Brief Humanistic and Existential Therapies
Chapter 6 Brief Humanistic and Existential Therapies
Humanistic and existential psychotherapies use a wide range of approaches to case conceptualization, therapeutic goals, intervention strategies, and research methodologies.
They are united by an emphasis on understanding human experience and a focus on the client rather than the symptom. Psychological problems (including substance abuse disorders) are viewed as the result of inhibited ability to make authentic, meaningful, and self-directed choices about how to live. Consequently, interventions are aimed at increasing client self-awareness and self-understanding.
Whereas the key words for humanistic therapy are acceptance and growth, the major themes of existential therapy are client responsibility and freedom. This chapter broadly defines some of the major concepts of these two therapeutic approaches and describes how they can be applied to brief therapy in the treatment of substance abuse disorders. A short case illustrates how each theory would approach the client's issues.
Many of the characteristics of these therapies have been incorporated into other therapeutic approaches such as narrative therapy.
Humanistic and existential approaches share a belief that people have the capacity for self-awareness and choice. However, the two schools come to this belief through different theories. The humanistic perspective views human nature as basically good, with an inherent potential to maintain healthy, meaningful relationships and to make choices that are in the interest of oneself and others.
The humanistic therapist focuses on helping people free themselves from disabling assumptions and attitudes so they can live fuller lives. The therapist emphasizes growth and self-actualization rather than curing diseases or alleviating disorders. This perspective targets present conscious processes rather than unconscious processes and past causes, but like the existential approach, it holds that people have an inherent capacity for responsible self-direction. For the humanistic therapist, not being one's true self is the source of problems.
The therapeutic relationship serves as a vehicle or context in which the process of psychological growth is fostered. The humanistic therapist tries to create a therapeutic relationship that is warm and accepting and that trusts that the client's inner drive is to actualize in a healthy direction.
The existentialist, on the other hand, is more interested in helping the client find philosophical meaning in the face of anxiety by choosing to think and act authentically and responsibly. According to existential therapy, the central problems people face are embedded in anxiety over loneliness, isolation, despair, and, ultimately, death.
Creativity, love, authenticity, and free will are recognized as potential avenues toward transformation, enabling people to live meaningful lives in the face of uncertainty and suffering. Everyone suffers losses (e.g., friends die, relationships end), and these losses cause anxiety because they are reminders of human limitations and inevitable death.
The existential therapist recognizes that human influence is shaped by biology, culture, and luck. Existential therapy assumes the belief that people's problems come from not exercising choice and judgment enough--or well enough--to forge meaning in their lives, and that each individual is responsible for making meaning out of life. Outside forces, however, may contribute to the individual's limited ability to exercise choice and live a meaningful life. For the existential therapist, life is much more of a confrontation with negative internal forces than it is for the humanistic therapist.
In general, brief therapy demands the rapid formation of a therapeutic alliance compared with long-term treatment modalities. These therapies address factors shaping substance abuse disorders, such as lack of meaning in one's life, fear of death or failure, alienation from others, and spiritual emptiness. Humanistic and existential therapies penetrate at a deeper level to issues related to substance abuse disorders, often serving as a catalyst for seeking alternatives to substances to fill the void the client is experiencing.
The counselor's empathy and acceptance, as well as the insight gained by the client, contribute to the client's recovery by providing opportunities for her to make new existential choices, beginning with an informed decision to use or abstain from substances. These therapies can add for the client a dimension of self-respect, self-motivation, and self-growth that will better facilitate his treatment. Humanistic and existential therapeutic approaches may be particularly appropriate for short-term substance abuse treatment because they tend to facilitate therapeutic rapport, increase self-awareness, focus on potential inner resources, and establish the client as the person responsible for recovery.
Thus, clients may be more likely to see beyond the limitations of short-term treatment and envision recovery as a lifelong process of working to reach their full potential.
Because these approaches attempt to address the underlying factors of substance abuse disorders, they may not always directly confront substance abuse itself. Given that the substance abuse is the primary presenting problem and should remain in the foreground, these therapies are most effectively used in conjunction with more traditional treatments for substance abuse disorders.
However, many of the underlying principles that have been developed to support these therapies can be applied to almost any other kind of therapy to facilitate the client-therapist relationship.
Using Humanistic and Existential Therapies
Many aspects of humanistic and existential approaches (including empathy, encouragement of affect, reflective listening, and acceptance of the client's subjective experience) are useful in any type of brief therapy session, whether it involves psychodynamic, strategic, or cognitive-behavioral therapy. They help establish rapport and provide grounds for meaningful engagement with all aspects of the treatment process.
While the approaches discussed in this chapter encompass a wide variety of therapeutic interventions, they are united by an emphasis on lived experience, authentic (therapeutic) relationships, and recognition of the subjective nature of human experience.
There is a focus on helping the client to understand the ways in which reality is influenced by past experience, present perceptions, and expectations for the future. Schor describes the process through which our experiences assume meaning as apperception (Schor, 1998). Becoming aware of this process yields insight and facilitates the ability to choose new ways of being and acting.
For many clients, momentary circumstances and problems surrounding substance abuse may seem more pressing, and notions of integration, spirituality, and existential growth may be too remote from their immediate experience to be effective. In such instances, humanistic and existential approaches can help clients focus on the fact that they do, indeed, make decisions about substance abuse and are responsible for their own recovery.
By their very nature, these models do not rely on a comprehensive set of techniques or procedures. Rather, the personal philosophy of the therapist must be congruent with the theoretical underpinnings associated with these approaches. The therapist must be willing and able to engage the client in a genuine and authentic fashion in order to help the client make meaningful change. Sensitivity to "teachable" or "therapeutic" moments is essential.
When To Use Brief Humanistic and Existential Therapies
These approaches can be useful at all stages of recovery in creating a foundation of respect for clients and mutual acceptance of the significance of their experiences. There are, however, some therapeutic moments that lend themselves more readily to one or more specific approaches.
The details of the specific approaches are laid out later in this chapter. Client-centered therapy, for example, can be used immediately to establish rapport and to clarify issues throughout the session.
Existential therapy may be used most effectively when a client is able to access emotional experiences or when obstacles must be overcome to facilitate a client's entry into or continuation of recovery (e.g., to get someone who insists on remaining helpless to accept responsibility).
Narrative therapy may be used to help the client conceptualize treatment as an opportunity to assume authorship and begin a "new chapter" in life. Gestalt approaches can also be used throughout therapy to facilitate a genuine encounter with the therapist and the client's own experience.
Transpersonal therapy can enhance spiritual development by focusing on the intangible aspects of human experience and awareness of unrealized spiritual capacity.
These approaches increase self-awareness, which promotes self-esteem and allows for more client responsibility, thus giving the client a sense of control and the opportunity to make choices. All of these approaches can be used to support the goals of therapy for substance abuse disorders.
Duration of Therapy and Frequency of Sessions
Although many aspects of these approaches are found in other therapeutic orientations, concepts like empathy, meaning, and choice lie at the very heart of humanistic and existential therapies. They are particularly valuable for brief treatment of substance abuse disorders because they increase therapeutic rapport and enhance conscious experience and acceptance of responsibility.
Episodic treatment could be designed within this framework, with the treatment plan focusing on the client's tasks and experience between sessions.
Humanistic and existential therapies assume that much growth and change occur outside the meetings. When focused on broader problems, these therapies can be lifelong journeys of growth and transformation. At the same time, focusing on specific substance abuse issues can provide a framework for change and more discrete goals. These techniques will also work well in conjunction with other types of therapy.
The opening session is extremely important in brief therapy for building an alliance, developing therapeutic rapport, and creating a climate of mutual respect.
Although the approaches discussed in this chapter have different ways of addressing the client's problems, the opening session should attempt the following:
Start to develop the alliance
Emphasize the client's freedom of choice and potential for meaningful change
Articulate expectations and goals of therapy (how goals are to be reached)
Developing the alliance can be undertaken through reflective listening, demonstrating respect, honesty, and openness; eliciting trust and confidence; and applying other principles that emerge from these therapies. The therapist's authentic manner of encountering the client can set the tone for an honest, collaborative therapeutic relationship.
Emphasizing freedom of choice and potential for meaningful change may be deepened by a focus on the current decision (however it has been reached) to participate in the opening session. Expectations and goals can be articulated through strategic questions or comments like, "What might be accomplished in treatment that would help you live better" or "You now face the choice of how to participate in your own substance abuse recovery."
Because of time constraints inherent in approaches to brief substance abuse treatment, the early phase of therapy is crucial. Unless the therapist succeeds in engaging the client during this early phase, the treatment is likely to be less effective. "Engaging" includes helping the client increase motivation for other aspects of substance abuse treatment such as group therapy.
Moreover, the patterns of interaction established during the early phase tend to persist throughout therapy. The degree of motivation that the client feels after the first session is determined largely by the degree of significance experienced during the initial therapeutic encounter.
A negative experience may keep a highly motivated client from coming back, whereas a positive experience may induce a poorly motivated client to recognize the potential for treatment to be helpful.
Compatibility of Humanistic And Existential Therapies and 12-Step Programs
Humanistic and existential approaches are consistent with many tenets of 12-Step programs. For example, existential and humanistic therapists would embrace the significance stressed by the "serenity prayer" to accept the things that cannot be changed, the courage to change what can be changed, and the wisdom to know the difference.
However, some would argue against the degree to which Alcoholics Anonymous (AA) identifies the person's "disease" as a central character trait, or the way in which some might interpret the notion of "powerlessness." The principles of existentialism, free choice, and free will may appear incompatible with the 12-Step philosophy of acceptance and surrender. Yet, such surrender must result from conscious decisions on an individual's part.
The AA concept of rigorous self-assessment--of accepting one's own personal limitations and continually choosing and rechoosing to act according to certain principles as a way of living life--are compatible with both existential and humanistic principles.
The predominant research strategy or methodology in social science is rooted in the natural science or rational-empirical perspective. Such approaches generally attempt to identify and demonstrate causal relationships by isolating specific variables while controlling for other variables such as personal differences among therapists as well as clients. For example, variations in behavior or outcomes are often quantified, measured, and subjected to statistical procedures in order to isolate the researcher from the data and ensure objectivity.
Such strategies are particularly useful for investigating observable phenomena like behavior. Traditional approaches to understanding human experience and meaning, however, have been criticized as an insufficient means to understanding the lived reality of human experience. Von Eckartsberg noted, "Science aims for an ideal world of dependent and independent variables in their causal interconnectedness quite abstracted and removed from personal experience of the everyday life-world" (Von Eckartsberg, 1983, p. 199).
Similarly, Blewett argued, "The importance of human experience relative to behavior is beyond question for experience extends beyond behavior just as feeling extends beyond the concepts of language" (Blewett, 1969, p. 22). Thus, traditional methodological approaches seem ill-suited for understanding the meaning of human experience and the process by which self-understanding manifests itself in the context of a therapeutic relationship.
A humanistic science or qualitative approach, which has its roots in phenomenology, is claimed to be more appropriate for the complexities and nuances of understanding human experience (Giorgi, 1985). The personal and unique construction of meaning, the importance of such subtleties as "the relationship" and the "fit" in therapy, and shifts in internal states of consciousness can be quantified and measured only in the broadest of terms. A more subtle science is required to describe humans and the therapeutic process.
Rather than prediction, control, and replication of results, a humanistic science approach emphasizes understanding and description. Instead of statistical analysis of quantifiable data, it emphasizes narrative descriptions of experience. Qualitative understanding values uniqueness and diversity--the "little stories" (Lyotard, 1984)--as much as generalizability or grander explanations. Generally, this approach assumes that objectivity, such as is presumed in rational empirical methods, is illusory.
For the qualitative researcher and the therapist, the goals are the same: openness to the other, active participation, and awareness of one's own subjectivity, rather than illusory objectivity. Intersubjective dialog provides a means of comparing subjective experiences in order to find commonality and divergence as well as to avoid researcher bias.
Because humanistic and existential therapies emphasize psychological process and the therapeutic relationship, alternative research strategies may be required in order to understand the necessary and sufficient conditions for therapeutic change. For example, Carl Rogers "presented a challenge to psychology to design new models of scientific investigation capable of dealing with the inner, subjective experience of the person" (Corey, 1991, p. 218).
Some 50 years ago, he pioneered the use of verbatim transcripts of counseling sessions and employed audio and video taping of sessions long before such procedures became standard practice in research and supervision.
The Humanistic Approach to Therapy
Humanistic psychology, often referred to as the "third force" besides behaviorism and psychoanalysis, is concerned with human potential and the individual's unique personal experience.
Humanistic psychologists generally do not deny the importance of many principles of behaviorism and psychoanalysis. They value the awareness of antecedents to behavior as well as the importance of childhood experiences and unconscious psychological processes. Humanistic psychologists would argue, however, that humans are more than the collection of behaviors or objects of unconscious forces.
Therefore, humanistic psychology often is described as holistic in the sense that it tends to be inclusive and accepting of various theoretical traditions and therapeutic practices. The emphasis for many humanistic therapists is the primacy of establishing a therapeutic relationship that is collaborative, accepting, authentic, and honors the unique world in which the client lives.
The humanistic approach is also holistic in that it assumes an interrelatedness between the client's psychological, biological, social, and spiritual dimensions. Humanistic psychology assumes that people have an innate capacity toward self-understanding and psychological health.
Some of the key proponents of this approach include Abraham Maslow, who popularized the concept of "self-actualization," Carl Rogers, who formulated person-centered therapy, and Fritz Perls, whose Gestalt therapy focused on the wholeness of an individual's experience at any given moment. Some of the essential characteristics of humanistic therapy are
Empathic understanding of the client's frame of reference and subjective experience
Respect for the client's cultural values and freedom to exercise choice
Exploration of problems through an authentic and collaborative approach to helping the client develop insight, courage, and responsibility
Exploration of goals and expectations, including articulation of what the client wants to accomplish and hopes to gain from treatment
Clarification of the helping role by defining the therapist's role but respecting the self determination of the client
Assessment and enhancement of client motivation both collaboratively and authentically
Negotiation of a contract by formally or informally asking, "Where do we go from here?"
Demonstration of authenticity by setting a tone of genuine, authentic encounter
These characteristics may prove useful at all stages of substance abuse treatment. For example, emphasizing the choice of seeking help as a sign of courage can occur immediately; placing responsibility and wisdom with the client may follow. Respect, empathy, and authenticity must remain throughout the therapeutic relationship.
Placing wisdom with the client may be useful in later stages of treatment, but a client who is currently using or recently stopped (within the last 30 days) may not be able to make reasonable judgments about his well-being or future.
Each therapy type discussed below is distinguished from the others by how it would respond to the case study presented in Figure 6-1.
Carl Rogers' client-centered therapy assumes that the client holds the keys to recovery but notes that the therapist must offer a relationship in which the client can openly discover and test his own reality, with genuine understanding and acceptance from the therapist. Therapists must create three conditions that help clients change:
- Unconditional positive regard
- A warm, positive, and accepting attitude that includes no evaluation or moral judgment
- Accurate empathy, whereby the therapist conveys an accurate understanding of the client's world through skilled, active listening
According to Carson, the client-centered therapist believes that
Each individual exists in a private world of experience in which the individual is the center.
The most basic striving of an individual is toward the maintenance, enhancement, and actualization of the self.
An individual reacts to situations in terms of the way he perceives them, in ways consistent with his self-concept and view of the world.
An individual's inner tendencies are toward health and wholeness; under normal conditions, a person behaves in rational and constructive ways and chooses pathways toward personal growth and self-actualization (Carson, 1992).
A client-centered therapist focuses on the client's self-actualizing core and the positive forces of the client (i.e., the skills the client has used in the past to deal with certain problems). The client should also understand the unconditional nature of the therapist's acceptance.
This type of therapy aims not to interpret the client's unconscious motivation or conflicts but to reflect what the client feels, to overcome resistance through consistent acceptance, and to help replace negative attitudes with positive ones.
Rogers' techniques are particularly useful for the therapist who is trying to address a substance-abusing client's denial and motivate her for further treatment. For example, the techniques of motivational interviewing draw heavily on Rogerian principles (see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999c], for more information on motivational interviewing).
Response to the case study
A client-centered therapist would engage in reflective listening, accepting the client and her past, and clarifying her current situation and feelings. As Sandra developed trust in the therapist, he would begin to emphasize her positive characteristics and her potential to make meaningful choices to become the person she wants to (and can) become. Another goal of therapy would be to help her develop sufficient insight so that she can make choices that reflect more closely the values and principles to which she aspires. For example, she may want to tell her husband about her symptoms and try to strengthen her marriage.
If Sandra began to feel guilt about her past as a prostitute, the therapist would demonstrate appreciation of her struggle to accept that aspect of herself, highlighting the fact that she did eventually choose to leave it. He may note that she did the best she could at that time and underscore her current commitment to choose a better life. Sandra would be supported and accepted, not criticized. She would be encouraged to express her fear of death and the effect this fear has on her.
This might be the first time in her life that someone has been unconditionally accepting of her or focused on her strengths rather than her failings. She apparently has the ability to solve problems, which is reflected by her return to therapy and her insight about needing help. By being understood and accepted, her self-esteem and sense of hope would increase and her shame would decrease. She would feel supported in making critical choices in her life and more confident to resume her recovery.