APPLICATIONS Problems The clinical setting often determines the applicability of the existential approach. In each course of therapy, the therapist must consider the goals appropriate to the clinical setting. To take one example, in an acute inpatient setting where the patient will be hospitalized for approximately one to two weeks, the goal of therapy is crisis intervention. The therapist hopes to alleviate symptoms and to restore the patient to a pre-crisis level of functioning. Deeper, more ambitious goals are unrealistic and inappropriate to that situation.
In situations where patients desire not only symptomatic relief but also hope to attain greater personal growth, the existential approach is generally useful. A thorough existential approach with ambitious goals is most appropriate in long-term therapy, but even in briefer approaches some aspect of the existential mode (e.g., an emphasis on responsibility, deciding, an authentic therapist-patient encounter, grief work, and so on) is often incorporated into the therapy.
An existential approach to therapy is appropriate with patients who confront some boundary situation—that is, a confrontation with death, the facing of some important irreversible decision, a sudden thrust into isolation, milestones that mark passages from one life era into another. But therapy need not be limited to these explicit existential crises. In every course of therapy, there is abundant evidence of patients’ anguish stemming from existential conflicts. The availability of such data is entirely a function of the therapist’s attitudinal set and perceptivity. The decision to work on these levels should be a joint patient-therapist decision.
Evidence Psychotherapy evaluation is always a difficult task. The more focused and specific the approach and the goals, the easier it is to measure outcome. Symptomatic relief or behavioral change may be quantified with reasonable precision. But more ambitious therapies, which seek to affect deeper layers of the individual’s mode of being in the world, defy quantification. These problems of evaluation are illustrated by the following vignettes reported by Yalom (1981, p. 336).
A 46-year-old mother accompanied the youngest of her four children to the airport, from which he departed for college. She had spent the last 26 years rearing her children and longing for this day. No more impositions, no more incessantly living for others, no more cooking dinners and picking up clothes. Finally she was free.
Yet as she said good-bye she unexpectedly began sobbing loudly, and on the way home from the airport a deep shudder passed through her body. “It is only natural,” she thought. It was only the sadness of saying good-bye to someone she loved very much. But it was much more than that, and the shudder soon turned into raw anxiety. The therapist whom she consulted identified it as a common problem: the empty-nest syndrome.
Of course she was anxious. How could it be otherwise? For years she had based her self-esteem on her performance as a mother and suddenly she found no way to validate herself. The whole routine and structure of her life had been altered. Gradually, with the help of Valium, supportive psychotherapy, an assertiveness training group, several adult education courses, a lover or two, and a part-time volunteer job, the shudder shrunk to a tremble and then vanished. She returned to her premorbid level of comfort and adaptation.
This patient happened to be part of a psychotherapy research project, and there were outcome measures of her psychotherapy. Her treatment results could be described as excellent on each of the measures used—symptom checklists, target problem evaluation, and self-esteem. Obviously she had made considerable improvement. Yet, despite this, it is entirely possible to consider this case as one of missed therapeutic opportunities.
Consider another patient in almost precisely the same life situation. In the treatment of this second patient the therapist, who was existentially oriented, attempted to nurse the shudder rather than to anesthetize it. This patient experienced what Kierkegaard called “creative anxiety.” The therapist and the patient allowed the anxiety to lead them into important areas for investigation. True, the patient suffered from the empty-nest syndrome; she had problems of self-esteem; she loved her child but also envied him for the chances in life she had never had; and, of course, she felt guilty because of these “ignoble” sentiments.
The therapist did not simply allow her to find ways to help her fill her time but plunged into an exploration of the meaning of the fear of the empty nest. She had always desired freedom but now seemed terrified of it. Why?
A dream illuminated the meaning of the shudder. The dream consisted simply of herself holding in her hand a 35-mm photographic slide of her son juggling and tumbling. The slide was peculiar, however, in that it showed movement; she saw her son in a multitude of positions all at the same time. In the analysis of the dream her associations revolved around the theme of time. The slide captured and framed time and movement. It kept everything alive but made everything stand still. It froze life. “Time moves on,” she said, “and there’s no way I can stop it. I didn’t want John to grow up . . . whether I like it or not time moves on. It moves on for John and it moves on for me as well.”
This dream brought her own finiteness into clear focus and, rather than rush to fill time with various distractions, she learned to appreciate time in richer ways than previously. She moved into the realm that Heidegger described as authentic being: She wondered not so much at the way things are but that things are. Although one could argue that therapy helped the second patient more than the first, it would not be possible to demonstrate this conclusion on any standard outcome measures. In fact, the second patient probably continued to experience more anxiety than the first did; but anxiety is a part of existence and no individual who continues to grow and create will ever be free of it.
Treatment Existential therapy has its primary applications in an individual therapy setting. However, various existential themes and insights may be successfully applied in a variety of other settings including group therapy, family therapy, couples therapy, and so forth.
The concept of responsibility has particularly widespread applicability. It is a keystone of the group therapeutic process. Group therapy is primarily based on interpersonal therapy; the group therapeutic format is an ideal arena in which to examine and correct maladaptive interpersonal modes of behavior. However, the theme of responsibility underlies much interpersonal work. Consider, for example, the following sequence through which group therapists, explicitly or implicitly, attempt to guide their patients:
1. Patients learn how their behavior is viewed by others. (Through feedback from other group members, patients learn to see themselves through others’ eyes.)
2. Patients learn how their behavior makes others feel. (Members share their personal affective responses to one another.)
3. Patients learn how their behavior creates the opinions others have of them. (By sharing here-and-now feelings, members learn that, as a result of their behavior, others develop certain opinions and views of them.)
4. Patients learn how their behavior influences their opinions of themselves. (The information gathered in the first three steps leads to the patient formulating certain kinds of self-evaluations.)
Each of these four steps begins with the patients’ own behavior, which underscores their role in shaping interpersonal relations. The end point of this sequence is that group members begin to understand that they are responsible for how others treat them and for the way in which they regard themselves.
This is one of the most fascinating aspects of group therapy: All members are “born” simultaneously. Each starts out on an equal footing. Each gradually scoops out and shapes a particular life space in the group. Thus, each person is responsible for the interpersonal position he or she scoops out for himself in the group (and in life).The therapeutic work in the group then not only allows individuals to change their way of relating to one another but also brings home to them in a powerful way the extent to which they have created their own life predicament—clearly an existential therapeutic mechanism.
Often the therapist uses his or her own feelings to identify the patient’s contribution to his or her life predicament. For example, a depressed 48-year-old woman complained bitterly about the way her children treated her: They dismissed her opinions, were impatient with her, and, when some serious issue was at stake, addressed their comments to their father. When the therapist tuned in to his feelings about this patient, he became aware of a whining quality in her voice that tempted him not to take her seriously and to regard her somewhat as a child. He shared his feelings with the patient, and it proved enormously useful to her. She became aware of her childlike behavior in many areas and began to realize that her children treated her precisely as she “asked” to be treated.
Not infrequently, therapists must treat patients who are panicked by a decisional crisis. Yalom (1981) describes one therapeutic approach in such a situation. The therapist’s basic strategy consisted of helping the patient uncover and appreciate the existential implications of the decision. The patient was a 66-year-old widow who sought therapy because of her anguish about a decision to sell a summer home. The house required constant attention to gardening, maintenance, and protection and seemed a considerable burden to a frail elderly woman in poor health. Finances affected the decision as well, and she asked many financial and realty consultants to assist her in making the decision.
The therapist and the patient explored many factors involved in the decision and then gradually began to explore more deeply. Soon a number of painful issues emerged. For example, her husband had died a year ago and she mourned him yet. The house was still rich with his presence, and drawers and closets brimmed with his personal effects. A decision to sell the house also required a decision to come to terms with the fact that her husband would never return. She considered her house as her “drawing card” and harbored serious doubts whether anyone would visit her without the enticement of her lovely estate. Thus, a decision to sell the house meant testing the loyalty of her friends and risking loneliness and isolation. Yet another reason centered on the great tragedy of her life—her childlessness. She had always envisioned the estate passing on to her children and to her children’s children. The decision to sell the house thus was a decision to acknowledge the failure of her major symbolic immortality project. The therapist used the house-selling decision as a springboard to these deeper issues and eventually helped the patient mourn her husband, herself, and her unborn children.
Once the deeper meanings of a decision are worked through, the decision generally glides easily into place, and after approximately a dozen sessions the patient effortlessly made the decision to sell the house.
Existentially oriented therapists strive toward honest, mutually open relationships with their patients. The patient-therapist relationship helps the patient clarify other relationships. Patients almost invariably distort some aspect of their relationship to the therapist. The therapist, drawing from self-knowledge and experience of how others view him or her, is able to help the patient distinguish distortion from reality.
The experience of an intimate encounter with a therapist has implications that extend beyond relationships with other people. For one thing, the therapist is generally someone whom the patient particularly respects. But even more important, the therapist is someone, often the only one, who really knows the patient. To tell someone else all one’s darkest secrets and still to be fully accepted by that person is enormously affirmative.
Existential thinkers such as Erich Fromm, Abraham Maslow, and Martin Buber all stress that true caring for another means to care about the other’s growth and to want to bring something to life in the other. Buber uses the term unfolding, which he suggests should be the way of the educator and the therapist: One uncovers what was there all along. The term unfolding has rich connotations and stands in sharp contrast to the goals of other therapeutic systems. One helps the patient unfold by meeting, by existential communication. The therapist is, in Sequin’s terms, a “possibilitator” (1965, p. 123).
Perhaps the most important concept of all in describing the patient-therapist relationship is what May et al. term presence (1958, p. 80). The therapist must be fully present, striving for an authentic encounter with the patient.
CASE EXAMPLE A Simple Case of Divorce A 50-year-old scientist, whom we will call David, had been married for 27 years and had recently decided to separate from his wife. He applied for therapy because of the degree of anxiety he was experiencing in anticipation of confronting his wife with his decision.
The situation was in many ways a typical midlife scenario. The patient had two children; the youngest had just graduated from college. In David’s mind the children had always been the main element binding him and his wife together. Now that the children were self-supporting and fully adult, David felt there was no reasonable point in continuing the marriage. He reported that he had been dissatisfied with his marriage for many years and on three previous occasions had separated from his wife, but, after only a few days, had become anxious and returned, crestfallen, to his home. Bad as the marriage was, David concluded that it was less unsatisfactory than the loneliness of being single.
The reason for his dissatisfaction with his marriage was primarily boredom. He had met his wife when he was 17, a time when he had been extremely insecure, especially in his relationships with women. She was the first woman who had ever expressed interest in him. David (as well as his wife) came from a blue-collar family. He was exceptionally intellectually gifted and was the first member of his family to attend college. He won a scholarship to an Ivy League school, obtained two graduate degrees, and embarked upon an outstanding academic research career. His wife was not gifted intellectually, chose not to go to college, and during the early years of their marriage worked to support David in graduate school.
For most of their married life his wife immersed herself in the task of caring for the children while David ferociously pursued his professional career. He had always experienced his relationship to his wife as empty and had always felt bored with her company. In his view she had an extremely mediocre mind and was so restricted characterologically that he found it constraining to be alone with her and embarrassing to share her with friends. He experienced himself as continually changing and growing, whereas his wife, in his opinion, had become increasingly rigid and unreceptive to new ideas.
The prototypic scenario of the male in midlife crisis seeking a divorce was made complete by the presence of the “other woman”—an intelligent, vivacious, attractive woman 15 years younger than himself.
David’s therapy was long and complex, and several existential themes emerged during the course of therapy.
Responsibility was an important issue in his decision to leave his wife. First, there is the moral sense of responsibility. After all, his wife gave birth to and raised his children and had supported him through graduate school. He and his wife were at an age where he was far more “marketable” than she; that is, he had significantly higher earning power and was biologically able to father children. What moral responsibility, then, did he have to his wife?
David had a high moral sense and would, for the rest of his life, torment himself with this question. It had to be explored in therapy, and, consequently, the therapist confronted him explicitly with the issue of moral responsibility during David’s decision making process. The most effective mode of dealing with this anticipatory dysphoria was to leave no stone unturned in his effort to improve and, thus, to save the marriage.
The therapist helped David examine the question of his responsibility for the failure of the marriage. To what degree was he responsible for his wife’s mode of being with him? For example, the therapist noted that he himself felt somewhat intimidated by David’s quick, facile mind: The therapist also was aware of a concern about being criticized or judged by David. How judgmental was David? Was it not possible that he squelched his wife, that he might have helped his wife to develop greater flexibility, spontaneity, and self-awareness?
The therapist also helped David explore another major issue. Was he displacing onto the marriage dissatisfaction that belonged elsewhere in his life? A dream pointed the way toward some important dynamics:
I had a problem with liquefaction of earth near my pool. John [a friend who was dying from cancer] sinks into the ground. It was like quicksand. I used a giant power auger to drill down into the quicksand. I expect to find some kind of void under the ground but instead I found a concrete slab five to six feet down. On the slab I found a receipt of money someone had paid me for $501. I was very anxious in the dream about that receipt since it was greater than it should have been.
One of the major themes of this dream had to do with death and aging. First, there was the theme of his friend who had cancer. David attempted to find his friend by using a giant auger. In the dream, David experienced a great sense of mastery and power during the drilling. The symbol of the auger seemed clearly phallic and initiated a profitable exploration of sexuality—David had always been sexually driven, and the dream illuminated how he used sex (and especially sex with a young woman) as a mode of gaining mastery over aging and death. Finally, he is surprised to find a concrete slab (which elicited associations of morgues, tombs, and tombstones).
He was intrigued by the numerical figures in the dream (the slab was “five to six feet” down and the receipt was for precisely $501). In his associations David made the interesting observation that he was 50 years old and the night of the dream was his 51st birthday. Though he did not consciously dwell on his age, the dream made it clear that at an unconscious level he had considerable concern about being over 50. Along with the slab that was between five and six feet deep and the receipt that was just over $500, there was his considerable concern in the dream about the amount cited in the receipt being too great. On a conscious level he denied his aging.
If David’s major distress stemmed from his growing awareness of his aging and diminishment, then a precipitous separation from his wife might have represented an attempt to solve the wrong problem. Consequently, the therapist helped David plunge into a thorough exploration of his feelings about his aging and his mortality. The therapist’s view was that only by fully dealing with these issues would he be more able to ascertain the true extent of the marital difficulties. The therapist and David explored these issues over several months. He attempted to deal more honestly with his wife than before, and soon he and his wife made arrangements to see a marital therapist for several months.
After these steps were taken, David and his wife decided that there was nothing salvageable in the marriage and they separated. The months following his separation were exceedingly difficult. The therapist provided support during this time but did not try to help David eliminate his anxiety; instead, he attempted to help David use his anxiety in a constructive fashion. David’s inclination was to rush into an immediate second marriage, whereas the therapist persistently urged him to look at the fear of isolation that on each previous separation had sent him back to his wife. It was important now to be certain that fear did not propel him into an immediate second marriage.
David found it difficult to heed this advice because he felt so much in love with the new woman in his life. The state of being “in love” is one of the great experiences in life.
In therapy, however, being in love raises many problems; the pull of romantic love is so great that it engulfs even the most well-directed therapeutic endeavors. David found his new partner to be the ideal woman, no other woman existed for him, and he attempted to spend all his time with her. When with her he experienced a state of continual bliss: All aspects of the lonely “I” vanished, leaving only a very blissful state of “we-ness.”
What finally made it possible for David to work in therapy was that his new friend became somewhat frightened by the power of his embrace. Only then was he willing to look at his extreme fear of being alone and his reflex desire to merge with a woman. Gradually he became desensitized to being alone. He observed his feelings, kept a journal of them, and worked hard on them in therapy. He noted, for example, that Sundays were the worst time. He had an extremely demanding professional schedule and had no difficulties during the week. Sundays were times of extreme anxiety. He became aware that part of that anxiety was that he had to take care of himself on Sunday. If he wanted to do something, he himself had to schedule the activity. He could no longer rely on that being done for him by his wife. He discovered that an important function of ritual in culture and the heavy scheduling in his own life was to conceal the void, the total lack of structure beneath him.
These observations led him, in therapy, to face his need to be cared for and shielded. The fears of isolation and freedom buffeted him for several months, but gradually he learned how to be alone in the world and what it meant to be responsible for his own being. In short, he learned how to be his own mother and father—always a major therapeutic objective of psychotherapy.
SUMMARY Existential psychotherapy perceives the patient as an existing, immediate person, not as a composite of drives, archetypes, or conditioning. Instinctual drives and history are obviously present, but they come into existential therapy only as parts of the living, struggling, feeling, thinking human being in unique conflicts and with hopes, fears, and relationships. Existential therapy emphasizes that normal anxiety and guilt are present in all of life and that only the neurotic forms of these need to be changed in therapy. The person can be freed from neurotic anxiety and guilt only as he or she recognizes normal anxiety and guilt at the same time.
The original criticism of existential therapy as “too philosophical” has lessened as people recognize that all effective psychotherapy has philosophical implications.
Existential therapy is concerned with the “I-Am” (being) experience, the culture (world) in which a patient lives, the significance of time, and the aspect of consciousness called transcendence.
Karl Jaspers put his finger on the harmfulness of a therapist’s lack of presence and of its importance: “What we are missing! What opportunities of understanding we let pass by because at a single, decisive moment we were, with all our knowledge, lacking in the simple virtue of a full human presence!” It is this presence that existential therapy seeks to cultivate.
The central aim of the founders of existential psychotherapy was that its emphases would influence therapy of all schools. That this has been occurring is quite clear.
The depth of existential ideas is shown in what is called the existential neurosis. This refers to the condition of the person who feels life is meaningless.
Existential therapy always sees the patient in the center of his or her own culture. Most people’s problems are now loneliness, isolation, and alienation.
Our present age is one of disintegration of cultural and historical mores, of love and marriage, the family, the inherited religions, and so forth. This disintegration is the reason psychotherapy of all sorts has burgeoned in the twentieth century; people cried for help for their multitudinous problems. Thus, the existential emphasis on different aspects of the world (environment, social world, and subjective world) will, in all likelihood, become increasingly important. It is predicted that the existential approach in therapy will then become more widely used.