Existential Therapy

February 13, 2021

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Existential therapy seems like an ideal way to go about psychological healing, given the philosophy it grew out of. Unfortunately, like existentialism it suffers from 'great man' syndrome—a huge number of idiosyncratic practices that make it difficult to know how good it really is.

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Existential therapies are psychological interventions that are built off the back of, funnily enough, existential philosophy. It seems like a fairly straightforward match. Existentialism concerns itself with the universal challenges we face as humans by existing, like the search for meaning or the inevitability of death. Existentialism was also built, in part, off the back of early research into phenomenology—the study of being or the lived experience. A form of therapy aimed at these challenges and the phenomenology of the individual—the extent to which each person differs in their response to these challenges based on their unique history and characteristics—seems like an ideal way to go about psychological healing.

Turns out, not so much. And the problem isn't so much with the therapy as with the philosophy.

Existential debate centres on the question of what it means to exist as a human. You might not be surprised to learn that this has produced a prodigious body of literature on the subject. It's probably also unsurprising that there's no particular consensus on the central tenets of existentialism. This is a critical challenge for existential therapists. With no unity on underlying concepts, there's no way to adopt standardised techniques and or evaluate outcomes. It's not a very sexy problem, but it means that therapists are left to develop individual procedures that often vary considerably in terms of their efficacy.

Interestingly, this outcome reflects the same problems that face existential philosophy. Existentialism is very much a 'great man' field. Dostoevsky, Nietzsche, Sartre, Heidegger, and so on, each big name has his own formulations on the challenges of existence.

The four 'great man' equivalents in the existential therapy world similarly differ in terms of their emphasis and their overall structure:

  1. the British school of existential therapy is primarily concerned with the phenomenological experiences of clients and their relationships with others;
  2. meaning- or logo-therapies place emphasis on creating meaning and purpose in a pedagogical environment that encourages attitude change;
  3. Daseinanalysis focuses on the individual’s relationship to the world with emphasis on openness to aspects of living; and
  4. existential-humanistic approaches focus on the individual’s interpretations of existential challenges.

Of these four, logo-therapies have received the most attention, and as a result are thought to be the most effective at improving the clinical distress of clients and improving their self-efficacy in facing existential challenges. That said, existential-humanistic approaches seem particularly useful in the treatment of those facing crises of physical health, as well as in culturally and contextually diverse populations.

The efficacy of the rest is still basically unknown and the reason is primarily because of the practitioners. Existential therapists, like existential philosophers, contend that these processes are largely subjective in nature and shouldn't therefore be measured objectively. This might be true, but it's odd enough in a culture where there is an almost obsessive preoccupation with evaluating outcomes to be eyebrow-raising. One wonders how one knows clients are improving if one has no particular way of checking, and existential therapists really don't. I guess you just have to believe in yourself.

That said, some core dimensions of existential thought are common, and these core dimensions provide a skeletal model of clinical distress that therapists can use (the literal handbooks for which can be found here and here). Existential therapies are primarily based on some variation of the following common existential assumptions:

  1. humans are self-aware and agentic, and so have the freedom and responsibility to make choices;
  2. humans will face universal challenges that stem from existing in the world, such as mortality and isolation;
  3. humans are driven to derive meaning and purpose from life;
  4. the human condition is invariably defined to some extent by relationships with others.

Importantly, existential therapies have stayed close to their phenomenological origin; they take the view that the subjective experiences and unique characteristics of the individual shape how these dimensions might apply and how individuals might respond to them. This means that another set of core dimensions emerge across different practices. Existential therapies assume clinical distress arises when individuals make choices, either intentionally or through inaction that:

  1. deny or avoid these universal challenges;
  2. fail to create meaning and purpose; and/or
  3. perpetuate an identity defined not by the self, but merely by relationships with others.

This makes things easier for therapists. In fact, it helps therapists focus on the most crucial aspect of any therapy—the relationship between the therapist and the client. Because the core of an existential approach rests on the phenomenology of the client, the therapist must develop a deep and empathic relationship with the individual, with a focus on their subjective understanding of the world.

This aspect of therapy is the most reliable predictor of success in any given therapeutic approach, accounting for somewhere in the vicinity of 10% of the variance in therapeutic outcomes. This might not sound like a lot, but given that the majority of the variance in therapeutic outcomes is generally unexplainable, it's no joke.

For existential therapists, it's important for a couple of other reasons. The two major challenges that therapists face, beyond having no particular way of checking if what they're doing is working, are that:

  1. understandably, clients can be resistant to confronting existential challenges, and employ unconscious defence mechanisms in order to deny or avoid these (ch. 7).
  2. the idiosyncrasies in practice mean that it's hard to learn existential therapy and it's thought that successful therapists require a prohibitive level of experience and training in order to be successful (pt. 2.2).

Both of these challenges are not particularly minor. Clients don't generally resist confronting challenges in cognitive-behavioural therapy, for example, because cognitive-behavioural therapy is mostly psychoeducation. Similarly, the core features of cognitive-behavioural therapy can be learned from a textbook. CBT is easy, operationally-speaking.

But with a strong enough therapeutic alliance, a therapist who is facing resistance, or who's unskilled at existential therapy, can work in other therapeutic methodologies to fill the gaps. Narrative and psychodynamic assessments, for example, are great for addressing defence mechanisms. Cognitive-behavioural therapy provides a host of easily implemented interventions to assist clients through difficult periods in the therapeutic process. If the client trusts the therapist, and the therapist can clearly identify the psychological problem that needs solving, there's no need to remain in the existential realm if it becomes too troubling.

And this might be the greatest strength of existential therapies. An existential model of distress provides a great deal of depth to more structured and less difficult interventions. Evidence suggests as much for cognitive behavioural techniques, humanistic orientations, positive psychology approaches, and acceptance/commitment and schema therapies.

Taken together, existential therapies provide a unique model of clinical distress based on existential themes. However, the uncoordinated philosophical basis of these themes makes them difficult to operationalise in a therapeutic context. A whole slew of methodologies exist for the existentially inclined, but the disunity in the theoretical foundation means that their actual implementation is highly idiosyncratic and thus the efficacy of their implementation is worryingly unknown. Their greatest strength seems to be their ability to augment more structured interventions with existential depth, rather than their merit as a practice alone.

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