Existential Psychotherapy Rollo May and Irvin Yalom overview



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HISTORY
Precursors
There are two streams in the history of human thought. One is of essences, seen most clearly in Plato’s belief that there are perfect forms of everything and that things such as a specific chair are imperfect copies. These essences are clearest if we imagine mathematics: a perfect circle and a perfect square exist in heaven, of which our human circles and squares are imperfect copies. This requires an abstraction that leaves the existence of the individual thing out of the picture. A proposition can be true without being real. Perhaps just because this approach has worked in certain areas of science, we tend to forget that it omits the living individual.
But there is another stream of thought coming down through history: namely, existence. This viewpoint holds that truth depends upon the existing person, existing in a given situation (world) at that time. Hence the term existential. This is what Sartre meant in his famous statement, “Existence precedes essence.” The human being’s awareness (i.e., his or her existence) precedes everything he or she has to say about the surrounding world.
Down through history, the existential tradition is exemplified by many thinkers. These include Augustine, who held that “Truth dwells in the inner man”; Duns Scotus, who argued against Thomas Aquinas’s rational essences and insisted that human will must be taken as basic to any statement; and Blaise Pascal, as in his famous statement, “The heart has its reasons which reason knows nothing of.”
There remains in our day the chasm between truth and reality. And the crucial question that confronts us in psychology is precisely this chasm between what is abstractly true and what is existentially real for the given living person.


Beginnings
Kierkegaard, Nietzsche, and those existentialists who followed them foresaw this growing split between truth and reality in Western culture, and they opposed the delusion that reality can be comprehended in an abstracted, detached way. Though they protested vehemently against arid intellectualism, they were by no means simple activists, nor were they antirational. Anti-intellectualism and other movements that make thinking subordinate to feeling must not be confused with existentialism. Either alternative—making a human being entirely subject or object—results in losing the living, existing person. Kierkegaard and the existential thinkers appealed to a reality underlying both subjectivity and objectivity. We must not only study a person’s experience as such, they held, but even more, we must study the one who is doing the experiencing.
It is by no means accidental that the greatest existentialists in the nineteenth century, Kierkegaard and Nietzsche, happen also to be among the most remarkable psychologists of all time. A contemporary leader of existential philosophy, Karl Jaspers, originally a psychiatrist, wrote a notable text on psychopathology. When one reads Kierkegaard’s profound analyses of anxiety and despair or Nietzsche’s amazingly acute insights into the dynamics of resentment and the guilt and hostility that accompany repressed emotional powers, it is difficult to realize that one is reading works written more than 100 years ago and not a contemporary psychological analysis.
Existential therapists are centrally concerned with rediscovering the living person amid the dehumanization of modern culture, and in order to do this they engage in in-depth psychological analysis. Their concern is not with isolated psychological reactions in themselves but rather with the psychological being of the living person doing the experiencing. They use psychological terms with an ontological meaning.
Existential therapy sprang up spontaneously in different parts of Europe and among different schools and has a diverse body of researchers and creative thinkers. There were psychiatrists—Eugene Minkowski in Paris, Erwin Straus in Germany and then in America, V E. von Gebsattel in Germany—who represent chiefly the first, phenomenological stage of this movement. Ludwig Binswanger, A. Storch, Medard Boss, G. Bally, Roland Kuhn in Switzerland and J. H. Van Den Berg and F J. Buytendijk in Holland represented the second, or existential, stage.
Current Status
Existential psychotherapy was introduced to the United States in 1958 with the publication of Existence: A New Dimension in Psychiatry and Psychology, edited by Rollo May, Ernest Angel, and Henri Ellenberger. The main presentation and summary of existential therapy was in the first two chapters, written by May: “The Origins of the Existential Movement in Psychology” and “Contributions of Existential Psychology.” The remainder of the book is made up of essays and case studies by Henri Ellenberger, Eugene Minkowski, Erwin Straus, V E. von Gebsattel, Ludwig Binswanger, and Ronald Kuhn. The first comprehensive textbook in existential psychiatry was written by Irvin Yalom (1981) and entitled Existential Psychotherapy.
The spirit of existential psychotherapy has never supported the formation of specific institutes because it deals with the presuppositions underlying therapy of any kind. Its concern was with concepts about human beings and not with specific techniques. This leads to the dilemma that existential therapy has been quite influential, but there are very few adequate training courses in this kind of therapy simply because it is not a specific training in technique.
The founders of the existential movement always stated that specific training in techniques of therapy could be obtained at any number of schools of therapy, and that the student was responsible for molding his or her own presuppositions in existential form.
Rollo May, an existentialist before he knew the word, found that the existing person was the important consideration, and not a theory about this person. He had argued in his Ph.D. dissertation, published under the title The Meaning of Anxiety in 1950, for a concept of normal anxiety as the basis for a theory of human beings. He had already, before his training in the William Alanson White Institute, experienced the futility of going to analysis five times a week for two years. He was trained as a psychoanalyst in the William Alanson White Institute, the neo-Freudian institute in New York, and was already a practicing analyst when he read in the early 1950s about existential therapies in Europe. He felt these new concepts in existential psychology were the ones he needed but had never been able to formulate.
The founders of existential psychotherapy believe that its contributions will be absorbed into other schools. Fritz Perls, in the foreword of Gestalt Therapy Verbatim (1969), states quite accurately that gestalt therapy is a form of existential psychotherapy. Therapists trained in different schools can legitimately call themselves existential if their assumptions are similar to those described in this chapter. Irvin Yalom was trained in the neo-Freudian tradition. Even such an erstwhile behavior therapist as Arnold Lazarus uses some existential presuppositions in his multimodal psychotherapy. All of this is possible because existential psychotherapy is a way of conceiving the human being. It goes deeper than the other forms of psychotherapy to emphasize the assumptions underlying all systems of psychotherapy.
Major works include May’s The Meaning of Anxiety (1977), Man’s Search for Himself (1953), and Existential Psychology (1961). Others are James Bugental’s The Search for Existential Identity (1976), Medard Boss’s The Analysis of Dreams (1957a) and Psychoanalysis and Daseinanalysis (1982), and Viktor Frankl’s Man’s Search for Meaning (1963). Helmut Kaiser has written valuably on existential therapy in his Effective Psychotherapy (1965). Leslie Farber (1966, 1976), Avery Weisman (1965), and Lester Havens (1974) have also contributed significantly to the existential literature.

PERSONALITY
Theory of Personality
Existential psychotherapy is a form of dynamic psychotherapy that posits a dynamic model of personality structure. Dynamic is a commonly used term in psychology and psychotherapy. We often, for example, speak of the patient’s “psychodynamics,” or a “dynamic” approach to therapy. Dynamic has both lay and technical meanings, and it is necessary to be precise about its meaning in the context of personality theory. In its lay meaning dynamic has the connotation of vitality.
The technical meaning of dynamic relevant to personality theory refers to the concept of force. Its use in personality theory was first invoked by Freud, who viewed the personality as a system consisting of forces in conflict with one another. The result of this conflict is the constellation of emotions and behavior (both adaptive and pathological) that constitute personality. Furthermore (and this is an essential part of the definition), these forces in conflict exist at different levels of awareness. Indeed, some of the forces are entirely out of awareness and exist on an unconscious plane.
Thus, when we speak of the “psychodynamics” of an individual, we refer to that individual’s conflicting conscious and unconscious forces, motives, and fears. “Dynamic psychotherapy” is psychotherapy based upon this dynamic model of personality structure.
There are many dynamic models of personality. To differentiate these various models and to define the existential model of personality structure, we must ask: What is the content of the internal, conscious, and unconscious struggle? Forces, motives, and fears conflict with one another within the personality. But which forces? Which motives? Which fears?
The existential view of the internal struggle can be made clearer by contrasting it with two other common dynamic views of personality: the Freudian model and the interpersonal (neo-Freudian) model.
The Freudian Model of Psychodynamics
The Freudian model posits that the individual is governed by innate instinctual forces that inexorably unfurl throughout the psychosexual developmental cycle. Freud postulated conflicts on several fronts: dual instincts collide with one another (ego instincts versus libido instincts in Freud’s first theory or, in the second theory, Eros versus Thanatos); the instincts also collide with the demands of the environment, and later the instincts collide with the superego (the internalized environment).
We can summarize the nature of the conflict in the Freudian dynamic model by stating that an instinctually driven being is at war with a world that prevents the satisfaction of these innate aggressive and sexual drives.
The Interpersonal (Neo-Freudian) Model of Psychodynamics
In the interpersonal model of personality the individual is not instinct-guided and preprogrammed, but is instead almost entirely shaped by the cultural and interpersonal environment. The child desperately requires acceptance and approval by important survival figures. But the child also has an inner press toward growth, mastery, and autonomy, and these tendencies are not always compatible with the demands of significant adults in the child’s life. If the child is unlucky enough to have parents who are too caught up in their own neurotic struggles to provide the child security and encourage the child’s autonomous development, then a conflict develops between the child’s need for security and natural growth inclinations. In such a struggle, growth is always compromised for the sake of security.
Existential Psychodynamics
The existential model of personality rests on a different view of inner conflict. It postulates that the basic conflict is not with suppressed instinctual drives or with the significant adults in the individual’s early life; instead the conflict is between the individual and the “givens” of existence. What are these “givens”? The reflective individual can discover them without a great deal of effort. If we “bracket” the outside world, if we put aside the everyday concerns with which we ordinarily fill our lives and reflect deeply upon our situation in the world, then we must confront certain “ultimate concerns” that are an inescapable part of the human being’s existence in the world.
Yalom (1981) identifies four ultimate concerns that have considerable relevance for psychotherapy: death, freedom, isolation, and meaninglessness. The individual’s confrontation with each of these constitutes the content of the inner conflict from the existential frame of reference.
Death Death is the most obvious ultimate concern. It is apparent to all that death will come and that there is no escape. It is a terrible truth, and at the deepest levels we respond to it with mortal terror. “Everything,” as Spinoza states, “wishes to persist in its own being” (1954, p. 6). From the existential point of view a core inner conflict is between awareness of inevitable death and the simultaneous wish to continue to live.
Death plays a major role in one’s internal experience. It haunts the individual as nothing else. It rumbles continuously under the membrane of life. The child at an early age is pervasively concerned with death, and one of the child’s major developmental tasks is to deal with the terror of obliteration.
To cope with this terror, we erect defenses against death awareness. These defenses are denial-based; they shape character structure and, if maladaptive, result in clinical maladjustment.
Psychopathology, to a very great extent, is the result of failed death transcendence; that is, symptoms and maladaptive character structure have their origin in the individual terror of death.
Freedom Ordinarily we do not think of freedom as a source of anxiety. Quite the contrary, freedom is generally viewed as an unequivocally positive concept. The history of Western civilization is punctuated by a yearning and striving toward freedom. Yet freedom in the existential frame of reference has a technical meaning—one that is riveted to dread.
In the existential frame of reference, freedom means that, contrary to everyday experience, the human being does not enter and ultimately exit from a structured universe with a coherent, grand design. Freedom refers to the fact that the human being is responsible for and the author of his or her own world, own life design, and own choices and actions. The human being, as Sartre puts it, is “condemned to freedom” (1956, p. 631). Rollo May (1981) holds that freedom, in order to be authentic, requires the individual to confront the limits of his or her destiny.
The existential position that the human being constitutes a personal world has been germinating for a long time in philosophic thought. The heart of Kant’s revolution in philosophy was his postulate that human consciousness, the nature of the human being’s mental structures, provides the external form of reality. Kant stated that even space “is not something objective and real but something subjective and ideal; it is, as it were, a schema issuing by a constant law from the nature of the mind for the coordinating of all outer sensa [sense data]” (1954, p. 308).
This existential view of freedom has terrifying implications. If it is true that we create our own selves and our own world, then it also means that there is no ground beneath us: there is only an abyss, a void, nothingness.
An important internal dynamic conflict emanates from our confrontation with freedom: conflict issues from our awareness of freedom and groundlessness on the one hand and, on the other hand, our deep need and wish for ground and structure.
The concept of freedom encompasses many themes that have profound implications for psychotherapy. The most apparent is responsibility. Individuals differ enormously in the degree of responsibility they are willing to accept for their life situation and in their modes of denying responsibility. For example, some individuals displace responsibility for their situation onto other people, onto life circumstances, onto bosses and spouses, and, when they enter treatment, they transfer responsibility for their therapy to their psychotherapist. Other individuals deny responsibility by experiencing themselves as “innocent victims” who suffer from external events (and remain unaware that they themselves have set these events into motion). Still others shuck responsibility by temporarily being “out of their minds”—they enter a temporary irrational state in which they are not accountable even to themselves for their behavior.
Another aspect of freedom is willing. To be aware of responsibility for one’s situation is to enter the vestibule of action or, in a therapy situation, of change. Willing represents the passage from responsibility to action. Willing, as May (1969) points out, consists first of wishing and then of deciding. Many individuals have enormous difficulties in experiencing or expressing a wish. Wishing is closely aligned to feeling, and affect-blocked individuals cannot act spontaneously because they cannot feel and thus cannot wish. Impulsivity avoids wishing by failing to discriminate among wishes. Instead, individuals act impulsively and promptly on all wishes. Compulsivity, another disorder of wishing, is characterized by individuals not pro-acting, but instead being driven by ego-alien inner demands that often run counter to their consciously held desires.
Once an individual fully experiences a wish, he or she is faced with decision. Many individuals can be extremely clear about what they wish but still not be able to decide or to choose. Often they experience a decisional panic; they may attempt to delegate the decision to someone else, or they act in such a way that the decision is made for them by circumstances that they, unconsciously, have brought to pass.
Isolation A third ultimate concern is isolation. It is important to differentiate existential isolation from other types of isolation. Interpersonal isolation refers to the gulf that exists between oneself and other people—a gulf that results from deficient social skills and psychopathology in the sphere of intimacy. Intrapersonal isolation, a term first introduced by Freud, refers to the fact that we are isolated from parts of ourselves. Enclaves of self (of experience, affect, desire) are dissociated out of awareness, and the goal of psychotherapy is to help the individual reclaim these split-off parts of self.
Existential isolation cuts beneath other forms of isolation. No matter how closely we relate to another individual, there remains a final unbridgeable gap. Each of us enters existence alone and must depart from it alone. Each individual in the dawn of consciousness created a primary self (transcendental ego) by permitting consciousness to curl back upon itself and to differentiate a self from the remainder of the world. Only after that does the individual, now “self-conscious,” begin to constitute other selves. Beneath this act, as Mijuskovic (1979) notes, there is a fundamental loneliness; the individual cannot escape the knowledge that (1) he or she constitutes others and (2) he or she can never fully share his consciousness with others.
There is no stronger reminder of existential isolation than a confrontation with death. The individual who faces death invariably becomes acutely aware of isolation.
The third dynamic conflict is between the awareness of our fundamental isolation and the wish to be protected, to merge and to be part of a larger whole.
Fear of existential isolation (and the defenses against it) underlies a great deal of interpersonal psychopathology. This dynamic offers a powerful, parsimonious explanatory system for understanding many miscarried interpersonal relationships in which one uses another for some function rather than relates to the other out of caring for that person’s being.
Although no relationship can eliminate isolation, it can be shared with another in such a way that the pain of isolation is assuaged. If one acknowledges one’s isolated situation in existence and confronts it with resoluteness, one will be able to turn lovingly toward others. If, on the other hand, one is overcome with dread in the face of isolation, one will not be able to turn toward others but instead will use others as a shield against isolation. In such instances relationships will be out-of-joint miscarriages and distortions of what might have been authentic relationships.
Some individuals (and this is particularly true of individuals with a borderline personality disturbance) experience panic when they are alone that emanates from a dissolution of ego boundaries. These individuals begin to doubt their own existence and believe that they exist only in the presence of another, that they exist only so long as they are responded to or are thought about by another individual.
Many attempt to deal with isolation through fusion: they soften their ego boundaries and become part of another individual. They avoid personal growth and the sense of isolation that accompanies growth. Fusion underlies the experience of being in love. The wonderful thing about romantic love is that the lonely “I” disappears into the “we.” Others may fuse with a group, a cause, a country, a project. To be like everyone else—to conform in dress, speech, and customs, to have no thoughts or feelings that are different—saves one from the isolation of the lonely self.
Compulsive sexuality is also a common response to terrifying isolation. Promiscuous sexual coupling offers a powerful but temporary respite for the lonely individual. It is temporary because it is only a caricature of a relationship. The sexually compulsive individual does not relate to the whole being of the other but relates only to the part of that individual that meets his or her need. Sexually compulsive individuals do not know their partners; they show and see only those parts that facilitate seduction and the sexual act.
Meaninglessness The fourth ultimate concern is meaninglessness. If each person must die, and if each person constitutes his or her own world, and if each is alone in an indifferent universe, then what possible meaning can life have? Why do we live? How shall we live? If there is no preordained design in life, then we must construct our own meaning in life. The fundamental question then becomes, “Is it possible that a self created meaning is sturdy enough to bear one’s life?”
The human being appears to require meaning. Our perceptual neuropsychological organization is such that we instantaneously pattern random stimuli. We organize them automatically into figure and ground. When confronted with a broken circle, we automatically perceive it as complete. When any situation or set of stimuli defies patterning, we experience dysphoria, which persists until we fit the situation into a recognizable pattern.
In the same way individuals organize random stimuli, so too do they face existential situations: In an unpatterned world an individual is acutely unsettled and searches for a pattern, an explanation, a meaning of existence.
A sense of meaning of life is necessary for still another reason: From a meaning schema we generate a hierarchy of values. Values provide us with a blueprint for life conduct; values tell us not only why we live but how to live.
The fourth internal conflict stems from this dilemma: How does a being who requires meaning find meaning in a universe that has no meaning?
Variety of Concepts
The content of the internal conflict from the existential frame of reference consists of ultimate concerns and the conscious and unconscious fears and motives spawned by them. The dynamic existential approach retains Freud’s basic dynamic structure but has a radically different content. The old Freudian formula of:
DRIVE → ANXIETY → DEFENSE → MECHANISM
is replaced in the existential system by:

AWARENESS OF ULTIMATE CONCERN → ANXIETY → DEFENSE MECHANISM1


Both psychoanalysis and the existential system place anxiety at the center of the dynamic structure. Anxiety fuels psychopathology: Conscious and unconscious psychic operations (i.e., defense mechanisms) are generated to deal with anxiety. These psychic operations constitute psychopathology: They provide safety, but they also restrict growth.
An important difference is that Freud’s sequence begins with drive, whereas an existential framework begins with awareness. The existential frame of reference views the individual primarily as fearful and suffering rather than as driven.
To an existential therapist, anxiety springs from confrontation with death, groundlessness (freedom), isolation, and meaninglessness. The individual uses two types of defense mechanisms to cope with anxiety. The first, the conventional mechanisms of defense, thoroughly described by Sigmund Freud, Anna Freud, and Harry Stack Sullivan, defend the individual against anxiety regardless of source. The second are specific defenses that serve to cope with specific primary existential fears.
For example, consider the individual’s defense mechanism for dealing with the anxiety emerging from awareness of death. Yalom (1981, p. 115) describes two major, specific intrapsychic defenses: an irrational belief in personal “specialness” and an irrational belief in the existence of an “ultimate rescuer.” These defenses resemble delusions in that they are fixed, false beliefs. However, they are not delusions in the clinical sense, but are universally held irrational beliefs.
Specialness
Individuals have deep, powerful beliefs in personal inviolability, invulnerability, and immortality. Although, at a rational level, we recognize the foolishness of these beliefs, nonetheless, at a deeply unconscious level, we believe that the ordinary laws of biology do not apply to us.
If this defense is weak or absent, then the individual manifests one of a number of clinical syndromes: for example, the narcissistic character, the compulsive workaholic consumed by a search for glory, the self-aggrandizing, paranoid individual. The crisis in the lives of these individuals occurs when their belief system is shattered and a sense of unprotected ordinariness intrudes. They frequently seek therapy when the defense of specialness is no longer able to ward off anxiety—for example, at times of severe illness or at the interruption of what had always appeared to be an eternal, upward spiral.


The Belief in the Existence of an Ultimate Rescuer
The other major mechanism of defense that serves to block death awareness is our belief in a personal omnipotent servant who eternally guards and protects our welfare, who may let us get to the edge of the abyss but who will always bring us back. A hypertrophy of this particular defense mechanism results in a character structure displaying passivity, dependency, and obsequiousness. Often such individuals dedicate their lives to locating and appeasing an ultimate rescuer. In Silvano Arieti’s terms, they live for the “dominant other” (1977, p. 864)—a life ideology that precedes and prepares the ground for clinical depression. These individuals may adapt well to life while basking in the presence of the dominant other, but they decompensate and experience extraordinary distress at the loss of this dominant other.
Another major difference between the existential dynamic approach and other dynamic approaches lies in temporal orientation. The existential therapist works in the present tense. The individual is to be understood and helped to understand himself or herself from the perspective of a here-and-now cross-section, not from the perspective of a historical longitudinal section. Consider the use of the word deep. Freud defines deep as “early,” and so the deepest conflict meant the earliest conflict in the individual’s life. Freud’s psychodynamics are developmentally based. Fundamental and primary are to be grasped chronologically: Each is synonymous with “first.” Thus, the fundamental sources of anxiety, for example, are considered to be the earliest calamities: separation and castration.
From the existential perspective, deep means the most fundamental concerns facing the individual at that moment. The past (i.e., one’s memory of the past) is important only insofar as it is part of one’s current existence and has contributed to one’s current mode of facing ultimate concerns. The immediate, currently existing ground beneath all other ground is important from the existential perspective. Thus, the existential conception of personality is in the awareness of the depths of one’s immediate experiences. Existential therapy does not attempt to excavate and understand the past; instead it is directed toward the future’s becoming the present and explores the past only as it throws light on the present. The therapist must continually keep in mind that we create our past and that our present mode of existence dictates what we choose to remember of the past.
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