Existential therapy: empirical evidence and clinical applications from a Christian perspective.

Tan, Siang-Yang ; Wong, Timothy K.

Existential therapy is a philosophical approach to psychotherapy. It focuses on meaning, freedom, authenticity, and self-awareness in the present moment. This article will cover the empirical evidence for the efficacy or effectiveness of existential therapy and its clinical applications from a Christian perspective.

History and Theory

Existential therapy is rooted in existentialism, a philosophy concerned with the meaning of human existence. The tenets of existential philosophy serve as the foundational blocks that drive the theory of existential therapy. Therefore, existential therapy can be considered as both a philosophy and model of therapy. Instead of existing as a unitary modality of therapy, existential therapy encompasses the diversity and variety within existential thought. Thus, "existential psychotherapies" may serve as a more accurate description of the approach (Walsh & McElwain, 2002, p. 254). Nonetheless, this article will use "existential therapy" to refer to the methods of therapy based in existentialism (see Tan, 2011, pp. 102-127).

Existential therapy was strongly influenced by philosophers such as S0ren Kierkegaard (1813-1855), Friedrich Nietzsche (1844-1900), Martin Heidegger (1889-1976), Jean-Paul Sartre (1905-1980), Martin Buber (1878-1965), Gabriel Marcel (1889-1973), Paul Tillich (1886-1965), Edmund Husserl (1859-1938), and Karl Jaspers (1883-1969). Collectively, their work challenged society to consider the purpose and meaning of human existence. Influential psychiatrists and analysts who contributed to the formation of existential therapy include Ludwig Binswanger (1881-1966), Medard Boss (1903-1991), Viktor Frankl (1905-1997), Rollo May (1909-1994), James Bugental (1915-2008), and Irvin Yalom (1931-). Each pioneer of existential therapy uniquely integrated existential thought into their work with clients, bridging the gap between philosophy and psychology. Despite each key figure's distinctive existential perspective, they converged on views of human nature and theory of personality.

The existential perspective on human nature emphasizes individual freedom to choose one's values and meaning in life. Through the process of defining values and discovering meaning in life, human beings are faced with basic existential questions such as "Where have I come from? Why am I here? Where am I going? What do I value?" (Mendelowitz & Schneider, 2008, p. 299). Existential therapy does not view human nature as fixed, fatalistic, or deterministic; rather, individuals are seen as constantly changing and evolving in accordance with their values and meaning in life. Future aspirations, past experiences, and goals influence each individual. Yet, it is awareness in the present moment that allows one to choose freely and responsibly to that which he or she is becoming. Thus, existential therapy views humans as having a dynamic nature due to one's freedom to choose values and meaning in the present moment.

Personality is understood as existing as being-in-the-world, or Dasein. One's being and existence in the world coalesce according to the unique way in which he or she perceives and constructs it. There are three dimensions or levels of existence that describe one's relation to the world (i.e., being-in-the-world): Umwelt, Mitwelt, and Eigenwelt (Binswanger, 1963; Boss, 1963). Umwelt (physical dimension) refers to the physical, biological, and natural environments. Comprising both animate and inanimate

objects, this includes attitudes toward one's body, natural surroundings, and material possessions. Mitwelt (social dimension) refers to how individuals relate to others in the world. This includes interaction with the culture, race, gender, and class one belongs to. Eigenwelt (psychological dimension) refers to one's inner, personal world. It involves individuals relating to themselves through their subjective experiences, perceptions, evaluations, and reflections. Van Duerzen-Smith (1997, 1998) added an additional dimension, Uberwelt. Uberwelt (spiritual dimension) refers to one's pursuit of a philosophical outlook or ideology and often has a religious or spiritual basis. It relates to an ideal world that one desires to live in (see Sharf 2008, p. 153).

A healthy existence involves authentically maintaining harmonious, integrated, and spontaneous relationships with all four dimensions. Such authenticity entails transparency, honesty, and openness to oneself in the midst of relating to the four dimensions. However, an authentic interaction requires a level of awareness that produces an experience of dread, or existential anxiety (Tillich, 1952). Sources of existential anxiety include death or nonbeing, the need to act, meaninglessness, and isolation or aloneness. Known as existential givens or basic contingencies of life, these sources of existential anxiety point to our finiteness. Rather than being overwhelmed by finiteness and nonbeing, a healthy and adaptive individual embraces existential anxiety. The individual realizes that existence is an ongoing, cyclical process of nonbeing to being. Thus, out of death, meaninglessness, and isolation come life, meaning, and intimacy, respectively. Authentic being, then, occurs in the present moment through authentic experience in the world where one exercises his or her freedom to choose.

Psychopathology results when one avoids existential anxiety and nonbeing. The development of psychological problems also occurs with people who live inauthentically; that is, they lie to themselves. As Prochaska and Norcross (2010, p. 101) state, "Lying is the foundation of psychopathology," from an existential perspective. Psychopathology is often associated with imbalanced levels of being-in-the-world. For example, an overemphasis on one level of being-in-the-world accompanied by a disregard for other dimensions may lead to neurotic anxiety. Lying occurring on any dimension of being-in-the-world often results in the development of psychological problems. For example, such psychopathology is seen in an individual with hypochondriasis who lies to himself about the condition of his physical body (physical dimension) or a workaholic who believes the lie that she can work to gain self-approval (psychological dimension). Psychopathology results in individuals who fail to be authentic with themselves by avoiding existential anxiety and nonbeing.

Existential therapy has four major treatment goals. First, clients are encouraged to embrace their freedom to choose and act responsibly. Second, existential therapists assist clients to grow in self-awareness. Third, meaning and purpose of the client's life is explored. Fourth, clients are encouraged to let go of self-deception, in-authenticity, and lying in exchange for authenticity and being truthful to oneself. Naturally, authenticity is the fundamental goal of existential therapy (Cooper, 2003). Core issues surrounding existential therapy include living and dying (grieving losses and authentically accepting mortality); freedom, responsibility, and choice (using one's freedom to take responsibility for one's actions and choices); isolation and intimacy (courageously reaching out to others to develop mutual and reciprocal relationships); and meaning and meaninglessness (discovering meaning from existential realities of meaninglessness or emptiness in life).

The therapeutic relationship is an essential aspect of existential therapy. It represents a warm, respectful, and authentic relationship in which the client and therapist experience a deep therapeutic encounter (May, 1958). The relationship exists to explore, examine, and elucidate deep, existential issues. Martin Buber (Sharf, 2008, p. 163) described this genuine relationship as an "I-Thou" relationship while Yalom (1980, p. 207) referred to it as a "loving friendship." This therapeutic relationship is the source of healing (Yalom, 1980). Generally, existential therapists do not emphasize specific therapeutic techniques or interventions. In fact, some therapists believe that techniques objectify clients and their problems, preventing clients from subjectively experiencing themselves and the therapist in the present moment. Existential therapy is often long term due the nature of its therapeutic goals and emphasis on the therapeutic relationship. Issues of transference may be interpreted. However, transferential interpretations are not a focus as they may interfere with the development of an authentic therapeutic relationship and encounter (Cohn, 1997).

Empirical Evidence

Existential therapy research studies are limited. Generally, existential therapists do not conduct controlled outcome studies evaluating the effectiveness of their approach. As to date, there have been no controlled outcome research studies conducted on the effectiveness of existential therapy (Prochaska & Norcross, 2010). Research on existential therapy is often conducted in the form of "eloquent case studies" (Schneider 2003, p. 169). It must be noted that existential therapy may not be well-suited for the traditional, predominant research strategy of social science that is heavily rooted in methodology (i.e., isolating variables while controlling for others to demonstrate causal relationships). For example, the meaning of human existence, self-awareness, and authenticity may be difficult to quantify. A qualitative approach that closely examines the nuances and subtleties of human experience and meaning may be a more suitable research method for existential therapy.

Several studies have generally been supportive of the effectiveness of existential therapy. However, such studies incorporated components of existential therapy, integrating it with other therapies. Schneider (2003) argues that there is empirical support for the effectiveness of existential-humanistic therapy that incorporates major existential concepts such as the therapeutic relationship and the therapist's personality or presence (see Mendelowitz & Schneider, 2008, p. 317). Mosher (2001) compared therapeutic outcomes of patients with schizophrenia who were treated with an existentially based growth-oriented treatment with patients treated with conventional psychiatric treatment or medication. The existentially based growth-oriented approach focused on providing caring, empathic, and supportive relationships. The outcome measures were focused on psychopathology, rehospitalization, independent living, social functioning, and occupational functioning. Patients with schizophrenia treated with the existentially based growth-oriented treatment achieved better therapeutic outcomes. Although the findings of some of these studies are promising, it is difficult to ascertain the effectiveness of existential therapy as a standalone approach as it has been lumped together with the broader range of experiential and/or humanistic therapies (e.g., Carl Rogers's person-centered or client-centered therapy and Friz Perls's Gestalt therapy).

The therapeutic technique known as paradoxical intention (helping the client overcome a feared behavior by exaggerating or following through with the behavior), which is used in Frankl's logotherapy, one approach to existential therapy, has been examined empirically. Meta-analyses of research studies have shown paradoxical interventions to be equally, but not more, effective than other treatment interventions. The main effect size compared to no-treatment controls was 0.99. Thus, a client receiving paradoxical interventions would experience greater improvement than 84 percent of clients receiving no treatment (Hill, 1987). One meta-analysis found paradoxical interventions to be more effective than other typical treatments on more severe cases of pathology (Shoham-Salomon & Rosenthal, 1987). However, these empirical findings are from outcome studies of paradoxical intention but not logotherapy or existential therapy per se.

Existential therapy has the possibility of effectively treating various populations and disorders. Various case studies and theoretical articles have contended that existential therapy has the potential to effectively treat older adults (Suri, 2010), violence survivors with post-traumatic stress disorder (Day, 2009), and trauma survivors (Corbett & Milton, 2011). Existential therapy may be well-suited for clients who present with spiritual issues (Bartz, 2009), sexual issues (Barker, 2011), and cultural issues (Felder & Robbins, 2011). In reviewing research on existential therapy, Sharf (2008) argued that existential themes are easily conveyed in existential group therapy. Research has also explored existential concerns such as death, meaninglessness, and discovering meaning in life through the use of the Purpose in Life Test (Crumbaugh, 1968; Crumbaugh & Henrion, 1988). These theoretical articles provide an initial step toward achieving a comprehensive understanding of an empirically sound, existential therapy.

There have been attempts at integrating existential therapy with empirically supported psychotherapies. Such endeavors may orient existential therapy toward the more quantitative, traditional, research strategy. However, integrating existential therapy with empirically supported psychotherapies no longer presents a pure form of existential therapy. In his theoretical article, Langdridge (2006) argued for integrating existential therapy with solution focused therapy. Existential therapy can benefit from solution focused therapy's emphasis on enabling clients to discover their own solutions. Specifically, central techniques of solution focused therapy such as the miracle question, exception questions, and deconstructing the problem complement existential theory and practice (Langdridge, 2006). Existential therapy can benefit from solution focused therapy's emphasis on "encouraging clients to engage in concrete descriptions of past and present experience whilst always having an eye to the future and the importance of setting goals for action" (Langdridge, 2006, p. 365).

Due to the limited number of well-controlled outcome studies available (see Prochaska & Norcross, 2010), no definitive conclusions can be made at this time about the effectiveness of existential therapy. However, as Schneider (2003) noted, the expansion and broadening of empirical work being conducted on existential components and therapy is encouraging (e.g., see Walsh & McElwain, 2002). Research on existential therapy has utilized case studies and theoretical articles to closely scrutinize and examine existential concepts. Research on existential therapy has also explored integrating concepts with other empirically supported psychotherapies. Additionally, studies have explored the possibility of effectively treating various populations and disorders such as older adults and trauma survivors as well as clients who present with cultural, sexual, or spiritual issues. These efforts serve as an initial step toward a comprehensive understanding of existential therapy; nevertheless, additional well-controlled outcome studies evaluating the therapeutic effectiveness of existential therapy are greatly needed.

Clinical Applications

From a Christian, biblical perspective, existential therapy has both strengths and weaknesses. The following section will discuss potential opportunities and challenges in incorporating a Christian perspective with existential therapy by examining issues of objectivity, meaninglessness, the therapeutic relationship, and the role of the therapist (see Tan, 2011, pp.120-124).

First, existential therapy's major treatment goals include embracing freedom and authenticity. The focus is on one's freedom to choose and define oneself in an authentic and honest manner. This freedom is similar to God granting us with freedom to choose who we will serve (Josh. 24:15). However, existential therapy helps identify authentic answers subjectively discovered by the client. That is, all self-originating, authentic answers are deemed beneficial to one's well-being. Such relativism and self-autonomy in the process of seeking an authentic life conflicts with a biblical perspective. The Bible views human beings as needing objective morals centered in the character of God, the ultimate source of eternal, objective values (Tweedie, 1961). Self-chosen, arbitrary values may be incongruent with biblical values and God's will. A biblical perspective of existential therapy will strive to uphold absolute and moral truths as revealed in the inspired Word of God (Matt. 24:35; 2 Tim. 3:16) through careful and thoughtful interpretation of the Bible.

Second, authentically maintaining harmonious relationships with all four levels of being-in-the-world is consistent with a biblical perspective. For example, Luke 2:52 states, "And Jesus grew in wisdom and stature, and in favor with God and men." The author of Luke uses a comprehensive view of human nature, commenting upon Jesus' psychological (grew in wisdom), physical (grew in stature), spiritual (favor with God), and social (favor with men) health. This corresponds with the holistic approach of Dasein or being-in-the-world. However, once again, existential therapists encourage clients to subjectively discover values on levels of being-in-the-world that are congruent with authentic living in the present. Such self-originating values that are considered healthy to the existential therapist might conflict with the objective values centered in God. Existential therapists working from a biblical perspective will carefully focus values on spiritual formation and development into Christ-likeness in one's character and lifestyle (Rom. 8:29). The practice of spiritual disciplines and the cultivation of Christian virtues or the fruit of the Spirit (Gal. 5:22-23) will be promoted.

Third, existential therapy can become stoical and nihilistic. Due to an overemphasis on the meaninglessness of life, the ultimate emptiness of humankind, and mortality and death, the client may become overwhelmed with feelings of hopelessness. Within a biblical framework, this provides an opportunity for the gospel of Jesus Christ to counteract feelings of despair. The Christian, biblical perspective is more complete as existential emptiness points to the need for meaning in life and salvation that only Jesus Christ can provide. It is Christ's action on the cross, his death and resurrection, that has reconciled each fallen, sinful human to God (2 Cor. 5:17-21). Christ is the ultimate answer to meaninglessness and death. Of course, we must not provide religious answers prematurely or superficially. Instead, we must do so tactfully with clients who desire therapists to explicitly integrate his or her faith (see Tan, 1996) in dealing with questions such as inner emptiness and meaninglessness.

Fourth, the therapeutic relationship serves as a major healing factor in existential therapy. The person of the therapist and the provision of therapeutic love and authentic caring for the client is consistent with the biblical perspective of agape love (1 Cor. 13) that deeply cares and touches others (Mark 12:31). It is important to note, however, that such a therapeutic love, authenticity, and vulnerability may pose limitations and dangers. Therapeutic love is not agape love, which is the fruit of the Holy Spirit (Gal. 5:22-23) and comes only from God. As fallen, imperfect human beings (Jer. 17:9, Rom. 3:23), existential therapists are limited in their expression of therapeutic love, authenticity, and vulnerability. The danger exists when therapists over-exert therapeutic love in harmful ways (e.g., boundary violations, enmeshment with the client which may lead to overdependency, attempting to comfort the client through inappropriate physical touch). While the Bible teaches that we are created in the image of God (Gen 1:26-27) and have the potential to be somewhat like God in our character, we must humbly accept our sinful nature that needs transformation into deeper Christlikeness (Rom. 8:29). Christian existential therapists must continually surrender to God, being prayerfully dependent on the Holy Spirit for his guidance in the therapeutic relationship.

Fifth, the existential therapist assumes a sacred responsibility of helping clients find meaning in their lives. This role is similar to that of a priest, pastor, spiritual director, or midwife who helps clients "birth" authenticity and meaning in their lives (Evans, 1989). The therapist must use great caution in assuming this role, avoiding inadvertently influencing the client to embrace certain secular values (e.g., authentic atheism) that may breed a sense of feeling spiritually bankrupt. Instead, the existential therapist working from a Christian perspective needs to sensitively direct clients toward God. Directing clients ultimately toward God will allow clients to be grounded in the Spirit rather than the autonomous self of the individual (see Jones & Butman, 1991, pp. 299-300). The autonomous self is unable to fill the deep existential vacuum in each individual, which is ultimately shaped by God and which only God can fill. Frankl correctly asserted that fulfillment and meaning is found in something or someone beyond oneself (i.e., self-transcendence). Yet, self-transcendence must be based in the transcendent reality of God, who objectively and truly exists (see Hurding, 1985, pp. 136-137; Tweedie, 1961, p. 175). Also, empowering clients to find meaning may result in increased self-effort and confidence in oneself (cf. Vitz, 1994). Existential therapists working from a biblical perspective must emphasize the client's need to be filled with the Holy Spirit (Eph. 5:18; Gal. 5:16-25). Rather than depending on one's fallen, autonomous self, clients will be encouraged to depend on the Holy Spirit (Zech. 4:6, Eph. 5:18) who will direct them to the God who brings healing and wholeness.

Concluding Comment

Rooted in existentialism, existential therapy focuses on individual freedom to choose one's values and freedom in life, with an emphasis on authentic living in the present moment. Case studies and theoretical articles have provided some support for the effectiveness of existential therapy; however, there have been no well-controlled outcome studies. The expansion of empirical work on existential therapy, while somewhat encouraging, is still greatly needed. A biblical perspective on existential therapy presents various opportunities and challenges. Existential therapists working from a Christian perspective need to tactfully use existential therapy to point to the transcendent reality of God, who objectively exists to bring true freedom, authenticity, and meaning to human lives.

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Siang-Yang Tan & Timothy K. Wong

Fuller Theological Seminary

Please address all correspondence to Siang-Yang Tan, Ph.D., Professor of Psychology, Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101.

Siang-Yang Tan, Ph.D. (McGill University) is Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA, and Senior Pastor of First Evangelical Church Glendale, in Glendale, CA. He has published numerous articles and 13 books, the latest of which is Counseling and Psychotherapy: A Christian Perspective (Baker Academic, 2011).

Timothy K. Wong, M.A. is a Ph.D. graduate student at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA. He currently works as a psychological assistant in private practice. His dissertation examines the neurological underpinnings of sexual abuse, and he is pursuing ordination in the Free Methodist Conference as a ministerial candidate.