prioritization takes place, interventions
can in turn be matched to address each of
these symptoms and vulnerabilities respectively. As this kind of approach is based on
one or more assumptions about what is most
fundamental to human experience and, as
a consequence, to psychological well-being
and mental health, it can only be developed
within the context of a philosophy of human nature. In this regard, our philosophical

Particpation-Engagement

roots are to be found mainly in continental

thought, drawing from phenomenological,
existentialist, and poststructuralist traditions
(e.g., Davidson, 1987, 1988, 1992, 1997;
Davidson & Cosgrove, 1991, 2002; Davidson & Shahar, 2007). Similar positions with
respect to the distinguishing characteristics
of human nature can be found within the
analytic philosophy tradition (e.g., Wittgenstein, 1958), however, as well as within contemporary political thought (e.g., Sen, 1992,
1999).
For our current purpose, we shall
conceptualize the overarching commonality
across these various traditions under the rubric of action theory (Shahar, 2006). In addition to emphasizing explicitly the focus of
this framework on human action, this term
is less intimidating than many abstract philosophical concepts and may be more accessible to psychiatric practitioners who distrust
philosophy but have some familiarity with
the history of the social sciences. Herein we
choose to begin with Talcott Parsons, the sociologist who was perhaps the most seminal
of the American action theorists, and who
provided the following definition of action
and its component parts:
Action is a process in the actorsituation system which has motivational
significance to the individual actor . . .
This means that the orientation of the
corresponding action processes has a
bearing on the attainment of gratifications or the avoidance of deprivations of
the relevant actor, whatever concretely
in the light of the relevant personality
structures these may be. Only in so far
as his relation to the situation is in this
sense motivationally relevant will it be
treated . . . as action in a technical sense.
It is presumed that the ultimate source
of the energy or effort factor of action
processes is derived from the organism,
and correspondingly that in some sense
all gratification and deprivation have
an organic significance. But though it is
rooted in them the concrete organization
of motivation cannot for purposes of
action theory be analyzed in terms of the
organic needs of the organism [alone].

Shahar and Davidson

This organization of action elements

is, for purposes of the theory of action,
above all a function of the relation of
the actor to his situation and the history
of that relation, in this sense of experience.

It is a fundamental property of action

thus defined that it does not consist only of
ad hoc responses to particular situational
stimuli but that the actor develops a system of expectations relative to the various
objects of the situation. (1951, pp. 4-5; italics in the original)
In our earlier paper, we attempted to
convey the central contribution of action
theory by stating that human beings act
as well as are acted upon, and argued that
the study of psychopathology therefore
must take both of these elements of experience into account (Davidson & Shahar, in
press). What Parsons explains is that these
actions take place within the context of an
actor-situation or person-environment
interaction and only make sense within this
relationship. Actions are motivated by the
persons own desires and goals (for gratification), and by his or her wish to avoid pain,
failure, and rejection (deprivation), and are
not reducible to reactions to a given environment. This is in part because the persons
motivations and actions play a key role in
her/his selection of settings within which to
act and in conferring on these situations the
personal and social significance they have
as properly human situations (i.e., imbued
with meaning; see Buss, 1987). The person
brings to each situation his or her system
of expectations which, in turn, contributes
to shaping the situation itself. A simple, but
perhaps useful, example would be that of the
self-fulfilling prophecy: I expect you to reject
me so I act in such a way as to protect myself
from your rejection, which only serves to distance me from you and eventually cause you
to lose interest in me (Shahar, 2001, 2004,
2006; Shahar, Cross, & Henrich, 2004).
Action theory suggests that all situations are in part constituted by the persons
expectations, which in turn are based on his

159

or her prior experiences. At any point in the

process, we are stepping into a hermeneutic
circle in which my actions are both based
on prior meanings and, at the same time,
generating additional meanings which will
then serve as the basis for future meaninggenerating actions, and so on. Within the
continental philosophical tradition, this perspective was derived initially from the work
of Brentano and Husserl on the constitutive
role of intentionality, the term by which
they referred to the interdependent relationship between person and world upon which
both depend for their identity (e.g., Husserl,
1982).
Despite Husserls emphasis on this relationship, his phenomenology remained embedded within German Idealism, a perspective in which action unfortunately played
a subordinate role to awareness (see also
Cooper, 1990, who characterized this philosophical approach as spectatorial). It was
not until the work of Heidegger (1962), Sartre (1956), and Merleau-Ponty (1962)and
their turn to an existentialist phenomenologythat the person as spectator of the world
was dragged into this world and viewed as an
engaged participant. To capture the unavoidable and all-encompassing nature of this relationship, Heidegger proposed that human
being was first and fundamentally a beingin-the-worldthe hyphens being used to
highlight that it is the relationship itself, the
intentional act, which is primary rather than
either of the two objects. In other words, a
person cannot exist in a vacuum, apart from
any concrete situation or social environment,
just as a world of meaning cannot exist apart
from the subjects (i.e., human beings) for
whom it holds such meaning. The two come
into existence together, of a piece, with each
new action. Action therefore does not follow
from awareness, but awareness from action.
As the Russian psychologist, Lev Vygotsky
was to suggest around the same time: All
functions of consciousness . . . originally
arise from action (1978).
Heidegger, Sartre, and Merleau-Pontys emphasis on action was obviously not

160

derived from Vygotsky, however, but from

the earlier thoughts of Kierkegaard and
Nietzsche, widely considered to be the two
founding fathers of Existentialism. While
they came from two diametrically opposite
points of view (Nietzsche being an atheist
and Kierkegaard a devout Protestant theologian), both agreed that what fundamentally
defines human nature is the subjectivity, the
unique existence of each individual, and what
each person then makes of his or her life. In
other words, people are not defined by the
various categories to which they may belong
(e.g., Jew or Gentile, faithful or heathen, idealist or romantic, aristocrat or proletariat,
psychiatrist or psychologist) or by what they
do or do not have (e.g., land owner vs. serf,
CEO vs. unskilled worker); all of these are
historically contingent, somewhat arbitrary,
and fickle. They offer only an illusory sense
of identity or permanence, a sense which also
remains dependent on the complicity of others (e.g., there can be no Pope in the absence
of faithful Catholics). People are defined instead by what they do. It is the persons actions, and the decisions on which they are
based, which both determine and demonstrate who and what they are.
As it is not only my consciousness but
also my very being which arises from and is
created by my actions, then it is my actions
which are of utmost interest and importance
in psychology. The central questions in such
a psychology are framedas we suggested in
an earlier paperby asking what the person is doing and what he or she is doing it for
(i.e., with what intended aims) (Davidson &
Shahar, 2007). What has this person chosen
to value, what is she or he trying to achieve,
and how is any particular action in which he
or she engages intended to bring this about.
As an organizing construct for this series of
questions, Sartre proposed that each person
is best understood in terms of his or her own
fundamental project (1956). Although Kierkegaard did suggest that purity of heart
was achieved through the willing of one
thing (1938), neither Kierkegaard nor Ni-

Particpation-Engagement

etzsche viewed people as limited in this way

to only one definitive project.
Such philosophical thinking germinated into a formidable, albeit recently overlooked, contribution by existential psychology and psychiatry. Seminal contributions
by May (1958), Frankel (1963) and more
recently Yalom (1980) spoke eloquently
about the importance of the future, and the
pursuit of key goals in the psyche. Effective
psychotherapy, writes Yalom, must focus
on patients project relations, as well as on
their object relations (1980, p. 291, italics in the original). Similarly, Yalom argues,
engagement in life, in its vicissitudes, challenges, and missions, is the major therapeutic
answer to meaninglessness. Specifically,
Wholehearted engagement in any of the
infinite array of lifes activities . . . enhances the possibility of ones completing
the patterning of the events of ones life
in a coherent fashion. To find a home,
to care about other individuals, about
ideas and projects, to search, to create,
to buildthese, and all other forms of
engagement, are twice rewarding: they
are intrinsically enriching, and they alleviate the dysphoria that stems from being
bombarded with the unassembled brute
data of existence. (p. 482)

What a marvelous existential description of behavioral activation, an empirically

based therapeutic intervention aimed at helping unipolar depressed patients participate in
rewarding activities so as to boost positive
operant conditioning (Jacobson, Martell, &
Dimidjian, 2001; see most recently Dmidjian
et al., 2006 for an empirical demonstration
of the superiority of this intervention over
cognitive therapeutic techniques).
It is only befitting that, finally, recent
contributions in academic personality psychology focus on goal-related constructs
(Austin & Vancouver, 1996), referred to under the various labels of Life Tasks (Cantor, 1990; Harlow & Cantor, 1994), Personal Goals (Brunstein, 1993), Personal
Strivings (Emmons, 1986), Life Planning
(Smith, 1999), and Personal Projects (Lit-

Shahar and Davidson

tle, 1999). Like Sartre, these writers view the

setting and pursuit of such goals as not merely the things people choose to pursue within
the context of their everyday lives, but more
fundamentally as creating, shaping, and giving meaning to the persons everyday life. In
essence, we maintain, there is no me separate from, or standing outside of, this goal
structure.
What implications does this framework have for understanding the nature of
psychopathology and conducting the enterprise of psychotherapy? We summarize these
in the following key points. First, people are
best understood as social agents who exercise
volition in the pursuit of meaningful desires
and goals. These desires and goals, colored
by their prior experiences and personality
structure, lead to their selecting and imbuing
with personal significance those situations
and social environments in which they then
attempt to pursue gratification and avoid
pain, failure, and rejection (Buss, 1987).
Second, since action is generated in
part by the persons projects, it is best
understood from what Parsons described as
the point of view of the actor (1951, p.
543). This principle suggests that clinicians
need to cultivate an empathic understanding
of their clients own perspective prior to, and
as the foundation for, other interventions.
Third, psychological well-being, or
mental health, is determined by the degree to
which the person is fully engaged in and pursuing his or her own hopes, dreams, and aspirations (i.e., projects)that is, the degree
to which his or her energy is being channeled
into activities consistent with his or her own
values and goals. This is not to suggest an
acquisitive model of mental health, however,
in which the expectation or requirement is
that the persons goals are actually achieved
(as in, he who has the most is the happiest).
Rather, it is in the nature of human beings
that with each goal achieved new ones will
be set, that we will always be in the process
of becoming, and that the only static state we
will ever know will be our eventual death.
As no goal we can set or accomplish will

161

ever reverse this ultimate outcome, it is the

process itself of pursuit (the journey) which
matters most, not the particular desired object or end state (the destination). Within this
framework, people are more defined by the
choices they make (Maddi, 1998) and the
actions they undertake (i.e., what they do;
Shahar, 2006) than by what roles they occupy or what objects they possess (i.e., what
they have).
Fourth, psychopathology is adverse
not only, or even primarily, because it causes
psychological distress, but also, and mainly,
because it impedes the attainment of personal projects. Comorbid and complex
psychiatric cases are particularly adverse because they include multiple syndromes and
vulnerability, each of which has potential to
impede the persons projects. Consider, for
example, the case of Jonathan. This young
man struggled with panic disorder with agorophobia, dysthymic disorder, a personality
disorder, and interpersonal skill deficits, each
of which obstructed his attempt to pursue
his autonomously chosen vocation (i.e., to
become a professional philosopher) and to
find romantic love. To the extent that we
are condemned to meaning (Merleau-Ponty, 1962, p. xix), these comorbid conditions
pose major impediments to its attainment.
So what does one do first? We propose
to take Yalom (1980) seriously and to conduct an analysis of project relations, that
is, to explore, with our patients, their hierarchy of personal goals, assess with them these
goals authenticity, and employ evidencebased interventionsboth pharmacological
and psychotherapeuticthat address symptoms and vulnerabilities which impede the
attainment of key personal goals. Consistent
with the strategy employed in some forms of
family therapy, we propose employing a onedown, low-key approach, asking the patient
what sort of improvement he or she envisions
that would be deemed as constituting a reasonable therapeutic benefit. As is illustrated
graphically in Figure 1, we propose addressing one goal at a time, targeting only the key
symptoms and vulnerabilities that impede

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Particpation-Engagement

FIGURE 1. Visual Illustration of PA-REN.

Note. S = symptom. V = vulnerability.

the putative goal, andas strange as it may

soundnot addressing the rest, consistent
with the principle of Primun non nocere.
To illustrate further, let us return to
Jonathan. In evaluating treatment options, a
cumbersome issue became apparent: To effectively prioritize interventions, treatment
stability must first be secured. This young
mans (unconscious) dependency, coupled
with his suspiciousness and interpersonal
sensitivity, made it difficult for him to benefit
from treatment, and we (GS and the psychiatrist) needed to help him feel safe in each of
the respective therapeutic relationships. To
do that, we surmised, we first had to adhere
to a supportive-emphatic, self-psychological
(Kohut, 1971; Stolorow, Brandshaft, & Atwood, 1987) therapeutic modality, whereby
most of the therapeutic sessions were focused on immersing ourselves in Jonathans
fears of being hurt in treatment, constraining
those fears without retaliation (Winnicott,
1971), linking them in an empathic way to

Jonathans security operations (Sullivan,

1953) within treatmentfor instance, his
cancellations and argumentativenessand,
most of all, waiting for them to sufficiently
subside, so that Jonathan may feel that he is
in treatment rather than against it.
After about two months of treatment,
we could proceed by conducting an analysis
of Jonathans project relations. The personal
project that was top on Jonathans list was
excelling in school. He loved philosophy,
and he knew that embarking on a career as
a professional philosopher meant he needed
to study hard and get very high grades in order to be admitted to a top notch graduate
school. We jointly examined this ambition at
length, and it appeared to be self-determined,
stemming from his unique talents and proclivities, rather than serving a defensive function and/or representing a wish to adhere to
social norms or expectations. But Jonathan
had difficulties studying because he was exhausted most of the day due to not sleeping

Shahar and Davidson

well during the night. It was therefore apparent that this young man needed our help
first and foremostin getting some sleep.
Accordingly, Jonathan agreed to a
trial of cognitive-behavioral treatment for
insomnia. This, however, did not work.
While he followed the sleep hygiene instructions scrupulously, he still had trouble falling asleep because his mind was racing with
anxious thoughts, including thoughts of not
being able to sleep. In consultation with the
psychiatrist, we therefore resorted to a low
dose (.5 mg) of Lorazepam, instructed to
be taken two hours before bedtime. Fortunately, this worked, and enabled him to fall
asleep, which was his major nocturnal obstacle. When he woke up during the night,
he was quick to implement the sleep hygiene
instructions that had been given to him and
was able to go back to sleep. In the course of
the next five weeks, his sleep improved markedly in terms of both quantity and quality.
This, while not improving his mood, did improve his concentration and enabled him to
study better. Such an improvement, in turn,
helped persuade him that treatment, instead
of being potentially detrimental, actually had
something concrete to offer him.
What next? This is what we asked
Jonathan. He was still suffering from severe
panic attacks, alongside the aforementioned
depressive symptoms. Evidence-based psychotherapy for panic disorder is quite different from that employed for depression, the
former comprising interceptive exposure and
the latter, either cognitive behavioral treatment or interpersonal psychotherapy. It was
up to Jonathan to decide which syndrome he
wanted to address first. Again, he reached
this decision based on his prime personal
project.
Of all the debilitating symptoms he
suffered, negative depressive cognitions
were the most troublesome with respect to
his struggle for becoming (a philosopher).
Constant social comparison with classmates,
obsessive and depressive ruminations about
his (perceived meager) prospects of success,
as well as the potential of failure, pervaded

163

his psyche, reducing his self-confidence and

interfering with his curiosity and quest for
knowledge. An attempt was made to employ cognitive restructuring consistent with
Beck, Rush, Shaw, and Emery (1983), but
this was countered by a negative transferential reaction. Jonathan experienced me (GS)
as the know-it-all, ridiculing, punitive, omnipotent object, and his argumentativeness increased. This impasse was addressed
by reverting to a psychodynamic exploration
of these transference-countertransference
exchanges, leading to an enhanced understanding of Jonathans early development
and his frustrating relationships with two
highly educated, successful, and impossibly
demanding parents. In light of this upbringing, the therapists encouragement of Jonathan to think differently about his studies
evoked schemas, scripts, and object relations
characterized by a punitive parent attacking an overwhelmed, agitated self, leading
to counterattacks by way of ongoing argumentations (there were also key issues in the
countertransference that contributed to this
impasse, but they will be left out of the present discussion).
Once these exchanges were worked
through, Jonathan was able to put his brilliant mind to work in construing his studies as an opportunity to feed his consuming
curiosity rather than to compete with others.
He learned, by way of employing mindfulness techniques, to focus on present learning
rather than envision future failures. This, in
turn, improved his negative condition and
consequently reduced, although not eliminated altogether, his negative affect (see Layne,
Porcerelli, & Shahar, 2006, for a similar integration of psychodynamic and cognitive
therapeutic techniques).
What then? Jonathan was still having
panic attacks, and they were quite severe,
although he reported that his perspective
on these attacks had changed. With an increased sense of self-efficacy ensuing from
the successful management of his sleep and
studies, Jonathan felt that his self-labeled
craziness, while not fully resolved, was

164

Particpation-Engagement

pretty much contained, and that he was interested in moving forward in another direction. Its time for me to find a woman, he
said. Up to this point, Jonathan had never
had a stable, ongoing romantic relationship.
A major impediment to this quest was the
fact that Jonathan was extremely insecure in
approaching women, and he felt that there
was little chance they would be attracted to
him.
Concerned that Jonathans zeal to
find a woman would set him up for a failure (and most of Jonathans projects were
conceived, albeit secretly, with great zeal),
I (GS) proposed to Jonathan to view this
stage in the treatment as opening up to the
world. Consulting the manual for Interpersonal Therapy (IPT) for depression (Weissman, Markowitz, & Klerman, 2000), I construed Jonathans predicament at this stage as
that of interpersonal deficits, and proceeded,
vis--vis the manual, to (a) review past interpersonal relationships, (b) reexamine the
therapeutic relationship, but this time with a
focus on social skills rather than on unconscious, transference-countertransference exchanges, and (c) systematically employ communication analysis of Jonathans attempt
to form relationships, as well as role playing
pertaining to new friendships, in order to
help him acquire needed skills (for extensive
description, see Weissman et al., 2000, pp.
103-116).
This process is still ongoing. Jonathan
is currently in treatment, still having sporadic panic attacks, and has not yet found
a woman. I await his lead on working on
these issuesor, as often happens, on addressing something else based on the dictum
of his personal projects.
PAR-EN and patients
spontaneous gestures

As is clear in Jonathans case, in implementing PAR-EN, one should be constantly

reminded that the patient is in the drivers

seat. It is s/he who decides what syndromes/

vulnerabilities to address and in what order. The role of the therapist in the course
of making such a decision is to help the patient bring to awareness her/his key personal
projects, that is, the particular way in which
s/he would like to participate-engage in the
world, and to realize how her/his various
syndromes and vulnerabilities impede this
participation.
Thinking psychoanalytically about
this division of labor, we suggest construing
the patients decision in terms of Winnicotts
notion of the spontaneous gesture (Winicott,
1987). As is well known, Winnicott posited
that the child individuates slowly out of an
inseparable mother-infant matrix in which
full dependency of the infant on the mother (or in more politically correct terms, the
primary caregiver) is encouraged, as well as
supported by the mothers outstanding responsiveness to the infants needs (Primary
Maternal Preoccupation, Winnicott, 1971).
The infant, helpless in the face of an overwhelming world, needs this maternal membrane in order to survive, and indeed, the
mother supplies his/her needs before they are
felt. Out of this dependency, however, emerges a True Self, the source of the infant-tobe-persons authenticity and creativity. One
knows that this emergence of the true self
takes place when the infant gestures spontaneously that s/he has needs that are not identified and hence are not fulfilled, a process
that is miraculously synchronized with the
dissipation of the primary maternal preoccupation.
A disclaimer is in order here. Adult
patients are not infants, and so we would
like to proceed with caution with this analogy. What we take from the notion of the
spontaneous gesture is the realization that
adult patients, like infants, are constantly
evolving, constantly striving for autonomy,
that they do so in creativesometimes even
illusiveways, and that if we are open to listening, they will do a fine job of signaling
how they would like their autonomy to be
supported. Indeed, it is the beginning stage

Shahar and Davidson

of treatmentthe most important stage, we

believeduring which the patients gestures
are collaboratively made sense of. Specifically, we find that once the therapeutic dyad
patient and therapistnails down the particular syndrome/vulnerabilities that stand in
the way of participation-engagement, and assuming that the appropriate evidence-based
psychotherapeutic and/or pharmacological
interventions are employed, improvement
in terms of these syndrome/vulnerabilities
is quite likely. It is the burdensome journey
made by the therapeutic dyad in the course
of identifying the meaning systems underlying patients spontaneous gestures, which is
in need of heightened conceptual and clinical
attention.
To illustrate the importance of patients spontaneous gestures further, we appeal to a more recent therapeutic session
with Jonathan. This particular session was
scheduled on a different day than usual
because of the Jewish holidays. Over the
phone, Jonathan mentioned: I have to see
you before Rosh Hashana. I am quite depressed. In the session, Jonathan alluded to
intense negative affect, anhedonia, and lack
of motivation. I (GS) was prepared to present a behavioral activation regimen. But then
Jonathan said he did not have a place to stay
during the holiday, and he didnt want to go
to his parents house because they dont understand him. Upon further inquiry into his
parents failure to understand him, Jonathan
revealed, for the first time, chronic feelings of
isolation and alienationnot only from his
family but from people in generalowing to
the fact that his conscientiousness, seriousness, and intense affectivity often clash with
those around him. By way of illustrating
this alienation, he related a moving childhood memory about his trying to defend a
stray dog from being attacked by boys in his
neighborhood. When he told this to his parents, they did not understand why he had to
put his neck on the line.
Upon getting in touch with these experiences, Jonathan lit up, the depression in
his face dissipating and replaced by angered

165

determination. My attempts, towards the

end of the session to still offer behavioral activation, were dismissed off-hand. Jonathan
was spontaneouslyand quite compellinglygesturing to me not to reenact his interpersonal exchange with his parents whereby
he was continuously misunderstood and
misperceived. He did not want, in this session, treatment for his depressive symptoms.
What he really wanted was to be seen and
acknowledged for those personality tendencies that, up until now, kept him at a distance
from others.
Daily activities: The revealed
preference of participation

We have learned in the course of time

that patients gestures might be manifested
through their daily activities. Specifically,
given that time is a key resource, to be readily consumed by daily activities, what people
actually do with their time might represent
the things they care about the most, namely,
their key personal projects. Here we draw,
quite metaphorically, from the notion of
revealed preference, developed in economics (Samuelson, 1948), according to which
consumers preferences are best identified
by their purchasing habits. Similarly, how
patients spend their time, each and every
day, may be taken to be indicative of their
existential preferences. We found this perspective to be particularly helpful under two
circumstances.
1. Patients say they want A, but
actually spend most of their day
pursuing B. For instance, a medical
student patient declared, from the
outset of treatment, that he cared
deeply about his studies and wanted very much to excel. However,
he spent most of his day hanging
around the university cafeteria,
looking for friends. Upon further
exploration, it was revealed that

166

Particpation-Engagement

this student never really wanted

to go to medical school, and that,
in fact, he was more interested in
developing a social life and romantic relationships, and had gone
to medical school to please his
parents.
2. Patients make noticeable changes
in their daily activities, reflecting a
deep- seated change in the priority
of their personal projects. Thus,
without being aware of it patients
might begin spending more time
with their families, at the expense
of work, or vice versa, or they will
spend more time with one person
than another. At times, changes in
daily schedules are synchronized
with the vicissitudes of treatment.
For instance, we now find that
with some patients with eating disorders, spending time in activities
unrelated to food and weight considerations is correlated with an
enhanced therapeutic alliance and
an ability to open up in treatment
and bring to the fore burgeoning
fears of gaining weight. It is as if
the disorder is now deposited in
the therapy room, freeing the day
to be spent on participation in
other areas of life.
Relatedness (communion)
and self-definition (agency)
as general clues for the
identification of patients
participation-engagement

Whereas the patient is the one taking

the drivers seat, the therapist assumes the
role of a navigator, enabling the driver to locate his/her destination and the road leading
to it. In the course of our clinical work, we
found that acquaintance with relatedness,
or communion, and with self-definition, or

agency, may assist the driver-navigator team

in their journey. Relatedness/communion
pertains to the need to be a part of interpersonal relationships and larger social groups,
and to the pursuit of intimacy and union
with others. In contrast, self-definition/
agency refers to theindividuals tendency to
form a differentiated, highly articulated, and
essentially positive sense of self, and to the
pursuit of mastery and power. In personality theory and research, these tendencies
reflect two basic developmental trajectories
and personality organizations that serve as
key individual difference variables (Bakan,
1966; Blatt, 1974, 1998, 2004, 2007; Blatt
& Blass, 1996; Helgeson, 1994; Wiggins,
1991, 2003).
Blatt and his colleagues (Blatt, 1974,
1995, 1998, 2004, in press; Blatt & Blass,
1996; Blatt & Zuroff, 1992) made a unique
contribution to the elucidation of relatedness/communion and self-definition/agency
as key determinants of personality development and psychopathology. Specifically,
juxtaposing Eriksons life span theory of
development with the notion of relatedness/
communion and self-definition/agency, Blatt
and Blass (1996) argued compellingly that
life span psychological development oscillates between a focus on forming close relationships and a focus on the formation of
a stable sense of self, whereby accomplishments pertaining to each developmental trajectory lay the foundation for the other.
How can these constructs assist PAREN? We contend that psychiatric symptoms,
whatever their origin, acquire a significant
meaning and status in the context of individuals agentic and communal pursuits, each
of which is alternately highlighted at different developmental periods. Thus, a specific
symptom, for instance, insomnia, would hold
different meanings for an ambitious young
adult trying to pursue a demanding career
than for a retired person with a lot of free
time. Whereas for the latter insomnia might
represent an unpleasant nuisance, for the

Shahar and Davidson

former it might pose a serious threat to his/

her principal agentic project. Consequently,
we believe that the symptoms and vulnerabilities which should be addressed first are
those that threaten the basic agentic or communal projects pursued by patients. Accordingly, we argue that an enhanced sensitivity
to the differential manifestation of agency
and communion in different developmental periods might assist in identifying these
symptoms and in prioritizing interventions
to address them.
Two qualifications are in order here.
First, one should be reminded that agentic
and communal concerns are individualized
and particular, and that the very same behaviorsay, sexual intercoursemight represent
an agentic pursuit for one person (e.g., the
need to control and conquer) and a communal pursuit for another (e.g., the need for intimacy). It therefore follows that the agentic
and communal meaning of motivated behaviors could not be determined exogenously by
the therapist. Rather, the meaning of such behaviors ought to be explored collaboratively,
and be appreciated first and foremost from
the point of view of the patient, in a manner
consistent with the phenomenological basis
of PAR-EN.
Second, and related to the first issue,
we see the spontaneous gesture guideline as
taking precedence over the self-definition/
agency and relatedness/communion one.
Specifically, while we encourage therapists to
be informed by the notions of self-definition/
agency and relatedness/communion in their
attempt to identify patients principal personal projects, we are cognizant of the fact
that not all projects, and not all gestures,
are neatly categorized in terms of these two
highly abstract notions. More importantly,
what a patient wants is what s/he wants. It
is an irreducible primary that exists beyond
this or that theoretical construction. PAR-EN
addresses symptoms and vulnerabilities that
impede key personal projects, whether these
are agentic, communal, both, or neither.

167

Implications for clinical

assessment and the
therapeutic relationship

Hopefully, it is clear by now that the

employment of PAR-EN is contingent on a
careful assessment process. Without a preliminary understanding of a patients locomotion, namely, an understanding of where
s/he is heading, we cannot assist her/his participation and engagement. As is exemplified by Jonathans case, we are advocating
a formal assessment procedure that includes
1) evidence-based semi-structured interviewing (e.g., Structural Clinical Interview for
DSM, or SCID) and self-report questionnaires for the assessment of symptoms, and
2) self-report questionnaires and projective
procedures that allow for the assessment of
personality tendencies and social context
predicaments (e.g., stress and availability of
social support). Such instruments are invaluable in providing information about patients
motivations, mental structures, and obstructive symptoms and vulnerability. Nevertheless, psychiatric and psychological tests yield
bits and pieces of information, which need
to be integrated into an overarching case formulation that, in the context of the present
discussion, addresses a relatively straightforward question: How does the patient wish
to participate in life, and what prevents her/
him from doing so?
It is here that we propose to take into
consideration the interpersonal nature of
participation-engagement. Specifically, we
hold it axiomatic that goals and personal
projects are intimately tied to relationships
and social contexts. Because individuals are
not passive recipients of social contexts, but
rather actively, if inadvertently, shape these
contexts (Buss, 1987; Shahar, 2004, 2006),
it follows that individuals impact on their
social context holds the key to a constructive
participation-engagement. It is here that we
propose to draw from Shahar and Porcerelli
(2006) who propose The Action Formula-

168

tion (TAF) as heuristic for clinical case formulation. The purpose of TAF is to identify
individuals actions on their social environment, with a focus on the interplay between
vicious, maladaptive, and risk-related interpersonal cycles (e.g., a person generates
life stress, which in turn increases her/his
depression, cf. Hammen, 1991, 2006) and
protective, adaptive, and resilience-related
ones (e.g., the very same person might generate social support in response to her/his
depression, which might alleviate the latter
condition; Shahar & Priel, 2003).
The action formulation relies on four
guidelines. The first guideline is to map the
clients social environment and the role it
plays in the pertinent outcome, particularly
as it is manifested by the presence of stress
(both acute and chronic), positive life events,
and social support. The second guideline is
to identify how the client, in the context of
her/his personality, psychopathology, and
strengths, shapes her/his own environment,
that is, how s/he generates stressful events,
contributes to the maintenance of chronic
stress, engages in positive life events, and
elicits social support. The third guideline, intimately tied to the second, is to differentiate
between maladaptive, risk-related, interpersonal cycles, and adaptive, protective, and
resilience-based ones, as well as to identify
the interplay between adaptive and maladaptive cycles.
These three guidelines are illustrated
in Figure 2, in which TAF is applied to Jonathans case. The figure, which only approximates the complexity of Jonathans difficulties, depicts several vicious cycles emanating
from Jonathans malevolent representations
of self and others (i.e., object relations) to
depression through two pathways: 1) attacking authority figures and 2) isolating himself.
Note that both lead to depression, that depression leads to academic setback, which itself strengthens malevolent representations,
and that depression is a likely contributor to
insomnia, which further leads to academic
setback. Note also that panic attacks exacerbate social isolation, thereby amalgamating

Particpation-Engagement

the interpersonal cascade. At the same time,

Jonathan also generates benevolent mental
representations, which, when activated, facilitate his attachment, in turn increasing his
adherence to evidence-based treatment, leading to symptomatic improvement that enables academic and social growth, culminating in enhanced benevolent representations.
The fourth and final guideline is to tailor integrative techniques to short-circuit the
maladaptive cycles and bolster the adaptive
ones. The objective of these techniques is to
assist patients in minimizing maladaptive interpersonal cycles and in maximizing adaptive ones, thereby navigating themselves into
holding environments (Winnicott, 1971).
Various models of integrative psychotherapy
are currently available and may greatly assist in translating TAF into treatment planning (Connors, 2001; Frank, 1990; Gold &
Stricker, 2001; Olds, 1981; Wachtel, 1977,
1997). In particular, we find Oldss (1981)
treatise informative, because it not only advocates the integration of psychoanalytic and
behavioral (active) techniques, but also
highlights the potential of such integration
to increase individuals abilities to shape an
adaptive, as opposed to maladaptive, social
context, leading in turn to greater self-exploration. Specifically, in discussing the effect of
active techniques, he argues:
Any new behavior will lead to new
responses from the environment, which
becomes important to the treatment.
Thus, a new assertiveness may provoke
anger or respect from the patients associates, quickly leading to possibilities for
a change in self-image; this breaks a recurrent cycle in which passivity depresses
self-esteem, which, in turn, increases the
tendency to passivity. Again, the new
experience may lead to new associations
and memories as well as to new integration of previously uncovered material.
(Olds, 1981, p. 137)

The fourth guideline is particularly

pertinent to the integration of psychotherapy
and pharmacotherapy in the treatment of comorbid, complex, and chronic cases. For the

Shahar and Davidson

169

FIGURE 2. Application of The Action Formulation (TAF) to Jonathans Case.

patient to be able to participate adaptively,

a prompt and decisive treatment of obstructive symptoms needs to be employed. Oftentimes, this aim is best realized through the
use of medications. In order to decide which
symptom to target, and by what medication,
one needs to understand the patients unique
mode of participation, that is, her/his personal project profile. In cases where treatment is
conducted jointly by a psychotherapist and a
psychopharmacologist, these two professionals are well advised to confer regularly so as
to identify the patients personal projects and
tailor medications accordingly, as well as to
preempt, or treat, ensuing side effects that
might themselves compromise key personal
projects.
This latter consideration brings to the
fore the issue of the therapeutic relationship.
As shown by empirical research, a rapid
symptomatic improvement is likely to lead
to considerable remoralization, followed by

further improvement (e.g., Gilboa-Shechtman & Shahar, 2006). From a psychodynamic point of view, such an improvement
might constitute the therapist as a benevolent object, or selfobject, in the patients
inner world (Connors, 2001). Located in the
context of the present discussion, we submit
that these psychodynamic gains would be
particularly pronounced following a kind of
symptomatic improvement which is sensitive
to patients participation (i.e., to their pursuit of key personal projects).
On the other hand, the very vigor
characterizing patients participation might
also lead to psychotherapeutic ruptures. Shahar (2004) describes this two-person politics
as follows:
An AT [action theory] approach,
superimposed on the relational view of
transference and countertransference,
depicts patients and therapists as representatives of each others environment.

170

Particpation-Engagement

Both parties enter into the therapeutic

arena with core personal projects (Little,
1999), and both attempt to shape the
environment (i.e., each other) to enhance
these personal projects. Because these
core personal projects tend to be rigid
and uncompromising, they are likely to
lead to escalating pressure that results
in vicious interpersonal cycles (P. L.
Wachtel, 1994). These vicious cycles are
likely to lead to therapeutic ruptures,
whichironicallythreaten the core
personal projects so vigorously sought by
the participants. (p. 382)

Therapists should therefore expect

that at least some parts of the quest for patients participation-engagement will be turbulent. Specifically, therapists might, perhaps
inevitably, misunderstandor even pathologizepatients key personal projects. Or
they might (perhaps also inevitably) fail, or
only partly succeed, in alleviating symptoms
and vulnerabilities obstructing these projects. Both eventualities might lead to hostile
reactions from patients. Where treatment is
conducted jointly by a psychotherapist and
a pharmacologist, patients might perceive
one of these professionals as supportive of
her/his participation and the other as obstructive, consequently attempting to pit one
against the other. Even more surreptitiously,
therapists own personal projects, summoned
in the context of transference-countertransference exchanges, are likely to come to the
fore, jeopardizing an effective administration
of psychotherapy and/or pharmacology. The
recommended approach for the mitigation of
these eventualities is straightforward; it includes the consistent and judicial attention to
patient-therapist exchanges, an anticipation
of early signs of conflict, and an increased
sensitivity to ones (i.e., therapists) own
struggles pertaining to participation-engagement, as well as to likely ways in which we
are tempted to use patients as vehicles for
the fulfillment of our own personal projects

(Winnicott, 1971; see also Shahar, 2004, for

further illustrations).
Limitations

Having described PAR-EN in detail,

we would like to note several limitations of
this formulation, which also pave the way
to future work. First, it should be emphasized that Jonathans case does not prove
the efficacy of PAR-EN, not only because it
represents a conglomeration of patients (see
footnote 1), but also because no case proves,
or even demonstrates, a theoretical formulation. That is, cases are people, and people are
multivariate beings that are inexhaustible by
any theory, let alone a circumscribed theoretical formulation such as PAR-EN. The merit
of our formulation will be tested, not by reference to a single case, but by 1) the independent experience of clinicians who might
find PAR-EN useful for their work with
people suffering from comorbid, complex,
and chronic psychiatric conditions, and by
2) standardizing PAR-EN and offering it in
a semi-manualized form, subsequently testing its efficacy in a randomized clinical trial
with comorbid patients, an endeavor which
we are currently pursuing.
Two other limitations should be
noted.3 First, because we have formulated
PAR-EN around work with largely strongwilled, if seriously disturbed, individuals, the
extent to which this formulation is suitable
to individuals whose will is impoverished,
for example, people with negative symptoms or those afflicted with brain injuries
that adversely affect the reward system, is
unclear. Second, we wish to caution against
use of PAR-EN in the service of using active
techniques prematurely, often in lieu of exploratory, insight- oriented work. The tension between action and insight (Wachtel,
1987) should be respected and retained, with

3. We are indebted to an anonymous reviewer for pointing out these limitations.

Shahar and Davidson

therapists resisting the temptation to launch

active techniques just for the sake of doing something. A careful examination of
transference-countertransference exchanges,
and repeated consultation with peers and supervisions, may serve as a guard against such
a temptation (Shahar, 2004).
Conclusion

With those limitations in mind, we

wish to conclude by drawing from Rollo
May, another giant of existential psychology
and psychiatry. In his treatise on freedom
and destiny, he noted:
The word possibility comes from the
Latin posse, to be able, which is the
original root of our word power . . . Personal freedom, on the contrary, entails
being able to harbor different possibilities in ones mind even though it is not
clear at the moment which way one must
act. (May, 1981, pp. 10-11, italics in the
original)

He continues:
But most of all, I believe that the therapists function should be to help people
to be aware of and to experience their
possibilities. A psychological problem, I
have pointed out elsewhere, is like fever;
it indicates that something is wrong
within the structure of the person and
that a struggle is going on for survival.
This, in turn, is a proof to us that some
other way of behaving is possible . . .
Problems are the outward sign of unused
inner possibilities. (May, 1981, pp.
19-20, italics in the original)

171

We agree and argue further: Problems

(e.g., symptoms, vulnerabilities) encapsulate
peoples authentic cry for participation, for
being-in-the-world, for realizing their key
personal projects. Difficult problems, namely
comorbid, complex, and chronic psychiatric
conditions, are difficult because the encapsulation is particularly impervious. It is difficult to penetrate through the concrete of
symptoms, vulnerability, and risk factors and
uncover patients locomotion, where they
are heading, their destination (as opposed to
destiny; see May, 1981).
To aid in this quest, we propose PAREN, a philosophically based heuristic that
facilitates identification of patients participation-engagement. An effort to identify
patients key personal projects, as they are
manifested, often emblematically, in their
spontaneous gestures and everyday activities, an awareness of the dialectics between
relatedness/communion and agency/self-definition in the course of personality development, a systematic, evidence-based assessment of symptoms, contextual risk factors,
and personality vulnerabilities, as well as the
ways in which people act on their environment, promises to dilute the aforementioned
encapsulation comprised of comorbidity,
case complexity, and chronicity. This is done
to the effect of prioritizing symptoms and
vulnerabilities so that they may be treated
using the integrative, evidence-based techniques available in our psychiatric arsenal
granted, a very difficult, albeit surmountable, task. What makes it poss(e)ible is the
therapeutic power of our own participationengagement in our patients lives.

172

Particpation-Engagement

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