Existential Therapy

Selection criteria

Clients who come specifically for existential therapy usually already have the idea that their problems are about living, and are not a form of pathology. This basic assumption must be acceptable to clients if they are to benefit from the approach. A genuine commitment to an intense and very personal philosophical investigation is therefore a requirement. A critical mind and a desire to think for oneself are an advantage. People who want another’s opinion on what ails them and who would prefer symptom relief to a search for meaning might be better referred to other forms of therapy.

The approach is especially suitable for people who feel alienated from the expectations of society or for those seeking to clarify their personal ideology. The approach is relevant to people living in a foreign culture, class or race, as it does not dictate a specific way of looking at reality. It also works well with people confronting adversity in their lives or who are trying to cope with changes of personal circumstances (or want to bring those about). Bereavement, job loss or biological changes (in adolescence, middle age or old age) are a prime time for the reconsideration of the rules and values one has hitherto lived by. Generally speaking the existential approach is more helpful to those who question the state of affairs in the world, than to those who prefer the status quo. This approach seems to be most right for those at the edge of existence: people who are dying or contemplating suicide, people who are just starting on a new phase of life, people in crisis, or people who feel they no longer belong in their surroundings. It is less relevant for people who do not want to examine their assumptions and who would rather not explore the foundation of human existence.

Even though existential work consists in gaining understanding through talking, the client’s level of verbal ability is not important. Very young children or people who speak a foreign language will often find that the simpler their way of expressing things, the easier it becomes to grasp the essence of their worldview and experience. The approach is not about intellectualizing, but about verbalizing the basic impressions, ideas, intuitions and feelings a person has about life.

The existential approach can be applied in many different settings: individual, couple, family or group. When it involves more than one person at a time, the emphasis will be on clarifying the participants’ perceptions of the world and their place in it, in order to encourage communication and mutual understanding. The focus is always on the individual’s experiences and relationships. A dimension of existential exploration can easily be added to almost any other approach to psychotherapy, but it will soon be found that this makes a re-evaluation of one’s method necessary. Many of the more directive or prescriptive forms of therapy are in flagrant contradiction of existential principles. Interpretative methods such as psychoanalysis or analytical psychology betray the existential rule of openness to the different meanings that emerge for individuals. In the final analysis existential work requires a commitment to a philosophical investigation, which necessitates its own guidelines and parameters.

Qualities of effective therapists

Good existential therapists combine personal qualities with accomplishment in method, but on balance it is more important that they have strength of character as people than that they have a high level of skill. Qualities can be described as falling into four categories: (a) life experience, (b) attitude and personality, (c) theoretical knowledge, (d) professional training.

Life experience

Existential therapists will be psychologically and emotionally mature as human beings. This maturity will manifest itself in an ability to make room in oneself for all sorts of, even contradictory, opinions, attitudes, feelings, thoughts and experiences. They will be open-minded about the many different facets of human living. Rather than clinging to one point of view, existential therapists will be capable of overseeing reality from a wide range of perspectives. They will also be able to tolerate the tension that such awareness of contradictions generates. There are a number of life experiences that appear to be particularly helpful in preparing people for such maturation and broad-mindedness. Cross- cultural experience is an excellent way to stretch the mind and one’s views on what it means to be human. People who have permanently had to adjust their whole way of perceiving and dealing with the world (especially when this includes a change of language) have had the all-important experience of questioning previous assumptions and opening up to a new culture and perspective.

Raising a family, or caring for dependants in a close relationship, is another invaluable source of life experience relevant to creating an open attitude. Many women have great practical experience in this area. Their life experience can become one of the building blocks of the kind of maturity needed to become an existential therapist.

The experience of having been immersed in society from several angles, in different jobs, different academic studies, different social classes and so on, is a definite advantage. The existential therapist is likely to be someone who has lived seriously and intensely in a number of ways and not just through the caring professions. People opting for psychotherapy as a second career are often especially suitable. Finally, the sine qua nonof becoming an existential therapist is to have negotiated a number of significant crossroads in one’s personal life. Existential therapists will have had their share of existential crises. Of course they will also have had to develop their ability to deal with these satisfactorily, so that their own lives were enriched rather than impoverished by the experience. Although all this maturity conjures up the image of someone advanced in age, it must be noted that maturity is not always commensurate with years. Some young people may have weathered greater storms than their elders and, what is more, may have lived their relatively shorter lives with greater intensity, maturing into fuller human beings.

Attitude and personality

Existential therapists should be capable of critical consideration of situations, people and ideas. They are serious, but not heavy-handed, downtrodden or cynical. They can be light-hearted, hopeful and humorous about the human condition, whilst intensely aware of the tragic poignancy of much of existence. They should be capable of self-reflection, recognizing the manner in which they them- selves represent the paradoxes, ups and downs, strengths and weaknesses that people are capable of. They should have a genuine sense of curiosity and a strong urge to find out what it means to be human. They should be capable of sustaining an attitude of wonder. Existential therapists will now and then abandon psychological theory altogether and reach for poetry, art or religion instead. They will tend to be quite personal in their way of working. Before anything else they must demonstrate their ability to tolerate experiences of anxiety and despair without faltering and without succumbing.

Theoretical knowledge

A basic working knowledge of philosophy, that is of the controversies and perspectives that the human race has produced over the centuries, is more useful to this approach than any other kind of knowledge. Included in this would be a familiarity with the history of psychology and psychoanalysis and a wide study of the many different approaches to psychotherapy that have been developed over the years. This will provide a map of different views on human nature, health and illness, happiness and unhappiness, which again will train and broaden the mind and personal outlook of the therapist. In addition a practical knowledge of human interaction and the dynamics of the therapeutic relation- ship is essential.

Professional training

The existential therapist needs the kind of training that an eclectic therapist needs: a generic one. But instead of borrowing bits and pieces of technique from each to produce a complex amalgam, essentials are distilled and applied within a consistent philosophical framework. Specific skills of dialectical interaction can then be developed. Training should consist of a significant amount of therapeutic work under supervision and of self-reflection and analysis. Here again it is the quality that will be judged instead of the quantity. Numbers of hours of individual and group therapy are irrelevant. Some people will not reach the necessary perspective and depth with any amount of therapy. Others will be well ahead by having engaged in a discipline of self-reflection for years. The degree of readiness usually becomes obvious in supervision sessions, for one’s response to other people’s troubles is an excellent test of one’s own attitude to life and level of self-knowledge. Existential training will enable therapists to think creatively about complex human dilemmas.

Therapeutic relationship and style

It is important for the existential therapist to have a flexible attitude towards therapeutic style. Not only do different therapists interpret the approach in diverse ways, but clients also have their own individual requirements, which may vary over time. The existential therapist is ready and willing to shift her stance when the situation requires this. In a sense this variability is characteristic of the existential therapeutic style.

There are, of course, common features running through all of this. All existential therapists, for example, strive to recognize and question their preconceptions and prejudices as much as possible in their work. There is also a consistent appreciation of the unique situation of the client. The existential therapist strives to take the dilemmas of the client seriously – eschewing recourse to diagnoses and solutions. This seriousness includes openness and wonder as essential attributes of the existential attitude and does not preclude humour when appropriate.

Existential therapists are fundamentally concerned with what matters most to the client. He or she avoids making normative judgements, and renounces any ambition to, even implicitly, push the client in any particular direction. The attitude is non-directive, but not directionless. The client is assisted in finding his or her own perspective and position in the world in relation to the parameters and limits of human existence. At times the therapist might facilitate the client’s investigations through an attitude of relative passivity and silent intervention. At other times active dialogue and debate are required. On such occasions the therapist intervenes to point out contradictions in or implications of the client’s avowed point of view. The use of confrontation to offer opinions or moral evaluations of the client is not consistent with the existential attitude. The existential therapist resists the temptation to try and change the client. The therapy is an opportunity for the client to take stock of her life and ways of being in the world. Nothing is gained from interfering with these. The client is simply given the space, time and understanding to help her come to terms with what is true for her. What she wants to do with this afterwards is up to her. The therapist does not teach or preach about how life should be lived, but lets the client’s personal taste in the art of living evolve naturally within the context of existential and social constructions.

The only times when the therapist does follow a didactic line is when she reminds the client of aspects of a problem that have been overlooked. She gently encourages the client to notice a lack of perspective, think through consequences and struggle with contradictions. She puts forward missing links and underlying principles. The therapist never does the work for the client but makes sure that the work gets done. The client’s inevitable attempts to shirk and flee from the task in hand are reflected on and used as concrete evidence of the client’s attitude to life. The same can be said of the actual encounter between the client and the therapist, which is also reflected on and seen as evidence of the client’s usual ways of relating.

Generally speaking the therapeutic style follows a conversational pattern. Issues are considered and explored in dialogue. The rhythm of the sessions will follow that of the client’s preoccupations – faster when emotions are expressed and slower when complex ideas are disentangled. Existential therapists need to learn to allow clients to take the amount of space and time in this conversation that they need in order to proceed at their own pace. Existential therapists create sufficient room for the client to feel that it is possible to unfold their troubles.

Existential sessions are usually quite intense, since deep and significant issues often emerge. Moreover, the therapist is personally engaged with the work and is willing to be touched and moved by the client’s conflicts and questions. The human dilemmas expressed in the therapeutic encounter have as much relevance to the therapist as to the client. This commonality of experience makes it possible for client and therapist to work together as a team, in a co-operative effort to throw light on human existence. Every new challenge in the client’s experience is grist for the mill. The therapeutic relationship itself brings many opportunities to grasp some- thing of the nature of human interaction. The therapist, in principle, is ready to consider any past, present or future matter that is relevant to the client. The therapist is constantly aware of her own bias in approaching the client’s difficulties and aims to recognize it sufficiently for it not to interfere with the work on the client’s bias.

Major therapeutic strategies and techniques

The existential approach is well known for its anti-technique orientation. It prefers description, understanding and exploration of reality to diagnosis, treatment and prognosis. Existential therapists will not generally use particular techniques, strategies or skills, but they will follow a specific philosophical method of enquiry, which requires a consistent professional attitude. This method and attitude may be interpreted in various ways, but it usually includes some or all of the following ingredients.

Cultivating a naive attitude

By consistently meeting the client with an open mind and in the spirit of exploration and discovery a fresh perspective on the world will emerge. This requires a great deal of intellectual discipline on the part of the therapist, who continuously has to observe and question her own prejudice and bias.

Themes: clear themes will run through the apparently confused discourse of the client. The therapist listens for the unspoken links that are implicit in what is said. When the theme is obvious and has been confirmed several times, the client’s attention can be drawn to it. Personal myths and stories are recognized and beliefs and fantasies about the world unveiled. Existential work enables people to create more satisfactory life narratives (Tantam, 2002).

Assumptions: much of what the client says will be based on a number of basic assumptions about the world. Generally people are unaware of these. Clarifying implicit assumptions can be very revealing and may throw new light on a dilemma. Every statement we make reveals our assumptions, and therapists need to make sure these become explicit.

Vicious circles: many people are caught up in self-fulfilling prophecies of doom and destruction without realizing that they set their own low standards and goals. Making such vicious circles explicit can be a crucial step forward. Self- fulfilling prophecies can become positive instead of negative.

Meaning: often people assume that they know what they mean when they talk about something. But the words they use can hide, even from themselves, the significance of what they mean. By questioning the superficial meaning of the client’s words and asking her to think again of what she wants to express, a new awareness may be brought about.

Values: people live their lives by standards and principles that establish values which they often take for granted and of which they are only dimly aware. Getting clarity about what makes life worth living and which aspects of life are most important and deserve making sacrifices for is a key step towards finding one’s sense of direction and purpose.

Facing limitations

As the existential approach is essentially concerned with the need to face the limitations of the human condition, the therapist will be alert for opportunities to help the client identify these. This means facing up to ultimate concerns, such as death, guilt, freedom, isolation, meaninglessness, etc.

Self-deception: much of the time we pretend that life has determined our situation and character so much that we have no choices left. Crises may provide us with proof to the contrary. The safe crisis of the therapeutic interaction is a suitable place for rediscovering opportunities and challenges that had been forgotten.

Existential anxiety: the anxiety that indicates one’s awareness of inevitable limitations and death is also a dizziness in the face of freedom and a summoning of life energy. Existential anxiety is the sine qua non of individual awareness and full aliveness. Some people have dulled their sensitivity so as to avoid the basic challenges of life, others are overwhelmed by them and yet others have found ways of disguising them. Optimal use of anxiety is one of the goals of existential work. The therapist will recognize the client’s existential anxiety and will assist in finding ways of living with it constructively.

Existential guilt: the sense of being in debt to life and owing it to oneself to accomplish certain task before it is can give us, too late insight into our limitations and priorities. Therapists watch for existential guilt hidden in various disguises (such as anxiety, boredom, depression or even apparent self-confidence).

Consequences: clients are sometimes challenged to think through the consequences of choices, both past and future. In facing the implications of one’s actions it becomes necessary to recognize limitations as well as possibilities.

Some choices become easier to make; others become less attractive. Existential therapy does not condone the clients’ tendency to want only support and acceptance and wallow in a sense of their own suffering; it encourages clients to confront their own responsibilities in relation to the world, other people and themselves.

Paradoxes: in helping the client to become more authentic the concept of paradox can be of great help. If people are inclined to evade the basic human dilemma of life and death and contradictions that flow from it, their self- affirmation may look more like egocentricity. Checking that a person is aware of her capacity for both life and death, success and failure, freedom and necessity, certainty and doubts, allows one to remain in touch with a fundamental search for truth.

Exploring personal world view

The existential approach is open to all of life’s dimensions, tasks and problems, and the therapist will in principle explore together with the client all information that the latter brings along. It is essential to follow the client’s lead and under- stand her particular take on the world.

The fourfold world: using the model of four dimensions of existence discussed earlier it becomes possible to listen to the client’s account of herself as revealing her preoccupations with particular levels of her existence. A systematic analysis of how the client expresses her relationship to the physical, social, psychological and spiritual dimensions of her world can provide much insight into imbalance, priorities and impasses. An impression can be formed of where on the whole territory of human existence the client is struggling for clarity. Intuitions, feelings, thoughts, sensations, dreams and fantasies are all grist for the mill.

Dreams: listening to dreams with this model in mind can be extremely enlightening. The dream is seen as a message of the dreamer to herself. The dream experience reflects the dreamer’s attitudes on the various dimensions of existence and the client’s dream existence and world relations in it are considered as concrete as those of waking life.

Of course the same applies to the fantasies or stories that the client reports. Each of these is a miniature picture of the way in which she relates to the world and much can be learned from examining them carefully.

Questioning: exploring the client’s worldview is an ongoing enterprise and it is best done with an observation-orientated attitude. Questions are often asked in order to check whether a certain event or situation is seen in a particular light. Existential therapists will make observations and inferences and elicit further material that will either confirm or disconfirm hypotheses. The therapist draws the client’s attention to what seems to be the case. Sometimes an enquiry might be made in order to clarify a perception, along the lines of an exploration: ‘What makes this so important to you?’, or ‘What is this like for you?’, or ‘What does it mean to you?’ The question never suggests a solution or judges right or wrong, but investigates the client’s personal opinion and inclination. Initial explanations will almost always be questioned and explored in greater depth.

Enquiring into meaning

All investigations eventually lead to a greater understanding of what makes the world meaningful to the client. The idea is to assist the client in finding purpose and motivation, direction and vitality. In the process a number of irrelevant and misleading motivations may be encountered and eliminated. Quite often new interpretations of past or present events are arrived at, altering the client’s orien- tation to life and the future.

Emotions: feelings are of great help in this process. Understanding the meaning of one’s emotions and moods and the message they contain in terms of what one aspires to or is afraid to lose is of crucial help in finding the pattern of purpose currently at work. Each emotion has its own significance (van Deurzen, 2002) and the whole range of the emotional spectrum can be used as a compass in indicating one’s direction in life. Emotions like shame, envy and hope are indicators of values that are still missing but implicitly longed for. Love, joy and pride are within the range of emotions that indicate a sense of ownership of what is valued. Whereas jealousy and anger express an active response to the threat that what is valued may be lost, fear and sorrow come with the giving up and eventual loss of what really mattered.

Beliefs: all observations on the client’s preoccupations lead to a picture of her opinions, beliefs and values. It is important to extract these respectfully. Nothing can be gained from opposing the client’s values with an alternative set of values. It is the client’s conscience that has to be uncovered and revitalized. If deeply held values are contested or criticized conformity will be encouraged rather than reliance on an inner sense of purpose. Light is thrown on the ways in which personal beliefs may fail to take into account wider implications for others. This will expand the system of beliefs into something that can encompass the facts of life and a broader frame of reference.

Talents: many talents, abilities and assets will have been hidden by the client’s preoccupation with what is wrong with her. The therapist will attend to these and strive to draw attention to the wisdom and strength that are lying fallow. Often it is useful for the therapist to build on the example of the client’s abilities as they come to the fore and use them as the point of reference for further understanding.

Recollection: memories will be seen as malleable and open to new interpretation. While clients often set out with fixed views of their past they discover the possibility of reconsidering the same events and experiences in different ways. It is essential to encourage clients to discover how they influence their future with their own version of the past and how it is within their power to re-collect themselves in new ways, thereby opening new vistas. When the client realizes that she is the ultimate source of the meaning of her life, past, present and future, living is experienced as an art rather than a duty.

The change process in therapy

The aim of existential therapy is not to change people but to help them to come to terms with the transformative process of life. The assumption is that when people do face reality they are likely to find a satisfactory way forward. People are often hurried and under the impression that they can speed life up and force great rewards out of it with relatively little effort. One of the aims of existential therapy is to enable people to stop deceiving themselves about both their lack of responsibility for what is happening to them and their excessive demands on life and themselves. Learning to measure one’s distress by the standards of the human condition relieves pressure and at the same time provides a clearer ideological basis for making sense of personal preoccupations and aspirations. Clients change through existential therapy by gradually taking more and more of life’s ups and downs in their stride. They can become more steadfast in facing death, crises, personal shortcomings, losses and failures if they accept the reality of constant transformation that we are all part of. They can find ways of tuning into these changes, instead of fighting them or trying to speed them up.

In other words they can acquire a measure of wisdom in learning to distinguish between the things they can change and those they cannot change. They can come to terms with the givens and find the courage to tackle the uncertain- ties. They can find out what matters enough to them to be committed to it, live for it and ultimately perhaps even die for it.

As they are constantly reminded to do their own thinking on these issues, people can learn to monitor their own actions, attitudes and moods. The therapy gives clients an opportunity to rediscover the importance of relating to them- selves and taking time for contemplation and recreation. Existential therapy teaches a discipline for living which consists of a frequent process of checking what one’s attitude, inclination, mood and frame of mind are, bringing them back in line with reality and personal aspirations.

Change is initiated in the sessions, but not accomplished in them. The process of transformation takes place in between the sessions and after therapy has terminated. The therapeutic hour itself can never be more than a small contribution to a person’s renewed engagement with life. It is only a kind of rehearsal for life. The change process is never-ending. As long as there is life there will be change. There is no place for complacency or a self-congratulatory belief in cure.

As existential therapy has no criterion for cure, it could in theory be an end- less process. To make sure it does not become this, the criterion for finishing a series of sessions is simply to stop when the client feels ready to manage on her own again. To encourage such self-reliance, relatively short-term therapy is encouraged (three months to two years), though sometimes the process will take a little longer.

Limitations of the approach

The emphasis that the existential approach places on self-reflection and under- standing can lead to certain limitations. The approach often attracts clients who feel disinclined to trust other human beings because they perceive the existential approach as leaving them in total control. This limitation can only be overcome by a therapist who neither fights the need nor leaves it unchallenged, but who assists the client in turning such self-reliance to a positive end.

The approach is also often misconstrued as ‘intellectual’. Some existential therapists tend to emphasize the cognitive aspect of their clients’ preoccupations and some clients are attracted to the approach with the hope of avoiding senses, feeling and intuition. A good existential therapist would heed all these different levels of experience, as full self-understanding can be achieved only through openness to all different aspects of being. Nevertheless the emphasis on self- reflection remains central and the criticism is therefore a valid one to some degree.

The practical limitations of the approach have already been referred to in the section on selection criteria. As the approach does not stress the illness–health dimension, people who directly want to relieve specific symptoms will generally find the existential approach unsuitable though they may cover that symptoms tend to disappear when these fundamental life issue are addressed.

The existential therapist neither encourages the client to regress to a deep level of dependency nor seeks to become a significant other in the client’s life and nurture the client back to health. The therapist is a consultant who can provide the client with a method for and systematic support in facing the truth, and in this sense is there to allow the client to relate to herself more than to the therapist. This might be considered a limitation of the approach by clients who wish to regress and rely on the therapist as a substitute parental figure. Good existential therapists obviously enable the client to confront that issue just as bravely as any other issue and come through with greater self- understanding.

Perhaps the most absolute limitation is that of the level of maturity, life experience and intensive training that is required of practitioners in this field. It should be clear from the above that existential therapists are required to be wise and capable of profound and wide-ranging understanding of what it means to be human. The criteria of what makes for a good existential therapist are so high that the chances of finding bad existential therapists must be considerable.

One can imagine the danger of therapists pretending to be capable of this kind of wisdom without actual substance or inner authority. Little would be gained by replacing technological or medical models of therapy, which can be concretely learned and applied by practitioners, with a range of would-be existential coaches who are incapable of facing life’s problems with dignity and creativity themselves. The only way around this is to create training organizations that select candidates extremely carefully on personal qualities and experience before putting them through a thorough training and a long period of intensively supervised work.

Case example

The client

Jerry R. enters my consulting room with a combination of confidence and coyness. He immediately strikes me as a young man with more than his fair share of gravitas, which he somehow seems to carry as a burden. With great aplomb he pauses to shake my hand and introduce himself. I indicate an armchair by the fire and invite him to take a seat. Before sitting down, he carefully folds his raincoat and places it over another chair, glancing at me sideways, checking for approval. Every gesture is made with precision and attention to detail. He unbuttons his smart black jacket and crosses his legs, exposing perfectly matched blue socks and shirt. He wears pristine black patent leather shoes, which he taps gently in rhythm with his words. His appearance is handsome and he carries his rather sultry Mediterranean looks with self-assurance. He brushes a lock of wavy black hair off his forehead with panache and poses both elbows on the armrests of his seat, folding his hands into a neat dome; index fingers pressed firmly together pointing upwards. He retains this posture with great poise and dignity for at least ten minutes. His manner is polite and friendly. He smiles hesitantly with one corner of his mouth when I ask him what brings him to my practice. When he speaks it is to express his hesitance in coming to see me upon his solicitor’s recommendation and his voice is sophisticated and melodious. I encourage him to give me some background in spite of his doubts about therapy and without much further prompting he provides me with a full and systematic picture of his life.

He tells me again that his name is Jerry R. (and he puts great emphasis on his last name as if I ought to recognize it). He is a single man of thirty-two. He was born in Paris, but raised in London where his father is an executive director for a large French company. He confirms that both his parents are French though he now has dual nationality himself. When I remark that his name sounds English, he blushes unexpectedly and explains that he is really called Jerôme and that he has adopted a more English sounding name in order to fit in with his peers. I say affirmatively: ‘to avoid teasing’, whilst looking at him enquiringly. He agrees with one firm nod that makes his hair flop back onto his forehead, but instead of pushing it back with his fingers, this time he tosses it back with an energetic movement of his head. He grins at me disarmingly and I hold his gaze, noticing that his brown eyes are watering, belying his exterior poise. He is still blushing. ‘There was a lot of teasing’, he says quietly and I can hear a hint of a French accent for the first time.‘You went to an English school then?’ I speculate. He nods again, vigorously and tells me that he is an only child and has always been very close to his mother. He went to the French school in London for his primary education but for his secondary education his father insisted that he should be sent away to a boarding school somewhere in the Home Counties. There he had to fit in with the English upper middle classes and he had decided it would be wise to change his name. He never felt at ease in his school and used to complain about this bitterly to his parents. His mother tried to convince his father for many years to let him be educated at home instead, but his father was adamant that Jerry should tough it out and stop being a mother’s boy.

Jerry thinks he has never forgiven his father for this callousness, but all the same he does take some pride in having managed to comply with his father’s expectations, sticking it out till his final exams. He pauses for a minute before admitting (blushing again) that he did have regular illnesses during this period of his life which afforded him time off at home being cosseted by his mother. He tells me, animatedly, that she is a fantastic and elegant woman with a great sense of beauty and fun. His genuine admiration for his mother is refreshing and touching but it also arouses my suspicion, because it is rare in one so young. He informs me with relish that he has always been the apple of her eye. She did not fail to convey to him that she favoured him over his father, who was often absent. He has no siblings, though his mother had a miscarriage soon after the family moved to England when he was about two years old.

After his secondary education he went to University in York, at which point his parents, at his mother’s insistence, bought a country house in Yorkshire, where he would usually spend his weekends with mother, while father was in the flat in London or the apartment in Paris. After his degree he lived in the London flat himself for a few years, sometimes sharing with his father. This was a relatively good time in his life, especially when dad was away in Paris or elsewhere. He had really enjoyed his professional training in photography, making portraiture his speciality. Since then he has been working as a freelance photographer and enjoys his job when it leaves him enough room for creativity. He has occasionally done photography jobs for his father’s company at official functions. He has mixed feelings about working with Dad, who is rather controlling.

Jerry has many friends, some very successful in their careers, some unemployed and he spans between these two worlds with ease and relish. He tells me with pride that he has had two girlfriends and that the second one, Jessica, is still part of his life now. From the way in which he describes Jessica in a rather detached and photo- graphic manner, I catch myself wondering whether there have been any boyfriends as well. He seems to expect my reaction and pre-empts a question by volunteering somewhat shyly that before his first girlfriend, he used to ‘occasionally indulge in sexual play’ with male friends. Here again he blushes and averts his eyes to avoid my gaze. I ask him if he finds men and women equally attractive and he confirms this, saying tentatively: ‘I suppose I could be described as bi-sexual’. I weigh these words for a moment, pondering his hesitancy before asking him kindly whether this is indeed how he would describe himself. Now he looks at me rather mischievously and he sounds relieved and rather reckless as he replies: ‘That all depends on who I am speaking to. My parents for instance do not know about any of this and Jessica certainly does not have a clue.’ His voice trails off. I declare sympathetically: ‘Ah, so you lead a double life!’ He nods regretfully and tells me of his inner conflicts in relation to his choice of partners and of his mother’s insistence that he should behave the same way as his cousins and all of her friends’ children, who by his age generally were married. He feels he has tried, for he has lived with Jessica occasionally over the past three years, but they decided to go their separate ways after his accident. I reckon there is a little bit more to it. There is a pause. We look at each other meaningfully. We both know we need to pursue this particular path for a bit. ‘Your accident then … ’ I state calmly and look at him to invite his account of what has brought him to my consulting room today.

Presenting problem

Jerry reminds me that he is coming to see me for post-traumatic stress. His solicitor has referred him to me to help him overcome the after effects of a motorbike accident. About nine months ago Jerry was coming back from a holiday in France when he got caught sideways by a lorry on the slip road to a petrol station. He was dragged along for thirty yards and remained in a coma for several hours, had multiple fractures, including a skull fracture, and severe concussion. His physical recovery is nearly complete though he is still walking with some difficulty, something I only fully observe when he leaves my office at the end of the session.

Mentally and emotionally he feels a wreck. He says that he has terrible trouble sleeping since the accident. He feels anxious and depressed most of the time. He is incapable of doing work and cannot concentrate. He hates being with people. He has some flash- backs even though he has retrograde amnesia that stops him clearly recollecting the accident. Mostly he just doesn’t think the world is a safe place anymore. He figures he has had too much time to lie in bed and worry about things and a lot of his old problems have come back to haunt him. He sounds casually and painfully dismissive of his own plight and I stop him in his tracks by raising my eyebrows questioningly. He takes my cue immediately and informs me that these were his dad’s words. Mum and Dad have had arguments over his illness. Dad has written it off as ‘all in the mind’. Mum has been over-protective. He does not know what to think of it himself and he hates having to go through all the legal stuff and psychiatric examinations to get the settlement sorted. He doesn’t want to come across as weak and wishes he could just get back to normal. Yet, when he has tried to resume his old life, he has felt incapable of doing so. He has had to bail out of a photographic assignment in London, when he started to panic and feel queasy on the train down for instance. He does not recognize himself anymore. Somehow the accident has changed him and he thinks that nothing can ever be the same again. He thinks he could do with some help in getting his self-assurance back. We agree to work together for as long as it takes to build up his confidence and re-establish his independence again.

Therapy

Initial phase

A. formulating the predicament:

As Jerry engages with the therapy and reveals more about himself and his shocking lack of self-confidence his previous front of cool composure melts like snow before the sun. His posture shifts markedly as he slumps in the chair, pulling his legs underneath him and hugging himself. He says he has lost the

capacity to enjoy himself and feels unable to socialize. Other people just seem to him to talk nonsense, especially Jessica. He has told her he does not want to see her any- more. She doesn’t like coming up to Yorkshire anyway and she hates dealing with his illness, so the break-up has suited them both, he says cynically. He is also quite happy to avoid seeing his Dad now that he is not going to London anymore. Dad has been insensitive about the entire accident and just keeps talking about ‘getting back into the saddle’, he sneers. He makes a face and I invite him to put his grimace into words. I am aware that he is dismissing all the people in his life and I gently keep him exploring his disappointment rather than letting him pretend to not care. At first though he just needs encouragement to speak his frustration with the way he feels treated by others.

B. rethinking the predicament:

He says his Dad is always in the saddle and has no other way to live. He has no time for anyone but himself or his business. Dad, he says with a pained expression, is a sad and twisted figure. I help Jerry look at this slightly differently by suggesting that he simply cannot take his Dad seriously anymore. He agrees wholeheartedly and adds that he does not understand why he used to feel so overawed by his father. He feels Dad understands nothing about other people at all. When I query what people he means, Jerry recognizes that he feels Dad understands him least of all. But he can also see how Dad is ruining his mother’s life by not loving her and by having regular affairs in London and abroad. He is strongly dismissive of his father’s conduct. I meekly point out that he speaks as if he feels superior to his Dad and this surprises him. Upon reflection he thinks he is probably beginning to feel strong enough to take his Dad on. He does not understand why his mother accepts his father’s odious behaviour. I point out he is now also challenging his mother’s behaviour and ask him if he himself has stood up to his dad about this. He can see now that he used to turn a blind eye to his father’s deceitful way of life and that he was too cowardly to confront him. He is tearful again but is annoyed with himself for crying. When I reassuringly suggest that his accident has made him more sensitive to all these experiences and that there may be some good in allowing the process to unfold, he gratefully accepts this idea. He does want to allow himself to experience and understand what was previously out of his ken. This is the first time he acknowledges that something positive may come out of what so far has seemed mostly negative. This will become a repeated theme: that the accident has revealed things that were previously hidden and that he wants to be in a new and better position to con- tend with all this. At the moment he sees human tragedy, danger and risk every- where and he feels overwhelmed by it. He is very concerned that he has lost his touch: he perceives and understands more than before but he lacks the strength to deal with it.

He sighs: ‘The world has become overpowering. It is all too much … ’ He looks down avoiding my gaze and his voice trails off as if he can’t cope anymore and is appealing for mercy. But rather than folding and going along with his weakness I now up the stakes: ‘Because you are both more vulnerable and more aware now. There is a great challenge to you here. You cannot hide any longer.’ He nods thought- fully, but he doesn’t look up. I wait before I continue speaking very slowly and whilst carefully observing his reaction: ‘and you also just acknowledged that this is freeing you from some old ideas and gives you a new perspective on other people, for instance on your father’. ‘Yes’, he says softly, hesitantly, as if he is wondering whether or not to pick up the gauntlet thrown at him: ‘but it makes me feel as if I am losing it. It feels as if I am reverting to what I used to be in secondary school: I feel different to other people.’ As I say nothing, he carries on: ‘I just feel so weak’. There is a brief silence between us. I speak tentatively when I reply eventually: ‘It is your feeling of weakness that is the real problem then?’ ‘Hmmm’, he mumbles. I want to establish whether we are on the same page and continue: ‘if you were able to feel stronger in relation to your new sensitivity and clear observations about others, then this new way of being might actually become a good thing, you think?’ He ponders and sways from side to side as he considers my point, literally wavering. Then a frank smile breaks through on his face as if a new idea has just sprung to mind. He hazards an interpretation: ‘Well, yes, it would actually. If I could hold on to my under- standing of what is happening around me and would not feel so overwhelmed by it all the whole time, then I could really quite enjoy it. It is quite creative in a way.’ He glances at me sideways as if to check my response. I smile encouragingly and he carries on: ‘You know, it’s a bit like artistic inspiration. I am in a new groove.’ I nod, smiling too. I say nothing. He beams and looks at me expectantly. I know he needs me to nail it down for him, summarize it somehow. I speak unhurriedly, finding the words little by little by thinking back to what he has discovered and articulated so far. He listens attentively, all ears, as if it is all coming together at last. What I say is nothing new, but somehow it needs saying. He needs to hear his predicament summarized and brought down to manageable size. He needs to be reminded of what he is up against, so that he can get ready to deal with it. ‘Something awful and important has happened in your life: a terrifying experience, an accident, out of the blue, shaking everything up, bringing you close to death, making everything seem different, giving you lots of new insights, a new perspective, different ideas about the world’. He approves. I look at him, wondering whether that is enough and whether he can take over and pursue the thought further, or whether he wants me to continue. He looks into my eyes now, openly, kind of confirming that he can stand it after all. He knows now that I don’t think him ridiculous or outrageous and that I value his struggle. He can begin to trust me. He can work with me and he does as he steps in to correct me: ‘But sometimes it doesn’t feel like that though’, he hastens to add. ‘Sometimes I just feel like I have been smashed to bits.’ ‘Yes’, I say mildly, ‘you still need to digest and process all this new experience so that you can integrate it and use it to good effect. You need to build new strength gradually, so as to be equal to your new sensitivity.’ He agrees again, enthusiastically. He feels buoyed up by my explanation of his weakness and the implied remedy for it. I see a glint of hope in his eyes as he smiles broadly.

C. tackling the predicament:

Then he tells me spontaneously how he has actively been avoiding his former group of friends and fears he is becoming a bit of a recluse. As is so often the case my encouragement makes him able to expose his lack of courage. I only need to prompt him a little bit for him to acknowledge that all this avoidance keeps him weak. We immediately agree that he has needed to avoid people for a while just to protect himself. It is alright. He really could not cope with all these people while he was so unwell. My approach is one of approving his past coping strategy whilst exposing its current redundancy. He speaks with gusto of how much he hates being in London nowadays. He cannot tolerate the noise and the traffic and he is scared of buses and trucks. This is a bit of a problem. He knows he will have to tackle it eventually. He feels much better in his mother’s country house, away from it all and cannot see himself going back to work. He has been living in Yorkshire with his mother ever since he came out of hospital and hopes to get a big insurance pay-out to allow him to continue living like this for a long time to come. Mother is worried about him, but enjoys fussing over him and she has told him and her friends that the accident has been a blessing in disguise because it has brought her son back to her. I point out that he looks both pleased and worried about this. This brings a wry smile to his lips. He is relieved to be able to speak the unspeakable love/ hate relationship he has with his Mum. We spend a long time debating this. He wants closeness with her and yet feels squashed by her. He agrees it will be best not to stay living at home for too long. This makes it so the more important for him to engage with the therapy.

He is beginning to formulate now what he wants from therapy: processing the distress and help him to get a new understanding of his past and present life, so that he can make something good out of the pieces he seems to have broken into when the lorry hit his head. He would like to sleep properly again and to feel less insecure when he goes out, but he does not want to go back to his old life. That is out of the question. He checks with me about the confidentiality of our conversations and then admits freely that he wants to get as much money out of the insurance company as possible and has no particular motivation to get back to normal. At the same time he does not want to end up as a disabled person, nor as someone who lacks in moral fibre or who is afraid all the time, as he is now. He is worried about his panic attacks and his lack of appetite for life. He cannot carry on this way and will make sure he gets himself sorted out as we work together over the next few months.

We agree then that he will use this time of weakness and incapacity to take stock of his life and make a new start. He can see how having hit rock bottom provides him with an opportunity to rebuild himself from scratch. He does not want to pre- tend and try to be the popular boy who pleases his mother and father anymore. He wants to rebuild his life on solid ground this time. He now feels therapy is a real chance of getting things right and he becomes a bit of a fan, reading therapy books and self-help books for fun.

Middle phase

A. recognizing the vicious circles:

By taking things so seriously Jerry quickly gets the hang of therapy and makes the most of it. He brings his concerns openly and does not hide his feelings and fears. Although he tries to play his PTSD symptoms down it becomes clear that the accident has nonetheless left a serious mark on him: the world seems unpredictable and sometimes he feels terrified in the face of things he used to take for granted as part of everyday life. Essentially he cannot face any form of transportation; he hates trains and cars and feels uncomfortable even on an ordinary bike. During the first months of therapy his mother drives him into Sheffield for the sessions and this becomes quite an issue since it brings out the conflicts in his relationship to her. His physical dependency on his Mum feeds the craving for her affection, but it also makes him increasingly impatient with her. I just encourage him to speak about it all and help him become aware of the old vicious circle. I also draw his attention to his frustration and his desire to escape from it.

B. facing limitations:

I keep telling him to simply observe his relationship to his mum rather than to try to change it. This frees him to realize he wants to change it for his own sake. He starts noticing that she seems to encourage his reliance on her. Then, with very little prompting, he begins to think about her dependency on him. It strikes him for the first time that she has always needed him as much as he needed her. It occurs to him that his mother has claimed him as the special person who can shield her from the world in the same way in which he needs her to shield him from the world just now. The difference is that he wants to get independent of her, whilst she seems to want him to remain dependent. But then he is not certain about this either. There is much evidence to the contrary too and sometimes he feels confused about it. In many ways it is him who is clinging to her. He wonders: ‘Is it wrong for my mother and I to feel comfort in each other’s company?’ and he returns to this question regularly. It is the central dilemma of his life. Sometimes it is phrased as: ‘should I be independent and suffer alone or should I rely on another and learn to be close?’ At other times it is formulated as: ‘is it possible to tolerate the difficulties of a hazardous world without hiding in a safe place?’ By allowing these questions to emerge out of his struggles with the concrete problems of his daily existence he begins to reflect on his life in a way he has not done before. He comes to accept that his mother’s love has always been an essential part of his self-confidence and that there is nothing wrong with reclaiming it at this point in his life to help him to find his feet again. Once he feels entitled to making the most of their closeness and stops fighting it, he can begin to see the limits of their mutual dependency as well. It becomes obvious to him that it can stop them both from exploring further afield and can hinder as much as help his recovery. He is starting to see how it is stopping his mother from moving on in her own life as well. She spends time with him, protecting him from his panic attacks instead of finishing her interior decorating course. He notices how she reproaches his father for not spending more time with them in Yorkshire to be with their injured son, rather than confronting the reality of the long standing estrangement in the marriage. Quite quickly simply by being able to talk about his observations and understand what is going on, he becomes able to confront her on her hypocrisy rather than siding with her against Dad as he used to in the past. He can even tell her that he knows how she has always encouraged Dad to live his own life and has pushed him away because she would rather just be with her son anyway. He is surprised to find that his mother is grateful to him for saying these things to her rather than feeling hurt. It proves to him that he is now getting stronger than he has ever been before and he relishes this idea.

C. finding new meaning:

We generally talk very little of his post-traumatic symptoms, though we spend a little time thinking about suitable strategies in relation to insomnia and fear of public transport. By sticking to the very basic daily struggles he brings to therapy and helping him to clarify and understand his own experience and observations, he begins to recognise his own capacity for solving each of these problems. He comes for some twenty sessions before he realizes that he is dealing with his daily life in a new way. He is getting stronger. He isn’t fighting his symptoms and fears anymore but looks forward to facing them because in doing so he can take up the challenge of understanding the underlying dynamics. He recognizes that the trauma of the accident has opened his eyes to the complexities and dangers of living in a way he had never thought possible and he admits one day that he is beginning to enjoy the work of relearning to exist and that he now looks forward to therapy sessions.

His general therapeutic reading is moving towards a focus on existential literature and he becomes an expert at arguing with me about philosophical interpretations of his experience. He enjoys sitting up at night reading books and he stops complaining of insomnia all together. I challenge him to apply his newly found philosophical expertise to the concrete problems that persist in his physical existence and he starts experimenting with ways of overcoming his fear of transportation at this stage. He begins a programme of country walking, working up from two miles a day to seven or eight miles a day. He is aware that walking is safer for him than relying on mechanical means of transport, even though he finds it quite challenging to walk on the side of A-roads where cars and trucks rush past him. As he gets used to the traffic on these roads, he feels his confidence returning and he starts riding his old push- bike along small country lanes. He finds the freedom of this experience so exhilarating that he acquires a new cross-country bike and a lot of sophisticated biking equipment and learns new skills in negotiating the hills of the Yorkshire countryside. He has no interest in going back on a motorbike, but without even mentioning it to me, he resumes driving a car to come into town to attend sessions or to pick up new materials for his bike.

End phase

A. facing anxiety and guilt:

Jerry’s fears of traffic are slowly abating as he finds a way to negotiate the world of transportation by relying on his own wits. He is somewhat concerned at his progress, for we are now some 30 weeks into the therapy and his insurance claim for the posttraumatic stress has still not been settled. He worries that his forthcoming psychiatric report will not corroborate his original PTSD diagnosis, since he is now ‘nearly cured’, and that his insurance claim will be in jeopardy. This is a strange, but not unusual, predicament and we talk about it quite a bit. He agrees that it is not worth pretending to be ill for the sake of a pay- off if the price of this is to stop him getting better. Honesty and facing up to his experience have been the core of his improvement. He cannot undo this now. Would it be so bad if he did not have a huge pay out? Might it even be better to challenge himself and pick up his life by himself rather than being cushioned by the insurance company? We think about how he might cope if he were destitute and alone. He gets great comfort from the idea that he would actually relish the challenge.

B. getting real:

When the psychiatric assessment does come, he finds, to his relief that the assessment is mainly related to his professional life. The fact that he has not resumed his job and is not likely to fully do so for another few months, makes all the difference to the settlement. We both breathe a sigh of relief when this is sorted, for now there is nothing more to stop his improvement. I had grave doubts about his willingness to get back to work until his compensation claim had been put behind him. Now we can finally discuss his ambivalent attitude towards his job. Eventually he comes to the conclusion that he misses his photography but not the work in London.

The moment the case is settled he starts to take his camera out on his rides into the hills and gets engrossed in landscape photography, very quickly building up a portfolio of work which leads to some professional contracts. When he finally receives the money from the insurance company for loss of income and in compensation for the physical and emotional trauma he has suffered, he decides to stay in the area rather than moving back to London and he buys a flat in an up and coming area of town, from which he decides to set up a new photography business. His Mum and Dad are both surprised at his regeneration and each in their own way respond with some ambivalence. This leads to some arguments and rows. Jerry needs quite a bit of help in thinking his way through these at times, but it is all his doing that he doesn’t give up and keeps sorting things out with them. At first it is his father who begins to treat him in a more mature and respectful way. At this point Jerry decides to revert back to his given name, Jerome and feels he is well on the way towards a full recovery, capable of standing up for himself.

Conclusion

After about a year and a half of weekly sessions Jerôme/Jerry starts seeing me fort- nightly. We talk mostly about his relationships now, rather than about physical or psychological problems. His relationship to his mother is still problematic and he is still in two minds about how much to condone her desire to be close. This same question arises about his relationship to me. As a mother substitute I have become quite neces- sary to him as well. He agrees with me that finding a new distance from me will help him in doing the same with his mother. A few months later he switches to coming to see me once a month and continues to see me on this basis for another ten sessions.

I am not surprised when some time during this period he tells me that he has found a new partner, Josh, also a photographer, eight years his senior. Very quickly they build a mutual and committed relationship and when Jerome comes to see me for the final session, he and Josh have started not only to work but also live together. He brings his partner along to introduce us to each other. Jerome appears full of confidence and is brimming over with plans and projects in his new life. The two of them seem extremely happy together: as far as I can tell they are relaxed and affectionate with each other. He introduces me as: ‘the lady who changed my life’ and when I correct him with: ‘you mean, the lady who helped you to see how you could change your life’, I laugh at my own impudence disguised as false modesty. For really, it was neither me nor him who did the work, for all we did was to let life guide him through the complexity of his accident, so that he could thrive on rather than suffer from the far reaching effects it had on his life.

References

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Boss, M. (1957b) The Analysis of Dreams. London: Rider. Boss, M. (1979) Existential Foundations of Medicine and Psychology. New York: Jason Aronson.

Bugental, J.F.T. (1981) The Search for Authenticity: An Existential-Analytic Approach to Psychotherapy. New York: Irvington.

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Cohn, H.W. (1997) Existential Thought and Therapeutic Practice. London: Sage.

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Cooper, M, (2003) Existential Therapies, London: Sage. De Koning, A.J.J. and Jenner, F.A. (1982) Phenomenology and Psychiatry. New York: Academic Press.

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Deurzen-Smith, E. van (1997) Everyday Mysteries: Existential Dimensions of Psychotherapy. London: Routledge. Second edition, 2010.

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Deurzen, E. van (2002) Existential Counselling and Psychotherapy in Practice, 2nd edn. London: Sage.

Deurzen, E. van and Arnold-Baker, C. (2005) Existential Perspectives on Human Issues: a Handbook for Practice. London: Palgrave/Macmillan.

Deurzen, E. van and Kenward, R. (2005) Dictionary of Existential Psychotherapy and Counselling, London: Sage.

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Suggested further reading:

Cohn, H. W, (2002) Heidegger and the Roots of Existential Therapy. London: Continuum.

Cooper M, (2003) Existential Therapies, London: Sage.

Deurzen, E. van (1998) Paradox and Passion in Psychotherapy. Chichester: Wiley & Sons.

Deurzen, E. van (2002) Existential Counselling and Psychotherapy in Practice, 2nd edn. London: Sage.

Macquarrie, J. (1972) Existentialism: an Introduction, Guide and Assessment. Harmondsworth: Penguin.

Warnock, M. (1970) Existentialism. Oxford: Oxford University Press.

Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.

Summary of Existential Therapeutic Practice.

• Existential psychotherapy is based on philosophical and ontological, rather than psychological or medical parameters.

• The objective is to help client become aware of who they are and what they want to be, in the context of given possibilities and limitations.

• The process begins by enabling people to become more truthful with themselves.

• The method encourages people to learn to uncover what is the case instead of covering up.

• It helps people discover what the tensions are between the universal and particular aspects of a person’s existence, between the finite and the infinite aspects of their lives.

• It aims to achieve greater awareness of where in life one is at and get a new sense of direction.

• This is done by describing what is happening carefully and attentively. This is about teaching people to observe, explore, search, question, create.

• The objective is to better understand the challenges of human living and acquire a map of the human condition as well as clarity on where one is in the overall landscape of one’s personal life.

• This also requires a quest to get to know one’s position in the world, the objective of the journey and of our own talents in making something special of the travelling.

• Existential therapy uses systematic phenomenological description of the person’s situation and experience of the situation. Phenomenology throws light by elucidating what is observed from different angles and perspectives.

• Existential therapy aims to bring out the contradictions and paradoxes: this allows us to find balance and flexibility.

• It also recognizes the person’s assumptions and prejudices, getting a sense of a person’s worldview. This is done systematically on four dimensions: Physical, social, personal and spiritual.

• Existential therapy sees the person as the centre of a network of relationships rather than as a substantial self.

• It therefore helps a person to become aware of their connectivity and relational nature, in order to help them gain authority and authorship over the way in which they seek to engage with these relationships.

• Becoming more tuned in to sensations, emotions, thoughts and intuitions allows a person to become more centred as the source of experience.

• This also allows us to bring a person back to hearing the call of conscience: experiencing anxiety and heeding the sense of unease with self and world.

• In this process time is an important parameter as well as space. We learn to recollect the past, explore the present and project into the future, rather than be all in the past or trying to focus exclusively on the present.

• In this way people are enabled to get a sense of what it is that really matters to them, enough to live and die for.

• An exploration of a person’s original project, their intentionality, values and beliefs will lead to them being able to create a more meaningful life.

• The whole of existential therapy is based on the Socratic idea that the un-reflected life is not worth living.

• Existential therapy leads to understanding the difference between living by default or by deliberation: setting priorities and investigating consequences of actions and attitudes.

• While the person becomes Responseable and of moments of vision, ultimately they grasp the idea of the possibility of their own liberation.