Existential therapy

Existential psychotherapy is partly based on the existential belief that human beings are alone in the world. This aloneness leads to feelings of meaninglessness which can be overcome only by creating one's own values and meanings. We have the power to create because we have the freedom to choose. In making our own choices we assume full responsibility for the results and blame no one but ourselves if the result is less than what was desired. The psychotherapist helps his or her patients/clients along this path: to discover why the patient/client is overburdened by the anxieties of aloneness and meaninglessness, to find new and better ways to manage these anxieties, to make new and healthy choices, and to emerge from therapy as a free and sound human being.

Background
Existential therapy focuses on the development of a patient/client's self-awareness by looking deeply into the issues of our aloneness, meaninglessness, and mortality. The therapist emphasizes the historical background to this approach is that of 3,000 years of philosophy.

Throughout the history of humankind people have tried to make sense of life in general and of their personal predicaments in particular. Much of the philosophical tradition is relevant and can help us to understand an individual's position in the world. The philosophers who are especially pertinent are those whose work is directly aimed at making sense of human existence. But the philosophical movements that are of most importance and that have been directly responsible for the generation of existential therapy are phenomenology and existential philosophy.

The starting point of existential philosophy (see Warnock, 1970; Macquarrie, 1972; Mace, 1999; Van Deurzen and Kenward, 2005) can be traced back to the last century and the work of Kierkegaard and Nietzsche. Both were in conflict with the predominant ideologies of their time and committed to the exploration of reality as it can be experienced in a passionate and personal manner.

Kierkegaard (1813–55) protested vigorously against Christian dogma and the so-called 'objectivity' of science (Kierkegaard, 1941, 1944). He thought that both were ways of avoiding the anxiety inherent in human existence. He had great contempt for the way in which life was being lived by those around him and believed that truth could ultimately only be discovered subjectively by the individual in action. What was most lacking was people's courage to take the leap of faith and live with passion and commitment from the inward depth of existence. This involved a constant struggle between the finite and infinite aspects of our nature as part of the difficult task of creating a self and finding meaning. As Kierkegaard lived by his own word he was lonely and much ridiculed during his lifetime.

Nietzsche (1844–1900) took this philosophy of life a step further. His starting point was the notion that God was dead (Nietzsche, 1961, 1974, 1986) and that it is up to us to re-evaluate existence in light of this. He invited people to shake off the shackles of moral constraint and to discover their free will in order to soar to unknown heights and learn to live with new intensity. He encouraged people not to remain part of the herd, but to dare stand out. The important existential themes of freedom, choice, responsibility and courage are introduced for the first time. While Kierkegaard and Nietzsche drew attention to the human issues that needed to be addressed, Husserl's phenomenology (Husserl, 1960, 1962; Moran, 2000) provided the method to address them in a rigorous manner. He contended that natural sciences are based on the assumption that subject and object are separate and that this kind of dualism can only lead to error. He proposed a whole new mode of investigation and understanding of the world and our experience of it. Prejudice has to be put aside or 'bracketed', in order for us to meet the world afresh and discover what is absolutely fundamental and only directly available to us through intuition. If we want to grasp the essence of things, instead of explaining and analysing them we have to learn to describe and understand them.

Heidegger (1889–1976) applied the phenomenological method to understanding the meaning of being (Heidegger, 1962, 1968). He argued that poetry and deep philosophical thinking can bring greater insight into what it means to be in the world than can be achieved through scientific knowledge. He explored human being in the world in a manner that revolutionizes classical ideas about the self and psychology. He recognized the importance of time, space, death and human relatedness. He also favoured hermeneutics, an old philosophical method of investigation, which is the art of interpretation. Unlike interpretation as practised in psychoanalysis (which consists of referring a person's experience to a pre-established theoretical framework) this kind of interpretation seeks to understand how the person herself subjectively experiences something.

Sartre (1905–80) contributed many other strands of existential exploration, particularly in terms of emotions, imagination, and the person's insertion into a social and political world. He became the father of existentialism, which was a philosophical trend with a limited life span. The philosophy of existence on the contrary is carried by a wide-ranging literature, which includes many other authors than the ones mentioned above. There is much to be learned from existential authors such as Karl Jaspers (1951, 1963), Paul Tillich, Martin Buber, and Hans-Georg Gadamer within the Germanic tradition and Albert Camus, Gabriel Marcel, Paul Ricoeur, Maurice Merleau-Ponty and Emmanuel Lévinas within the French tradition (see for instance Spiegelberg, 1972, Kearney, 1986 or van Deurzen-Smith, 1997). Few psychotherapists are aware of this literature, or interested in making use of it. Psychotherapy has traditionally grown within a medical rather than a philosophical milieu and is only just beginning to discover the possibility of a radical philosophical approach.

From the start of this century some psychotherapists were, however, inspired by phenomenology and its possibilities for working with people. Ludwig Binswanger, in Switzerland, was the first to attempt to bring existential insights to his work with patients, in the Kreuzlingen sanatorium where he was a psychiatrist. Much of his work was translated into English during the 1940s and 1950s and, together with the immigration to the USA of Paul Tillich (Tillich, 1952) and others, this had a considerable impact on the popularization of existential ideas as a basis for therapy (Valle and King, 1978; Cooper, 2003). Rollo May played an important role in this, and his writing (1969, 1983; May et al., 1958) kept the existential influence alive in America, leading eventually to a specific formulation of therapy (Bugental, 1981; May and Yalom, 1985; Yalom, 1980). Humanistic psychology was directly influenced by these ideas, but it invariably diluted and sometimes distorted their original meanings.

In Europe existential ideas were combined with some psychoanalytic principles and a method of existential analysis was developed by Medard Boss (1957a, 1957b, 1979) in close co-operation with Heidegger. In Austria, Viktor Frankl developed an existential therapy called logotherapy (Frankl, 1964, 1967), which focused particularly on finding meaning. In France the ideas of Sartre (1956, 1962) and Merleau-Ponty (1962) and of a number of practitioners (Minkowski, 1970) were important and influential but no specific therapeutic method was developed from them.

Development in Britain
Britain became a fertile ground for the further development of the existential approach when Laing and Cooper took Sartre's existential ideas as the basis for their work (Laing, 1960, 1961; Cooper, 1967; Laing and Cooper, 1964). Without developing a concrete method of therapy they critically reconsidered the notion of mental illness and its treatment. In the late 1960s they established an experimental therapeutic community at Kingsley Hall in the East End of London, where people could come to live through their madness without the usual medical treatment. They also founded the Philadelphia Association, an organization providing alternative living, therapy and therapeutic training from this perspective. The Philadelphia Association is still in existence today and is now committed to the exploration of the works of philosophers such as Wittgenstein, Derrida, Levinas and Foucault as well as the work of the French psychoanalyst Lacan. It also runs a number of small therapeutic households along these lines. The Arbours Association is another group that grew out of the Kingsley Hall experiment. Founded by Berke and Schatzman in the 1970s, it now runs a training programme in psychotherapy, a crisis centre and several therapeutic communities. The existential input in the Arbours has gradually been replaced with a more neo-Kleinian emphasis.

The impetus for further development of the existential approach in Britain has largely come from the development of a number of existentially based courses in academic institutions. This started with the programmes created by Emmy van Deurzen, initially at Antioch University in London and subsequently at Regent's College, London and since then at the New School of Psychotherapy and Counselling, also in London. The latter is a purely existentially based training institute, which offers postgraduate degrees validated by the University of Sheffield and Middlesex University. In the last decades the existential approach has spread rapidly and has become a welcome alternative to established methods. There are now a number of other, mostly academic, centres in Britain that provide training in existential counselling and psychotherapy and a rapidly growing interest in the approach in the voluntary sector and in the National Health Service.

British publications dealing with existential therapy include contributions by Jenner (de Koning and Jenner, 1982), Heaton (1988, 1994), Cohn (1994, 1997), Spinelli (1997), Cooper (1989, 2002), Eleftheriadou (1994), Lemma-Wright (1994), Du Plock (1997), Strasser and Strasser (1997), van Deurzen (1997, 1998, 2002); van Deurzen and Arnold-Baker (2005); van Deurzen and Kenward (2005). Other writers such as Lomas (1981) and Smail (1978, 1987, 1993) have published work relevant to the approach although not explicitly 'existential' in orientation. The journal of the British Society for Phenomenology regularly publishes work on existential and phenomenological psychotherapy. An important development was that of the founding of the Society for Existential Analysis in 1988, initiated by van Deurzen. This society brings together psychotherapists, psychologists, psychiatrists, counsellors and philosophers working from an existential perspective. It offers regular fora for discussion and debate as well as major annual conferences. It publishes the Journal of the Society for Existential Analysis twice a year. It is also a member of the International Federation for Daseinsanalysis, which stimulates international exchange between representatives of the approach from around the world. An international Society for Existential Therapists also exists. It was founded in 2006 by Emmy van Deurzen and Digby Tantam, and is called the International Community of Existential Counsellors and Therapists (ICECAP).

View of the Human Mind
Although humans are essentially alone in the world, we long to be connected to others. We want to have meaning in their lives while they have meaning in ours, but ultimately we must come to realize that we cannot depend on others for our validation, and with that realization we finally acknowledge and understand that we are fundamentally alone. The result of this revelation is anxiety in the knowledge that our validation must come from within and not from others.

Because we are alienated and isolated our lives are also meaningless. Nothing exists which is greater than ourselves, therefore there are no external sources of values and absolutes from which we can draw. Taken to an extreme, we might conclude that there is nothing for which to live. However, we also possess the freedom to create our own values and personal life-meaning, and apply them to our condition. This freedom gives us feelings of significance and purpose that are strong enough to carry us through life. Still, the freedom to choose is another source of anxiety: we must summon the requisite strength and courage to choose our personal life-meaning and hold fast to it. This is undoubtedly a task which many find difficult.

Human beings are also mortal. As we come to grips with the fact that our lives are limited, we develop even more anxiety: we are afraid of death. The knowledge that at some point in the future we will cease to be, while frightening, is at the same time invigorating because it is relevant right now. The juxtaposition of life and death is one thing that does give us some certainty.

Finally, humans are responsible. Being isolated, alone, and free to choose means that one cannot assign blame for his or her problems to someone else. The individual alone makes the choices and therefore is responsible for the outcomes. At any point we are free to make different choices and thus re-invent ourselves; we are at once the architect, the planner, and the builder of our lives, throughout our lives.

Psychological Dysfunction
There is no such thing as psychological dysfunction or being ill in the existential view. Every way of being is merely an expression of how one chooses to live one's life. However one may feel unable to come to terms with the anxiety of being alone in the world. If so an existential psychotherapist can assist one in accepting these feelings rather than trying to change them as if there is something wrong. Everyone has the freedom to choose how they are going to be in life, however this may go unexercised because making changes is difficult; it may appear easier and safer not to make decisions that you will be responsible for. Many people will remain unaware of alternative choices in life for various societal reasons.

The Good Life
It is possible for people to face the anxieties of life head-on and embrace the human condition of aloneness, to revel in the freedom to choose and take full responsibility for their choices. They courageously take the helm of their lives and steer in whatever direction they choose; they have the courage to be. One does not need to arrest feelings of meaninglessness, but can choose new meanings for their lives. By building, by loving, and by creating one is able to live life as one's own adventure. One can accept one's own mortality and overcome fear of death.

Existential Therapy
The existentially-oriented psychotherapist guides his or her patients/clients to confront life's anxieties. If the patient/client has not been fully exercising the freedom to choose, the counselor will lead a discovering into how and why he or she is stuck. Perhaps the patient/client has been allowing others to make the important decisions which he or she alone should be making. Possibly the patient/client is afraid to take the risks required to grow and is instead choosing an easy and non-threatening path. The counselor will encourage his or her patient/clients to reflect on the aloneness and meaninglessness of life, and to understand that they must find their own ways to cope with these anxieties. The counselor does not try to eliminate these anxieties, but instead encourages the patient/client to face them head-on. Alternative paths can be explored together. The risks entailed with these paths can be evaluated, and then the patient/client will be able to make new, more authentic choices. The existential counselor is not overly concerned with the patient's/client's past. Instead, the emphasis is on the choices to be made in the present. The counselor and the client may reflect upon how the client has answered life's questions in the past, but then attention shifts to searching for a new and increased awareness in the present and enabling a new freedom and responsibility to act.

Four worlds
Existential thinkers seek to avoid restrictive models that categorize or label people. Instead they look for the universals that can be observed cross-culturally. There is no existential personality theory which divides humanity into types or reduces people to part components. Instead there is a description of the different levels of experience and existence with which people are inevitably confronted. The way in which a person is in the world at a particular stage can be charted on this general map of human existence (Binswanger, 1963; Yalom, 1980; van Deurzen, 1984). One can distinguish four basic dimensions of human existence: the physical, the social, the psychological and the spiritual. On each of these dimensions people encounter the world and shape their attitude out of their particular take on their experience. Our orientation towards the world defines our reality. The four dimensions are obviously interwoven and provide a complex fourdimensional force field for our existence. We are stretched between a positive pole of what we aspire to on each dimension and a negative pole of what we fear.

Physical dimension On the physical dimension (Umwelt) we relate to our environment and to the givens of the natural world around us. This includes our attitude to the body we have, to the concrete surroundings we find ourselves in, to the climate and the weather, to objects and material possessions, to the bodies of other people, our own bodily needs, to health and illness and to our own mortality. The struggle on this dimension is, in general terms, between the search for domination over the elements and natural law (as in technology, or in sports) and the need to accept the limitations of natural boundaries (as in ecology or old age). While people generally aim for security on this dimension (through health and wealth), much of life brings a gradual disillusionment and realization that such security can only be temporary. Recognizing limitations can bring great release of tension.

Social dimension On the social dimension (Mitwelt) we relate to others as we interact with the public world around us. This dimension includes our response to the culture we live in, as well as to the class and race we belong to (and also those we do not belong to). Attitudes here range from love to hate and from co-operation to competition. The dynamic contradictions can be understood in terms of acceptance versus rejection or belonging versus isolation. Some people prefer to withdraw from the world of others as much as possible. Others blindly chase public acceptance by going along with the rules and fashions of the moment. Otherwise they try to rise above these by becoming trendsetters themselves. By acquiring fame or other forms of power, we can attain dominance over others temporarily. Sooner or later we are, however, all confronted with both failure and aloneness.

Psychological dimension On the psychological dimension (Eigenwelt) we relate to ourselves and in this way create a personal world. This dimension includes views about our character, our past experience and our future possibilities. Contradictions here are often experienced in terms of personal strengths and weaknesses. People search for a sense of identity, a feeling of being substantial and having a self. But inevitably many events will confront us with evidence to the contrary and plunge us into a state of confusion or disintegration. Activity and passivity are an important polarity here. Self-affirmation and resolution go with the former and surrender and yielding with the latter. Facing the final dissolution of self that comes with personal loss and the facing of death might bring anxiety and confusion to many who have not yet given up their sense of self-importance.

Spiritual dimension On the spiritual dimension (√úberwelt) (van Deurzen, 1984) we relate to the unknown and thus create a sense of an ideal world, an ideology and a philosophical outlook. It is here that we find meaning by putting all the pieces of the puzzle together for ourselves. For some people this is done by adhering to a religion or other prescriptive world view, for others it is about discovering or attributing meaning in a more secular or personal way. The contradictions that have to be faced on this dimension are often related to the tension between purpose and absurdity, hope and despair. People create their values in search of something that matters enough to live or die for, something that may even have ultimate and universal validity. Usually the aim is the conquest of a soul, or something that will substantially surpass mortality (as for instance in having contributed something valuable to humankind). Facing the void and the possibility of nothingness are the indispensable counterparts of this quest for the eternal.