Three Therapeutic Approaches – Case Examples
Introductory statement about the formulations on this web page
The three formulations within these web features are each written from a different therapeutic approach and have been written by counselling psychologists who were given the client study of Alesha presented in Chapter 9 of the Handbook, entitled ‘Conceptualising in Client Work’. In order to get the most from these examples of potential formulations, you should first read the chapter.
Alesha – An Integrative Case Formulation
A Bit About Me
Formulation begins the moment I meet my client. Of course, early sessions are geared towards the art of assessment, and yes, there are particular questions, tools and techniques to carry this out, but formulation is always front of mind from the start of therapy. My advice to a trainee is to pay close attention to what you see and how you feel. You will often not have many facts at the start of an assessment, but early impressions and the quality of connection are readily available and form the first pieces of your formulation puzzle.
I tend to use a genogram and a timeline as my main assessment tools. I like them as I find them a great way to gather large amounts of complicated information quickly and easily without furiously writing down words and taking attention away from my client. I keep these pieces of paper between us and often check-in to confirm my understanding. I will invite the client to correct things on the page. Not only does this quickly create a shared narrative, but it orients clients to the collaborative nature of the therapy process. Furthermore, I find this approach very quickly enables me to observe and experience my client’s way of relating to me and the task.
I am an Integrative Psychologist. I am fairly directive and pull substantially from a cognitive behavioural perspective. All this means is that when I see an opportunity for behavioural change, I go for it. For me, therapy is about the removing the obstacles to behavioural change. That is, what makes it hard for my client to do the functional/healthy thing and how can we navigate through it? For most clients, this is not a rational or intellectual reason. It is an emotional and relational one that beckons back to an earlier childhood experience. Formulation is the process of feeling around for what happens and how it feels when doing the healthy thing is too hard. It’s about naming these moments and connecting them back to earlier experiences. Once you have done this, formulation is well underway and the treatment plan unfolds on its own.
Alesha’s current presentation and history necessitated we take good time to formulate her distress, ensure we keep her safe, and mutually decide upon the best way forward. I knew she was being medically monitored by our Consultant Psychiatrist and that while her weight was low, her bloods were normal and she was not at any imminent physical risk. Those immediate concerns aside, I gave myself a full three three sessions to get a sense of her story and begin our formulation.
I began our extended assessment by asking Alesha to tell me why she believed she had become unwell and what her theory was regarding her own distress. She said that while her health scare at 13 certainly marked the formal beginning of her eating problems, things were difficult her before then, and that she remembers feeling low and anxious even as a little girl. She seemed keen to speak about her childhood, so I suggested we discuss this through using a genogram and sketching out relationships and patterns in diagrammatic form as we went along. Alongside this, I drew a timeline, and explained we could place important life events across this, as well. Putting a large sheet of paper in front of us, she began speaking and I began sketching, interrupting only to clarify my understanding and make tentative observations regarding what I saw.
Alesha described that as the youngest of three girls (by six years), she’d always felt separate from her sisters. At the time of her birth, her older sisters were in school already and didn’t take much interest in her. Her parents were both heavily invested in their business and were rarely home. Although it was never overtly said in the family, Alesha has always wondered if she was not a ‘planned child’. Unlike her sisters’ upbringing, during which time her mum was home full-time caring for the girls, her mum didn’t spend much time with Alesha. She was cared for primarily by her maternal grandmother, who doted on her and whom she loved dearly.
Alesha cried when she described her grandmother’s death when she was six years old. She was devastated by this loss, and things at home become increasingly lonely.
At this juncture, I tentatively formulated that Alesha’s sense of being unwanted by her parents and not belonging to the family contributed to early feelings of anxiety and low self-esteem. Her grandmother provided her with a healthy attachment figure that acted as a protective factor for her. Just as she was transitioning into primary school, she lost this safe figure, leaving her increasingly disconnected from home life. Alesha never talked through her feelings of grief regarding her grandmother’s death with anyone before, and I noted that this unresolved grief was a likely key developmental factor in her difficulties.
Alesha said that her teachers in primary school were nurturing and gave her extra support after her grandmother’s death. She began to spend more time there, finding after school clubs preferable to being home and watched by her adolescent sisters. Both in primary and secondary school, she excelled both academically and in sports. She made a small group of close friends, many of whom were on the junior hockey team and netball team with her.
Following her grandmother’s death, I posit that Alesha was able to find connection and a sense of belonging through her school. She was bright and athletic, both of which gained her approval from her teachers and admiration from her peers. She began to feel good about herself and her abilities, and hence a large part of her self-esteem and self-worth became linked with academic success and sporting prowess. She had a small group of friends, many of whom knew her from primary to secondary school. This added to school feeling like a safe place for her.
I noted to myself that through her relationship with her grandmother and her establishment of good friendships, Alesha demonstrated a genuine capacity for intimacy. This was hopeful and certainly bade well for her recovery. As I expected, she was guarded in these early sessions, but I also felt her vulnerable side peeking out and reaching for connection.
Entry into secondary school was a good time for Alesha. She was feeling more confident about herself and continued thriving at school. Shortly after her period began, however, Alesha developed glandular fever. It all happened very suddenly, and what began as a sore throat quickly escalated into serious illness. She was home for three weeks and missed key exams and a championship hockey game. Her mother became very worried about her and stayed home to look after her. They spent the days playing board games, watching television, and chatting about this and that. She remembers that the only thing she could eat was a special soup that her mum made for her during this time. She lost a tremendous amount of weight. Slowly, she recovered from glandular fever and went back to school. She was intent on catching up and finding her place back in sport, but she found that she was incredibly weak and unable to concentrate for any length at time. Both coaches and teachers initially put this down to ‘normal recovery’, but after a couple of months, it became clear something else was going on. Alesha became increasingly frustrated with her inability to perform and her mood plummeted. Once again, she had to take many weeks off of school and missed out on further sports events. She was devastated to lose her places on both the netball and hockey teams.
After several months, Alesha felt strong enough to return to school. However, she had fallen far behind her peers, and for the first time, she felt unable to keep up with lessons. In addition, so much had seemed different to her. The girls she used to be friends with were now interested in boys and had formed new cliques. They were into makeup and appearance and some of them were on diets. She tried hard to fit in, but inside she felt awkward and different. As a result of her illness, she had already lost a substantial amount of weight. The girls at school seemed envious of this and often complimented her on how ‘lucky’ she was to be so ‘skinny’. She felt flattered and decided to cut back a bit more on her eating. Her parents became increasingly concerned about Alesha and her refusal to eat caused tremendous disturbance at home. Within three months, she had lost another eight kilograms.
Alesha’s glandular fever and post-viral infection were clearly key activating events. Age 13 is a crucial transitional time for girls, and just as Alesha was entering this delicate period, she became ill. Her body, once strong, able and powerful, failed her, became weak, and felt out of her control. When she was finally able to return to school, she panicked as she struggled to pass her exams. The other girls in her friendship group had changed. Without her academic and sporting prowess to anchor her identity, Alesha felt lost and out of control. Her loss of health and all that accompanied it represented second major loss for her, and what followed at school likely reactivated her earlier sense of exclusion at home. Alesha felt desperate to make things feel right again and did what she could to gain approval and reconnect with her friends at school. At first, her effort to ‘cut back’ was simply an exercise targeted at losing a few more kilograms. However, it soon morphed into something more powerful. She noticed that cutting back was much easier for her than other girls in her school. They complimented her and this flattery gave a sense of worth and inclusions for which she was desperate. For the first time since becoming sick, she began to feel back in control of something and it felt good. Alesha found that the more she focussed on what she was eating and how much weight she could lose, the less chaotic her life felt. She might not be able to control her post viral fatigue, but she could certainly control how much food she ate. She might not be able to control the difficulties she felt at school, but she could control the numbers on the scale.
I also noted that it was only when Alesha became ill that her mother and father rallied around and care her care and nurturance. From a systemic perspective, there was much to gain in love through loss in weight.
What followed was Alesha’s entrance into the mental health system. Her GP referred to the local CAMS service where she was seen as an outpatient for two months. Her weight did not increase, however, and she was admitted into hospital. All meals were supervised and Alesha’s plan was closely monitored by the dietician. She attended groups during the day and had individual support with mental health nurse each week, who monitored her weight and talked to her about whatever was on her mind. Her family attended a few sessions of family therapy. Frightening as it was, Alesha was able to increase her weight and she was discharged to outpatient care. A few months after being discharged, and despite weekly meetings with her therapist, Alesha lost the weight she had gained and was hospitalised once again. This pattern of weight gain during admission and weight loss upon discharge persisted over the next four years.
It was essential that Alesha and I understand why she was consistently able to gain weight in hospital and then lose it as an outpatient. Formulating this would give clear clues as to how we might proceed in treatment. When we explored this pattern together, it became clear that hospital provided her with an environment of total care. Unlike her life outside of those inpatient walls, her days were structured and contained; her meals were planned and monitored, and she had various outlets for support amongst the nurses, the doctors, her nurse therapist and fellow inpatients. Upon discharge to outpatient care, Alesha struggled to integrate herself back into her life without feeling overwhelmed by its perceived demands. She launched back into her studies and fervently worked to ensure she could pass her exams. Disconnected from her friendship group, Alesha focussed her energies on studying and little else. To break up the days, she would walk. She said this was a way of ‘clearing her mind’ and ‘calming down’ when she got stuck in her studies and felt anxious. Without her walks, she would cry and sometimes panic. Although she was given a meal plan to follow, she struggled to eat without support. Her parents did try, but they were unable to be there throughout the day and evening meals felt rushed and uncomfortable. Each day, Alesha cut back a bit more, and the call to control her eating and weight, while hushed in hospital, quickly increased its volume and took over again. Soon, the overriding messages she heard were that she was not working hard enough, that she was lazy, and that she didn’t deserve to eat.
Although her health continued to suffer, Alesha did succeed in passing her exams and securing a place at her university of choice. She had a short inpatient stay in the summer preceding her first year at university and although still below a normal BMI, she left this stay with a renewed vigour regarding her future. She was determined to start over, make new friends, stick to her meal plan, and leave Anorexia behind her.
Alesha loved her classes and felt positive about demonstrating her intelligence through hard work and high marks. However, she struggled to manage her time outside of studying and exercise. She liked some of the other students in her halls and did talk to them when they were in, but Alesha felt the other girls treated her differently and was uncomfortable by the attention she received from some of the boys. Social life seemed to revolve around meals and drinking, both of which Alesha avoided and felt unable to manage. Angry with herself for not fitting in and frightened about failing, Alesha studied harder and exercised more. Her Anorexic voice strengthened and urged her to restrict further. After two particularly difficult days of eating very little, Alesha binged for the first time. She was hysterical afterwards and completely disgusted with herself. She immediately ‘had to get rid of it’ and vomited in the toilets. Try as she did to continue restricting for long periods, she found herself continuing to binge and then vomit. These cycles began to consume her days, and Alesha fell deeper and deeper into depression. She was horrified with herself, and began to cut her arms, her stomach and her legs. She had never been so low and hopeless. She couldn’t go on like this anymore, and went to see her GP.
As excited as she was to go to university and start over, Alesha was ill-prepared to cope with the changes and stresses this new life would bring. She had not yet developed adequate coping strategies to manage her feelings of distress. Her difficulties adjusting to university life quickly activated a familiar sense of exclusion and difference from her peers. The anxiety and overwhelm this caused only drove her harder into her dysfunctional, yet familiar coping strategies – restriction and exercise. Of course, studying was also a way of feeling worthy and valuable for her, but her concentration and ability to work hard suffered as she lost weight and pushed herself harder.
Not surprisingly, Alesha began to binge. Her body was desperate for sustenance and Alesha could no longer override this natural drive for survival. As her fragile self-worth was largely invested in her ability to restrict, she experienced bingeing not only as a failure in itself, but as evidence of her failure as a human being. She vomited to compensate for her ‘greediness’ and ‘gluttony’, and this quickly became a cruel and punishing ritual in response to eating. Of course, the vomiting only led to further bingeing and the cycle continued. Alesha felt more out of control and chaotic than ever. She hated herself and began cutting as a way of punishing her herself and her ‘unacceptable’ body. The cutting also served to help her manage her emotional overwhelm – it provided a temporary sense of relief from her emotional pain as she could channel this into a tangible physical experience which had a beginning, middle, and end.
By the end of the third session, Alesha felt she had told her story and that I had a good sense of her experience. She was frightened about treatment and what it would look like. She desperately wanted to feel different but couldn’t imagine how this could happen. She described her therapy experiences in the Child & Adolescent services as largely focussing on re-feeding and weight gain, and a little bit of family therapy that ‘didn’t really do anything because my parents were too busy to show up half the time.’ She wanted things to be different this time but didn’t know where to begin. She felt so hopeless and ashamed about not being able to manage university and wanted to ‘get better’ so she could get back to studying.
I assured Alesha that she was experiencing normal feelings about therapy. Change is difficult and can be scary. I told her that it wouldn’t be fair to ask her to stop restricting if we didn’t give her some other ways to cope with her feelings of low mood and anxiety. In some ways, restriction was her best practiced tool, and that I wanted to help her add to her toolbox. It was clear from her earlier childhood experiences that had not yet developed the ability to self-soothe, tolerate distress and emotionally self-regulate. I framed this as a wonderful opportunity for new learning – an opportunity that would hopefully make it feel safer to use restriction a bit less as her main coping tools.
That said, I made it clear to Alesha that we had a responsibility to keep her physically safe. This would mean ensuring that she did not fall below a particular weight, that her bloods and heart rate were being regularly monitored, and that we make a plan for times when she cut and/or felt desperately low. With regards to her eating and weight, it was important Alesha keep food diaries so we could work together towards increasing her intake. This would likely require close work with the dietitian and great patience for all of us. I anticipated that Alesha might struggle to keep records due to her high levels of shame and self-criticism. We would approach this through psycho-education, encouragement and some work around self-compassion.
In addition, Alesha acknowledged that she needed a space to better understand and talk about her difficult feelings in childhood. I anticipated this might take the form of some limited re-parenting and experiential work in which we could help Alesha better cope with early losses and develop a stronger sense of her healthy adult self.
Dr. Courtney Raspin, C.Psychol. AFBPsS
Cognitive Analytic Therapy Reformulation Letter
Chartered and Registered Counselling Psychologist
Manchester University Counselling Service
This is the letter I said that I would write after a few sessions as part of the cognitive analytic therapy (CAT). If any of this is inaccurate or if I've misunderstood anything please let me know and we will revise it. This letter will hopefully act as a guide to us in our work ahead. The aim is to summarise what I've understood so far from what you've told me, list our therapeutic goals, describe the patterns we've identified that keep your difficulties in place, and highlight issues that may come up between us for us to be aware of.
You entered CAT because you’ve changed from restricting your food intake to bingeing and purging. Additionally, you have started self-harming by cutting yourself. From what you told me thus far, restricting your eating made you feel good about yourself and in control. It seems to be the way you coped with difficult feelings. Now that you find yourself unable to do so, you would like to understand your disordered eating and learn better ways to cope with things.
When you were a child, your parents were busy working, which you said made you feel overlooked/unseen by them and you were cared for instead by your grandmother, then your sisters. We’ve spoken of how close you were to your grandmother, who you felt loved you the best, and how lost you felt after her death. After her death, your older sisters reluctantly looked after you. You felt they could be either critical or overlooking, which left you feeling either criticised or overlooked by them. You coped by pleasing them, staying out of their way and ignoring your own feelings and needs.
You received the attention you craved from school where you had a close group of friends and excelled both academically and at sports. From your description, you felt at the centre of things and won admiration for your achievements. However, when you returned to school after being seriously ill, you noticed that your friends had drifted from you, leaving you feeling overlooked, a bit lost. It sounds as if you could have felt abandoned and on the periphery again, a bit like after your grandmother died?
You also fell behind academically and had to stop playing sports, two areas for which you were recognised by others and admired. But people admired your new figure and you felt an increased sense of control over yourself and your feelings. You also described feeling a bit like the eating disorder was a friend who wouldn’t abandon you, so you also felt less vulnerable.
This began a cycle of in- and outpatient treatment for anorexia. At home you felt criticised and controlled by your parents yet continued to restrict. In hospital you would eat – perhaps wanting to please the medical staff by excelling as a patient, or perhaps it felt like you were receiving special care? If so, I wonder how it was for you when you were discharged by them?
When home, you would begin to restrict again. We are still exploring whether this was a reaction to feeling controlled and criticised by your parents, or a way for you to feel better by regaining control. Or perhaps both? Since you then achieved well academically despite the anorexia, this may have reinforced the idea that you needed to be in control to achieve and be accepted.
At first you enjoyed the freedom you felt at uni away from home, but described struggling to structure your time and find your place amongst your new peers. This seemed to make you feel a bit lost and alone again. Even your eating disorder, which you could always rely on, was a struggle. You would try to restrict, lose control and binge, then vomit in an attempt to regain control. You said you were caught in this cycle, so preoccupied you didn’t notice the effects this has had on your sense of wellbeing and how isolated from others you became. You looked ashamed when you told me about losing this important bit of who you are, and how you would then cut yourself to either get emotional relief/control or sometimes to punish yourself.
We have agreed to work on:
- Identifying new ways to recognise and cope with difficult emotions rather than managing them through restricting, bingeing, purging and cutting.
- Challenging your beliefs about yourself – that you must please others to receive special care or be the best at something to be admired; otherwise you feel alone, worthless and that your life is chaos.
- Establishing new patterns with others where you have realistic expectations of both yourself and them, and no longer have to rely on your eating disorder as your only friend.
Unhelpful patterns with yourself and others:
- Feeling overlooked, you would like to be noticed and admired. However, you only believe this is possible if you shine or stand out in some way. This causes you to strive very hard and you do achieve your goals, which attracts admiration from others. But it doesn’t last – either it feels like it’s not enough, or you’re not enough if you can’t keep it up and you become critical and controlling of yourself.
- Feeling criticised and controlled, you want to feel better. You rebel by restricting again (‘if I must then I won’t’) to take control, or you restrict to seek control over your body and feelings, and in the hope of admiration or care from others.
- You crave love and acceptance, but believe to get this you must please others, even it if means putting your own needs aside to be everything to everyone. You’re then part of everything going on, which makes you feel especially cared for. However, it can become too much and you are exhausted. You feel that others then overlook or abandon you while you’re vulnerable, or you overlook your own needs. Whether it’s self-to-other relationships or your self-to-self relationship, it leaves you feeling abandoned again, alone and fearful.
To contain these painful emotions, you turn to your eating disorder, which has ‘always been there for you’. Restricting is now difficult, which ‘saved’ you before. You now binge then purge to compensate, feeling ashamed at losing control and abandoned by your old friend. You then cut to relieve your emotions, but afterwards are back to the dreaded feelings of loss and abandonment.
We will continue to develop the map over the course of the therapy to identify where you – and others – could be located on it, so we can ‘see’ what’s going on, and in time identify exit strategies from the unhelpful patterns. As the map represents roles you have developed in your self-to-self and self-to-other relationships, this means that you and I will also be on the map, whereby you may experience me as critical and controlling, or, perhaps if I get something wrong, you may feel overlooked, unseen. I hope that we can address these issues as they arise between us.
This is a time-limited therapy and it can feel disappointing that not everything can be addressed in the time we have. Perhaps we should be aware that feelings of disappointment or abandonment may arise towards the end of our work. I hope that we can recognise these feelings together and address them if they do arise.
I do hope though that your therapy will be helpful in exploring these patterns and finding more helpful ways of relating to yourself and others and I look forward in continuing our work together.
Living with the Tensions: An Existential Phenomenological Case Formulation
As I am about to embark on this project I notice a degree of ambivalence and trepidation; writing a case formulation from an existential/phenomenological perspective seems to me paradoxical if not an oxymoron. For an approach that is firmly rooted in existential philosophy and the phenomenological method, which sets out to describe and clarify subjective experience as it is lived, the concept of formulation and its derivatives (i.e., explanation and concretisation) doesn’t sit comfortably. Moreover, this focus on experience necessitates critical examination and suspension of pre-conceived ideas and theories with regards to the phenomenon under investigation in an effort to allow things to be and emerge as they are lived.
Yet competency in assessment and formulation lies at the heart of our discipline, which is firmly rooted in humanistic values and stresses an understanding of human beings as inherently dynamic, embodied, and relational in nature always embedded within the socio-political, historical, and economic systems that sustain us all. This relational, dynamic, and dialogical stance that counselling psychology practice embraces attempts to facilitate clients’ understanding of their subjective experience and to promote wellbeing. A therapeutic relationship that respects the Otherness of the Other and that is characterised by trust, openness, and commitment is coupled with the practitioner’s inquisitive and critical attitude to theories and practice and together they become the main vehicles for change.
I am now noticing my initial ambivalence and trepidation subsiding because the above discourse, so central to counselling psychology, lies at the heart of the existential/phenomenological attitude and so I am suddenly filled with a glimpse of hope that maybe, just maybe, it would be possible to live with the paradox as long as we don’t forget the ethos and the values that guide us.
There are many ways of understanding our clients’ predicaments; and no ‘way’ should be seen as the ‘way’ because at the heart of all ‘ways’ lies an interpretation rather than a claim of absolute truth or certainty. It is not accidental that within our field, a case formulation takes the form of a tentative hypothesis that is co-constructed with our clients and that is under constant examination in the face of progress and change. This is because ultimately a formulation is nothing but an interpretation that facilitates understanding; the question is what kind of interpretation.
It won’t come as a surprise that the kind of interpretation I will be talking about will be one that is informed by a given understanding of Being (capital ‘B’ to denote existence). It is therefore an interpretation that attempts to disclose and understand a person’s manner of existence (i.e., his/her own unique how in living) as it is experientially lived in relation to the temporal, affective, embodied, and intersubjective dimensions of the kind of Being we all share. It is also important to note that the existential/phenomenological movement is not a unified one and so this attempt is mine and mine only. As I don’t prescribe to any particular school of thought – an idea that in itself would contradict the study of Being - I prefer to talk about an attitude which is analytical in nature but with very different (from the mainstream) ontological foundations. It is my hope to show that a consideration of our responses (and those of our clients) to the structure of existence can enrich counselling psychology practice irrespectively of the specific therapeutic modality used. Below I will focus on an explication of what I consider essential for this attitude, it is a choice that can never do justice to the richness of this philosophical approach, so should not be seen as the choice.
I Exist therefore I Think
What a start! I say to myself sarcastically and yet this Heideggerian reversal of the famous Cartesian dictumCogito ergo sum (I think therefore I am) is indeed the starting point of the existential/phenomenological attitude to theory and practice. It is also the reason why existential/phenomenological philosophy introduced a different language that is at times obscure to say the least. However, once language is conceived as a constructive rather than descriptive tool, concepts become powerful discourses that create particular ways of seeing and understanding. The new vocabulary is intentional as it attempts to communicate a kind of understanding that challenges the taken for granted ontological and epistemological assumptions of Western thought.
The Heideggerian quote is quite simple really, so simple that we take it for granted without examining its nature: what it really brings to our attention is that thinking presupposes Being (once again capital ‘B’ to denote existence). I first exist and engage with the world and other people and only after I contemplate and theorise about the world. It is Being – the fact that I exist – that creates such possibilities. Ontology (i.e., the study of Being) – in other words – precedes epistemology (meaning the study of knowledge). As I am writing, I am aware that I am stating the obvious and yet we tend to forget the obvious because psychology as a discipline – for reasons that go beyond the scope of this project – detached from philosophy and allied itself to the natural sciences. The irony is that Science (capital ‘S’ to encompass all branches) is also part of philosophical ideas that can be traced back to ancient philosophers such as Empedocles, Plato, and Aristotle and more contemporary figures like Descartes, Kant, and Hegel. So the message I am trying to communicate here is that scientific discoveries do not happen in a vacuum: like everything else, they rest upon the particular ontological assumptions that sustain them.
We have chosen a profession that is steeped in power. It is our responsibility and a matter of ethics to be critically aware and reflexive of the presuppositions that underlie our chosen therapeutic modalities and the ways in which they interpret the world, human beings, and our efforts to understand our clients’ predicament. With this in mind I will first provide a ‘sketch’ of the ontological assumptions upon which the approach rests and only after will attempt to offer an interpretation of the case study that is being presented.
Historical Context and Fundamental Presuppositions
Nothing exists in a vacuum; like every paradigm or movement – be it philosophical and/or epistemological in nature – existentialism and its application to therapeutic practice can only be understood in relation to the Zeitgeist of a particular time. It is a philosophical approach to clinical practice that emerged in the beginning–middle of the twentieth century when a number of psychiatrists that had been trained as analysts became dissatisfied with the predominant view of natural sciences and the positivistic, rationalistic, deterministic, compartmentalising, and reductionist conceptualisation of human beings and ultimately distress.
These clinicians applied the conceptual framework introduced by existential philosophy in an effort to restore the fragmentation of human beings into different compartments and the reciprocal depersonalising effect this had upon their relation to themselves, others and life/world as a whole. A number of philosophers like Kierkegaard and Nietzsche had already noticed the ‘breakdown’ of the nineteenth century but, as mentioned before, psychology had already made a ‘choice’ to detach itself from philosophical ideas and concerns about living that were so vividly represented not only in philosophy but also the arts and literature of that time.
Starting with the etymology of the word existence that has its roots in the Greek ek-stasis and the Latin ex-sistere is important as both terms denote a movement: to emerge, to stand out, to become visible, to reveal. It is along the same lines that human beings, who are their existence, are conceptualised as a verb, as an action that reveals, an openness that illuminates, and actively
(co-)creates one’s mode of being, rather than a static entity or an object that can be manipulated and controlled. Like psychoanalysis, existential analysis is concerned with an examination of the human condition and our ability to surrender our self awareness – the very capacity that lies at the heart of what it means to be human – in order to protect ourselves from the inevitable suffering and loss that living entails. Unmasking the mode of self-deception is at the heart of both approaches but the difference lies in the how; in a conceptual framework that breaks free from binary oppositions such as subject/object, inner/outer, self/other, mind/body and introduces the unitary phenomenon of being-in-the-world-with-others. This concept is inherently dynamic in nature as it is founded upon an understanding of human existence as an action, involvement, and engagement rather than detached observation and disinterested contemplation.
It is a framework that focuses on immediate experience as it is lived, an affirmation of one’s existence as a whole and as it unfolds in action. From this perspective one is not born an individual, one becomes an individual through an act of passion, commitment and deliberation – through struggle and determination that affirm and shape life rather than living it as an accident (i.e., unreflectively or passively). This is the ‘price’ we pay for our inherent relatedness that places everything (truth included) in the in-between rather than within or outside human subjectivity. The self, the world and others co-constitute one another – they don’t exist as separate entities and so when we are confronted with human experience no truth has reality by itself, instead it always depends on the reality of the immediate relationship.
This stance further strengthens our field’s understanding of therapeutic practice as it highlights the intersubjective dimension of human relatedness that positions the therapist as an active participant of the relational field s/he is part of. It follows that clarification of the client’s world cannot happen in the absence of involvement and interaction – the absence of the human encounter in other words. It is an understanding that commences in our embodied encounter with another rather than with the knowledge we have about the other. Experience is therefore prioritised as the knowledge we have about another person can never grasp the Being of that he person, a kind of Being that unfolds in the flesh, in the immediate interaction with the living person that is our client. This is where the information we have been given acquires meaning and significance; this is where therapist and client shape and influence one another. This discourse is not unfamiliar for counselling psychology practice that prioritises the therapeutic relationship over medical concepts such as diagnosis and treatment.
The Heideggerian quote I introduced raises an important question: ‘What does it mean to be, to exist in human terms?’ This concern with Being does not refer to your being or mine but Being as such (hence the capital ‘B’). This refers to the ontological dimension of our existence; a dimension that is shared by all of us as it constitutes the manner in which we all exist. Your being and mine (notice the lower case of ‘b’) refer to the ontic dimension of our existence, which is personal to you and me as it denotes our own, idiosyncratic responses to the ontological. The existential/phenomenological attitude is grounded upon the constant dialectic between the ontological and the ontic; I hope I have managed to communicate that the two are not the same but nevertheless are inextricably linked to each other.
This brings us to the linguistic concept of existentialia, which I promise is less obscure than it sounds! Existentialia refer to the intrinsic aspects of human existence – of the manner in which we exist in other words. These are: temporality (i.e., we are beings in time), embodiment (i.e., the collapse of the mind/body dichotomy), relatedness (i.e., the understanding of humans as social beings rather than a closed system that exists in isolation), embeddedness (i.e., the understanding of human beings as inextricably linked to particular social, political, economic, and historical contexts. To this I would like to include planet Earth as we are also part of an ecosystem), and mood (i.e., our emotional attunement, the affective dimension of our Being). So ultimately, existentialia is a ‘fancy’ word that brings to the fore counselling psychology’s ontological foundations.
As mentioned my attempt to provide an existential/phenomenological case formulation rests upon presuppositions that need to be explicated (brace – brace position!)
An Outline of the Ontological Assumptions of the Approach
- Understanding human experience from the vantage point of Being (ontology) rather than epistemology (here I am referring to theories of knowledge). Being cannot be reduced to segments; any attempt to say ascribe an abstract principle or a numerical figure is at the expense of the meaning of Being that resists a clear definition. Being has an inherent concealment, which is so often demonstrated by our clients’ (and our own) experience of ambivalence, ambiguity, and anxiety. Staying with these emotions and the uncertainty they evoke is absolutely necessary and at the heart of therapeutic practice and all understanding.
- The aforementioned existentialia are considered to be the ‘ground’ upon which everything else rests. They refer to the manner of our existence on an ontological level and they present us all with particular, unavoidable, human limitations. For example, we are beings towards death (time); our embodiment can at times be felt as restrictive; relatedness presents us with unavoidable tensions as who we are is not a private affair but one that is shaped by the Other; mood is always present – we engage with the world in an emotional manner that is meaningful and that at times can be overwhelming; finally embeddedness brings to our awareness that we are part of something bigger that we have no control of.
- Ontic dimension: as mentioned the ontological – ontic dialectic lies at the heart of the existential approach. It is a view that in turn highlights an understanding of a person’s life and experience of well-being or distress in the light of their particular responses to the human predicament and the possibilities and limitations it entails. As we will see below human distress is the product of this perpetual dialectic that stems from our ability to stand out and reflect upon our Being.
- Embodiment: there is not enough space in this work to do justice to the richness of this concept that lies at the heart of our practice. I can only attempt to offer the gist of what it means to exist as an embodied being that engages with the world and other people.
Our corporeal existence immediately presents us with an ambiguity: I am my body but I can also take my body to be an object I can control. My body, in other words, is both subject and object for me. This ambiguity is not based on a dualism – as the world and others are not what I think of, but what I live and experience through my body. From this angle, human beings are conceptualised not as a pure disembodied consciousness that represents the world, but one that directly engages with the world in an embodied fashion. Our bodily interactions with the world and others give rise to another kind of language, a body language, that precedeslogos and is inextricably linked to the manner in which we are attuned.
My body also creates (physical) boundaries that in turn give rise to my sense of a unique perspective and orientation in the world as well as the experience of separateness and differentiation from another. This goes hand in hand with my ability to see my body as an object, which in turn gives me a sense of control which might be absent in my relational experience with others (as we will see this is particularly pertinent to the case study).
- Dasein and Mitsein or Being-in-the-world-with-other-people: All these hyphens are not there to irritate but to denote a unitary phenomenon; it is an alternative conceptualisation that affirms the aforementioned critique of binary oppositions. These are concepts that try to capture the existentialia of relatedness and that highlight that our being, the being of others, and the world as a whole co-constitute one another. They are also words that often replace the notion of the ‘self’ or rather a particular understanding of the self as a fixed, inner entity with a stable essence.
So it is important to note that Dasein refers to a manner of existence, which – yes is in the world with others, but is also mine. I stressed the mineness of the Dasein that I am, in order to avoid the misconception that absence of self in existential thought also implies absence of an individual existence.
A final note with regards to the existential conceptualisation of this individuality: centuries ago (or at least that’s how it feels) I conducted a research investigation that never saw the light of the day and which focused on existential practitioners’ conceptualisation of the self. Unsurprisingly a paradox emerged: I called it, the fluid permanence of the self. It was meant to be – and still is – an intentional oxymoron that encapsulates the existential attitude – namely the synthesis of polarities. It refers to a ‘relative constancy’ (to use Jaspers’ term) that denotes a sense of gravity which emerges from the past experiences that make me me without the notion of a fixedness that restricts or defines me in the totality of my Being. Deurzen’s (see footnote) metaphor still makes sense to me: we are like a river, which constantly flows; but there is bound to be concretisation as well, because every river needs its bottom, it can’t exist without it. The two are inter-dependent; we are a temporal, fragile balance that can easily be lost.
- Temporality: we are beings-towards-death. Woody Allen comes to mind! His films are often seen as a neurotic contemplation of death and the meaning of life. Regardless of whether you are a fan or not there is a vital message here. Creativity is inextricably linked to our awareness of finitude. Life and death are twins holding hands (this is part of the paradoxical nature of our Being; this is a tension that cannot be avoided). The existential approach conceptualises time in non-linear terms. Specifically, our present is ‘carrying’ the past and at the same time anticipates the future (and ultimately death). It follows that my Dasein cannot be understood outside the concept of time as my relation to my past, present, and future – this ability of human beings to reflect upon the dimension of time, is bound to influence the way I understand my life and my being in it. The relevance for practice is evident: understanding of our present cannot be ‘divorced’ from our understanding of our past and our future aspiration (including the ultimate limitation that is death).
From an existential perspective Time is of the Essence – an exploration of our clients’ lived time can be beneficial to our practice especially when we are confronted with clients who are understandably ‘imprisoned’ in the past, given that the past has an enormous gravity when it comes to our experience. Nevertheless, remembering that our temporal Being is such that it opens us up to all dimensions of time can prove to be very fruitful. Making time an issue in our practice by bringing to our client’s attention their particular mode of engaging with temporality can further facilitate their efforts to reflect upon their lives this time in temporal terms. It is a dialogue that can provide them with the possibility of incorporating the horizon ahead in their understanding of who and how they are and most importantly start reflecting upon what matters to them with regards to the person they would like to become.
- Thrownness: this is very important concept that refers to the existentialia of embeddedness. It denotes the manner in which we are embedded in the world: specifically, we are thrown (find ourselves) into a world, a particular culture, society, time, situation that we have not chosen and over which we have no control. It is a world that is already meaningful and has already defined me. It is a relational matrix out of which we cannot extricate ourselves and which creates possibilities and limitations for our existence. It is therefore a state that introduces fragility as we realise that there are limits to our freedom and power over our lives. My embedded existence – in other words – is such that my life is conditioned in ways that I have not chosen but nevertheless have to confront and respond to (this includes my physical limitations). This response – be it passive or active, reflective or unreflective – is unavoidable; it is happening all the time and it shapes the who and how I am.
- Existence precedes Essence: perhaps one of the most famous existential dictums that is based on the presupposition that we first exist in the world and only after define ourselves. It follows that my essence as a human being lies in my existence rather than the other way around. It is a view that holds hands with the aforementioned understanding of human beings from an ontological perspective (i.e., theexistentialia we have discussed). From this angle, human beings’ essence is inextricably linked to the lived experiences of theirs rather than to a pre-determined, indispensable quality that is pre-given (e.g., human beings as inherently good, or bad, or aggressive, etc.). The convictions we all hold at times with regards to our nature, become (inevitable) concretisations that have their roots in our lived experiences and active engagement with the world and others. The absence of a pre-determined essence implies that it is my actions in the world and my relationships that make me who I am; upon reflection and a different course of action, I can create (always within existential limitations) a different kind of essence. The emphasis on action and co-creation is once again evident.
As if this was not complex enough let me introduce you to another quote that should come with a warning because it is bound to sound paradoxical (to put it mildly!). Sartre, with his usual pompousness argued that I am what I am not and I am not what I am. It is a view – that despite its pompousness – introduces freedom and nothingness as fundamental aspects of the structure of our consciousness. For Sartre, nothingness and freedom lie at the heart of our existence. I am the kind of Being that introduces (through the process of negation) nothingness to the world. My consciousness is an intentional act (intentionality here implies direction and understanding derived from the phenomenological view that consciousness is always consciousness of something rather than an entity in itself) that illuminates what is but also what is not (i.e., presence and absence, Being and Nothingness). Consciousness can also take itself as an object (i.e., self-consciousness). However, for consciousness to be able to take itself as an object there needs to be a gap that is nothing but our ability to transcend what is and reflect upon it (take stock in other words). For Sartre this is the dialectic of facticity and transcendence (i.e., I am simultaneously a subject that is freedom and an object that is facticity, my concrete experience). Reducing myself either to either polarity is an act of bad faith or self-deception.
The above paradox makes us the beings that are able to take stock, stand out (ec-stasis) and reflect upon our existence. This dynamic relationship between facticity and transcendence make us the being that has possibilities and a choice over our own becoming.
The above views – when taken out of context – have led to a number of misinterpretations, especially the one that sees existential philosophy with an inherent absolutism at its heart. If we see them in context however (i.e., in relation to our ontological predicament that creates possibilities and limitations) we cannot talk about absolute freedom, absolute choice, absolute responsibility, absolute individuality, and absolute relativism. Absolutism and the omnipotence and omniscience that evoke can only be the product of a solipsistic view. Form an existential perspective, our freedom, choices, and responsibility are always in relation to – situated in other words.
Contextually, ‘existence precedes essence’ constructs a view of human nature that is fluid; a dynamic synthesis of opposites, which is active and malleable rather than passive, and static in nature. It is a kind of existence that resembles a ‘dance’ – and we all know that it takes (minimum) two to tango! – it’s a relational process in other words, which is inevitably characterised by tensions, paradoxes, ambiguity, and uncertainty. From an existential perspective I am not a formed character or personality that has been handed down to me either as a result of psychological and physical laws or hereditary and environmental pressures. This view would make me a being in possession of an essence with a relatively stable disposition that determines my existence.
- Care or concern: So where does this dialectic leave me? It leaves me with an encounter that is inextricably linked to my engagement with the Other and existence as a whole. This encounter matters to me as my life, my Dasein, my relationship with others and my projects in living are an issue for me. This concern that characterises my existence is possible because I am a meaning-making and meaning-seeking being.
- Meaning and the absurd: from an existential perspective meaning is what sustains me; and meaning like everything else is not static in nature. It fluctuates and changes as it is created rather than found. Life in itself is meaningless; this creates a fundamental absurdity at the heart of the human condition – a recognition that gives voice to the most disquieting question of all: to be or not to be? It is a question that brings to the fore the possibility of suicide. Camus interprets the Greek myth of Sisyphus as the symbol of absurdity; Sisyphus becomes the absurd hero whose punishment is the aimless and repetitive task of rolling a rock up the hill in full knowledge that once it reaches the peak it will once again roll down. A pointless struggle one might argue and indeed it would be if we were to consider the task in abstractum. Once we view the task in relation to all the aforementioned existential presuppositions, Sisyphus also becomes the grandeur of what it means to be human. Life and living is absurd when lived accidentally but when we seize the day it becomes a worthwhile project that will inevitably entail gains and losses. It all depends on the presence or absence of meaning. Note that the struggle is not eliminated – Sisyphus is happy (as Camus urges us to imagine him) not because he escaped from the task per se but because he embraced it in a deliberate, purposeful manner. Life is a struggle but does not need to be a meaningless one; to quote Nietzsche he who has a why to live for can bear with almost any how.
Notice the ‘almost’ in the quote; it is essential as we simply don’t know how much we can bear – let alone how much our clients can bear. Allowing the depths of such despair to enter our consulting room and showing willingness to ‘travel’ with them, side by side, without pretending that we are holding an answer is extremely therapeutic in itself. It is also anxiety-provoking as it is in these moments that we come face to face with the recognition that all we can do – if we are to remain respectful – is facilitate understanding and the process of meaning-making in the midst of adversity. This is a very vulnerable position to be in and so I am certainly not proposing that the therapist needs to pull it off alone. Supervision and possible engagement with other services (if the context is that of private practice) remain possibilities that equally show respect and professionalism. What I am pointing out here is an attitude towards a kind of intensity that overwhelms but nevertheless is part of the human condition. Being-with another in such times, the mere presence, connection, and co-existence with such vulnerability is an act of humanity that we all long for.
- Freedom and its derivatives – choice and responsibility: these concepts need to come with a warning because they are often being misunderstood as they tend to be seen from the vantage point of the ontic rather than the ontological. As mentioned the structure of our existence (i.e., existentialia) is such that it is founded on freedom – we are not a ‘thing’, an object, or a closed system with a pre-existing essence. However, the ontological freedom that we are does not secure experience of freedom on an ontic level. Quite the contrary – as will be argued below – freedom holds hands with existential anxiety; the two ‘walk’ together. It takes resilience, deliberation, and ownership (the very stance we are trying to facilitate in therapy) to embrace both.
It follows that most of the times in an effort to avoid the inherent anxiety of our being human we live in ‘self-deception’ either by reducing ourselves to a ‘thing’ (a stance that can certainly offer a sense of security that reduces anxiety) or by following, unreflectively, a ‘status quo’. Either way, the mode of ‘self deception’ is seen as part of the human predicament. When our clients (and ourselves) find themselves in a situation or indeed a mode of being, where they feel that they have no freedom or choice (let alone responsibility), we need to examine and illuminate the obstacles they experience. Obstacles that are bound to be personal and situational in nature as well as the conclusions our clients have drawn from their unique, ontic perspective. The task of therapy is therefore to re-introduce the fluidity in their permanence so that the paradox that we are is revived. This process will inevitably create anxiety but in the words of Kierkegaard anxiety is the dizziness of freedom.
- Anxiety (angst) and its derivatives – authenticity and inauthenticity: hopefully it is clear by now why anxiety is given an ontological status; why it is considered to be the sine qua non of what it means to be human. Anxiety is not about something specific like fear; it is uneasiness, it is disquiet, it is apprehension without a target, it is primordial, it is existence in the presence of freedom and nothingness and the recognition that nothing can be taken for granted – including our perception of ourselves. Anxiety is therefore not a mood in the sense that cheerfulness or anxiousness is; instead it is an experience during which everything – including the meaningful relational matrix that sustains us – becomes uncanny. In anxiety Dasein finds itself estranged from Being as anxiety opens up to the nothingness that we also are. In this confrontation with nothingness there is no compass, no direction, nothing to hold on to, and nothing to understand (including our own being and other people).
It is easy to classify angst as a disorder or illness – however doing so would render it meaningless; it would strip this experience of any truth. From an existential perspective this experience lies at the heart of our Being as it illuminates our ontological status the very fact that we are, we exist as a process, as a field of openness, as possibilities and limitations. It is therefore seen as an experience that illuminates our very constitution and so in fleeing from anxiety, we are fleeing from ourselves. It follows that there is something vital in this experience, which – if it were to be eradicated or cured – we would lose what makes us human.
In the words of Kierkegaard those who have learned to live with anxiety, have learned the ultimate. When human existence is sketched in the above terms, anxiety is bound to be viewed and understood as a curse and a blessing (paradoxically in other words). A curse because it constantly destabilises and a blessing because its presence allows the creation of new possibilities. Heidegger argued that anxiety individuates as it ‘forces us’ to take stock and ultimately own our existence in the midst of thrownness and vulnerability. The paradox is that anxiety is both an excruciating, embodied experience that can paralyse and the driving force for the creation of new meaning, purpose, and values.
When we flee from anxiety or turn it into fear, we evade the constitution of our own Being as a result we unreflectively disown our potentialities (this can be seen as an inauthentic mode of existence); in contrast when we embrace it, withstand it, an own it, we claim ourselves and affirm our existence (authentic mode). Notice the choice of the word mode, as it is purposeful. From an existential perspective both modes are a possibility; there is no permanent state of authenticity in the same way that there is no permanence in anything! Instead we all enter and exit these modes as we are always ‘thrown’ and in relation to others and circumstances. Authenticity is an achievement that requires courage as it necessitates a struggle and determination that holds hands with angst. Counselling psychology practice sees meaning in emotions and difficulties; understanding anxiety in similar ways can facilitate our efforts to strengthen our clients’ ability to withstand adversity and live their lives deliberately.
- Human distress; introducing the Hermeneutics of Dasein: this long albeit necessary detour that explicated the presuppositions of the approach brings us back to the how of the existential interpretations. To begin with a couple of points need to be noted.
First of all the discourse of interpretation is opposed to the discourse of the medical model, which conceptualises distress as an illness or deficiency. The moment we choose an interpretative stance we also acknowledge that there is meaning involved (albeit a hidden one). The hermeneutic method seeks to explore, understand, and disclose the hidden meaning inherent in all distress. It is important to notice that the kind of assumption we are working from makes a fundamental difference to the therapeutic process itself: in the first case we are positioned to treat an illness whereas in the second to discover something hidden.
The second point that needs to be made, relates to the ontological presuppositions I have attempted to explicate. For an approach that views human beings in active rather than passive terms, it would make no sense to conceptualise distress as a deficiency – let alone an illness. It follows that we are actively involved in well-being and distress; the latter hides an intention and a purpose which is inextricably linked to the existentialia, the dialectic between the ontological and the ontic. This view is not unique to the existential approach as it was Freud who claimed that a symptom has a historic meaning (usually traced back to childhood) and a meaning that is purposeful and serves a function. The starting point of the two approaches is therefore shared what differs is the ‘journey’ to the discovery of the hidden. It’s not a question of right and wrong but one of perspective, as both approaches remain truthful and committed to the presuppositions that sustain them.
From an existential perspective human distress is an active response to our ontological constitution; a kind of response that is not necessarily reflected upon – let alone chosen. Distress inevitably weakens our ability to stand our ground and take stock. Based on the aforementioned presuppositions – especially in relation to the meaning of anxiety – human distress is conceptualised as a meaningful conduct of self-deception. The task of therapy is to provide the space where therapist and client together reflect upon the latter’s modes of existence in an attempt to discover the hidden meaning that lies behind his/her own actions. It follows that there is no point in talking about freedom, choice, and responsibility prior to this examination of one’s predicament that facilitates awareness. Freedom, choice, and responsibility come with awareness and so does the possibility for change.
The hermeneutics of existential interpretations:
Hermeneutic interpretations adhere to disparities between the ontological and the ontic: from an existential perspective we are suffering from our own Being (i.e., the human constitution). Existential interpretations therefore attempt to illuminate the relationship between the two and the ways in which each one of us responds to the human condition. It is therefore an interpretation that surpasses the life-historical experience of our clients – meaning the ontic (e.g., their childhood) to encompass the horizon of the ontological dimension that provides with the possibilities and limitations of being human.
Moreover they are interpretations that are firmly rooted in phenomenology and therefore the exploration and clarification of the immediate lived experience of the person we are with. This fidelity to the lived experience of our clients’ is based on two presuppositions: i) we are all attuned to our ontological predicament – although not necessarily in a reflective manner; and ii) we often find ourselves trapped in an equation of the ontic and the ontological which in turn gives rise to ‘symptoms’. So from this vantage point distress is seen as meaningful because it hides the manner of our attunement to our Being.
It follows that the aim of the interpretations that emerge out of the above conceptualisation focuses on making the implicit–explicit; the un-reflected–reflected. An interpretation is therefore seen as a kind of illumination that brings to light the relationship between the ontological and the ontic. Ultimately the interpretation re-introduces the difference that lies between the two by clarifying the uniqueness of the person’s ontic mode. It is for this reason that you will often read that hermeneutic interpretations as understood from the existential angle are not theory driven but experientially driven. This is an important point that can easily be misunderstood. The theory of the existential attitude lies in the aforementioned pre-suppositions. However, as already mentioned, Being cannot be reduced into segments; a person experience cannot therefore be theorised in advance. So all interpretations need to be made in the context of the human encounter, meaning the interaction between therapist and client and the space in-between. It is an interpretation that is based on the how of the client’s lived experience as understood in action/interaction with us the world and other people. They are not interpretations based on pre-existing theories or the about of our knowledge.
The presuppositions therefore create a ‘conceptual map’ that guides understanding on an ontological level (i.e., the kind of Being that human beings share) not on an ontic. The ontic lies in the person’s lived experience, the how of their existence in relation to the ontological; it is a how that remains unknown (i.e., undisclosed) until the point of engagement with our clients.
Interpreting as an illumination of the ontic–ontological difference
- Illumination of our clients’ understanding of their mode of existing in the world with others. How they are living/experiencing the existentialia (i.e., temporality, embodiment, relationality, spatiality, and mood).
- Illumination of the ways in which our past experience opens and closes are Being. This endeavour does not search for causality, instead it affirms the power of experiences (be it early ones or in the present).
- Illumination of expectations that long to surpass the limitations of existence (this could take the form of a desire for absolutism and certainty).
- Illumination of a mode of being that potentially has been reduced to something specific (this is when we find ourselves saying ‘that’s who I am and always have been’ – concretising Being, in other words).
- Illuminating the connections between the ontological and ontic that inform our active participation in living with others and our relationship to our own being. The dialectic/synthesis that we are creates tensions; clarifying what these are and how we respond to them is part of the interpretative stance.
- Illumination of the hidden intention (the unreflective self deception), which emerges out of an attempt to evade anxiety and its derivatives (freedom, choice, responsibilities). As mentioned self-deception is not necessarily known to the client.
Notice that all of the above is inextricably linked to the ways in which the approach understands Being – the kind of Being that humans share. The interpretation is therefore not neutral. However, a hermeneutic interpretation would cease to be hermeneutic if it lost the focus on the client’s lived experience, which indeed (presupposition) is seen from the vantage point of the Ontological. Equally they are interpretations that shake one out of the illusion of passivity or life without a struggle. Struggle is indeed at the centre of this philosophical view which, as mentioned, takes a holistic/relational stance as its staring point (i.e., and/with rather than either/or).
In line with counselling psychology philosophy and practice we need to remain as open as possible to the otherness of the Other, always bearing in mind that the focus is on experience and meaning. The ontological view does not dictate a particular mode of being (i.e., a particular ontic); it instead creates a number of possibilities and limitations. These need to be the focus; the client’s how in other words.
Finally, the Formulation!!!
Imagine you are on your way to work. It is a particularly rainy day and your journey has been quite hectic. You almost missed your stop as you were preoccupied by the argument you had the other day with a friend of yours. It was a confrontation that perplexed you and filled you with loneliness, pain and anger. You think of the day’s plan, first thing on your diary is that important meeting, which kept you awake the night before. Your tiredness overwhelms you but you compose yourself and walk into the building. Your colleague greets you and passes the workload for the day: first the meeting and then five clients with ten minutes’ break in between. You breathe and a secret smile is sketched on your face as you remember the promise you made to yourself to work less and take care of yourself more. You compose yourself and join your colleagues. Whilst in the meeting you can barely concentrate and can’t help wondering the point of it all. You start getting frustrated thinking of all the things you could have done if you were ‘free’ to do so. The meeting ends and with relief you get that drink that has been on your mind in the hope that you can make a fresh start.
This is the multidimensional embodied being that is you – on that day – constantly engaging with the world and others, interpreting and making sense of your experience and state of being as you are enveloped by your mood that ‘colours’ the inescapable relatedness of your being with others. This is you immersed in the situation you are in and yet capable of standing out and reflecting upon your experience.
This you with all your troubles and worries, longings and aspirations enters your office to find a file containing the assessment notes that someone else has conducted for you. You read the history and the presenting issues of the case study you just read, and before you know it you have already formed an impression of the person you haven’t even met. You care. Your profession and work is an issue for you. You want to facilitate your client’s understanding of her difficulties with the hope of resolving the issues that stand in her way, stopping her from living her life to the full. Your mind is working full time, using all the knowledge you have accumulated over the years: you can’t help it, your being a therapist is inextricably linked to the theories, the evidence, the research that you hope can enlighten your prospective client’s difficulties. Meaningful links are formed as you painstakingly connect the information provided to you in search of an explanation that can shed light to the obstacles, the symptoms, the attitude and patterns, of the person you haven’t even met.
At the back of your mind you are wishing you were well-versed on difficulties relating to eating and weigh loss but at least you can rely on your knowledge of attachment theories and the literature around anxiety, loss, and depression. This gives you peace of mind as more links emerge that calm down your own insecurities and strengthen your need for clarity and certainty as well as your desire to do your job properly.
You notice the presence of a mild headache and you wish you had that breakfast. You focus and bring yourself back to the present and you start wondering how she will present herself, what she is going to look like, and whether she will be on time. Once again you can’t help it – before you know it, an image has already been formed in your mind. It is an image that fits perfectly with the assumptions you have already made about the person you haven’t even met.
Finally she arrives and you are about to take part in a human encounter …
‘Unorthodox start,’ you are probably thinking, ‘this should be about Alesha, not me!’ And yet engaging in a human encounter rather than a relationship between a subject (therapist) and an object (client) to be analysed necessitates awareness and reflexivity on our part. We – the therapists – who are equal to our clients, the same fallible mortals, subject to our existential predicament, need to be in tune with our Being and being and the vulnerability it entails. This attunement lies at the heart of our practice that attempts to be respectful of our client’s subjective experience and tries to come as close as possible to her own understanding of herself and life. It is an attitude of openness and curiosity that is possible only if we bracket our pre-existing knowledge about her and the inevitable assumptions we have created. In the words of Buber all real living is a meeting. Awareness of our own humanity is absolutely necessary if we are to be with Alesha as another human being, ready to influence and be influenced, see and be seen, in the dialogical process that is therapy.
The Dasein of Alesha’s Being was thrown into a ‘landscape’ that was already inhabited by her two older sisters, parents, and maternal grandmother; notice that we know nothing of her culture, socio-political, and economic background. All these are aspects we need to explore if we are to understand her existence in relation to the pre-existing system she is embedded in and which has already shaped her.
In the process of growing up Alesha will continue being influenced by the relational dynamics inherent in her family as well as the overall atmosphere of the house and the presence or absence of comfort, security, and belonging. The first major crisis Alesha is confronted with is the loss of her beloved grandmother. She was six; and this matters. Time always matters. She tells us how ‘lonely’ she felt and we need to stay with this loneliness in order to get an experiential sense of its quality as well as of the impact it had on her relatedness and attitude towards life and her own being. We know something of that impact: her sisters were positioned as care-takers, a role that they reluctantly accepted and performed. This is bound to have had an impact on how Alesha perceived herself and her position in the family. Maybe she felt a burden and as a result detached, or maybe she became extremely anxious and insecure and as a result ended up being clingy. We check. We further assume that such a loss is bound to have been traumatic as her early age deprived her of a passage of time that would have created some sense of gravity in her own being. This assumption leads us to slow down and ask Alesha to notice how she feels being with us. Depending on her answer, we re-adjust and try to meet her at her own level; we tentatively invite her to continue reflecting – from where she is now – upon her past and how she feels it shaped the person she is now.
Her embodied existence seems to have played a key role from early on; Alesha actively engaged in sports. The manner of this engagement is absolutely crucial to notice. Competitive. It is an attitude that opened up new possibilities for Alesha as she won a place in the hockey and netball teams. This is a moment of authenticity for her as for the first time her Dasein has deliberately created a ground to belong to. We make sure that we let her know of that and we strengthen her being as much as possible. We assume that a sense of mastery over the powerlessness of her pre-existed state was probably felt and we interpret this as an attitude that contributed to a sense of gravity in her being. We point that out and we check with her.
Despite her efforts the fragility of her existence caught up with her; at the age of 13 her body failed her. This is the second major trauma of her life (more anxiety is creeping in) because her embodied existence was the very mode that sustained her and that had created a sense of mastery and belonging in the presence of others. As a result of her physical frailty she experiences a number of losses that affect her existence as whole. The Dasein that she is, lost the ‘landscape’ that sustained her; inevitably her being-in-the-world-with-other-people was reconfigured in the absence of a choice. We assume that a new mode of being emerged (as we are never passive but instead always in the process of becoming); we need to check what that new mode was and we wonder whether she went back to that ‘lonely place’ of her childhood feeling lost and disconnected.
Unsurprisingly her body once again becomes her mode of coping with adversity only this time it has dire consequences. We assume that she gains a sense of mastery over her loss of weight by controlling her intake of food; this active stance provides her with a fragile sense of re-connection with the Other (i.e., school mates) as they notice and give her flattering feedback. A glimpse of hope must have been created but she loses the balance and the Other (this time her parents) starts disapproving the very mode (i.e., control) that sustains her. The care of her family fails to be communicated respectfully and Alesha finds herself overpowered and misunderstood as nobody checked how she is and how she understands what she is going through. Instead she finds her self in the GP’s office. The GP does not exist in isolation; s/he is part of a meaningful system that creates a particular understanding of what is going on in Alesha’s life. Before she knows it, she becomes part of a relational matrix that is comprised by outpatient and inpatient treatment units. This constitutes the third trauma of her life which further deprived her of any sense of authorship over her living and own becoming. We need to check how this left her feeling; we assume that she further retreated into her self, losing any sense of trust and communication with the Other (an Other that includes us and so we need to actively reflect upon the possibility of her experiencing us in similar ways). We notice that Alesha despite everything manages to summon her courage and affirm her existence through an act of rivalry: she triumphantly loses the weight that was imposed on her and temporarily claims her Dasein back. This is another moment of authenticity for her – once again we let her know and validate the effort. We check!
Do you remember, the metaphor I used? The river that we are, the constant flow in need of a bottom? Well her ground is not concrete enough to sustain the intoxication of freedom she experienced upon entering university. The heightened sense of anxiety that has never left Alesha’s side is now a ‘monster’ that cannot be avoided and that grows bigger and bigger. Controlling the weight loss is no longer enough to sustain the dizziness of her freedom. Nevertheless the body continuous to be the only concrete existence she can count and rely on. Self harm becomes the only power she has; a power that gets out of control and makes her wonder what’s the point of it all. The Other she cannot rely on becomes her rescuer and with ambivalence (assumption) she reaches out and books an appointment with the very person that has already shaped her life outside her own will. Once again she enters the powerful discourse that positions her as a patient to be referred under medication.
OK I think I can live with the above concretisation despite the nervousness it creates given the absence of Alesha and my engagement with her. It is concretisation that needs to retain its paradoxical nature if it is to be of any help to her. Apart from the fact that I would constantly check every single intervention/interpretation of mine with her; I would also hold in mind that its nature is temporal and fluid rather than fixed. With every interpretation – together with Alesha – I would take stock upon the kind of understanding it constructs and where this understanding leaves her. I would reflect with her the limitations and possibilities, the tensions and paradoxes, and the uncertainty and ambiguity that all understanding entails. Finally I would be prepared to remain open, ready to critically reflect upon my own assumptions, in order to provide her with the space she never had; a space to reflect with another upon her own existence.
Dr Elena Manafi, CPsychol, AFBPS
Counselling Psychologist and Existential Psychotherapist (HCPC and UKCP Reg)
Chair, Training Committee in Counselling Psychology (TCCP)
Programme Director, PsychD in Psychotherapeutic and Counselling Psychology, University of Surrey
 For a clear explication of the nature of the phenomenological method and its relevance to therapeutic practice refer to Spinelli’s work The Interpreted World. An Introduction to Phenomenological Psychology, 2nd edn (SAGE, 2005).
 For a comprehensive account of the history of the existential movement and its application to clinical practice refer to R. May, E. Angel and H.F. Ellenberger’s Existence (Basic Books, 1958).
 For a very clear explication of the philosophical foundations of existential practice refer to Cohn’s Existential Thought and Therapeutic Practice. An Introduction to Existential Psychotherapy (SAGE, 1997).
 The reader is referred to Merleau-Ponty’s work especially Phenomenology of Perception as well as Sartre’sBeing and Nothingness and the more recent book edited by Martin Milton: Sexuality. Existential Perspectives(PCCS Books, 2014).
 These are Heideggerian concepts; Being and Time is the best source for their explication.
 For an excellent explication of the polarities of existence and the paradox they create refer to Deurzen’s books especially Paradox and Passion is Psychotherapy: an Existential Approach (Wiley-Blackwell, 2015).
 A heading I used in my chapter on the ‘Existential Contributions to Pluralistic Practice’, which can be found in Therapy and Beyond. Counselling Psychology Contributions to Therapeutic and Social Issues edited by Martin Milton (Wiley, 2010).