An Example of the Application of Existential Therapy

Joseph is a thirty-eight-year-old male and his presenting problem is having significant anxiety followed by severe panic attacks, which has him feeling hopeless and overwhelmed. His anxiety is tightly linked to his new position at a new company. He stated that the only days he does not feel anxious are on weekends, until Sunday night. To cope with the feeling of anxiousness at work, Joseph flees from his environment and attempts to calm himself.

The new job entails more responsibilities and a higher paid salary. He was recruited because of his skills and reputation. His boss stated that Joseph has several months to adjust before he expects sales to be high again. Regardless, Joseph’s personal subjection is that he has never enjoyed the profession, making him a fraud. He fears failure and losing his job.

There is additional pressure to keep this high paying job because him and his wife bought a more expensive home. Moreover, he does not trust his wife to be supportive with his anxiety, therefore withholds this information. He fears rejection from his wife and that she will think less of him and divorce him if she knew about his struggles.

Joseph has encountered fear of failure and rejection in the past from his former college coach after being injured and never being able to play sports again. Joseph called his coach a few years ago and attempted to seek closure and understanding but was unsuccessful.

Theoretical Assumptions, Principles, and Foundations

Existential therapy is meant to be a collaborative and integrated approach with other theories and techniques (Schulenberg et al., 2008; Yalom & Josselson, 2019), however it can stand on its own. Humans are deemed as meaning-making beings, who are both subjects of experience and objects of self-reflection (Yalom & Josselson, 2019, p. 274). Existentialists focus on the subjective experience over the objective observations. This means that many symptoms, like panic attacks, can stem from existential crises. Existential anxiety is an inevitable product of life, therefore life cannot be lived without anxiety (Yalom & Josselson, 2019, p. 288). The goal is to reduce anxiety to tolerable levels and harness it into productive measures. Otherwise, being unaware of these existential anxieties pushes the person to conform to external rules and guidelines of living, leading them to a state of inauthentic living (Temple & Gall, 2016).

Existentialists believe that humans are influenced by their environment and that they are stimulated and respond in certain ways to it (Yalom & Josselson, 2019, p. 282). A person then reflects on these experiences, determines what experiences are valuable, then acts accordingly. This process builds an existential frame of reference. This process is based on the existential assumption that all our reflections are based on relatedness (Spinelli, 2014). Because humans self-create their own existential frame of references, we are groundless (Yalom & Josselson, 2019, p. 282). This goes against a core human need to have ground and structure. Anxiety is a product of this groundlessness and inauthentic ways of being in relation to the main ultimate concerns of human existence, which are meaning, freedom, isolation, and death.

Ultimate Concerns

Awareness of ultimate concerns leads to feelings of anxiety, which, in turn, leads to the use and development of defense mechanisms (Yalom & Josselson, 2019). Joseph seems to be struggling the most with the concepts of meaning, freedom, and isolation. For the sake of this paper, these ultimate concerns will be expanded on because they best relate to Joseph’s scenario. However, it should be noted that death could be also a topic because without the knowledge of impermanence provoking a constant state of anxiety to the thought of non-being (Temple & Gall, 2016). This concern is assumed to be unconsciously processed in any state (Yalom & Josselson, 2019).

Meaning

Whenever a person is reflective, they enter a dimension of meaning (Das, 1998). With meaning comes a sense of purpose. It is curious whether Joseph agrees with the perceptions of his wife’s values and if they share this value or if this perceived value contradicts with his authenticity. Nonetheless, this perception influences the shaping and molding of his values. Commonly, when people are objectively successful according to society, they lack a sense of meaning (Schulenberg et al., 2008). This leads to feelings of emptiness or an existential vacuum.

Purpose is self-authored, which means that individuals must answer how and why to live to themselves (Yalom & Josselson, 2019, p. 276). This process is referred to as a self-transcending experience. If a person is focused on the external world, then it is likely they are in a healthy process of willfully fulfilling meaning. However, like Joseph, a neurotic individual is more concerned with their subjective state. The new stressors to adapt to his work and to maintain his income have upset Joseph’s world, triggering his search for meaning. It is then the therapist’s job to challenge the person to discover meaning by directing their attention to the outside world. Thankfully, the freedom to decide determines our purpose and every attempt to exercise freedom of choice helps create one’s character (Das, 1998).

Freedom

Joseph’s fear of failure can be seen as a sign for struggling with existential freedom. With existential freedom comes a certain amount of dread toward the responsibility for our lives (Yalom & Josselson, 2019, p. 275). When dread is experienced, then defense mechanisms are activated to cope with the responsibility. Joseph mentioned feeling hopeless and overwhelmed. There seems to be a sense that he feels trapped by his circumstances and paralyzed by the endless possibilities to move forward, but not knowing how to make a decision that is in line with his values. Additionally, the degree that one takes responsibility for one’s life relates to the degree of the sense of isolation (Yalom & Josselson, 2019, p. 275).

Isolation

Joseph’s fear of rejection plays a role in this concern. Because existentialists do not treat from just an intrapsychic perspective, other relational circumstances and conditions are considered (Spinelli, 2014). Perceptions of his wife and avoidance to share about his anxiety with her and his history of rejection likely add to his concerns of loneliness in this experience. The therapeutic relationship can help comfort this ultimate concern, but to reduce the level of anxieties in this area Joseph needs to learn to create meaningful and mutual relationships with others (Yalom & Josselson, 2019, p. 291).

Therapeutic Relationship

The client-therapist relationship is viewed as two fellow travellers (Yalom & Josselson, 2019). This stems from the view of being in a constant flow that can be referred to as being-always-becoming (Spinelli, 2014). Both the client and the therapist are in a state of being-always-becoming, travelling alongside each other. The client’s reflection on his flow of experiences can help establish meanings within the here and now. Simultaneously, the therapist should experience the relatedness between each other as well. Dialogues tend to take on its own direction. There should be awareness of the way the client is talking to facilitate truthful dialogue Throughout dialogue, the therapist can also help the client become less rigid and let go of their attachments to the psychological dimension (Martínez & Flórez, 2014).

The therapist should demonstrate empathy as it is the most powerful tool to harness a strong trusting alliance. This requires the therapist to be open to all the client’s experiences, thoughts, and behaviours, regardless how negative they may be (Yalom & Josselson, 2019). To accomplish this it helps to take an unknowing stance (Spinelli, 2014). This stance allows the therapist to have unfixed meanings to familiar, assumed, and understandable concepts. It is also important for the therapist to be genuine, authentic, and honest with existential issues, while being mindful and respectful of boundaries (Yalom & Josselson, 2019).

Focus on the Here and Now

Not a lot of time is spent pondering and analyzing the past. This is because, from an existential point of view, the past is created and remembered in the present modes of existence (Yalom & Josselson, 2019, p. 288). The therapist aims to focus on the client’s current life situation and unconscious fears. Further, they need to be mindful of what is happening and developing with their therapeutic relationship. Clues and implications can be discovered in finding meaning with the awareness of relatedness. Any disclosure to the client should be done with purpose and be about feeling in the here and now.

Regarding Joseph’s struggle with existential freedom, the therapists would use techniques to get the client to focus on responsibility. If there is no will or motivation to take responsibility, then the therapist helps to remove his obstacles to make decisions.

Applicable Interventions

Logotherapy

Logotherapy is the most common approach in existential therapy. It is meant for problems that stem from feelings of meaninglessness, value conflict, and moral confusion (Das, 1998). The main goal is to help the client discover their meaning in life. This approach promotes motivational effects, encouragement, positivity, hopefulness, and proactivity (Schulenberg et al., 2008). A central component to logotherapy claims that human beings experience overlapping dimensions including physical, psychological, spiritual (Das, 1998; Schulenberg et al., 2008), and social (Temple & Gall, 2016). The spiritual dimension is unique to the human species, which allows for reflection and discovering meaning. The essential skills of self-distancing and self-transcendence occur in this dimension (Martínez & Flórez, 2014). Furthermore, it is common through logotherapy to use metaphorical language (Das, 1998). Specifically, conceptual metaphors make abstract concepts (ultimate concerns) more comprehensive, which increases the likelihood of meaning being discovered (Landau, 2018).

Socratic Dialogue

The process of helping the client to discover or rediscovering meaning in their life is typically done through a process called Socratic-dialogue (Das, 1998; Schulenberg et al., 2008). The counsellor attempts to make the client aware of their resources and how to use them to discover meaning. These resources are typically spiritual in nature (Martínez & Flórez, 2014). Techniques of logotherapy bank of people’s ability for self-objectification through self-distancing and self-transcendence (Das, 1998).

First, a safe environment that harnesses trust between the client and therapist must be established (Martínez & Flórez, 2014). Then the therapists ask questions to get the client to self-reflect and discover personal life meanings, how to actualize them, and to recognize choices (Schulenberg et al., 2008). Through a stance of unknowing and naivety, the therapist attempts to identify the problem behind the client’s perceived perception (Martínez & Flórez, 2014). In the case of Joseph, discovering the problem(s) behind his feelings of hopelessness, overwhelmingness, anxiety, and panic attacks. This can be done by addressing the emotional, cognitive, and value perception, and value attraction. It is important to note that these steps are not necessarily meant to be followed in a linear process, instead the therapist determines what step is appropriate according to the client’s flow (Temple & Gall, 2016).

First, Joseph would be asked questions about his feelings towards work and his wife, and what those feelings mean to him. Second, he would be asked the thoughts that are associated with his thoughts. This provides rationale and substance behind possible values. Third, the therapist would guide Joseph to perceive those values and to figure out what is important to him. Lastly, Joseph would be asked to experience his value(s) and act naturally upon it. Through repetition of this process, Joseph can learn to independently perceive meaning. The repetition could occur through the following scenarios: the therapist could unpack the comments he made about being a fraud and never truly enjoying work or the situation with his wife possibly leaving him if she found out or the situation with his coach.

Additionally, the therapist has an active role in altering maladaptive patterns. Maladaptive patterns include avoidance and escape behaviours to eliminate discomfort, which Joseph has been doing withholding information from his wife and escaping his environment to calm himself. Humour is typically included in the process to encourage self-distancing that allows attitudinal and behavioural change.

Paradoxical Intention

This technique is useful in decreasing symptoms, promoting self-distancing, and enhancing meaning (Martínez & Flórez, 2014). The therapist can request Joseph to visualize doing this technique in session and/or attempting the technique when he feels anxious in general (Frankl, 1975). First, situations need to be identified that trigger anticipatory anxiety (fear). Joseph already stated that he feels severe anxiety at work. Typically, Joseph runs to the bathroom to flee from his fear. In the bathroom, he thinks about his anxiety and tries to calm himself, putting pressure on himself, which increases counter pressure, and thus the cycle continues until he has a full-blown panic attack. To break this feedback mechanism, Joseph would be encouraged to do, or wish to happen, the thing he is fearing. That could be his fear of failure, fear of rejection, or fear or embarrassment of having a panic attack in front of people. For example, he could focus on sweating (if this is a symptom) and focus on trying to sweat as much as possible to fill the room and make his colleagues swim in it. This ludicrous image hopefully causes a break in the cycle either by resulting in humour or until he recognizes that he is no longer panicking. This incorporates the significance of trying to get the client to externalize his motives and thoughts away from the inner-psychic dialogue and to externalize his purpose. Humour allows for the capacity for self-detachment and is therefore a useful defense mechanism in this circumstance.

Theoretical Limitations to Multiculturalism

All humans are prone to existential dilemmas, therefore existential therapy is possible to use with all unique cultural identities. Culture heavily influences the wat a person defines themselves (Das, 1998). Therefore, every trait, quality, and identification are considered and explored if it is relevant to the client’s concerns and perspective on a matter. This is particularly important when using logotherapy because it aids in clarifying values (Schulenberg et al., 2008). There is a lack of research on descriptive information regarding logotherapy and multicultural issues. Still, metaphors and figurative speech stem from historical and cultural contexts. These metaphors are typically expressed in spoken and written language, but also in non-linguistic ways including ceremonies, gestures, and images (Landau, 2018). This can be seen as an aide but can also cause room for more misunderstandings from either the therapist or client.

There can be difficulties using this approach if certain individuals have cultural, usually religious, frameworks that address and answer these concerns (Yalom & Josselson, 2019). This is not uncommon as many cultures create belief systems that ease the impact of ultimate concerns. Denial systems that believe in an ultimate rescuer overshadow personal struggles with ultimate concerns. This causes issues because then the individual will not directly confront the existential dilemmas.

Personal Alignment

This psychotherapeutic approach can provide many benefits and advantages for the client. In my opinion, it would be best used in combination with other therapy techniques, models, and frameworks. For example, the culturally responsive and socially just model (CRSJ) could enrich the oversimplification of culture in existential theories. Existentialists mention its importance and how belief and attitudes stem from it, but they do not go into detail to define ‘it’. Likewise, the fellow traveller stance acknowledges each person’s unique flow of being, but the CRSJ model elaborates on the complexity of intersectionality between the two flows of being.

In the existential approach, I also find that the therapist takes a much more assertive approach than Roger’s, Jung’s, or Freud’s approach. It seems to be more similar to the Adlerian method of questioning. To point out contradictions, challenging maladaptive patterns, and encouraging techniques, the therapeutic relationship must be built. I am not convinced that the existential approach provides enough time and techniques to build rapport and trust. Further, to be assertive, the therapist should be well-informed of the depths of existentialism.

Overall, this approach can be extremely helpful and insightful. The use of logotherapy, figurative language, Socratic dialogue, paradoxical intention, and other methods are creative and empowering for the client. The practical approaches and methods foster hope, even though its basis is groundless.

References

Collins, S. (2018). Embracing cultural responsivity and social justice: Re-shaping professional identity in counselling psychology (10th ed.). Counselling Concepts.

Das, A. K. (1998). Frankl and the realm of meaning. Journal of Humanistic Education and Development, 36(4), 199-212. Retrieved from https://search-ebscohost-com.libraryservices.yorkvilleu.ca/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=a9h&AN=776921

Frankl, V. E. (1975). Paradoxical intention and dereflection. Psychotherapy: Theory, Research & Practice, 12(3), 226–237. https://doi.org/10.1037/h0086434

Landau, M. J. (2018). Using Metaphor to Find Meaning in Life. Review of General Psychology, 22(1), 62–72. https://doi.org/10.1037/gpr0000105

Martínez, E. Y., & Flórez, I. A. (2015). Meaning-Centered Psychotherapy: A Socratic Clinical Practice. Journal of Contemporary Psychotherapy, 45(1), 37–48. https://doi.org/10.1007/s10879-014-9281-0

Schulenberg, S. E., Hutzell, R. R., Nassif, C., & Rogina, J. M. (2008). Logotherapy for clinical practice. Psychotherapy: Theory, Research, Practice, Training, 45(4), 447-463. Retrieved from https://search-ebscohost-com.libraryservices.yorkvilleu.ca/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=pdh&AN=2008-19012-003

Spinelli, E. (2014). An existential challenge to some dominant perspectives in the practice of contemporary counselling psychology. Counselling Psychology Review, 29(2), 7-14. Retrieved from https://search-ebscohost-com.libraryservices.yorkvilleu.ca/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=a9h&AN=97266018

Temple, M., & Gall, T. L. (2018). Working Through Existential Anxiety Toward Authenticity: A Spiritual Journey of Meaning Making. Journal of Humanistic Psychology, 58(2), 168–193. https://doi.org/10.1177/0022167816629968

Yalom, I. D., & Josselson, R. (2019). Existential psychotherapy. In D. Wedding & R. J. Corsini (Eds.), Current psychotherapies (11th ed.) pp. 273-308. Boston, MA: Cengage.