Existential psychotherapies

EXISTENTIALPSYCHOTHERAPIES RUSSELL A. WALSH AND BRTAN MCEL\UAIN

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What is existential psychotherapy, and in what sense is it one of the humanistic psychotherapies? Although there is no simple answer to either euery, this chapter highlighm issues that can assist one in answering such questions. By defening to the reader, we have adopted a decidedly existential stance, acknowledging imponant questions without presuming universal aruwers. lndeed, the posing of, and reflecting on, questions of meaning makes a course of psychotherapy existential. Faith in clients' abilities to discem their own answerc makes existential therapy a humanistic endeavor. And so, with our faith in the reader's ability to tolerate the ambiguity of foundational questions without definitive answers, we explore issues of impoftance to existentialists. To begin this process, we must address the "essence" of existential psychotherapy. ambiguity inherent in defining the

OF EXISTENTIALTHERAPY DEFINTNGTHE "ESSENCE" Existential psychotherapists share a basic concem with the philosophical foundations of their work with people. Answers to fundamental philo. sophical questions shape the th*ry and practice of all clinicians (Boos, 1979; Cannon, 1991; C-ohn, 1984). For existential psychotherapists, such questions are informed by the writings of philosophical scholan such as Soren Kierkegaard, Friedrich Wilhelm Nietzsche, Edmund Husserl, Martin Heidegger, Manin Buber, Jean-Paul Sarrre, Maurice Merleau.Ponty, Paul Johannes Tillich, and Emmanuel Levinas. Each of these authon grappled with questions about the essential narure and meanings of human existence. However, among these philosophers, as well as their clinical counterparts,

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there is considerable variability in the answers to those questions (Cohn, 1984; Misiak & Sexton, 1973; Norcross, 1987; Willis, 1994). It is thus appropriate to speak of existential psychotherapies rarher than of a single existential psychotherapy. A core theme within existentialism and the related field of phenome. nology is concem for the uniqueness and ineducibiliry of human experience. Accordingly, existential phenomenologists are critical of the application of natural scientific methods to the study of human beings. Existentialists argue that natural scientific methods are inadequate ro the task of understanding the meaningful complexities of human experience (Boss, 1979; May & Yalom, 1995; Norcross, 1987). For example, many such methods presuppose that all people operate in the same mechanistic way, that their behaviors are wholly determined by past and present, and that a person's subjective experience is of secondary importance. Existentialists and phenomenologists consider such accounts of individuals to be violently objectifring and reductive. Thus, they argue that if science is to be pursued with human beings as subjects, then their subjectiuirymust be respected. These psychotherapists and scholan have advocated the development of a suitably hunart scierce that respects the uniqueness of individuals and the distinctions berween human beings and other objects of scientific investigations (Cannon, 1991). Given the existential assumption that each human experience is unique, there is little interest in generalizing across individuals for "universally valid" laws of behavior. Thus, it can be said that existential thought is radically antisystematic (Hoeller, 1990). In fact, many of those who are identified as existential therapiss do not consider existential psychotherapy to be an independent school of therapy. Indeed, existential therapists may incorporate techniques from psychoanalysis (e.g., Boss, 1963) to clientcentered therapy (e.g., Willis, 1994) ro more directive-srrategic approaches (e.g., Frankl, 1967). Such techniques, however, are practiced in light of an existential attitude (van Kaam, 1966), a stance toward human beings that can be organized according to some common themes. These themes include assumptions about hlman freedorn andits attenuatiut, intnsubjectiuiq, tem\rality, and being as beconing, as well as the conceprs of existcntial mxiet), er&tendal guilt, and aukmticity. In the following pages, we outline these assumptions and concepts and discusstheir relevance in terms of the tlwapeutk relatiorchip, tmdnstnnding, Eberation, and therapist flcxibihry. We then review research supporting these ideas and discuss the practical implications of existential psychotherapies.

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The most common and fundamental assumption that existentialists make about human beings is that all individuals are, in significant respects,

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focus on context and responsibiliry. "factical"-embodied, limited, and For existentialists, being human is as the situated in a sociohistorical context. Thus, freedom is understd choices one makes within one's pafticular situation, which then shape the situations one encounters in the firture (Cannon, 1991; du Plock, 1997; van Deurzen-Smith, 1988). Indeed, people are unable to avoid the continual process of making choices that determine who they are and who they will be (Frankl, 1967; Lowenstein, 1993; Yalom, 1989). However, it is important to remember that people are always thrown into situations that they have not independently brought on themselves (Keen, 1970). An inescapable paradox of human existence is that it can be described in both object and subject terms; that is, there are always both given and chosen aspects of any pafticular moment. Intersubjectivity

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free. However, the freedom about which existentialists speak is not the absolute autonomy portrayed so optimistically by some humanistic psychotherapists (Lowenstein, 1993). Existentialists also emphasize limitations, frailry, and the tragic dimensions of human experience to a much greater degree than their humanistic colleagues (Yalom, 1980). Indeed, the moniker exktentillll-hmtrrtrstic is often used to denote a therapeutic approach that tempers the humanistic notion of individual freedom with an existential

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The dual, subiect-object nature of human existence has, in contemporary Westem societies, been obscured by the natural scientific approach that views people as merely objects for study. Thus, Inany existential psychotherapists focus on human subjectivity as a kind of corrective to an exclusively objectifuing view of people. Objects in the world are not free, but subjects in the world are. So existential psychotherapists tend to take people's private, inner experience of themselves more seriously than many other therapists (Keen, 19?0; Washington, 1972). From such an intemal frame of reference, a person's experience, perceptions, thoughts, feelings, and values are imbued with determinative significance that overshadows the objective facts as seen by extemal observers (Bugental, 198i). Existential psychotherapisS tend not to view people in terms of mechanisms that cause them to act in particular ways. Rather, they prefer to think of people in "lived worlds" (C. T. Fischer, 1991). terms of their own uniquely meaningful Despite the foregoing emphasis on the subject side of the subiect-object "objects' "subjects" and dialectic, it must be remembered that the notions of are abstractions. Existentialists seek an understanding of human existence that precedes the splitting apaft of subject and object (C. T. Fischer, 1991; May, 1958; Prochaska, 1979').Minds, psyches,and subjectivities are insepara' ble from the worlds (i.e., meaningful contexts) in which they exist (Boss,

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1979). Human beings always find themselves in relationship with others, and their experiences in relationships provide all of the raw materials from which their own subjective experiences are constructed. Thus, it makes little sense to attempt to understand people apaft from the fundamentally intersubjective contexts into which they are thrown and the histories that they carry with them into the consulting room (Cihn, 1984; du Plock, 1997).

in principle, fluid--despite one's security.motivated efforts to be stable and "rrue to one's self' (Strasser & Straser, t997). Thus, although some thera"self-stmctures," existential psy' peutic approaches seek to repair damaged "really" Lhotherapies may help clients let go of a confining senseof who one is (cannon, 1991). Such letting go acceprs the continuous unfolding, or becoming, of oneself, as well as the human potential to explore and incorpo' rare new possibilities.

Temporality Existential Existentialists have articulated an understanding o{Eved time that goes beyond the commons€nse notion that time passesas a continuous sequence of momenrs in which the future becomes present and is left behind as past (Boss, 1979).lnstead, it is more "experience-o€ilr'to say that the past and future always exist in a penon's present experience (Cohn, 1984; du Plock, 1997). Boss (1979) articulated the human experience of temporaliry as simultaneously being expectant of one's future, being aware of the present moment, and holding on to what has passed. This is not to say that all three temporal dimensions will always be equally open to a person at any given time, as often one dimension becomes figural while the others are unattended as ground. Additionally, existentialists have tended to reevaluate the relative significance of past, present, and future. In the light of deterministic science, the past is seen as causally determinative of the present and the future. In contrast, existential thought suggests that the immediate future is the crucially important temporal dimension of human existence. Human beings are always aiming toward certain ends. lndeed, the capacity of individuals to transcend their past and present situations and to imagine possible futures forms the very basis of human freedom (May, 1958). How' ever, this should not be taken as a denial of the significance of the past or present. Cannon (1991) articulated the following understanding of human temporaliry: The furure (as meaning) and the past (as ground) are equally significant in contributing to a person's choices in the present. Instead, it is more experience-near to say that the past and future always exist in the present experience of a person (Cohn, 1984; du Plock, 1997). Becoming Given the assumption of human freedom, it follows that existentialists conceptualize people as dynamic rather than as determined, predicable mechanisms. Indeed, for psychotherapy to be meaningfully practiced, therapisrc of all theoretical orientations must at least implicitly assumethat people are capable of change (Cohn, 1984). The uniqueness of the existential position is its assumption that radical change is possible at any point because the essence of being human is not to have an essence. One's self is always,

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Anxiety

and Existential

Guilt

In funher contrast to more conventional clinicians, existential psychotherapists view anxiety and guilt as potentially instructive signals that can be used toward the end of living more authentically (Handley, 1996) rather than as symptoms to be managed or eliminated. More specifically, enstrlrtllurl aniety is seen as the normal and unavoidable product of being confronted "givens of existence"-death, freedom and responsibility, existen' with the tial isolation, and meaninglessness(Yalom, 1980). The concems that people take to psychotherapy can often be understood asresulting from rigid pattems of defense against the anxiety.producing awarenessof the givens of existence. These defensive patterns may result in severely restrictive stances in relation to the world (Boss, 1963; Bugental, 1965; Colm, 19661- People may be morivated to impose limitations on their own freedom of thought, feeling, and action to avoid direct experiences of existential anxiety. Existential guilt arisesfrom one's failure to face existential givens and one's responsibility with respect to those givens (May, 1958; van Kaam, 1966). Existential anxiety and existendal guilt are invaluable insofar as they serve to mobilize what Bugental (1987, 1999) refened to as a person's concem,that is, the pain, hope, commitment, and inwardness that provide both the impetus and the intuitive guidance for pursuing significant life change. Deeply experienced concem demands actionAuthenticity A basic goal of an existential psychotherapy is the reduction of duplicity (Bergantino, 1981) or bad faith (sarne, 1953). Bad faith involves selfdeception by recognizing either one's freedom or one's limitations to the exclusion of the orher, that is, imagining one's self to be either purely an object at the whim of extemal forces or as a purely transcendent and autonomous subject (Cannon, 1991; Sartre, 1953). Authenticity involves a radical openness to the world, to others, and to one's own experience; it involves honest and direct confrontation with the givens of existence toward the end of living in conscious harmony with them (Bugental, 1965; Norcrocs, 198?; Prochaska, 1979). The resolution of pathological symptoms occurs

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when one moves from a self-deceptive posture to one that involves the empowering experience of one's sense of personal agency (Keen, 1970). Thus, authenticity involves not being tme to some limiting notion of one's "real self" but rather being open and mre to one's experience of the world (Cohn, 1995).ln this sense, authenticity is analogous to the humanistic notion of genuineness. However, some degree of inauthenticity is acceptd as an inescapable aspect of human experience, and an appreciation of the universaliry of such existential dilemmas enables therapists to engage their clients as equals. The Therapeutic

Relationship

In light of the inescapably relational character of human existence, it should come as no surprise that many existential psychotherapists regard the qualiry of the therapeutic relationship as of paramount imponance. Thus, several have emphasized the process of interaction between client and therapist over the content of what is said in the consulting room (e.g., Bugental, 1978; Yalom, 1989). The therapeutic relationship is itself the force that fosters a kind of corrective emotional experience (Moss, 1989; Yalom, 1989). It is assumed that all substantial human relationships are based on emotional contact (Willis, 1994) and that transformation in psychotherapy requires having a new experience in relation to the therapist, not intellectual explorations or explanations (Boss, 1963). In this view, then, much is made of the therapist's presanceand its role in facilitating a genuine mcutntet between the people who are present in the consulting room. On the pan of the therapist, Spinelli (1994) emphasized being there, being with, and being for a client in an exceptionally respectful manner over effofts to do anything to or for a client. Bugental (1987) hoped that both client and therapist will be optimally present, that is, both open to being deeply and personally affected by the other and willing to disclose their own experience as it pertains to the therapeutic encounter. Without dismissing the relational distortions to which the terms transference and "real relacountertransference refer, an existential approach emphasizesthe tionship," which involves mutual investment and risk on the part of both client and therapist (Bugental, 1978; May, 1983). Understanding Another major theme regarding the practice of existential psychother, apy is the emphasis on understanding in two different senses.First, several writers have stressedthat all technical concems in the practice of psychotherapy must be subordinated to the development of an empathic gntsp of the client's experience (e.g., Corey, 1985; May, 1958; Misiak & Sexton, 1973;

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Washington, L97Z).ln the broadest terms, the existential psychotherapist seeks to engage, understand, and illuminate a client's self-and-world con' struct system, that is, a client's implicit visions of himself or herself and of the character of the world in which he or she lives (Bugental, 1999). These are the operating irssumptions that lend form and stability to one's experiences across time in the face of the innumerable possibilities that confront a person at any given moment. However, existential psychothera' pists must not presume that they ever understand their clients in any ceftain or final sense given the dynamic character of human existence (Spinelli, 1997). They must continually be willing to call into question anything that they presume to understand and, thus, take for granted about their clients as they assist their clients in doing likewise toward their own liberation. The existential psychotherapists' emphasis on understanding involves at' "make the unconscious conscious" toward the end of helping tempting to people to more intentionally direct the course of their lives (May, 1983). It should be noted that existential psychotherapists assume that because people are generally caught up in the acts of conducting their daily lives, they are quite imperfectly aware of the ways in which they engage with the world (van Deurzen-Smith, 1997). Typically, people do not reflect on (or even recognize) their engagement with the world as such, but by attending to what is happening within and around oneseli one can discover much that usually remains hidden within one's experience. ln the radical terms of Sartre (1953), the existential psychotherapist illuminates the ways in which clients have already chosen to become exactly who they find them' selves to be. In this light, it would be a mistake to say that the existential therapist helps clients become more responsible for themselves. Rather, we would say that the therapist helps clients recognize the ways in which they are always already responsible and, thus, invites them to pursue more intentionally their continual process of self-construction (van DeurzenSmith, 1988). Psychotherapeutic Liberation Increasing the compass of conscious choice is held by existentialists to be liberating (May, 1983). The therapist's task is to clarifu the choices being made by the clients and to avoid colluding with clients' beliefs that they are inadequate to the task of directing their own lives (Prochaska, 1979). The existential psychotherapist's hope is that increased awareness of one's choices will connibute to a growing sense of potency in which one previously felt compelled to react to extemal forces (Bugental, 1987). Thus, Bugental (1999) used a focus on the present, momentary experience of the client in the consulting room to illuminate the unrecognized choices that the client is continually making. Bugental's intense focus on the liurng

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Instead, the theoretical and philosophical scholarship cited earlier, as well as qualitative research (e.g., Fessler, 1983; Hanna, Giordano, Dupuy, & Puhakka, 1995; Rahilly, 1993) and case study reports (Bugental, 1976; du Plock, 1997; Schneider & May 1995; Spinelli, 1997; Yalom, 1989), provide existential psychotherapists with compelling evidence in support of their clinical praitices. However, within natural science research literature, there are also hndings consonant with the common themes of existential psycho' therapy. We therefore summarize both mainstream and altemative research

m.oflwnt aims to foster gleater awareness of the choices being made and to help the client to overcome repetitive pattems by developing awarenessof them in the very moment of their activation. Van Kaam (1966) pointed out that personal freedom involves not only being able to change one's behaviors but also intentionally doing things that one had previously done mechanically or unconsciously. The existential psychotherapist illuminates clients' experience of themselves as passive victims and works to foster a sense of active agency (May & Yalom, 1995). As a result, clients can move from relatively constricted to much more flexible approaches to the dynamic contingencies of living. However, such experiential transformation depends on the therapist's own liberation, both personally and with respect to therapeutic technique (Bergantino, 1981). Therapewic

results that support existential psychotherapy. Existential Assumptions: Human Freedom, Intersubjectiviry Temporality' and Becoming Freedom and responsibility are implicitly assumed in all approaches to psychotherapy. Despite the deterministic rhetoric of much discourse about psychotherapyr the possibility of change through conversation, rather than ,oiely through manipulation of environmengl determinants, would make little sense without the assumption of client freedom and responsibility' Indeed, even radically behavioral therapies involve the client as an agent of change; in most cases,clients are instructed to refl.ect on and revise the "psychoeducation" is comprehen' contingencies of their own behavior. Such sible only in light of a client who is reflexively aware and adaptable, one

Flexibility

In light of each person's uniqueness and the dynamic character of human life, the practice of an existential psychotherapist will necessarily be characterized by its flexibility across clients, situations, and time (May, "cases," moments, or therapeutic 1958; Washington, 1972). Because no two relationships will be the same, a therapist must not mechanically use inter. ventions (du Plock, 1997; Willis,1994). C. T. Fischer (1991) described the practice of existential psychotherapy as involving a disciplined opennes, methodological eclecticism, and theoretical pluralism This fits with depictions of psychotherapy as having much more in common with the work of an artist than that of a scientist or technician (Bergantino, 1981; Bugental, 1987). An existential psychotherapist may use a wide variety of interventiolrs "existential attitude" and in the so long as they are used in light of an context of an authentic relationship with the client (May & Yalom, 1995; Moss, 1989). Thus, there are substantial variations in practice acrossexisten' tial psychotherapists as each develops a flexible style given his or her own unique set of experiences, values, and aptitudes (Bergantino, 1981). In all cases,however, the existential psychotherapist's practice will be sensitively responsive to the uniqueness of the given client and moment.

who is willing to apply the therapist's teachings. Research explicitly relevanr to the notions of client freedom and responsibility in psychotherapy can be found in qualitative srudies by Rennie (1t90, 1992, l99q and lyatson and Rennie (I99$, as well as in Bohart and Tallman's ( 1996) research. These authors demonstrated that successful psychotherapy as understood by clients involves a process of self-reflection, considering altemative coursesof action, and making choices. Other research concemin! client variables has demonstrated the significant role played by clients in determining the success or failure of psychotherapy (Gar6eld,

For the most part, existential psychotherapies have not been researched "empirical"r methods (Yalom, 1980). by means of quantitative, nomothetic,

1994; Lambeft, lggZ). This finding is far from surprising if one acknowledges client freedom and responsibitity. Indeed, it is only from the snnce of an "objective" expert imbued with the power to change "helpless" clients that this evidence iould be startling. Unfornrnately, such a stance' at odds with an understanding of human beings as active agents' remains evident in much of the discourse about psychotherapy and in psychotherapy research. As procedures for documenting and evaluating psychotherapy become in.reasingly objectivistic and intervention focused, the importance of clients'

"bescd on expenence," contrasts with its is set in quotes because ia literal meaning, present use in reference to quantitarive procedures. lndeed, qualitative and dirovery.oriented methods are argr-rably more empirical in that chey describe experience without ruofting to abstract, quantitative cansformations.

freedom and responsibiliry may be funher obscured. The implications of intersubjectivity for understanding human beings have been largely ignored by rraditional research methods in psychology. "naive" perspective of participants and The distinction drawn between the

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"objective" the standpoint of researchershas led to a privileging of the laner (Morawski, 1988). With respect to psychotherapy research,this means that clients' perspectives have been dismissed as biased, whereas researchers' obnervations have been assumed to be objective and reliable (e.g., Jacobson & Christensen, 1996). To remedy this problem, some researchers have explored clients'accounts of the psychotherapy process (Rennie, 1990,1997,, 1994; Watson & Rennie, 1994; see also Rennie, this volume, chapter 4). Others have sought to incorporate multiple perspectives of rhe same psychotherapy (Caskey, Barker, & Elliott, 1984;Fessler,1983; Walsh, 199$.These studies have shown that clients' perspecrives often differ from those of "objective" therapists and observers. This divergence of viewpoints, a problem for logical positivists, suggeststhe importance of recognizing the intersubjective foundations of psychotherapy and psychotherapy research (Elliott & Shapiro, 1992; Omer & Strenger,1997; Strupp, 1996; Walsh, Perucci, & Sevems, 1999). Thus, recent evidence suggesrsthat the subjectiviry of clients is an important but often neglected component of the psychotherapy process. The past 2 decades have seen a broadening ofresearch approaches to accommodate a view of humans as reflexive, relational, embodied beings. These human science research approaches (e.g., Giorgi, Bafton, & Maes, 1983; Giorgi, Fischer, & Murray, 1975; Giorgi, Fischer, & von Eckartsberg, 1971; Giorgi, Knowles, & Smith, 1979; Messer, Sass,& Woolfolk, 1988; Packer & Addison, 1989) aftempr to explore the inescapable relationship between person and world that defines human existence. Concurrent with these developments in research methods, accounts of psychothempy across various theoretical approaches have emphasized the intersubjective character of relationships both within and ourside of therapy (Friedman, 1992; Goncalves, 1994; Griffrth & Griffith,1994; Mahoney, 1991; Stolorow, Atwood, & Brandchaft,1995). This awareness is in many ways far from new, as the person.in-relation was acknowledged by such psychotherapists as H".ry Stack Sullivan (1953) and R. D. Laing (1965). Nevertheless, the explosion of interest in interpersonal or relarional approaches to psychotherapy suggestsa new appreciation for this existential theme. Research regarding temporality in the context of psychotherapy has been constrained by positivistic understandings of time as an objective variable (e.g., Howard, Kopta, Krause, & Orlinsky, 1986; Seligman, 19951. However, the human experience of time has been shown clearly to be variable across individuals and situations. Flaherty (1991), for example, explored the experience of protacted ame and showed that individuals' engagement with their circumstances shaped their experience of the passage of time. Similarly, Allison and Duncan (1988) found that the passageof time at work was experienced differently by people engaged in tasks at hand and those disinterested and bored with their jobs. These findings compare

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with researchby Maslow (1968) and Csikszentmihalyi (1990), who showed that lived time changes during peak or flow experiences. Research on the relativity of lived rime is complemenred by research conceming narrative and its role in human experience (e.g., Polkinghome, 1994).This literature has shown that people achieve a sense of meaning and purpose through storytelling and that stories reflecr the experience of temporaliry (Gergen, 1994; Mcleod, 1997). Gergen (1994), for example, showed that memories are structured according ro rhe narrative forms through which recollection occurs. Such storied memories are not veridical representations of past events but organizing stmctures for individuals'experiences (Spence, L98Z). Narratives entail ahistorical dirnmsion and an atticiWtory drrust that give meaning to the present through consrructing a pasr that projects a particular future (Neimeyer, 1994). This temporal dimension of narrative allows for revisions of both historical events and the significance of those events during the course of psychotherapy (Spence, 1982). It is, in other words, human temporaliry and its embeddedness in narrative forms that allow for change and the reconsrruction of meaning through therapeutic discourse. Evidence supponing the notion of becoming can be found implicitly in all psychotherapy research and, more directly, in studies of personality. All psychotherapies are intended to produce some sort of change. Although existential psychotherapies may be criticized for their lack of behavioral change criteria, the change of interest to existentialists is far more broad and transformative. This change is an expanding of the person's world such that the dynamic nature of experience can be embraced rather than endured. Such change is seen as constzrnt and continuous, rather than once and for all. Psychotherapy research conceming significant change events over the course of psychotherapy (Rice & Greenberg, 1984) is compatible with existential understandings of change. This research has shown that psycho. therapy comprises many small and significant changes-a reality that is missed when researchersfocus exclusively on the final outcome. To complicate matters, research has suggestedthat such change events are relative to "eye the of the beholder" (\Ualsh, Perucci, & Sevems, 1999). Thus, it appears that the process of becoming can be discemed no more objectively than any other aspect of human experience. The notion of becoming stands in contrast to that of a static and enduring personality or self. A shift toward a sense of human beings as dynamic, rather than fixed, is evident in the areasof personality and developmental psychology. C. T. Fischer (1994), for example, advocated an approach to psychological assessmentthat acknowledges and documents the mutable character of personality. Moreover, theory and research regarding the role of narrative in the construction of a meaningful sense of self (Hermans, 1993; McAdams, 1996; Van den Broek & Thurlow, 1991) suppoft rhe

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together, these findingrs complement \U. F. Fischer's (1989) conclusion that anxiety and its shadow, existential guilt, when explored in the presence of an empathic listener, can lead to transformation through the reconstruction of meaning. The concept of authenticity has support in reviews of research literature as well as in studies involving client and therapist recollections of psycho. therapy. Goldfried and Padawer (1982), for example, identified client selfawarenessas one of three basic change principles common acrossthe psycho. therapy literature (with the other two principles being a warrn, supportive therapeutic relationship and renewal of the client's senseof hope). Similarly, Rennie (1992) analyzed the experiences of clients and identified the pursuit of personal meaning to be a predominant theme, with clients' scrutiny of their own processes and experiences of heightened awareness as some of the most common elements. Likewise, Lietaer's (1992) study of helping and hindering processesin therapy (according to clients and therapists) led to the following characterization of successful psychotherapy:

understanding of human beings as continually engaged in a process of becoming. This process has been shown to be inherently indeterminate and dynamic (Thome & Latzke, 1996). As a result, lives are always subject to revision, redirection, and transforrnation. Existential

Concepts: Existential

Anxiety,

Guilt,

and Authenticity

Research suppofting the concepts of existential anxiety, guilt, and authenticity can be found in both qualitative and quantitative research literatures. The experience of anxiety and its potential for transformation have been documented in a series of srudies by W. F. Fischer (1989). Fischer used empirical-phenomenological methods to analyze paft icipants' accounts of situations wherein they experienced anxiety. His results showed that anxiety arose when participants' self-understandings were challenged by circumstances. Subsequently, they experienced a sense of being blocked concunent with bodily symptoms. Typically, these individuals tried to ignore their physical symptoms by engaging in a flurry of activity. Fischer identified "being wo distinct sryles of living out this anxiety: In the first, fear of "tum away from the possibiloverwhelmed by the unthinkable" leads one to "typically occurs in iry of reflecting upon it," whereas in the second, which the presence of some empathic friend or other . . . one explores and appropriates the ambiguiry that has been revealed" (\Y.F. Fischer, 1989, p. 135). "one's understanding of who one is [and] of what This leads to change in one's relations with the world are all about" (p. 135). W. F. Fischer's (1989) research fits readily with the existential understanding of the transformative potential of anxiery when it is tolerated, explored, and shared. It also supports the notion of existential guilt as a sign-which an individual can either heed or ignore-that the problem is a challenge inviting change. Other relevant research along these lines includes studies of Gendlin's (1981) focusing technique whereby clients attend to problematic bodily experiences, as well as research by Clarke ( 1989) regarding the process of meaning creation in therapy. Studies pertaining to Gendlin's focusing technique (Greenberg, Elliott, & Lietaer, 1994; see also Hendricks, this volume, chapter 7) have shown the therapeutic power of "dwelling" with distressing experience and incorporating that experience through understanding. [n their review of research by Oishi and Murayama (1989), Greenberg et al. (1994) summarized three conditions identified as "concentrating while being relaxed, dwelling in the important to focusing: body sense and putting this into words, and experiencing a comfortable psychological climate with the therapist" (p.525).ln a related vein, Clarke's (1989) research delineated three indicators for meaning-making events in psychotherapy: emotional arousal; a challenged cherished belief; and confu' sion, surprise, or lack of understanding (Greenberg et al., 1994).Taken

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Through exploring their own inner world with the empathic facilitation of their therapists,clients come to face, accept,and integrate hitheno denied aspectsof their experience.This processof self-exploration . . . opens new possibilities and encouragesthem to behave in new ways. (p. 147)

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These and other studies (Jones, Parke, & Pulos, 1992; McCullough et al., 191; Taurke et al., 1990) suppoft the notion that openness to one's experience of the world and the empowering experience of oneself as an important components of the process agent-aspects of authenticity-are of change in effective psychotherapy. Therapeutic Implications: and Flexibility

Relationship, Understanding, Liberation,

The importance of the therapeutic relationship has been demonsrrated repeatedly in psychotherapy research. The client-therapist relationship has been evaluated under the term dvrapeutk a)limrce,which includes the therapeutic bond beveen client and therapist as well as shared understandings of goals and tasks (Bordin, 1976).The therapeutic alliance has been shown to be a major contributor to clinical outcome regardlessof therapists' theoretical orientations (Beutler, Machado, & Neufeld, 1994; Horvath & Greenberg, 1994; Crlinsky, Grawe, & Parks, 1994). As Orlinsky et al. (1994) pointed out in their extensive review of psychotherapy process research, evidence supporting the power of the therapeutic bond comes from more than 1,000 process-outcome findingB. Among these studies, the strongest relationships are evident in studies that took rhe client's perspective into account.

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Understanding as a component of effective psychotherapy is supported by research exploring empathy. In studies of client-therapist interactions defined by participants as helpful, both clients' feeling understood by their therapists and their coming to understand themselves were identified as crucial (Greenberg et al., 1994). ln a study of significant events in psychotherapy, Elliott, Clark, and Kemeny (1991; cited in Greenberg et al., 1994) found that clients and therapists rated feeling understood as the most important therapeutic component. The therapeutic power of understanding was similarly demonstrated in research by Dormaar, Diikman, and DeVries (1989) and Lafferry, Beutler, and Crago (1989). In fact, a recent review of psychotherapy research regarding therapist variables led Beutler et al. ( 1994) "there are few things in the to reaffirm Patterson's (1983) conclusion that field of psychology for which the evidence is so strong as that supporting the necessity if not sufficiency, of the therapist conditions of accurate empathy, respect, or warrnth, and therapeutic genuineness" (p.243). Liberation, though couched in various terrns, has also been shown to be a crucial aspect of effective psychotherapy. Whether characterized as making the unconscious conscious, altering maladaptive cognitions, or even changing behavioral contingencies, all therapists help clients let go of harmful or self-limiting pattems in favor of altemative possibilities.In a qualitative study of people who experienced significant change both in and out of therapy, Hanna et al. (1995) identified ttanscetldence,or moving beyond limitations, as the essential structure of each change. Moreover, this tran" scendence consisted of insight (defined as penetrating, pervasive, global and enduringly stable understanding which included a new perspective on "psychological or metacognitive acts such the sell world, or problem") and as intending, deciding, willing, detaching, and confronting" (Hanna et al., 1995, p. 148). In a related research (Goldfried, 1980; cited by Drozd & Goldfried, 1996),a group of prominent psychotherapists of various theoretical orientations identifi ed cortectiueerperiarcesas key to therapeutic change. "experi' These conective experiences were seen asopportunities for clients to what is can survive that they ence themselves in a new way, to discover dreaded or feared, that they can once again experience themselves as agents of their experience, rather than victims" (Greenberg & Rhodes, 1991, cited in Drozd & Goldfried ,1996,p. I77). These findings highlight the importance of liberation as an outcome of effective psychotherapy. It is difficult to find evidence supporting the value of flexibiliry in the efficacy studies of the mainstream psychotherapy literature. As Seligman (1995) pointed out, well-controlled efficacy studies ignore the flexibility that is inherently part of the psychotherapy process. Instead, consistency across therapists and clients is sought through the use of reatment manuals (e.g., Chambless, 1996; Moras, 1993). The irrelevance of such manuals to the actual practices of psychotherapists has been highlighted by a number

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of psychologists (Bohaft, O'Hara, & Leitner, 1998; Fensterheim & Raw, 1996; Havik & VandenBos, 1996). As an altemative, they have advocated research addressing the effectiveness of psychotherapy as actually practiced by psychotherapists. In adapting their methods to the needs of their clients, practicing psychotherapists are likely to adopt an eclectic, pluralistic, or integrative approach. Surveys have shown that a large number of psychotherapists describe their approach with one of these terms (Jensen, Bergin, & Greaves, 1990). Thus, most psychotherapists tum away from rigid schools of therapy and comparative outcome studies (which continue in the face of consistent findings of equivalence across therapies). Instead, they tum toward their clients and seek to understand their experience. This tum is decidedly existential.

FROMRESEARCHTO PRACTICE From an existential perspective, every course of psychotherapy is unique. The notion of manualized psychotherapy is therefore an oxymoron. Arguably more important than uhat existential psychotherapists do is the manner in which they do it. This llrl.t o{ the existential psychotherapies"calls for continual attention to the one that the existential attitude-is patient's inner experience, and it recognizes that the prime instrument needed for that attention is the therapist's own subjectivity" (Bugental, "the 1987, p. 3). From this standpoint, therapist's primary fi.rnction is not that of provoking attitudinal or behavioral change in the client, but of clarifring the client's lived experience of being-in-the-world" (Spinelli, 1997, p. 88). Thus, the therapist maintains an attirude of curiosity and respect for the client's experience and invites the client to explore and reflect on his or her existence. This attitude is not a technique. It is an openness that emerges through the co-constitution of an empathic, empowering therapeutic relationship. Existential psychotherapies tend to be insight- rather than symptomoriented, although exploring symptoms as attempts to ward off existential anxieties may be useful (Cohn,1995; Handley, 1996; May & Yalom, 1995). An existential psychotherapist would be much less concemed with curing symptoms than with explicating their latent meanings as illuminating the structure of a client's life (Sipiora, 1988-1989). Some have gone so far as to suggest that existential psychotherapists should not even be concemed with facilitating change because such considerations will create pressures that interfere with the real purpose of existential psychotherapy: clarification of a person's attitude toward the givens of existence (Strasser, 1996; van Deurzen-Smith, 1988). The existential therapist helps illuminate ways in

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which clients avoid full openness to the world and to their experience of it (including rheir relationship with the therapist), that is, how and why they constrict their lives without recognizing that they have done so (Bugenral, 1965; May, 1958; Prochaska, 1979). Thus, existential therapists help ih"ir cliettts explore and set aside their surface anxieties and guilt-motivated defenses so that they may recognize and accept their existential anxiety and guilt (Colm,1966; Willis, 1994). To clarifu whar existential psychotherapists do, we consider examples from two published case studies. However, we want to emphasize the unique. ness of these (and any) particular cases. Maurice Friedman has recounted (in Schneider & May, 1995) his work with Dawn, a 40-year'old graduate student and married mother who came to therapy with marital difficulties, symproms of depression, and a history of physical and psychological abuse by her parenrs. Over a period of 4 years, Friedman's psychotherapy included individual therapy, couples therapy, and family therapy. In their long'term work together, Friedman and Dawn explored her troubled family relationships (past and present); facilitated Dawn's emotional expression, particularly with respect to feelings of anger; explored the significance of Dawn's decision ro separate from her husband; and discussed Dawn's plans for and struggles with graduate school. In addition, Friedman brought in a divorce mediator, refened Dawn to a psychiatrist for antidepressant medication, and eocouf, aged Dawn to write down and reflect on her dreams. ln describing his multifaceted work with Dawn, Friedman emphasized that The goal of Dawn's therapy was neither to preserveher (marital) relationship . . . nor to establishher in a new long'term relationship. . .. Nor was it any specific [Iatter, such as overcoming her anxiety and depression.. . . What was essential,rather was the relationship of mrst . that developedbetween us. (see Schneider & May, 1995, p. 3L2l Thus, for Friedman, as for mosr existential therapists, therapeutic techniques and behavioral goals are secondary to the therapist