‘What really matters’

Ernesto Spinelli, a winner of the Society’s Award for Distinguished Contribution to Practice, on what it’s like to be an existential therapist.

A long, long time ago, in the early years of modern psychology’s existence, Wilhelm Dilthey proposed a distinction between the natural sciences and the human sciences. In brief, while the former focused on explanation (broadly, matters of cause and correspondence), the latter centred upon understanding (broadly, all the issues surrounding the generation and experience of meaning). Dilthey argued that as well as both strands being equally valid scientific enterprises, it was necessary to clarify that neither strand should be confused with – nor subsumed by – the other.

Understanding and explanation may stand beside one another, but their focus and concerns are not one and the same. Whereas explanation seeks to disprove or ‘close down’ inadequate hypotheses of cause and correlation, understanding perpetually ‘opens up’ and illuminates novel, often unforeseen, possibilities of meaning. Understanding approaches within science must remain receptive to the inevitable uncertainty that accompanies their enterprise. To put it another way: the more adequate the understanding, the more hesitant becomes any explanatory endeavour.

Existential therapy, as I attempt to understand and practice it, aligns itself with the understanding branch of science. It concerns itself with the understanding of lived experience as uniquely embodied by a particular being. And it seeks to understand more adequately in what ways any understanding of the particular also illuminates our understanding of the general, or universal, experience of being.

Price and pay-off
As a therapeutic approach centred upon understanding, existential therapy is, therefore, unlike just about every other model of contemporary psychotherapy. It is not primarily concerned with directively generating change or amelioration from distress, or in assisting anyone to ‘live a better or healthier life’. Instead, its enterprise centres upon the attempt to ‘stay still with what is there’ so that it may be clarified, opened up to its unconsidered implications, limitations and possibilities. In short, its attempt to understand focuses upon the embodied meanings being assigned to an experience. What might such meanings extract as their undesired ‘price’, as well as provide as desirable ‘pay-off’?

This is not to suggest that existential therapy seeks to prevent ameliorative change from happening. It remains true to the origins of therapy itself – therapeia – which expressed the attempt to ‘stand side-by-side with the other’ (in Laing’s words). This is no quasi-medical enterprise, seeking to generate ameliorative change via directive interventions rooted in an explanatory-centred interpretation of psychotherapy. It is instead guided by the premise that the act of describing an experience will, in and of itself, change the experience being described.

Nonetheless, existential therapy embraces its inherent uncertainty. What will provoke change? What impact will it have on either the client or therapist, or both? What effects will ripple out through them, to any and all other beings with whom they interact?

An example
Ross comes to see me because he has, in recent months, begun to suffer from literally paralysing levels of anxiety. He is most often overwhelmed by these while at work. Increasingly, he feels the pressures of demonstrating his ‘know-how’ and superior expertise. These, in turn, wreak havoc on his sense of self-worth and self-confidence.

But it is not only in Ross’s work life that he becomes overwhelmed by these paralytic anxieties; his inability to find his ‘life-mate’ and to relax in the company of his friends (most of whom, unlike Ross, are now in permanent relationships) are in some ways even more anxiety-provoking. In turn, Ross’s fear of the life-threatening consequences of these attacks have begun to seriously disturb his sleeping patterns. Worst of all, as much as Ross craves social and intimate contact with others, his sense of failure – and being seen to be such – pushes him to avoid the very contacts he desires.

‘I need help,’ Ross says. ‘Help me to get rid of this anxiety’.

‘And what do you suppose would change in your life if this anxiety you speak of were gotten rid of? Alternatively, what might remain the same?’

Ross stares at me as though he is in the presence of some gibbering idiot. He’s not far wrong. Initially, my desire to understand is matched by my current inability to do so.

‘Tell me about this anxiety that you speak of. What is it? How do you experience it? What do you tell yourself about it?’

In asking such questions, existential therapists return the notion of diagnosis to its origins. In its earliest meanings, diagnosis was carried out by the patient or client. As such, every diagnosis had its unique, client-driven qualities (Jaspers, 1963). While often initially confounding, possibly even irritating, to some clients, this form of enquiry serves a number of important functions. Two key ones are that it replaces the abstraction – anxiety – with statements of concrete, embodied experience; and its unique aspects then become more apparent. In this way, the client gains a growing sense of ownership of the experience. While the experience may still be disturbing and disabling, it is also now ‘my experience’. In these moves towards concrete ownership, the seemingly alien, ‘not part of me’ aspects of the experience are challenged. If it is concretely describable as ‘mine’ then the possibility arises that I can better explore and consider both how I am currently relating to it and what possibilities I may have in reconfiguring that relationship.

The existential therapist’s primary skills in adopting this mode of enquiry rely upon assisting clients to better understand their experience from a descriptive focus. While this might often be a primarily verbal enterprise, it need not be so. Drawing, movement, and other forms of non-verbal dialogue can equally serve the client’s descriptive process. In instances of overwhelming distress and disorder, such methods may prove to be initially far more expressive, accessible and safe for clients to be willing to engage with.

In Ross’s case, three forms of verbally-focused description dominated our discussion:

  • embodiment, which focuses on the body – as a whole and in specific areas – and how it expresses the experience under investigation such that how, where, and in what ways it is felt bodily can be opened to description;
  • metaphor, descriptively exploring the various ‘what is it like’ associations given by the client and what these highlighted associations may add to the client’s understanding of his or her current ‘way of being’ with the experience; and
  • narrational scene setting, detailing several remembered instances of the experience as if re-creating a scenario for each example. Any one reconstructed narrative scene can then be explored both in itself and in relation to all the others so that recurring elements – no matter how seemingly insignificant, even absurd, they might initially appear to be – can be identified and further explored.

These descriptive explorations led Ross to understand that his anxiety expressed various desirable, if significantly competing and contradictory, ways of being that he sought to live out simultaneously. His inability to fulfil the demands of all of these ways of being in any satisfactory way led him to experiences of ‘splitness’ to the extent that the felt dissociations in mind and body led to a sort of paralysis. While deeply disturbing and debilitating, this anxiety-fuelled paralysis also served to ensure that no one of his competing desired ways of being took precedence over any other – much less reduced, if not eliminated, the continuing possibility of any and every possibility.

Ross began to understand that his paralysing anxiety attacks reflected his demand to ‘want it all’. And, in doing so, they maintained the whole of the desire but in a way that ensured that no element of it could be achieved. As painful and destructive as it was, Ross’s anxiety worked for rather than against him. Further, the ‘price’ required by him to confront that anxiety was nothing less than an act of choice on his part – a choice that, if carried out, would of necessity have condemned him, as he put it, ‘to wave goodbye’ to many of his imagined possibilities.

Even if Ross concluded that he was not prepared to make that choice and, instead, continued to remain anxious, the descriptive process and the understanding that accompanied it, would still have altered his way of being with his anxiety. He could not return to his earlier, less adequate, embodied understanding of his experience of being anxious. For one thing, now it was his choice rather than the outcome of some alien invader. For another, it was a meaningful consequence of Ross’s chosen way to be. In owning the experience and its consequences, the paralysing effects disappeared. Even so, Ross now found himself being anxious in a decidedly different way: painful as it still continued to be, he experienced it as primarily empowering rather than debilitating.

Curiosity and concern
I hope I have managed to convey something of the overall ‘atmosphere’ of being an existential therapist. Although I have been practising as one for well over 30 years now, I have yet to experience anything akin to ‘burn-out’. The curiosity and concern that are part and parcel of an understanding focus reduce any feeling of a ‘here we go again’ reaction to my clients’ stated concerns.

And what has all this done for me, personally? I don’t know if it has made me a better person. But it has certainly afforded me a lived awareness of how inescapably inter-related all beings are, and how our very uniqueness emerges through that inter-relation rather than in spite of it. This view has guided me over the years and has permitted me sufficient courage (perhaps arrogance as well) to respond as openly as possible to the challenges and possibilities that present themselves. I’ll seek to act on them regardless of the uncertainty of where such will lead.

I firmly believe that whatever I may have ‘achieved’ in life, be it professionally or interpersonally, is an expression of this pivotal existential challenge to be willing to embrace and cherish ‘who/what is there, in the way they are there, when they are there’. Sometimes joyful, sometimes painful, always surprising, this view fuels and enfolds me in every facet of my life. For me, existential therapy ultimately emboldens us to look at our own lives and at life in general from a standpoint that asks ‘what really matters?’; and then to do the best we can to act on that.

Nonetheless, I remain all too aware that much of existential therapy’s outlook sits uneasily with the current zeitgeist of ‘evidence-based practice’ that dominates explanatory-attuned definitions of psychotherapy. Yet in recent years, a new generation of existential therapists has taken up this challenge. Quantitative evidence demonstrating at least equal outcomes to those noted in CBT-based interventions both exists and continues to grow (Rayner & Vitali, 2016; Stephenson & Hale, 2017).

Many critics of existential therapy claim it’s not a scientific worldview. In recent years, I’ve taken to countering that existential therapy’s greatest strength lies in its acknowledgement that every statement it makes ends with a question mark rather than a full stop. Such a stance, it seems to me, exemplifies rather than forsakes the aims of any genuine scientific enquiry.

Key sources
Evans, R.I. (1981). Dialogue with R.D. Laing. New York: Praeger.
Hodges, H.A. (1952). The philosophy of Wilhelm Dilthey. London: Routledge.
Jaspers, K. (1963). General Psychopathology, vol. 1 (J. Hoening & M. W. Hamilton, Trans.). London: Johns Hopkins University Press.
Rayner, M. & Vitali, D. (2016). Short-term existential psychotherapy in primary care: A quantitative report. Journal of Humanistic Psychology, 56(4), 357-372.
Spinelli, E. (2015). Practising existential psychotherapy: The relational world (2nd ed.). London: Sage.
Stephenson, L. & Hale, B. (2017). An exploration into effectiveness of existential-phenomenological therapy as a U.K. NHS psychological treatment intervention. Journal of Humanistic Psychology. Advance online publication.

BPS Members can discuss this article

Already a member? Or Create an account

Not a member? Find out about becoming a member or subscriber