Existential Therapy Case Study Examples

Most of our troubles as human beings are traceable to one overriding problem: our suspension in the groundlessness of existence.

When a loved one dies, or we are attacked, or we fall ill; it often feels like the bottom has dropped out-and there is nothing left to hold us up. Like the astronaut who's cut from his tether, or the tight rope walker who slips, we suddenly come face to face, not just with our particular difficulty, but with the difficulty of existence itself.

This "difficulty" is eloquently portrayed in the opening credits of the award-winning television series Mad Men. In that signature scene, a male character is depicted in a free fall. We know very little about this character except that he is powerless, and that is revealing enough.

Trauma is a lot like this free fall-it makes us aware of what most of us, most of the day, contrive to deny-that we're all in suspense. Right now, for example, you're probably sitting on a comfortable chair in a building that feels solidly anchored to the ground, but this is not at all the complete picture. What is more fully taking place is that you're sitting on a comfortable chair in a building that rests on a gigantic ball that is whirling around the sun at 67, 000 miles per hour. This ball, furthermore, is situated in a galaxy that's hurtling through the universe at 1.2 million miles an hour, to a destination that is completely unknown. And as if that is not enough, you don't really know where you came from to get to this chair and building. Oh, I know you'll probably tell me that you made a thousand arrangements to arrive at this particular place and time, and that you can trace them all back to your past. But this doesn't really tell me much; nor does the ostensibly brilliant presumption that well before you arranged anything you were the "happy" product of a stray sperm and a receptive egg. The fact is that so much of what we take for granted, even today, is a culturally sanctioned artifact-a stop-gap-set against a sea of bewilderment.

Now trauma, which literally means shock, has a way of stripping bare this culturally sanctioned frame. It has a way of rupturing our culturally agreed upon security systems-for example, our bodies, our jobs, and our identities-and exposing us to our noncontrollable roots. And what happens when we come face to face with these roots? Depending on our own traumatic histories, this encounter tends to jar us in either of two directions-toward expansive grandiosity to overcompensate for the fragility we feel, or toward constrictive withdrawal to overcompensate for the unsustainability of grandiose expansion. Yet either way we are imprisoned by these extremes, and both sabotage our growth.

The idea here then is not so much to "get rid of" a condition that's inherently human but to help people to develop a new relationship to that condition. Helping people develop a new relationship to a shocking part of themselves is not easy, but this is precisely what existential oriented therapy attempts to promote. It attempts to help people face and gradually realign themselves with the groundlessness of their existence. What does such realignment look like? It looks like an improved ability to experience choice within that groundlessness; and to engage one's capacity to respond to rather simply react against its ferocity.

The chief and ongoing question of an existentially oriented therapy is "how is one willing to live, in this remarkable moment, with this exceptional opportunity to encounter one's pain"? As my client Janice* sat across from me one Friday afternoon, I tried my best to appreciate the struggle she experienced, and the awkwardness with which she attempted to convey it. It was the first time Janice and I met and from the moment we shook hands, I could sense a cloud over her demeanor.

Janice was a 45-year-old white working class female with a history of severe emotional and sexual abuse. Her father was an inveterate alcoholic with an explosive temper, and her grandfather sexually molested her when she was eight years old. When Janice was four, she would be regularly left alone with a "schizophrenic" aunt. These visits terrified Janice, but apparently, there was no parental recognition of this sentiment. When Janice was five, her mother suddenly died. This left Janice with her volatile alcoholic father, her rapacious grandfather, and her psychotic aunt. How Janice even partially emerged from these circumstances is still a mystery to me, but somehow she managed.

As Janice and I greeted each other, I was struck by her composure, and bright, articulate style. Janice told me that although she had brief brushes with therapy in her past, she did "tons" of work on her own. I emphatically believed that. Although Janice ostensibly came to therapy because of her lack of assertiveness with men, I sensed--and in her tacit way, she conveyed--that the assertiveness issue was not her ultimate concern.

At first I worked with Janice to help her build confidence when she confronted men. I invited her to engage in role plays with me where I would stand in for the menacing fellow, e.g., her boss or husband, and she would play herself in a particular dilemma. I also worked with Janice to cognitively restructure her thinking about how these men perceived her. Would she really be seen as a "bitch" if she clarified her needs to them, I would ask. And even if she was seen that way, would that make her one? As we deepened and rehearsed these scenarios, Janice was gradually able to develop new skills that would help her confront and successfully assert herself with the aforementioned men.

At the same time as she worked with these cognitive and behavioral restructuring skills, however, something else began to happen to Janice: she began to acknowledge, and I encouraged her to stay present to, fears that went beyond feeling intimidated by men. These fears related to a sense of being intimidated by life.

In this context, she began to share powerful dreams with me, like a dream she had recently of feeling like a burned out tree; and another about a monster attacking her home. In time I took the risk to invite Janice, not just to "talk about" such dreams and fantasies, but to experience them here and now with me. I invited her, in other words, to become more present to how she felt, sensed, and pictured these dreams and fantasies. I also invited her to share her responses about what it was like to interact with me, and to experience the difficult sides of herself, like shame or weakness, in my presence. This brought the work alive between me and Janice and significantly deepened our bond. It also enabled Janice to plumb depths only hinted at during our cognitive restructuring exercises. Finally, it moved Janice to realize how her suffering stemmed not just from her relationships with men (and sometimes women), but to her relationship with life's uncertainties, and to the need for courage in the face of them.

In this vein, Janice began to allude to a whole new language in our work together; this was a language that emphasized her concerns about existence, not just specific aspects of existence. For example, she started speaking about "unnamable fears" and a part of herself that felt like a "black hole." She told me she had never acknowledged these feelings with anyone before, but that she had often glimpsed them, especially when stressed. She also began talking about wonderments that she had rarely ever disclosed-such as her fascination with the occult and her resonance with ancient Mayan culture. When I shared my puzzlement about these identifications, given her background, she quipped: "they are freeing, and in tune with the natural world."

In my experience, these ranges of resonance are not all that extraordinary in depth existential therapy. As people feel safer to explore, they begin to unveil the parts of themselves that both torment, and potentially, set them free. These parts are not necessarily Freudian in nature. They don't necessarily evoke sexual or aggressive conflict or frustrated parental attachments, but they do in my experience stir very primordial undercurrents, some of which pertain directly to sexual, aggressive, or attachment conflicts. To put it succinctly: these undercurrents strike me and others who witness them as emphatically existential in nature-pertaining not just to turbulent sexual-aggressive drives or attachments to parental figures, but fears and desires toward the uncontrollability of existence itself. For example, behind the fear (and sometimes attraction) of aggression can be an even deeper anxiety about imminent disarray, uncontrollability, and ultimately chaos. Or beneath the terror of parental devaluation can be the thornier challenge of one's significance in existence.

These were precisely the mooring points I faced with Janice on a fateful afternoon some 6 months following our initial meeting. Janice was on the brink of a breakthrough, and we both knew it. But she also grappled with great fears and the need to come to terms with those fears. On this basis, I invited Janice to simply close her eyes and become aware of her breathing. As she seemed ready, I then invited her to become aware of any tension areas she experienced in her body-any areas that felt tight or blocked, and that she was willing to describe. She began by identifying a tension in her neck area, which loosened as she stayed present to it. Then she began perceiving an image of a tiny little girl trapped in a well. She couldn't identify where this well was, or how it got there, but she was clear that it felt fathomless with no end in sight. As I continued to invite her to stay present to this well, she began to feel the girl's terror. "It's like she's sinking," Janice told me, "and she doesn't know where she's going." Gently I supported her to continue with the experience, while at the same time reassuring her that if she needed to stop, she could do so at any time. She chose to proceed.

At about halfway into our session, Janice noticed that the little girl was fading, while the darkness around her grew. At times, the little girl struggled to unfold herself and peek out of the darkness, but invariably she sank back in. To this point Janice said very little about her relationship to the little girl, but as she "stayed with" her, her sense of connection grew. Suddenly, Janice panicked. She could no longer find the little girl!
Yet at that very same moment, tears welled up in Janice's eyes. I asked her what brought on the tears and after a long silence she whispered: "I reached out into the dark to touch her, and she reached out into the dark to touch me."

With this simple yet profound image, Janice began a remarkable self-transformation. She moved from a position of abject terror to one of wonder to one of love. Through embracing the little girl, Janice at the same time embraced the void in which the little girl (as well as adult Janice) had languished for many years; and now she found solace there, and a chance for self-renewal.

I won't say that this moment completely changed Janice's life, but it went a long way toward freeing her and relieving her panic. Although the specifics of Janice's life--for example, her long-time employment and her involvement with her family-essentially remained the same, what she brought to those specifics altered dramatically. She now had an expanded capacity to feel, for example, a deepened experience of the moment, and a broader appreciation of life's possibilities. In the end, Janice learned much more than assertiveness skills, or an ability to think more "rationally." She discovered how to be present to her life; and this presence enabled her to more fully experience her life.

                                                      Coda
Psychologists today can talk until they're blue in the face about pat formulas and programmatic treatments. They can cite chemical imbalances in the brain, for example, or the lack of ability to regulate emotions, or the irrationality of conditioned thoughts as the bases for our disorders. However, until psychologists get down to the fundamental problem which fuels all these secondary conditions-our precariousness as creatures-they will be operating at a very restrictive level. The work I did with Janice had elements of this very restrictive level-and that was important work to accomplish. However, the question needs to be continually raised, is helping a person to change behavior patterns and recondition thoughts enough? Or do we owe it to that person to make available to him or her a deeper dimension of self-exploration? Do we owe it to that person to enable him or her to discover what really matters about his or her life, wherever that may lead? I believe Janis would answer in the affirmative to that question--as would I, and many others I've known throughout my 30 year clinical career. In a recent review of my book on "Existential-IntegrativePsychotherapy," leading psychotherapy researcher Bruce Wampold offered a bold conjecture. "It could be," he wrote "that an understanding of the principles of existential therapy is needed by all therapists, as it adds a perspective that might...form the basis for all effective treatments" (PsycCritiques, 2008). Isn't it time that we took such propositions seriously? Or must we continue to sacrifice depth for expedience in psychotherapy; the transformed life for the alteration of routine?

*Note: The case of Janice is a composite drawn from my practice and not reflective of any individual client.

Copyright 2010 by Kirk J. Schneider, Ph.D.

Not for republication without the express, written consent of the author.



Using the Existential Approach with Patrick, Client Profile 3


Strengths


The existential approach will help Patrick integrate his painful emotional experiences into his life, develop self-acceptance, and discover purpose and meaning in his life (Corey, 2009). Developing Patrick's self-acceptance will lead to increased self-esteem and a decrease in his self-imposed isolation as he learns to engage in meaningful relationships with others (Laureate Education, Inc., 2006). This therapy will respect Patrick's life journey and emphasize his growth and development in spite of the arduous challenges he has experienced (Corey, 2009).

Limitations

An existential approach may not directly address Patrick's acute symptoms of anxiety, hyper-vigilance, and stress-related distress. Additionally, existential therapy may not provide enough structure and direction for Patrick's issues (Corey, 2009). In the cultural context of his profession, values emphasized in the existential approach may conflict with those of his comrades. For example, the idea of self-actualization self-reflection, self-awareness, and self-appreciation might seem effeminate or self-indulgent to a group of male firefighters. This could cause internal conflict with regard to the significance of the therapy.

Cultural/Gender/Age Issues


It may be helpful to gather more information about his parents' foundational belief systems and the values central to his childhood. These may have contributed to his low self-esteem. His marriage disintegrated before the September 11th crisis, so some issues began prior to that traumatic experience (Laureate Education, Inc., 2006). An additional consideration is the male dominant culture of firemen with which he associates, and from where he receives at least some affirmation of roles related to manhood (Laureate Education, Inc., 2006). Within this culture, he may have developed inappropriate measures of success for male roles, and these measures should be addressed, especially since Patrick appears insecure and lacks self-esteem.

Ethical or Legal Issues to Address


Patrick's depression should be assessed in the initial meeting with the therapist (Corey, 2009). If Patrick reports suicidal thoughts or appears to be a danger to himself, this would need to be addressed immediately. Another issue that requires immediate assessment is Patrick's use of alcohol. It is important to determine the extent of his use because of the critical nature of his work and the danger it poses to others if he drinks during work hours.

Overall Therapeutic Goal


One of the overall goals in existential therapy is to integrate one's life experiences and accept them as a natural condition of being human (Corey, 2009). In an existential approach, clients learn to find "a balance between recognizing the limits and tragic dimensions of human existence on one hand and the possibilities and opportunities of human life on the other hand" (Corey, 2009, p. 139). In Patrick's case, this will mean accepting the reality of the pain and loss he has suffered during the September 11th crisis and integrating these and other experiences into his life. Existential therapy will help Patrick discover meaning through his experiences, which will give him a greater sense of well-being (Diener & Seligman, 2004; Frankl, 1963).

The Therapeutic Process


The Beginning


The therapist will use a client-centered approach to develop trust in the relationship, and convey acceptance, respect, and appreciation to Patrick through careful and deliberate self-disclosure (Laureate Education, Inc., 2006). Creating an environment in which Patrick perceives the therapist as a caring comrade will help Patrick explore his emotional experiences. The therapist will demonstrate unwavering acceptance toward Patrick and will engage with him authentically. Additionally, using the I/Thou relationship will reflect a "direct, mutual, and present interaction" (Corey, 2009, p. 150). Developing such a caring and intimate relationship is central to existential therapy and crucial to strengthening Patrick's ability to trust others and decrease his social isolation (Laureate Education, Inc., 2006).

Goals of Therapy

Goals of Patrick's therapy would include increasing his self-awareness to understand more accurately his emotional life experiences exacerbated by the September 11th crisis. An equally crucial goal is to decrease his need for alcohol consumption and his tendency toward social isolation. Patrick will begin to question and develop personal meaning in his life (Corey, 2009). His experiences with the September 11th crisis left him in despair and a state of emptiness and meaninglessness, but with encouragement, he will find meaning, not only despite his experiences, but because of them.

Specific Strategies and Techniques

Although existential therapy lacks techniques and strategies, the therapist may borrow from other approaches appropriate for the client (Corey, 2009). In Patrick's case, using a person-centered approach will help to establish trust between Patrick and the therapist. Through this relationship, the therapist will encourage self-awareness and reflection to help Patrick gain self-esteem and find purpose and meaning in his struggle (Corey, 2009). Borrowing from Gestalt therapy, the therapist will use the empty chair technique by which Patrick has an opportunity to express his emotions to his lost comrades and others with whom he has unfinished business (Corey, 2009; Laureate Education, Inc., 2006).

References

Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Thompson Brooks/Cole.

Diener, E., & Seligman, M. E. P. (2004). Beyond money: Toward an economy of well-being.
Psychological Science in the Public Interest, 5, 1-31.

Frankl, V.E. (1963). Man's search for meaning: an introduction to logotherapy. New York:
Washington Square Press.

Laureate Education, Inc. (Producer). (2006). Case Study: A Humanistic/Person- centered Perspective [Streaming Video]. Baltimore: Author.





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