# Existential therapy

Existential therapy is a form of psychotherapy based on the model of human nature and experience developed by the existential tradition of European philosophy. It focuses on the psychological experience revolving around universal human truths of existence such as death, freedom, isolation and the search for the meaning of life. Existential therapists largely reject the medical model of mental illness that views mental health symptoms as the result of biological causes. Rather, symptoms such as anxiety, alienation and depression arise because of attempts to deny or avoid the givens of existence, often resulting in an existential crisis. For example, existential therapists highlight the fact that since we have the freedom to choose, there will always be uncertainty - and therefore, there will always be a level of existential anxiety present in our lives.
Existential therapists also draw heavily from the methods of phenomenology, a philosophical approach developed by Edmund Husserl and later expanded on by Martin Heidegger that concentrates on the study of consciousness and the objects of direct experience. When working with clients, existential therapists focus on the client's lived experience of their subjective reality. While other types of therapies like Freudian psychoanalysis are aimed at analyzing and interpreting the client's experience, existential therapists are encouraged to "bracket", or set aside, their preconceived notions and biases in order to identify the core aspects of the client's experience. In existential therapy, clients gain self-awareness into their own existence, confront existential concerns, and are encouraged to use their freedom to choose a path towards a more authentic and meaningful life.

## Background

The philosophers who are especially pertinent to the development of existential psychotherapy are those whose works were directly aimed at making sense of human existence. For example, the fields of phenomenology and existential philosophy are especially and directly responsible for the generation of existential therapy.
The starting point of existential philosophy (see Warnock 1970; Macquarrie 1972; Mace 1999; van Deurzen and Kenward 2005) can be traced back to the nineteenth century and the works of Søren Kierkegaard and Friedrich Nietzsche. Their works conflicted with the predominant ideologies of their time and committed to the exploration of reality as it can be experienced in a passionate and personal manner.

### Søren Kierkegaard (1813–1855)

Soren Kierkegaard (1813–1855) protested vehemently against popular misunderstanding and abuse of Christian dogma and the so-called 'objectivity' of science (Kierkegaard, 1841, 1844). He thought that both were ways of avoiding the anxiety inherent in human existence. He had great contempt for the way life was lived by those around him and believed truth could only be discovered subjectively by the individual in action. He felt people lacked the courage to take a leap of faith and live with passion and commitment from the inward depth of existence. This involved a constant struggle between the finite and infinite aspects of our nature as part of the difficult task of creating a self and finding meaning. As Kierkegaard lived by his word, he was lonely and much ridiculed during his lifetime.

### Friedrich Nietzsche (1844–1900)

Friedrich Nietzsche (1844–1900) took this philosophy of life a step further. His starting point was the notion that God is dead, that is, the idea of God was outmoded and limiting (Nietzsche, 1861, 1874, 1886). Furthermore, the Enlightenment—with the newfound faith in reason and rationality—had killed or replaced God with a new Truth that was perhaps more pernicious than the one it replaced. Science and rationality were the new "God," but instead took the form of a deity that was colder and less comforting than before. Nietzsche exerted a significant impact upon the development of psychology in general, but he specifically influenced an approach which emphasized an understanding of life from a personal perspective. In exploring the various needs of the individual about the ontological conditions of being, Nietzsche asserted that all things are in a state of "ontological privation," in which they long to become more than they are. This state of deprivation has major implications for the physiological and psychological needs of the individual.

### Edmund Husserl (1859–1938)

While Kierkegaard and Nietzsche drew attention to the human issues that needed to be addressed, Edmund Husserl's phenomenology (Husserl, 1960, 1962; Moran, 2000) provided the method to address them rigorously. He contended that natural sciences assume the separateness of subject and object and that this kind of dualism can only lead to error. He proposed a whole new mode of investigation and understanding of the world and our experience of it. He said that prejudice has to be put aside or 'bracketed,' for us to meet the world afresh and discover what is absolutely fundamental, and only directly available to us through intuition. If people want to grasp the essence of things, instead of explaining and analyzing them, they have to learn to describe and understand them.

### Max Scheler (1874-1928)

Max Scheler (1874-1928) developed philosophical anthropology from a material ethic of values ("Materielle Wertethik") that opposed Immanuel Kant's ethics of duty ("Pflichtethik"). He described a hierarchical system of values that further developed phenomenological philosophy. Scheler described the human psyche as being composed of four layers analogous to the layers of organic nature. However, in his description, the human psyche is opposed by the principle of the human spirit. Scheler's philosophy forms the basis of Viktor Frankl's logotherapy and existential analysis.

### Martin Heidegger (1889–1976)

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

### Jean-Paul Sartre (1905–1980)

Jean-Paul Sartre (1905–1980) contributed many other strands of existential exploration, particularly regarding emotions, imagination, and the person's insertion into a social and political world.
The philosophy of existence, on the contrary, is carried by a wide-ranging literature, which includes many authors, such as Karl Jaspers (1951, 1963), Paul Tillich, Martin Buber, and Hans-Georg Gadamer within the Germanic tradition and Albert Camus, Gabriel Marcel, Paul Ricoeur, Maurice Merleau-Ponty, Simone de Beauvoir and Emmanuel Lévinas within the French tradition (see for instance Spiegelberg, 1972, Kearney, 1986 or van Deurzen-Smith, 1997).

## Existentialism and Therapy

Throughout the 20th century, psychotherapists began incorporating both the themes of existentialism as well as the phenomenological methods of describing experience into their therapeutic practice:
Otto Rank (1884–1939) was an Austrian psychoanalyst who broke with Freud in the mid-1920s. He did not consider himself an existential therapist, but his ideas revolving the concept of "will" as a factor in human motivation, as well as the fear of death and the fear of living authentically would pave the foundation for later writers.
Throughout the 1930's and 40's, the Swiss psychiatrists Ludwig Binswanger and Medard Boss each developed a form of psychotherapy known as Daseinsanalysis. Daseinsanalysis merges Freudian psychoanalysis with the existential phenomenology of Martin Heidegger, particularly his concept of Dasein ("being"). It focuses on understanding the client's experience of Being-in-the-world, rather than diagnosing symptoms. Much of Binswanger's work was translated into English during the 1940s and 1950s and, together with the immigration to the USA of Paul Tillich (1886–1965) (Tillich, 1952) and others, this had a considerable effect on the popularization of existential ideas as a basis for therapy (Valle and King, 1978; Cooper, 2003).
Rollo May (1909–1994) played an important role in this, and is considered by many to be the "father" of existential therapy. His writings in the 1950's and 60's (1969, 1983; May et al., 1958) became the foundation of existential-humanistic therapy that would flourish in America (Bugental, 1981; May and Yalom, 1985; Yalom, 1980). May also worked closely with Carl Rogers and Abraham Maslow, founders of the humanistic psychology movement. As such, existential therapy in America became closely associated with humanistic psychology and the principles of Rogers' person-centered therapy, particularly regarding how the therapist and client should interact.
Viktor Frankl (1905–1997) was possibly the individual most responsible for spreading existential psychology throughout the world. His 1959 book Man's Search for Meaning created a unique branch of existential therapy known as Logotherapy. Logotherapy is premised on the idea that the primary motivation of individuals is to find meaning in life. He was invited by over 200 universities worldwide and accomplished over 80 journeys to North America alone, first invited by Gordon Allport at Harvard University.
In 1980, Irvin D. Yalom published 'Existential Psychotherapy'. This book was the first to provide a comprehensive overview of existential therapy. In it, Yalom identifies four existential concerns, or "givens", of life that underlie human experience - death, freedom, isolation, and meaninglessness. Yalom argues that the role of the therapist in existential therapy is not to provide solutions or answers, but to guide the client in exploring and confronting these challenges. Unlike other forms of therapy, Yalom does not prescribe specific techniques, rather, Yalom suggests existential therapy should be a personalized collaboration between therapist and client, tailored to each clients’ unique existential concerns.

## Development
### Development in Europe

The European School of existential analysis is dominated by two forms of therapy: Logotherapy, and Daseinsanalysis. Logotherapy was developed by psychiatrist Viktor E. Frankl. Frankl was heavily influenced by existential philosophy, as well as his own experience in the Nazi concentration camps of World War II. The three main components to Logotherapy are Freedom of Will, which is the ability to change one's life to the degree that such change is possible, Will to Meaning, which places meaning at the center of well-being, and Meaning in Life, which asserts the objectivity of meaning. The primary techniques of Logotherapy involve helping the clients to identify and remove any barriers to the pursuit of meaning in their own lives, to determine what is personally meaningful, and to then help patients effectively pursue related goals.
Daseinsanalysis is a psychotherapeutic system developed upon the ideas of Martin Heidegger, as well as the psychoanalytic theories of Sigmund Freud, that seeks to help the individual find autonomy and meaning in their "being in the world" (a rough translation of "Dasein").

### Development in Britain

Britain became a fertile ground for further development of the existential approach when R. D. Laing and David Cooper, often associated with the anti-psychiatry movement, took Sartre's existential ideas as the basis for their work (Laing, 1960, 1961; Cooper, 1967; Laing and Cooper, 1964). Without developing a concrete method of therapy, they critically reconsidered the notion of mental illness and its treatment. In the late 1960s, they established an experimental therapeutic community at Kingsley Hall in the East End of London, where people could come to live through their 'madness' without the usual medical treatment. They also founded the Philadelphia Association, an organization providing an alternative living, therapy, and therapeutic training from this perspective. The Philadelphia Association is still in existence today and is now committed to the exploration of the works of philosophers such as Ludwig Wittgenstein, Jacques Derrida, Levinas, and Michel Foucault as well as the work of the French psychoanalyst Jacques Lacan. It also runs some small therapeutic households along these lines. The Arbours Association is another group that grew out of the Kingsley Hall experiment. Founded by Joseph Berke and Schatzman in the 1970s, it now runs a training program in psychotherapy, a crisis center, and several therapeutic communities. The existential input in the Arbours has gradually been replaced with a more neo-Kleinian emphasis.
The impetus for further development of the existential approach in Britain has primarily come from the development of some existentially based courses in academic institutions. This started with the programs created by Emmy van Deurzen, initially at Antioch University in London and subsequently at Regent's College, London and since then at the New School of Psychotherapy and Counseling, also located in London. The latter is a purely existentially based training institute, which offers postgraduate degrees validated by the University of Sheffield and Middlesex University. In the past few decades, the existential approach has spread rapidly and has become a welcome alternative to established methods. There are now many other, mostly academic, centers in Britain that provide training in existential counseling and psychotherapy and a rapidly growing interest in the approach in the voluntary sector and the National Health Service.
British publications dealing with existential therapy include contributions by these authors: Jenner (de Koning and Jenner, 1982), Heaton (1988, 1994), Cohn (1994, 1997), Spinelli (1997), Cooper (1989, 2002), Eleftheriadou (1994), Lemma-Wright (1994), Du Plock (1997), Strasser and Strasser (1997), van Deurzen (1997, 1998, 2002), van Deurzen and Arnold-Baker (2005), and van Deurzen and Kenward (2005). Other writers such as Lomas (1981) and Smail (1978, 1987, 1993) have published work relevant to the approach, although not explicitly 'existential' in orientation. The journal of the British Society for Phenomenology regularly publishes work on existential and phenomenological psychotherapy. The Society for Existential Analysis was founded in 1988, initiated by van Deurzen. This society brings together psychotherapists, psychologists, psychiatrists, counselors, and philosophers working from an existential perspective. It offers regular fora for discussion and debate as well as significant annual conferences. It publishes the Journal of the Society for Existential Analysis twice a year. It is also a member of the International Federation of Daseinsanalysis, which stimulates international exchange between representatives of the approach from around the world. An International Society for Existential Therapists also exists. It was founded in 2006 by Emmy van Deurzen and Digby Tantam and is called the International Community of Existential Counsellors and Therapists (ICECAP).

### Development in Canada

New developments in existential therapy in the last 20 years include existential positive psychology and meaning therapy. Different from the traditional approach to existential therapy, these new developments incorporate research findings from contemporary positive psychology.
Existential positive psychology can reframe the traditional issues of existential concerns into positive psychology questions that can be subjected to empirical research. It also focuses on personal growth and transformation as much as on existential anxiety. Later, existential positive psychology was incorporated into the second wave of positive psychology.
Meaning therapy (MT) is an extension of Frankl's logotherapy and America's humanistic-existential tradition; it is also pluralistic because it incorporates elements of cognitive-behavioral therapy, narrative therapy, and positive psychotherapy, with meaning as its central organizing construct. MT not only appeals to people's natural desires for happiness and significance but also makes skillful use of their innate capacity for meaning-seeking and meaning-making. MT strikes a balance between a person-centered approach and a psycho-educational approach. At the outset of therapy, clients are informed of the use of meaning-centered interventions appropriate for their predicaments because of the empirical evidence for the vital role of meaning in healing and thriving. MT is a comprehensive and pluralistic way to address all aspects of clients' existential concerns. Clients can benefit from MT in two ways: (1) a custom-tailored treatment to solve their presenting problems, and (2) a collaborative journey to create a preferred better future.

## Themes

Existential themes are issues that are considered central to human existence or the human experience. As such, they are broad and are often difficult to describe. The most common framework is given by Irvin Yalom, who divides existental issues into four core themes:
Death. The fact that humans are aware of their own inevitable death - and uncertain about what happens after - can cause considerable distress. Some people go to great lengths to deny or avoid thinking about death, while others may succumb to despair or hopelessness. Existential therapy aims to help clients embrace life more fully by recognizing the finite nature of their existence.
Freedom and responsibility. Alongside humanistic psychology, existential therapy places a great deal of importance on the concept of free will. Humans have the freedom to make choices and create their own meaning in life. To be free means to be responsible for one’s life and to be the author of one’s own destiny. However, this freedom carries with it a tremendous amount of responsibility. Experiencing existential guilt over the choices we have made and the possibilities of what could have been is a natural part of life. If overwhelmed by the responsibility to choose, people may defer to external authorities and societal norms to make decisions for them. Existential therapy encourages clients to recognize their freedom and live more authentic lives by taking responsibility for their actions, choices, and direction in life.
Isolation. Yalom describes existential isolation as "An unbridgeable gap between oneself and any other being. It refers, too, to an isolation even more fundamental—a separation between the individual and the world." This represents the tension between the fact that humans are inherently social creatures, and long to be connected to others - Yet at the same time no one can fully share or take on another’s subjective experience, pain, or death. People may attempt to avoid these feelings of isolation through becoming dependent on others or conforming to social norms. Existential therapy helps clients confront their aloneness by building authentic relationships, where connections with others are based on mutual respect rather than an avoidance of isolation.
Meaning and meaninglessness. Humans seek out meaning - the question of "What is the meaning of life?" is one of the most central questions to philosophy. Existential philosophers argue that there is no "inherent," fundamental meaning in the world. Rather, the task falls on the individual for *discovering* or *creating* their own meaning in life. This realization can be incredibly distressing to people. In existential therapy, clients learn to create personal meaning through their actions, values, and relationships rather than relying on external, fixed sources of meaning. Viktor Frankl's logotherapy specifically focuses on how a lack of meaning in life can lead to severe mental distress.
In addition to these four themes, a central concept that underlies existential therapy is existential anxiety, more colloquially known as an existential crisis. When people become aware of these existential themes, they feel anxiety, guilt, or other forms of distress. Unlike Freudian or medical models of mental illness that strictly view anxiety as a "symptom" that must be "cured", existential therapy stresses that existential anxiety is an inevitable part of life. Under this framework, anxiety is not seen as something to be eliminated but as a natural and even necessary part of life, and that working through these anxieties can provide a powerful source of personal growth and transformation.
To this end, one of the central goals of existential therapy is to help clients live with authenticity. To live with authenticity means to fully acknowledge life's existential givens without avoiding them. It also means to live a life that is in line with one's personal values. Many people live inauthentic lives by succumbing to peer pressure or conformity. Existential therapists guide clients to reflect on their values, choices, and patterns of behavior to identify areas whether they may be living inauthentically. For example, a client may be stuck in an unfulfilling job that does not align with their values or stuck in an unsatisfying relationship due to their fear of loneliness. By helping clients confront existential anxiety, clarify their values, and find areas where they can exercise their freedom, therapists support them in creating a life that feels true, meaningful, and fully their own.

## Psychological dysfunction

Because there is no single existential view, opinions about psychological dysfunction vary.
For theorists aligned with Yalom, psychological dysfunction results from the individual's refusal or inability to deal with the normal existential anxiety that comes from confronting life's "givens": death, freedom, isolation, and meaninglessness.
For other theorists, there is no such thing as psychological dysfunction or mental illness. Every way of being is merely an expression of how one chooses to live one's life. However, one may feel unable to come to terms with the anxiety of being alone in the world. If so, an existential psychotherapist can assist one in accepting these feelings rather than trying to change them as if there is something wrong. Everyone has the freedom to choose how they are going to exist in life; however, this freedom may go unpracticed. It may appear easier and safer not to make decisions that one will be responsible for. Many people will remain unaware of alternative choices in life for various societal reasons.

## Personal element

Existential counsellors stress the importance of the examined life, and of preparatory work on oneself, in paving the way for effective counselling. Thus in counselling adolescents the counsellor can optimally model an autonomous life based on the making of realistic decisions, but one which also acknowledges the role of failure as well as success in everyday life, and the ongoing and inescapable presence of anxiety.
The strictly Sartrean perspective of existential psychotherapy is generally unconcerned with the client's past, but instead, the emphasis is on the choices to be made in the present and future. The counselor and the client may reflect upon how the client has answered life's questions in the past, but attention ultimately shifts to searching for a new and increased awareness in the present and enabling a new freedom and responsibility to act. The patient can then accept that they are not special and that their existence is simply coincidental, or without destiny or fate. By accepting this, they can overcome their anxieties and instead view life as moments in which they are fundamentally free.

## Four worlds

Existential thinkers seek to avoid restrictive models that categorize or label people. Instead, they look for the universals that can be observed cross-culturally. There is no existential personality theory which divides humanity into types or reduces people to part components. Instead, there is a description of the different levels of experience and existence with which people are inevitably confronted. The way in which a person is in the world at a particular stage can be charted on this general map of human existence (Binswanger, 1963; Yalom, 1980; van Deurzen, 1984).
In line with the view taken by van Deurzen, one can distinguish four basic dimensions of human existence: the physical, the social, the psychological, and the spiritual; some only believe in the first three.
On each of these dimensions, people encounter the world and shape their attitude out of their particular take on their experience. Their orientation towards the world defines their reality. The four dimensions are interwoven and provide a complex four-dimensional force field for their existence. Individuals are stretched between a positive pole of what they aspire to on each dimension and a negative pole of what they fear. Binswanger proposed the first three of these dimensions from Heidegger's description of Umwelt and Mitwelt and his further notion of Eigenwelt. The fourth dimension was added by van Deurzen from Heidegger's description of a spiritual world (Überwelt) in Heidegger's later work.

### Physical dimension

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

### Social dimension

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

### Psychological dimension

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

### Spiritual dimension

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

## Research support

There has not been a tremendous amount of research on existential therapy. Much of the research focuses on people receiving therapy who also have medical concerns such as cancer. Despite this, some studies have indicated positive efficacy for existential therapies with certain populations. Overall, however, more research is needed before definitive scientific claims can be made.
In the debate on evidence-based research in counselling, existential counsellors tend to stress the dangers of over-simplification, and the importance of qualitative as well as quantitative measurements of outcome. While not necessarily expecting an easy resolution of the specific/non-specific factors in therapy debate, an existential counsellor will nonetheless favor evidence-based practice.