EXISTENTIAL THERAPY: an introduction. Emmy van Deurzen Background Existential therapy is a philosophical approach. It aims to help people get more clarity and perspective on their difficulties. It zooms in on the detail of a person’s predicament, following their feelings to connect to their deepest point of pain in order to understand what it is that matters most to them. Existential therapy highlights the contradictions and paradoxes in a person’s experience and places these issues in the wider context of the inevitable challenges of human existence. It facilitates a better grasp of life, greater engagement with the world and a sense of inner authority, passion and liberation. It does this by inviting the person to ask her own questions, considering her troubles from many different angles and by teaching her to think for herself in tackling each problem. Such thoughtfulness is arrived at by carefully following emotions, intuitions and the felt sense of what the person values in life. Philosophical clarity comes from understanding our own struggles with life against the background of the rules and tasks of human existence. The therapeutic encounter is based in calm presence and open dialogue. The therapist engages with the client in a conversation that is searching, often challenging and playful where possible. The therapist never imposes or prescribes, but opens up new possibilities, encouraging the client to discover her own ability to explore and make sense of life. The objective is always to tackle apparent contradictions, confusions, fears and anxieties, starting from personal hurt, doubt, despair or curiosity. The aim is that of achieving real depth of understanding and with it a renewed sense of purpose and direction. Existential therapy helps people to uncover hidden meaning and recover lost freedom and possibility. The objective is for a person to become more at ease in life and more capable of finding her own wisdom in dealing with life’s inevitable challenges. Development of the therapy Existential therapy has a long pedigree, going back to ancient Greek philosophers who helped people to live better lives by interrogating their difficulties and misconceptions (Deurzen, 2009). When Socrates dialogued with the young men of Athens, calling himself a philosopher or lover of wisdom, he helped them distinguish between the illusions and errors of judgement that made them go astray and the realities and clarity of understanding that could point them in the right way. Later philosophers such as Aristotle, the Epicureans and the Stoics developed entire schools of philosophical therapy, which evolved and refined talking interventions. Philosophy lost touch with this objective till the 19th century when philosophers like Kierkegaard and Nietzsche reconnected with this idea. Their work inspired many existential therapists, as did the work of 20th century philosophers like Heidegger and Sartre. But it was the 19th century methodology of phenomenology, founded by Brentano and Husserl and literally meaning the science of appearances, that provided the method of observation and description so invaluable to therapists and psychologists. Several psychiatrists, including Jaspers and Binswanger applied these ideas directly to psychotherapy at the start of the 20th century (Deurzen 2010). Heidegger’s phenomenology led to Medard Boss’ analysis of human existence or Daseinsanalysis and Sartre’s ideas inspired R.D. Laing’s work and that of many other therapists. Viktor Frankl, created a method named ‘Logotherapy’ or meaning therapy to help people discover meaning in experiences of suffering, as he did when confined in concentration camps during the Second World War. For the past decades the method has evolved rapidly, especially in Europe (Deurzen and Adams, 2011), through the writing of authors like Deurzen (2010) and Spinelli (2007) and in the United States through humanistic-existential therapists like Yalom (1981) and Schneider (2009). The creation of training schools for existential therapists like the New School of Psychotherapy and Counselling in London and the creation of the Society for Existential Analysis have further consolidated existential therapy as a method of choice for those who favour independence of thought (Cooper, 2003). Theory and basic concepts The worldview of existential therapy is that human beings are meaning and purpose seeking. It is our consciousness that allows us to rise above our troubles. We are not just organisms primarily moved by instincts, determined by our genes and programmed by cognitive concepts. While all these aspects of being human need to be taken into account, the emphasis of the therapy itself is always on the human capacity for overcoming problems and transcending suffering or trauma. Existential therapists assume that people are generally strongly motivated by a deep desire to live a worthwhile and purposeful life in which their actions not only make sense but are freely undertaken and aimed at consequences which are beneficial, productive and fruitful. But existential philosophy is not humanistic, i.e. it does not foreground or idealize human beings, nor does it place them above and beyond other forms of life. It recognizes that the universe of which human beings are only a very small part is a complex place, where we are subject to many diverse forces and givens that we can only influence in minor ways. This includes the realities of space and time, of birth and death, of gravity and movement, of ageing and weakness, of adversity and conflict, love and hate, labour, failure and guilt, all of which we have to learn to reckon with and take in our stride along the way. The forces of nature, the laws of society, the rules of psychology and the principles we want to live by need to be carefully considered, before we start to make choices in life. It helps to understand something of the apparent contradictions, tensions and paradoxes that seem to abound, if we want to get better at making order out of chaos, or learn to live in tune with the universal harmony. Existential therapy is a wonderful opportunity for a person to learn the value of their capacity for sensation, perception, memory, emotion, imagination, thought, experience and understanding. Therapy is the start of an experimental and adventurous exploration of human living. When people come to therapy they are usually feeling confused, lost, overwhelmed, hurt, despondent or lonely. Existential therapists engage with their state of mind and propose a joint exploration of the things that need to be done for the person to free herself and open her mind and her life. Existential philosophers recognize that objectives like perfection, blissful happiness, ideal love or celebrity life-styles are not realistic and invariably lead to further grief. It is however always possible and desirable to help a person discover and develop their capacity for perfectibility and for productive, loving and diligent living. Existential therapy celebrates the enterprising spirit of each person who wishes to take stock of life before opting to take a new path at the crossroads of their daily existence. Existential thinkers do not see depression and anxiety as negatives or symptoms of mental illness that have to be cured. Rather they view these as necessary experiences in the process of becoming a complete, sensing-thinking-feeling-intuitive human being. Anxiety is inevitable, as it is the rising of our energy in the face of a new challenge. We cannot live without exposing ourselves to anxiety and we have to be prepared to use the energy of anxiety and take action. When you feel your heart beating with apprehension about the dangers in the world you know that life is asking something of you and that you need to find an effective way to respond to this challenge. We can all learn to heed these signs and benefit from this renewal of our energy. Anxiety primes our capacity for action unless we try to suppress it, remaining frozen in forced passivity, so that the energy of our anxiety starts looping in on itself and turns to panic, which is anxiety without purposeful action. Anxiety when employed effectively leads us towards engagement with the world and helps us to focus on the goals we set ourselves. This creates both movement towards feeling high and the tightness and tiredness of the stress that this naturally implies. Conversely depression is the feeling of coming down from something we had hoped for, worked towards or valued and it is associated with the loss of that value. When our energy dips away from effortful work towards our chosen objectives we feel low, which comes from a sense of disappointment, disaffection or distress. But when we learn to let go and relent, it may begin to feel like a kind of relief and release instead. It is also a preparation for a renewed bout of anxiety and energy as we lift our eyes and spirit towards a new goal, after a rest. All human living is cyclical and rises and falls. We cannot stay on the heights or with the peaks of achievement or happiness all the time, as we would totally exhaust ourselves. What goes up must come down and so the relaxation of loss and depression are equally necessary and can be experienced as not only restful but also as helping us to penetrate into the roots of our lives, where we can reconsider what we value and what really matters. We will then be better equipped next time to take the ride of our anxiety fuelled energy towards a brand new, or slightly reshaped and newly understood, objective. When people live fearfully they are afraid of their emotions and of the actions and experiences in the world that evoke them. Angst, or existential anxiety is a good indication that we are awakening to life. When we begin to see the wisdom of our own sensations, emotions, thoughts and intuitions we can learn to follow the flow of their natural course up and down with the rhythm of life. The human capacity for conscious understanding makes all the difference and gives us courage. We can make sense of all this intensity and all this confusing and complex experience that might otherwise either leave us perplexed or desirous to switch off and hide away from the world in a cocooned existence. Of course most of us will try all these methods sooner or later and unless we have the clarity of sight to understand what we are doing and where we are going wrong or what targets we may want to reach and how we might improve the way we are living we might be put off our own lives and feel sick of living and desperate, to a greater or lesser degree. In the extreme we may even want to die, fall ill, or escape from the world entirely by committing suicide. Existential therapists are very much at ease with such strategies and such existential crises. They know that people often have to come to a halt and experience dark nights of the soul, in fear and trembling, before they are able and willing to start thinking more carefully about their life. Such suffering matures a person, in the same way in which losses can break our hearts and open those up like the soil clots torn asunder in winter, ready for new growth in spring. Where we feel hurt and upset and bereft and broken we become human and capable of aspiring to goodness and kindness and wholesome productive efforts to live a better life. In our distress we come to ourselves for the first time and we learn that we can be aware of ourselves and of the world in a constructive manner to make life work better. We need to make mistakes to learn and while we may sometimes regret the past or the person we are, reflecting on this tells us what we do want to aim for. If the world seems unfair or harsh, we can learn how to contribute to a more fair society or family life. Existential therapists help people to evaluate reality and learn from life. Practice Existential therapists are trained, not just by studying philosophical theories but also by living intensely themselves to discover how to make use of ideas in practice. Training also teaches the insights and dialogical methods to engage effectively and productively with all the upsets, problems, disappointments, suffering, despair and defeats that people will bring to their therapist. To be an existential therapist is to be fully present with the other, open to both the person’s distress and her purpose and values. Existential therapists make themselves fully available to engage with the issues and aim to help the client come to grips with them and really understand what it is they are struggling with and how they may struggle more effectively. The first port of call is to learn to be co-present with the other in order to encounter the other with clarity and openness and candour. Then we aim to listen with kindness and firm attention as clients unfold their stories undisturbed. Existential therapists work with dialogue, in a friendly and open exchange where warmth and a companionable searching for truth is the established modus operandi. An existential therapy will usually include some of the following elements of theory and method. Time: Existential therapists trace a person’s evolution through life, from past through to the present and into the future. Philosophers are aware that all dimensions of time are important and need to be taken into account. A person will often also want to consider what their view of eternity or timelessness is. This exploration will bring out the values and beliefs of the person. Both past and future come together in the present and are altered by being re-considered and reconfigured. A person is dynamically transforming at all times. As soon as she begins to become more aware of this, she can more effectively steer the changes in the direction she wishes to take. The story of a person’s life needs to be woven together in such a way that she feels ownership over it again and recovers her authority to take charge of it. Worldview: Existential therapy is mindful of the way in which each person has come to see and interpret the world. This personal outlook is made explicit and engaged with. The person is helped to see how her worldview alters and colours the world. The therapy takes shape when it becomes more obvious how the person’s lens on the world might be sharpened or softened and how her knowledge and comprehension can be extended. This work often starts by helping people spot the unspoken assumptions that they operate with. Fourfold world: The work is aided by the mental map of the challenges of human existence that we all have to contend with on the different dimensions of our lives. The fourfold world is composed of: Our bodily existence in a physical environment, where we learn to manipulate objects, get to know and develop our own bodies and interact with the bodies of others, as well as with the wider natural world and even the global background of the cosmos. Our interpersonal existence with other people in a social world, where we have to build a sense of ego, in relation to the expectations of society, but where we also learn to love and be loved, to stand up for ourselves and to respect other people. Our personal existence where we come to feel at the centre of ourselves and get to know our own character and personality, our strengths and our weaknesses and learn to hone our talents and accept our limitations. Our ideological or spiritual existence in relation to the values, beliefs and ideals that we form for our own existence, guiding our choices and our evaluation of what we do, feel and think. Here we contend with the rights and wrongs of life and the challenges of good and evil. Paradox: At each of these levels and dimensions of existence we learn to grapple with the contradictions, conflicts and dilemmas thrown up by life. We can expect on-going tensions at all levels and need to learn how to take these in our stride. The more we learn to trust that we can solve any problems that daily life throws at us and the more life will seem like an adventure, where challenges make the journey more interesting. Some philosophical contemplation will often reveal that the avoidance of these problems inexorably creates bigger problems, whereas each time we face a challenge, the advantage is on our side. So, for instance we discover that to love another person requires us to allow our doubts and disagreements and even our feelings of disillusion or hatred for them rather than deny these negative feelings. As long as we avoid the idea of death, we will fear illness and do anything we can to avoid it, but make ourselves unwell in the process. When we face up to what it is like to live in relative poverty, we learn to appreciate material comforts in a new way. Allowing ourselves to explore the extremes of life makes us more flexible and able to see what is real. Dialectic progression: What existential therapy often shows is how such contradictions and opposite polarities lead to dialectical progression. This means that we learn to walk forwards by balancing our weight from one leg to the other. Progress is made by being light on our feet and allowing opposites to create a forward movement. The main thing is to know which direction we want to go in and to learn to make sense of apparent contradictions and surpass these, while retaining the lessons learnt on each side of the equation. Emotional Compass: Our emotions are essential in the process of recognizing what is good and bad for us, what we value and fear. They show us the way towards the things that are best and they also show us how to make the most of the times when we deal with the loss of value. The emotional compass shows how each feeling points in a particular direction, towards or away from a value, towards or away from our feeling high or low. Feelings are really about values and meanings. Feelings show us the way, but our reflection helps us refine the values that are worth working towards. Figure 1 Values and Purpose: It is when we understand our values and have a chance to think them through, that we can notice not only what we desire, but also what is important to us and what we are good at and have special talent for. It is important to learn to make a realistic assessment of who we are and what we are capable of and can contribute to the world. People feel a great deal more satisfaction if they have purpose and meaning and a readiness to take right action towards things that are not only good for themselves but also for other people. Engagement and meaningful living: This is how existential therapists aim to encourage clients to reengage with life in a more effective and more satisfying way: they help them become more self reflective and more aware of the advantages of their own consciousness and ability to make the most of their lives. They help them put their lives into context and perspective so that they can be more connected and meaning emerges. Freedom and Responsibility: There is always a strong moral aspect to the work. People, rather than becoming selfish in their pursuit of freedom and purpose, learn to think for themselves, weighing the choices and options available to them, daring to be different and self-motivating. But there is no real freedom without answerability. Existential therapists are always aware of the impact each person has on the world and they challenge clients to be responsible towards themselves and those around them, checking the effect and consequences of their actions. Truth: The change process comes about when clients learn the skills of attunement and understanding that help them become aware and more observant of their own feelings. This applies also to thoughts, sensations, intuitions and actions. People learn to review their experiences as well as their ideas and also to check their impact on the world around them. The touchstone of progress in therapy is always the truth about what is actually the case in reality. Clients will soon discover that truth is by far the best test for progress in life. And while it is always aimed for in therapy, in truthful modesty both therapist and client will recognize that we rarely know the whole truth about any matter. We have to keep asking questions. Format of session Sessions are open ended and conversational in nature, usually lasting 50 minutes. The therapist brings knowledge and wisdom about life and a spirit of open-minded discovery. The atmosphere of a session is always serious though friendly and warm hearted and humorous when possible. Therapists seek to encourage and empower and learn to stand back in favour of the client’s own lights whenever possible. Creativity is encouraged. Which clients benefit most? Existential therapy is particularly indicated for anyone who is going through a life crisis or who has suffered a loss. It is also very effective with people who are going through a normal life change or transformation, i.e. teenagers, young adults, those wondering about having children, people in midlife crisis, those considering retirement or people coming to terms with old age or the challenges of illness and death. People who have migrated to a different country or region and who feel estranged from their environment also benefit enormously from existential therapy as it allows them to consider their position in the world and get some perspective on their situation. Those who feel a sense of social alienation, either by being lonely or not fitting into their reference group for specific reasons, for instance because their life story is different to that of most other people around them, may also find this way of considering their problems helpful. But the existential approach has a long history of working well with much more challenging mental health issues too. It is almost essential to come from an existential angle when approaching someone who is suicidal or who feels desperate about life. The isolation, anxiety and withdrawal of people with autism can also be understood very well with a more philosophical approach, which does not pin the person down as suffering from a particular pathology but helps them deal with life from the position they find themselves in. Schizophrenia, as described by existential therapist R.D. Laing (1965), can be tackled from the perspective of a person’s alienation from their family and from themselves. Existential work will always emphasize a search for meaning within the realistic parameters of a particular person’s life situation. Existential therapy should not be considered the first port of call when someone is not very interested in reflection or self-reflection or wishes to be treated from a more medical or positivist perspective. When medication and symptom resolution are desired existential therapy is not the best method. However, existential aspects of a person’s troubles may usefully be highlighted alongside other issues and some existential explorations alongside other methods, say CBT or a more person-centred or problem solving based way of working may go a long way in helping a person find a new way of viewing their life situation. Case study The Client Lizzie is a nurse in her mid twenties, who finds herself in a terrible quandary, as she feels unable to carry on with her hospital duties after the death of her mother in the same hospital and ward. She has been very close to her mother and has lived with her for her entire life up to the moment of hospitalization. As soon as her mother went into hospital, Lizzie felt paralysed and panicked at the idea that some of her colleagues would be looking after mother. Though she visited her mother on the ward regularly, she felt unable to work there and had to take sick leave. By the time she comes for therapy she has been off sick for eight months and she is very worried, as her sick pay has been reduced. The personnel department has required her to have a medical assessment and the doctor she has seen has referred her on for therapy for what he terms a diagnosis of complex grief. Lizzie is somewhat reluctant and sceptical but at the same time expresses her sense of relief at finally being able to talk about something that she ‘cannot make head or tail of but which has totally grown over her head’. These are striking expressions, especially as a little later in the session she speaks of mother’s illness as having ‘messed with her head’. When the emphasis on the word ‘head’ is mentioned, she immediately states that she believes that ‘mom’s done her head in’. When asked whether she means that it is mom’s death that has done her head in, she hesitates and says ‘I suppose’. When I point out that she does not seem sure about this, she falls silent. I say: ‘is it mom’s death that’s the problem, or mom herself?’ She shamefully admits that she feels relieved that mom is gone and she no longer has to look after her. ‘She was a bit of a handful, you know. I could not really do what I wanted while I lived with her’, she says with a red face and in a rather frightened and contrite tone. ‘You sound like you feel guilty to feel relieved’, I observe mildly. She nods ponderously, moving her head up and down very slowly and very affirmatively. She tells me she can’t go to work because everyone there now claims to like her mother so much and to have made such a great connection with her before she died. She really does not want to be there and be reminded of mom. She also wants to savour the experience of being alone at home and having the place to herself. She needs to keep doing this until her head has cleared, she says. She has hardly seen anyone since her mother’s death. For there is so much to think about and so much buzzing around in her head that she cannot afford to share it with anyone. While others think she has collapsed into grief and mourning and can’t manage without mom, she is actually just feeling like she is taking time to settle herself. When I say: ‘You seem to know what is right for you. You are doing something very important, a bit like giving birth to yourself’, she stares at me for a short while before tears start trickling down her face. She has tried so hard to explain to herself what was happening and here it is. She has never felt as if she could really be herself, truly be alive and now that mom has died, this is her moment. She needs to catch up with herself and find out what her own head is made of. She has put her colleagues off visiting her when they offer and she has no other friends and no siblings. The Therapy The story now emerges slowly and will be elaborated on over the next weeks as we discuss her situation. Her father left her mother when Lizzie was two years old and she has never seen him since, though he has sent her birthday cards and presents every year. She had a boyfriend, Richard, for a couple of years when she was eighteen and nineteen, but had to end the relationship eventually when Richard wanted to move in together. She never had sex with him and was afraid to lose her virginity. Mom was always very dismissive about sexuality and warned her not to make the same mistake as she had made. Lizzie is shocked when she discovers how hurtful and controlling mom’s remarks often were. Mom had always made it clear that Lizzie owed her total loyalty, having been such an imposition on her. Lizzie had felt she needed to sacrifice her relationship to Richard, since mother needed her more than Richard did. At first she says she has no regrets as Richard is now happily married to one of her colleagues. She lost touch with them. Then, in a sudden burst of anger, she remarks that they did not even bother to come to her mother’s funeral. She sounds very upset about this and she becomes tearful speaking about it. As I point out how strongly she actually seems to feel about losing Richard, she sobs bitterly about losing him. She agrees that in spite of her quickly given forgiveness, she actually felt very slighted by him. It was as if she had not mattered. He didn’t fight or help her leave mom. He just married someone else instead. Now her value becomes clear: she had longed for someone to let her feel that she mattered and Richard instead rubbished her and messed with her head. She is devastated at the loss of the relationship, because it meant the loss of herself. What has made it so hard to cope with mom’s death is that her feelings became so confused in the process. She suddenly felt resentful of the way in which mom had prevented her independence and her chance of happiness with Richard. But she also felt inhibited to let herself think this. She tried to forgive both mom and Richard, but faltered and failed and felt hopeless about that. Lizzie agrees that she is mourning the lost years of her own life every bit as much as the passing of her mother. In the next session she will offer me the notion that now that mother is dead she could finally have had a relationship with Richard. What really does her head in is that she can’t make sense of this. Why did mother not die sooner so that there was still time to work things out with Richard? She is confusing herself about the situation and going around in loops. She feels very reassured when I invite her to stick with her feelings and intuitions and leave aside all the judgements for the moment. She finds it much easier that way to stay true to herself. She begins to see that she has been divided against herself and has tried to impose thoughts and feelings on herself way too much. Now she feels it is actually possible to get her own head sorted out. And what she means is to get clarity about how she actually feels about things and to know what it is she actually values. She even laughs when this becomes crystal clear. She chuckles that everything else will be easy. As Lizzie engages with the therapy more deeply she soon begins to feel a sense of safety in expressing her contradictory emotions. What we quickly recognize, together, is that she is afraid of her own feelings of wanting things for herself and becomes paralysed each time she begins to feel something deep inside of her pushing her towards desire, longing and self affirmation. At those moments she freezes and withdraws. This happens also in the sessions. It is as if mother has placed a taboo on her that she has fully accepted as the foundation of her existence. She is not allowed to feel any selfish feelings. Even now that mother is gone, she feels she has to uphold this general principle. It is a principle underpinned by a strong sense of religion as well and we talk much about her beliefs. She feels it is too late to change her way of being now and that mother is probably still watching her from somewhere up in heaven, expecting her to be good and caring instead of selfish. When asked to define what it means to be selfish, she describes it as having feelings of longing and yearning for something for herself. Loving Richard was the prototype of such selfish longings. She rejects the idea that it is about sexuality. She thinks it is about love. Secretly she wants to be able to love and be loved, but she feels she has wasted her opportunity by sacrificing Richard to the care of her mother. She admits to having misgivings about this now. Did she make a mistake? Should she have chosen for Richard instead of for her mother? She knows full well that it would not have been possible to go off with Richard when mother needed her so much. It would have been the death of her. Even now it still ‘messes with her head’ to let herself think such things, she says. She feels a buzz in her brain and a sensation of the brain becoming blocked and frozen as soon as she imagines the possibility of having abandoned her mother to go live with Richard. It takes a long time for her to accept that she is constantly working from the presumption that there had to be a choice and a total commitment one way or the other. Was it not possible for her to be with Richard and also still look after her mother, sufficiently to do right by her, but not so much as to do wrong by herself and Richard? Her brain is very full with this tempting idea for a bit, but she can’t get her head around it, she says. She looks slightly excited and tells me she feels quite ‘heady’ when she leaves. The next week it becomes clear that Lizzie is afraid that she will lose her identity and her very worth if she starts acknowledging her own feelings, let alone act on them. She can’t quite work out whether it is allowed to try to find solutions and combine different needs and demands to come to a conclusion that suits many people and different values. So, we begin to have philosophical discussions about morality and trace the assumptions about life and human beings that are holding her back and doing her head in. Changes made The work with Lizzie becomes relatively straightforward once she engages with the exploration of her own values and worldview. It becomes easier for her to understand why she was muddled and what it was that stopped her from moving on. She felt so very guilty at feeling so much relief at her mother’s death and at having failed to look after her while she was in hospital. She felt mortified and required to punish herself for it. It was as if she had just dumped mother there, on her own colleagues. She felt she must be a bad person for giving up on mother as soon as she had the chance of doing so. She also felt deeply flawed for falling ill and staying home for so long. Initially Lizzie feared that she was mentally ill because of the muddle in her head, but gradually she discovers that this wasn’t it at all the case. She begins to see that she has done what she needed to do, in order to sort things out for herself. Not going to work for a while may have been necessary, but is no longer required now as she is beginning to understand. She has done what she really wanted to do: stay at home, taking time for herself and refuse to be the ‘good girl going out to work being a nurse, with all the caring that the job implied’. The real break through is that she accepts that this was a good thing and the only way she could deal with all the confusion and hardship of the past. Now she is finding out who she is at last. One thing she knows from the guilt she is still feeling is that it matters to her to be productive and part of the world. Another thing she knows from the grief over Richard, is that she would value being in a relationship in a real way. For all these years she has been her mother’s good servant and has done someone else’s bidding. Now she has affirmed her own need to take charge of her own life. Translating Lizzie’s experiences into language that is reassuring brings great changes in her. She is learning to loosen up and let herself feel just exactly what she feels, without trying to gag herself or put herself into the straight jacket of thinking like mom or the religion she still holds on to. She is allowing herself to feel and to think and so of course learns to feel and think more and more clearly with a bit of help. She discovers that she has very strong morals and intuitions about wrong and right, but that questioning the very tight moral framework of her mother and her fundamentalist church makes her more rather than less able to find her moral compass. Much of my work simply consists in encouraging Lizzie to speak her mind and to express every feeling, worry, fear, anxiety, hope and disappointment she has experienced in her life. Sometimes I have to add a bit of educational material, such as saying ‘if you don’t allow yourself to think what you need to think about, your brain seizes up, for you are giving it contradictory instructions’ or ‘there is no harm in wanting your freedom and if your mother had been able to let you be free she would have been delighted and might have found some freedom for herself as well’. While Lizzie is occasionally a little shocked by such plain speaking, she learns to laugh at irreverent statements and shows a delicious sense of humour of her own in talking about the way she has been her own jailor. It is good when she stops blaming things on mom and Richard and takes charge of her own decisions, both in the past and the present. She becomes very clear about her own value system: she does want to be a good person, who cares for others, but not at the expense of herself anymore. It’s not rocket science how to put this into practice and she is keen to start experimenting and decides to go back to work. Virtue is no longer about cyphering herself away, it is about being fair to all concerned; to others as much as to herself. Her head is clear and she can think through any challenges rather effectively, with a little bit of help from therapy, but under her own steam, nevertheless. Discussion The Client: Lizzie, over the sixteen months of therapy, learnt to value her own existence in a new way. She began to want so many things that there was no time for regrets and withdrawal anymore. She recognized that she had been paralysed by her desire to serve and be good on the one hand and her desire to live and to be free to love and be loved on the other hand. She let go of her obsession with Richard as soon as she heard that Richard’s wife (a colleague of hers) was miserable in the marriage. She did not envy her. She said it would have been like jumping from the frying pan into the fire to marry Richard. He would have exploited her even more as he was now doing with her friend. It was harder for her to evaluate her relationship to her mother. She could never say that mom had exploited her goodwill, but she did realize that mom had been caught in the same trap as herself: hiding away and trying to be good by not spending much time with others. That was enough and it allowed her to remember some of the good things she and mom had shared. She became freed enough to speak about mother’s limitations and the harm they had brought upon them both. She now wanted to make sure she would not continue to do such things and she wanted to learn to keep her brain free to think for itself. To this effect she decided to take a course in mental health nursing, which her employers decided to support her in doing by giving her day release from her job whilst placing her in another department of the hospital. As soon as Lizzie began her training, her attitude to life changed and something further was released in her. She began to dress in a more relaxed and contemporary manner and started to make new, much closer friends. The Therapy Initially the work was about creating a strong enough relationship with Lizzie for her to trust that she could speak her mind and would not be judged or berated. This was essential to break the stalemate in her mind, which paralysed her. Initially all my interventions were enabling and had the objective of releasing her tension about herself. This was done by reassurance as well as by challenging some of her false assumptions. It was also done by showing her how life works and using evidence from her own descriptions to help her acquire a picture of the way she was stopping and freezing herself in an untenable position. Then the work moved to a phase of philosophical explorations of egoism versus altruism and of the examination of moral values and virtues versus sins. At this point it was important not to make any value judgements about Lizzie’s belief system, even though it was still very tight and fearful at that time. Lizzie was shown how she could gradually begin to question her own assumptions and make a little bit of room for doubt or alternative views. It was all about helping her claim the freedom to be herself. Approving of the ways in which she had tried to do this (by falling ill, by not nursing mother in the hospital and by shunning her friends for a while) rather than showing all these actions and attitudes to be pathological was a sure fire way to help her relax into understanding and being compassionate with herself. What mattered more than anything was to show her that she had been more expert about what had been wrong in her life than she dared to admit at first. She soon felt that her ‘head opened up’ and at that point it was essential to give her back the authority to think for herself. She discovered with a bit of encouragement that her intuitions and feelings were spot on and would help her to find the right track. By allowing Lizzie to feel good about herself and the opportunities now available to her, she saw the new paths ahead of her and could not wait to take them. References Cooper, M. (2003) Existential Therapies, London, Sage Publications. Deurzen, E. van (2009) Psychotherapy and the Quest for Happiness, London: Sage Publications Deurzen, E. van (2010) Everyday Mysteries: Handbook of Existential Therapy, London: Routledge, second edition. Deurzen E. van and Adams M. (2011) Skills in Existential Counselling and Psychotherapy, London: Sage Publications. Laing, R.D. (1965) The Divided Self, London: Penguin. Schneider, K.J. and Krug O.T. (2009) Existential-Humanistic Therapy, Washington D.C.: APA. Spinelli, E. (2007) Practising Existential Therapy: The Relational World, London: Sage Publications. Suggested Reading Adams, M (2013) Existential Counselling in a Nutshell, London, Sage Publications. Cooper, M (2012) The Existential Counselling Primer, Ross on Wye: PCCS books Deurzen, E. van (2012) Existential Counselling and Psychotherapy in Practice. Revised Third Edition. London, Sage Publications Yalom, I. (1980) Existential Psychotherapy. USA, Basic Books. Discussion Issues Is happiness the true objective of existential therapy? What is the role of time in existential therapy? How might an understanding of the idea of paradox improve human existence? What does it mean to say that the practice of existential therapy is philosophical?