PSYCHOTHERAPY Theory of Psychotherapy A substantial proportion of practicing psychotherapists consider themselves existentially (or “humanistically”) oriented. Yet few, if any, have received any systematic training in existential therapy. One can be reasonably certain of this because there are few comprehensive training programs in existential therapy. Although many excellent books illuminate some aspect of the existential frame of reference (Becker, 1973; Bugental, 1956; Koestenbaum, 1978; May, 1953, 1977; May et al., 1958), Yalom’s book (1981) is the first to present a systematic, comprehensive view of the existential therapeutic approach.
Existential therapy is not a comprehensive psychotherapeutic system; it is a frame of reference—a paradigm by which one views and understands a patient’s suffering in a particular manner.
Existential therapists begin with presuppositions about the sources of a patient’s anguish and view the patient in human rather than behavioral or mechanistic terms. They may employ any of a large variety of techniques used in other approaches insofar as they are consistent with basic existential presuppositions and a human, authentic therapist patient encounter.
The vast majority of experienced therapists, regardless of adherence to some particular ideological school, employ many existential insights and approaches. All competent therapists realize, for example, that an apprehension of one’s finiteness can often catalyze a major inner shift of perspective, that it is the relationship that heals, that patients are tormented by choice, that a therapist must catalyze a patient’s “will” to act, and that the majority of patients are bedeviled by a lack of meaning in their lives.
It is also true that the therapist’s belief system determines the type of clinical data that he or she encounters. Therapists subtly or unconsciously cue patients to provide them with certain material. Jungian patients have Jungian dreams. Freudian patients discover themes of castration, anxiety, and penis envy. The therapist’s perceptual system is affected by her or his ideological system. Thus, the therapist “tunes in” to the material that she or he wishes to obtain. So too with the existential approach. If the therapists tune their mental apparatus to the right channel, it is astounding how frequently patients discuss concerns emanating from existential conflicts.
The basic approach in existential therapy is strategically similar to other dynamic therapies. The therapist assumes that the patient experiences anxiety which issues from some existential conflict that is at least partially unconscious. The patient handles anxiety by a number of ineffective, maladaptive defense mechanisms that may provide temporary respite from anxiety but ultimately so cripple the individual’s ability to live fully and creatively that these defenses merely result in still further secondary anxiety. The therapist assists the patient to embark on a course of self-investigation in which the goals are to understand the unconscious conflict, to identify the maladaptive defense mechanisms, to discover their destructive influence, to diminish secondary anxiety by correcting these heretofore restrictive modes of dealing with self and others, and to develop other ways of coping with primary anxiety.
Although the basic strategy in existential therapy is similar to other dynamic therapies, the content is radically different. In many respects, the process differs as well; the existential therapist’s different mode of understanding the patient’s basic dilemma results in many differences in the strategy of psychotherapy. For example, because the existential view of personality structure emphasizes the depth of experience at any given moment, the existential therapist does not spend a great deal of time helping the patient to recover the past. The existential therapist strives for an understanding of the patient’s current life situation and current enveloping unconscious fears. The existential therapist believes, as do other dynamic therapists, that the nature of the therapist-client relationship is fundamental in good psychotherapeutic work. However, the accent is not upon transference but instead upon the relationship as fundamentally important in itself.
Process of Psychotherapy Each of the ultimate human concerns (death, freedom, isolation, and meaninglessness) has implications for the process of therapy. Let us examine the practical, therapeutic implications of the ultimate concern of freedom. A major component of freedom is responsibility—a concept that deeply influences the existential therapist’s therapeutic approach.
Sartre equates responsibility to authorship: To be responsible means to be the author of one’s own life design. The existential therapist continually focuses upon each patient’s responsibility for his or her own distress. Bad genes or bad luck do not cause a patient to be lonely or chronically abused or neglected by others. Until patients realize that they are responsible for their own conditions, there is little motivation to change.
The therapist must identify methods and instances of responsibility avoidance and then make these known to the patient. Therapists may use a wide variety of techniques to focus the patient’s attention on responsibility. Many therapists interrupt the patient whenever they hear the patient avoiding responsibility. When patients say they “can’t” do something, the therapist immediately comments, “You mean you ‘won’t’ do it.” As long as one believes in “can’t,” one remains unaware of one’s active contribution to one’s situation. Such therapists encourage patients to own their feelings, statements, and actions. If a patient comments that he or she did something “unconsciously,” the therapist might inquire, “Whose unconscious is it?” The general principle is obvious: Whenever the patient laments about his or her life situation, the therapist inquires how the patient created that situation.
Often it is helpful to keep the patient’s initial complaints in mind and then, at appropriate points in therapy, juxtapose these initial complaints with the patient’s in-therapy behavior. For example, consider a patient who sought therapy because of feelings of isolation and loneliness. During the course of therapy the patient expressed at great length his sense of superiority and his scorn and disdain of others. These attitudes were rigidly maintained; the patient manifested great resistance to examining, much less changing, these opinions. The therapist helped this patient to understand his responsibility for his personal predicament by reminding the patient, whenever he discussed his scorn of others, “And you are lonely.”
Responsibility is one component of freedom. Earlier we described another, willing, which may be further subdivided into wishing and deciding. Consider the role of wishing. How often does the therapist participate with a patient in some such sequence as this:
“What shall I do? What shall I do?”
“What is it that stops you from doing what you want to do?”
“But I don’t know what I want to do! If I knew that, I wouldn’t need to see you!”
These patients actually know what they should do, ought to do, or must do, but they do not experience what they want to do. Many therapists, in working with patients who have a profound incapacity to wish, have shared May’s inclination to shout “Don’t you ever want anything?” (1969, p. 165). These patients have enormous social difficulties because they have no opinions, no inclinations, and no desires of their own.
Often the inability to wish is imbedded in a more global disorder—the inability to feel. In many cases, the bulk of psychotherapy consists of helping patients to dissolve their affect blocks. This therapy is slow and grinding. Above all, the therapist must persevere and, time after time, must continue to press the patient with, “What do you feel?” “What do you want?” Repeatedly the therapist will need to explore the source and nature of the block and of the stifled feelings behind it.
The inability to feel and to wish is a pervasive characterological trait, and considerable time and therapeutic perseverance are required to effect enduring change.
There are other modes of avoiding wishing in addition to blocking of affect. Some individuals avoid wishing by not discriminating among wishes, by acting impulsively on all wishes. In such instances, the therapist must help the patient to make some internal discrimination among wishes and assign priorities to each. The patient must learn that two wishes which are mutually exclusive demand that one be relinquished. If, for example, a meaningful, loving relationship is a wish, then a host of conflicting interpersonal wishes—such as the wish for conquest or power or seduction or subjugation—must be denied.
Decision is the bridge between wishing and action. Some patients, even though they are able to wish, are still unable to act because they cannot decide. One of the more common reasons that deciding is difficult is that every yes involves a no. Renunciation invariably accompanies decision, and a decision requires a relinquishment of other options—often options that may never come again. There are other patients who cannot decide because a major decision makes them more aware of the degree to which they constitute their own lives. Thus, a major, irreversible decision is a boundary situation in the same way that awareness of death may be a boundary situation.
The therapist must help patients make choices. The therapist must help patients recognize that they themselves, not the therapist, must generate and choose among options. In helping patients to communicate effectively, therapists teach that one must own one’s feelings. It is equally important that one owns one’s decisions. Some patients are panicked by the various implications of each decision. The “what ifs” torment them. What if I leave my job and can’t find another? What if I leave my children alone and they get hurt? It is often useful to ask the patient to consider the entire scenario of each “what if” in turn, to fantasize it happening with all the possible ramifications, and then to experience and analyze emerging feelings.
A general posture toward decision making is to assume that the therapist’s task is not to create will but instead to disencumber it. The therapist cannot flick the decision switch or inspirit the patient with resoluteness. But the therapist can influence the factors that influence willing. After all, no one has a congenital inability to decide. Decision making is blocked by obstacles, and it is the therapist’s task to help move obstacles. Once that is done, the individual will naturally move into a more autonomous position in just the way, as Karen Horney (1950) put it, an acorn develops into an oak tree.
The therapist must help patients understand that decisions are unavoidable. One makes decisions all the time and often conceals from oneself the fact that one is deciding. It is important to help patients understand the inevitability of decisions and to identify how they make decisions. Many patients decide passively by, for example, letting another person decide for them. They may terminate an unsatisfactory relationship by unconsciously acting in such a way that the partner makes the decision to leave. In such instances the final outcome is achieved, but the patient may be left with many negative repercussions. The patient’s sense of powerlessness is merely reinforced and he or she continues to experience himself or herself as one to whom things happen rather than as the author of his or her own life situation. The way one makes a decision is often as important as the content of the decision. An active decision reinforces the individual’s active acceptance of his or her own power and resources.
Mechanisms of Psychotherapy We can best understand the mechanisms of the existential approach by considering the therapeutic leverage inherent in some of the ultimate concerns.
Death and Psychotherapy There are two distinct ways in which the concept of death plays an important role in psychotherapy. First, an increased awareness of one’s finiteness stemming from a personal confrontation with death may cause a radical shift in life perspective and lead to personal change. Second, the concept that death is a primary source of anxiety has many important implications for therapy.
Death as a Boundary Situation A boundary situation is a type of urgent experience that propels the individual into a confrontation with an existential situation. The most powerful boundary situation is confrontation with one’s personal death. Such a confrontation has the power to provide a massive shift in the way one lives in the world. Some patients report that they learn simply that “existence cannot be postponed.” They no longer postpone living until some time in the future; they realize that one can really live only in the present. The neurotic individual rarely lives in the present but is either continuously obsessed with events from the past or fearful of anticipated events in the future.
A confrontation with a boundary situation persuades individuals to count their blessings, to become aware of their natural surroundings: the elemental facts of life, changing seasons, seeing, listening, touching, and loving. Ordinarily what we can experience is diminished by petty concerns, by thoughts of what we cannot do or what we lack, or by threats to our prestige.
Many terminally ill patients, when reporting personal growth emanating from their confrontation with death, have lamented, “What a tragedy that we had to wait till now, till our bodies were riddled with cancer, to learn these truths.” This is an exceedingly important message for therapists. The therapist can obtain considerable leverage to help “everyday” patients (i.e., patients who are not physically ill) increase their awareness of death earlier in their life cycle. With this aim in mind, some therapists have employed structured exercises to confront the individual with personal death. Some group leaders begin a brief group experience by asking members to write their own epitaph or obituary, or they provide guided fantasies in which group members imagine their own death and funeral.
Many existential therapists do not believe that artificially introduced death confrontations are necessary or advisable. Instead they attempt to help the patient recognize the signs of mortality that are part of the fabric of everyday life. If the therapist and the patient are “tuned-in,” there is considerable evidence of death anxiety in every psychotherapy. Every patient suffers losses through death of parents, friends, and associates. Dreams are haunted with death anxiety. Every nightmare is a dream of raw death anxiety. Everywhere around us are reminders of aging: Our bones begin to creak, age spots appear on our skin, we go to reunions and note with dismay how everyone else has aged. Our children grow up. The cycle of life envelops us.
An important opportunity for confrontation with death arises when patients experience the death of someone close to them. The traditional literature on grief primarily focuses on two aspects of grief work: loss and the resolution of ambivalence that so strongly accentuates the dysphoria of grief. But a third dimension must be considered: The death of someone close to us confronts us with our own death.
Often grief has a very different tone, depending upon the individual’s relationship with the person who has died. The loss of a parent confronts us with our vulnerability: If our parents could not save themselves, who will save us? When parents die, nothing remains between ourselves and the grave. At the moment of our parents’ death, we ourselves constitute the barrier between our children and their death.
The death of a spouse often evokes the fear of existential isolation. The loss of the significant other increases our awareness that, try as hard as we can to go through the world two by two, there is nonetheless a basic aloneness we must bear. Yalom reports a patient’s dream the night after learning that his wife had inoperable cancer.
I was living in my old house in ___________ [a house that had been in the family for three generations]. A Frankenstein monster was chasing me through the house. I was terrified. The house was deteriorating, decaying. The tiles were crumbling and the roof leaking. Water leaked all over my mother. [His mother had died six months earlier.] I fought with him. I had a choice of weapons. One had a curved blade with a handle, like a scythe. I slashed him and tossed him off the roof. He lay stretched out on the pavement below. But he got up and once again started chasing me through the house. (1981, p. 168)
The patient’s first association to this dream was “I know I’ve got a hundred thousand miles on me.” Obviously his wife’s impending death reminded him that his life and his body (symbolized in the dream by the deteriorating house) were also finite. As a child this patient was often haunted by the monster who returned in this nightmare.
Children try many methods of dealing with death anxiety. One of the most common is the personification of death—imagining death as some finite creature: a monster, a sandman, a bogeyman, and so on. This is very frightening to children but nonetheless far less frightening than the truth—that they carry the spores of their own death within them. If death is “out there” in some physical form, then possibly it may be eluded, tricked, or pacified.
Milestones provide another opportunity for the therapist to focus the patient on existential facts of life. Even simple milestones, such as birthdays and anniversaries, are useful levers. These signs of passage are often capable of eliciting pain (consequently, we often deal with such milestones by reaction formation, in the form of a joyous celebration).
Major life events, such as a threat to one’s career, a severe illness, retirement, commitment to a relationship, and separation from a relationship, are important boundary situations and offer opportunities for an increased awareness of death anxiety. Often these experiences are painful, and therapists feel compelled to focus entirely on pain alleviation. In so doing, however, they miss rich opportunities for deep therapeutic work that reveal themselves at those moments.
Death as a Primary Source of Anxiety The fear of death constitutes a primary fount of anxiety: It is present early in life, it is instrumental in shaping character structure, and it continues throughout life to generate anxiety that results in manifest distress and the erection of psychological defenses. However, it is important to keep in mind that death anxiety exists at the very deepest levels of being, is heavily repressed, and is rarely experienced in its full sense. Often death anxiety per se is not easily visible in the clinical picture. There are patients, however, who are suffused with overt death anxiety at the very onset of therapy. There are often life situations in which the patient has such a rush of death anxiety that the therapist cannot evade the issue. In long-term, intensive therapy, explicit death anxiety is always to be found and must be considered in the therapeutic work.
In the existential framework, anxiety is so riveted to existence that it has a different connotation from the way anxiety is regarded in other frames of reference. The existential therapist hopes to alleviate crippling levels of anxiety but not to eliminate it. Life cannot be lived (nor can death be faced) without anxiety. The therapist’s task, as May reminds us (1977, p. 374), is to reduce anxiety to tolerable levels and then to use the anxiety constructively.
It is important to keep in mind that, even though death anxiety may not explicitly enter the therapeutic dialogue, a theory of anxiety based on death awareness may provide therapists with a frame of reference that greatly enhances their effectiveness. Therapists, as well as patients, seek to order events into some coherent sequence. Once that is done, the therapist begins to experience a sense of control and mastery that allows organization of clinical material. The therapist’s self-confidence and sense of mastery will help patients develop trust and confidence in the therapy process.
The therapist’s belief system provides a certain consistency. It permits the therapist to know what to explore so that the patient does not become confused.
The therapist may, with subtlety and good timing, make comments that at an unspoken level click with the patient’s unconscious and allow the patient to feel understood.
Existential Isolation and Psychotherapy Patients discover in therapy that interpersonal relationships may temper isolation but cannot eliminate it. Patients who grow in psychotherapy learn not only the rewards of intimacy but also its limits: They learn what they cannot get from others. An important step in treatment consists of helping patients address existential isolation directly. Those who lack sufficient experiences of closeness and true relatedness in their lives are particularly incapable of tolerating isolation. Otto Will2 made the point that adolescents from loving, supportive families are able to grow away from their families with relative ease and to tolerate the separation and loneliness of young adulthood. On the other hand, those who grow up in tormented, highly conflicted families find it extremely difficult to leave the family. The more disturbed the family, the harder it is for children to leave—they are ill equipped to separate and therefore cling to the family for shelter against isolation and anxiety.
Many patients have enormous difficulty spending time alone. Consequently they construct their lives in such a way that they eliminate alone time. One of the major problems that ensues from this is the desperation with which they seek certain kinds of relationships and use others to avoid some of the pain accompanying isolation. The therapist must find a way to help the patient confront isolation in a dosage and with a support system suited to that patient. Some therapists, at an advanced stage of therapy, advise periods of self-enforced isolation during which the patient is asked to monitor and record thoughts and feelings.
Meaninglessness and Psychotherapy To deal effectively with meaninglessness, therapists must first increase their sensitivity to the topic, listen differently, and become aware of the importance of meaning in the lives of individuals. For some patients the issue of meaninglessness is profound and pervasive. Carl Jung once estimated that more than 30 percent of his patients sought therapy because of a sense of personal meaninglessness (1966, p. 83).
The therapist must be attuned to the overall focus and direction of the patient’s life. Is the patient reaching beyond himself or herself? Or is he or she entirely immersed in the daily routine of staying alive? Yalom (1981) reported that his therapy was rarely successful unless he was able to help patients focus on something beyond these pursuits. Simply by increasing their sensitivity to these issues, the therapist can help them focus on values outside themselves. Therapists, for example, can begin to wonder about the patient’s belief systems, inquire deeply into the loving of another, ask about long-range hopes and goals, and explore creative interests and pursuits.
Viktor Frankl, who placed great emphasis on the importance of meaninglessness in contemporary psychopathology, stated that “happiness cannot be pursued, it can only ensue” (1969, p. 165).
The more we deliberately search for self-satisfaction, the more it eludes us, whereas the more we fulfill some self-transcendent meaning, the more happiness will ensue.
Therapists must find a way to help self-centered patients develop curiosity and concern for others. The therapy group is especially well suited for this endeavor: The pattern in which self-absorbed, narcissistic patients take without giving often becomes highly evident in the therapy group. In such instances therapists may attempt to increase an individual’s ability and inclination to empathize with others by requesting, periodically, that patients guess how others are feeling at various junctures of the group.
But the major solution to the problem of meaninglessness is engagement. Wholehearted engagement in any of the infinite array of life’s activities enhances the possibility of one’s patterning the events of one’s life in some coherent fashion. To find a home, to care about other individuals and about ideas or projects, to search, to create, to build—all 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.
The therapist must approach engagement with the same attitudinal set used with wishing. The desire to engage life is always there with the patient, and therefore the therapist’s activity should be directed toward the removal of obstacles in the patient’s way. The therapist begins to explore what prevents the patient from loving another individual. Why is there so little satisfaction from his or her relationships with others? Why is there so little satisfaction from work? What blocks the patient from finding work commensurate with his or her talents and interests or finding some pleasurable aspects of current work? Why has the patient neglected creative or religious or self-transcendent strivings?