CBT, the way I think about it, is an empowering tool I can offer to my clients to enable them to think about their mental health in a structured way.
I think about self-help and CBT as building blocks. The client can make their own 'tool box'.
Existential therapy is concerned with our existence as humans. The aim is to understand that existence. This approach was developed by philosophers, therapists and psychiatrists and can be used to work therapeutically with any presentations. (For a quick and easy introduction to what philosophy is, you can check my article here http://www.matteofrancescon.com/blog/what-is-philosophy)
In therapeutic terms we can also refer to this approach as Daseinanalysis. Dasein is from the German Da-Sein, the ‘there-being’, as is the person that is there. This term was introduced by Martin Heidegger (1903-1976). His philosophic work was not initially thought to be used for therapy. Heidegger was mainly concerned with philosophy and what it means to be, to exist.
Ludwig Binswanger (1881-1966) and Medard Boss (1903-1990) created a therapeutic approach based on existential philosophy. Binswanger and Boss produced more than simply adapting the work of Hidegger to support psychotherapeutic and psychiatric practice. These two Swiss psychiatrists worked on their own understanding of Hidegger and created two separate, yet somehow complementary, philosophical approaches. In the current landscape of Daseinanalysis it is still possible to distinguish different approaches. However they all refer to the original philosophies of Hidegger, Boss and Binswanger.
History of Existential Therapy
The end of the Renaissance produced a sceptic look on science and progress, which created brilliant thinkers and writers such as William Shakespeare (1564-1616) and Rene Descartes (196-1650). This scepticism was celebrated highlighting feelings and emotions by Shakespeare’s poetry and plays. On the flip side, Descartes created a more philosophical thought on the dualism between material thing (res extensa) and thinking thing (res cogitans). This is aligned with the difference between subject and object of knowing.
This split between subject and object was then explored further and expanded in philosophical terms during the following century. We now refer to that time as the Enlightenment. It prioritised objective knowledge, science and the power of the intellect. In the nineteenth century, the trend of putting science over passions was finally counterbalanced by Romanticism. This movement includes the work of brilliant writers such as Goethe, Kierkegaard, Dostoyevsky, Nietzsche and many others. The Romantics embraced nature, passion and everything that is ephemeral and enigmatic. This means looking into the depth of the human soul including its mysteries and contradictions.
In the beginning of the twentieth century, the interest for human existence became so prominent that it created a whole new science: psychoanalysis. Sigmund Freud has the merit of being the first of codifying a therapeutic approach; however he separated it from the original philosophical roots. So psychoanalysis became a scientific approach because it reconnected to the subject-object split (I’m the expert doctor and I analyse you!).
Medard Boss and Ludwig Binswanger took the interest for human existence back to the philosophical roots. Psychoanalysis is a hermeneutic approach because it’s a research methodology, rather than a philosophy. In an existential sense, Freud was right to say “we know nothing”, and yet misleading in saying that “we are obliged to assume” (Freud, 1933/1964, p.70). Another thing that needed to be left behind was the idea that there is something in the psychic that is hidden (namely the unconscious). Boss and Binswanger reluctantly accepted the idea of the unconscious, but understood in a different way. They thought it was an unnecessary construct (Boss, 1963).
Existential Therapy: Philosophy
A very accessible guide to existential therapy in Yalom’s Existential Therapy (1980). The author describes the human concerns in a simple, yet deep manner. He introduces the ‘givens of existence’: 1) Death, 2) Isolation, 3) Freedom, and 4) Meaninglessness. We all need to come to terms with these facts about our lives.
In existential therapy we think about issues on a continuum. For example:
- freedom, responsibility, and agency;
- human limitation, and finiteness;
- isolation and connectedness;
- meaning and meaninglessness;
- emotions, experience, and embodiment
As a therapist I want to ask myself where is my client in this continuum?
Another series of dimensions that need to be considered, are those proposed by Cooper (2007). As therapists, we can either move between these dimensions, or be consistent in one.
- Knowing / Not-knowing
- Directive / Non-directive
- Explanatory / Descriptive
- Pathologizing / De-pathologizing
- Techniques / Non techniques
- Immediacy / Non-immediacy
- Psychological / Philosophical
- Individualising / Universalising
- Subjective / Inner-worldly
I can ask myself where I want to place myself in this spectrum at any given point during the therapeutic encounter. It is something that changes and needs to serve the best interest of the client.
At this point it is important to introduce some philosophical terminology. First of all, we call hermeneutic the interpretation of something. So, for instance, Heidegger’s approach is hermeneutic, because it’s interpretative.
Another way to understand reality is via phenomenology. This is an approach to knowledge, based on description. The phenomenon is the event, ‘what is happening’, so phenomenology is the study of what happens. There are different ways to understand phenomenology in psychotherapy. For existential therapy we refer to the work of Edmund Husserl (1859-1938).
Another important point is the difference between ontic and ontological. In Heidegger we call ontic the everyday reality of existence. For example, my ontic experience is that I’m sitting in front of my laptop typing. The other side of the coin is ontology. Ontology deals with existence as such. This aspect is fundamental for existential therapy.
“The distinctive character of existential analysis is [...] that it is concerned with ontology, the science of being” (May, 1958 p.37).
We always move between the two dimensions: the everyday one and the ontological one. This ontic-ontological analysis is a central part of the existential analysis as such. We want to think about our existence from an ontic perspective, as well as from an ontological one.
Hidegger’s most important and successful publication on human beings (Dasein) is ‘Being and Time’ (1987/2001). Erik Craig (2019) individuates three important points to Being and Time:
1) My own being can relate to other beings, including itself.
2) The being is necessarily a ‘being-in-the-world’.
3) The ontic-ontological analysis is essential to understand what it means to be human.
Hidegger is mainly concerned with ontological questions, such as: what does it mean to be? The therapist would not necessarily need to find an answer to such questions, but the activity of questioning existence can be a valid topic of reflection.
Another important thing when we think about the ontological dimension of life is to come consider the facts of our existence. Hidegger introduces first the concept of existential angst. Various authors translated him in different ways, so sometimes we can also talk about existential anxiety. This is seen as a given in our existence. When I was doing my training as a psychotherapist, I used to say ‘I’m anxious because I’m alive’, and there is nothing else to add. We sometimes ‘hook’ this ontological anxiety to ontic situations, so that we can have anxieties about all sorts of things (health, relationships, open spaces, circumstances, performance and so on). All these ontic anxieties stem from the ontological angs/anxiety described by Hidegger as a given of existence.
For example illness reminds us of our mortality or a relationships break up reminds us of our existential isolation.
In Heidegger, there is this difference between living authentically or inauthentically. We live inauthentically when we see ourselves as passively caused by the past, and we wait for the circumstances to be more favourable. This usually condemns us to repeat previous mistakes, it reinforces the illusion of causation and denies the possibility for change.
We live authentically when we are in touch with ontological truth about our existence. This means freedom, self-determination, change, self-affirmation. In this case we are also inevitably embracing the anxiety that comes with it. It can be very hard for a client, because this implies being more in touch with uncomfortable feelings. Embracing this anxiety allows us to turn it perhaps into a motivation. I believe it’s important to use that anxiety and turn it into something I can use to my benefit. This could be a successful treatment course for anxiety.
I hope this article gave an accessible overview of existential psychotherapy. A good book to take things forward is The Wiley World Handbook of Existential Psychotherapy (2019) edited by Emmy Van Deurzen, which provides a more in depth explanation of theories and practice.
Bibliography and further readings
Boss, M. (1963). Psychoanalysis and Daseinanalysis. New York: Basic Books.
Cooper, M. (2007). Existential Therapies, 2e. London: Sage.
Craig, E. (2019). The history of Daseinanalysis. In: The Wiley World Handbook of Existential Psychotherapy (ed. E. Van Deurzen), 33-54. Hoboken, NJ: John Wiley & Sons.
Deurzen, E. van, Ed. (2019). The Wiley World Handbook of Existential Psychotherapy. Hoboken, NJ: John Wiley & Sons.
Freud, S. (1964). New introductory lectures on psycho-analysis. In: The Standard Edition of the Complete Psychological Work of Sigmund Freud, vol. 22 (ed. and trans. J Strachey), 1-182. London: Hogarth Press (Original work published 1933).
May, R. (1958). Contributions on existential psychotherapy. In: Existence: A New Dimension in Psychiatry and Psychology (ed. R. May, E. Angel, H.F. Hellenberger), 37-91. New York: Basic Books.
Yalom, I. (1980). Existential Psychotherapy. New York: Basic Books.
If you would like to know more about existential therapy and its approach to spirituality, follow this link to my blog article http://www.matteofrancescon.com/blog/spirituality-and-existential-therapy
You can also check my article 'What is philosophy?', here: http://www.matteofrancescon.com/blog/what-is-philosophy
A brief introduction
This is my core approach to therapy, the one I'm more trained and experienced in.
The Humanistic approach is rooted in the so-called ‘third force’ of psychotherapy. After psychoanalysis and behaviourism, in our post-industrial culture, therapist started to think about the human nature in a different way. This psychological perspective emphasises the individual’s ability to self-actualise. This is the inherited ability to express and potentially realise one’s own capabilities and creativity.
The humanistic philosophy is a holistic approach which pays attention to human existence and pays particular attention to creativity, free will, self-expression and human potential. The first main difference from the psychoanalytic approach and the behaviourism is that the humanistic approach is experiential; which means that it encourages self-exploration, as opposed to creating a study of the person’s psyche and behaviours. This means that the main goal of humanistic psychotherapy is self-awareness, which is seen as an essential prerequisite to a free choice and therapeutic change. Humanistic psychotherapy looks at the whole person, which includes: thoughts, behaviours, emotions and spirit. In humanistic terms, we all have a spiritual existence, but this means different things for different people. Transpersonal psychotherapy is a side branch of Humanistic therapy that looks at how we live our spiritual life (faith, religions, meditation, mindfulness…). In political terms, Humanistic-Existential therapy is the approach that models democracy more than any other. This is a truly relational approach, where the setting encourages an egalitarian power dynamic between the therapeutic dyad.
We can trace the humanistic philosophical roots all the way to Eraclitus. What we now call Humanistic Psychotherapy has its roots in the integration of three different modalities: Gestalt (Perls, Hefferline & Goodman, 1951), Person-Centred Therapy (Rogers, 1942) and Transactional Analysis (Berne, 1961; Clarkson, 1992). They all have their roots in the phenomenological and existential thoughts of Kierkegaard, Nietzsche, Heidegger, Marleau-Ponty and Sartre.
I believe there are no absolutes in therapy. However, in the Humanistic philosophy there is a fundamental element which gives us a direction for the therapeutic work. This ‘force’ is what the presocratic philosophers called physis (Heraclitus, c. 535 – c. 475 BCE). The ancient greek word means ‘growth’ and ‘becoming’. It indicates that the person is in a process of constant transformation. In the modern usage, I think about physis as described in Heidegger (1935): the tendency towards wholeness, growth and healing.
The same concept is also found in Transactional Analysis.
Rogers and Manslow
In my opinion, first complete Humanistic formulation needs to be attributed to Carl Rogers (1942). The American psychologist was strongly inspired by Otto Rank. He worked towards the goal of self-development and helped his patients to create a more creative and healthier functioning. Rogers coined the term ‘Actualising Tendency’, which was also described by Abraham Maslow as ‘Self-Actualisation’. Maslow described this as one of the basic human needs. I see Rogers and Manslow as the fathers of what we now call Humanistic Psychotherapy. Their work was positive and creative and in strong opposition to what they viewed as the pessimistic psychoanalytic views.
In Person Centred Therapy it is postulated that "the organism has one basic tendency and striving - to actualize, maintain, and enhance the experiencing organism” (Rogers, 1951: 487).
The Élan vital
In Gestalt, the physis is the equivalent to the élan vital (Perls, 1969; Clarkson, 1989). Also existential psychotherapists trust and value the person’s inner resources (Laing, 1960, 1961; Yalom, 1980; Van Deurzen, 1997, 2002). From a Humanistic perspective, addressing uncertainty in therapy starts with the underlying assumption that human nature is essentially constructive (Bozarth & Temaner Brodley, 1986). By ‘constructive’ I mean a move towards what is more wholesome.
Transactional Analysis (TA) is an approach to psychotherapy, initiated with the work of the Canadian psychiatrist Eric Berne (1910-1970). Since his death, this approach evolved and incorporated new theories and concepts.
Berne was an innovator and a divulgator, he believed his theories should be available and accessible to all. His books are very accessible, although his 1950s American English has not always aged well. Because of this openness and accessibility, TA was often labelled as pop-psychology. However, even if TA concepts are described using simple words, they are complex and profound.
What is a ‘transaction’ in TA? This refers to any exchange that happens in a communication.
One of the best known TA concepts is the Parent-Adult-Child model (P-A-C). We refer to those as ego-states. They are often referred to as ‘states of mind’, but I think this is somehow reductionist. An ego-state also involves body language, physical sensations and feelings. When the P-A-C is used to understand personality we talk about structural analysis.
Another important concept is the Life-script. This is the result of childhood decisions (these can be more or less conscious). The life-script is a proper plot with a beginning, a middle and an end. This is the best decision the child can make with the resources they have at the time in order to survive. In a way, the life-script is the result of the child adapting to the outside world, which can be perceived as hostile. The script can be reinforced in adolescence and by the time the individual reaches adulthood, they are no longer aware of it. This can bring people to distort and redefine reality to fit their script. We can do all sorts of things to fit our unconscious script, for example entering relationships and making important life decisions. Amongst therapists, there are two views on life-scripts: 1) with the help of therapy we can become aware of it and this is the end of it; or 2) we never really get rid of our life-script, we can just be more or less aware of it. Personally I feel more in line with the second option.
As children we want our personality to be validated and acknowledged by our caregivers. This sign of recognition is referred to as a stroke. Positive strokes reinforce our personality so we actively seek them. Growing up, we learn that certain feelings are allowed because we receive positive strokes for them, whilst others are discouraged because they are met with negative strokes. In adulthood we feel certain things more than others. We also replace certain feelings with others. For example, in western culture boys are discouraged to show sadness, but they are usually allowed to express anger; so grown-up men tend to display anger when they are actually sad. The feeling we feel to mask the authentic feeling is referred to as racket feeling.
The philosophy of TA
There would be a lot to say about the TA philosophy. In its original formulation, it was a product of its time; by that I mean it was very positivistic. Despite this bias, TA has a central role in Humanistic psychologies. (I also think that there is an important value in having a positive bias because it can counterbalance the negative bias that we have as humans, but this is another story.)
TA has some central philosophical assumptions (these are taken from Stewart and Joines, 2002):
- People are OK
This is best explained in the ‘I’m-OK, You’re-OK’ concept (Harris, 1967). There’s a fundamental sense of OK-ness about me and you. I accept myself as I am and accept you as you are. I might not accept what you do, but I’m OK with who you are. (This is a profound and meaningful philosophical ground that is more complex than a simple semantic play).
- Everyone has the capacity to think
(Except people who are brain-damaged), we’re all able to formulate thoughts and decide what we want from life.
- People are able to decide on their own destiny, and decisions can be changed.
This is a statement about empowerment and respect. I think it’s really important to allow others to make their own decision and not to be stuck with them. It’s OK to change, in fact, it’s always a good thing to try to.
The empowerment comes from the conviction that we cannot be made to feel or act in a certain way by the environment. The environment (other people, situations, circumstance…) can put us under a lot of pressure, but it’s ultimately our decision how we want to respond.
This article gave a very brief introduction to Transactional Analysis. As a theory, TA has evolved becoming a truly integrative approach. In my opinion it’s mainly a Humanistic approach, but it has strong links to Existential psychotherapy and behaviourism. For this reason, TA is often used as a key to link different theories and built complex and sophisticated integrations.
Berne, E. (1961,1966). Transactional Analysis in Psychotherapy. New York: Grove Press.
Harris, T. (1967). I’m OK, You’re OK. New York: Harper and Row.
Stewart, I & Joines, V. (2002). TA Today: A New Introduction to Transactional Analysis. London: Lifespace.
This is how I understand CBT. I worked in different services using CBT and delivering CBT intervention. Now I think about it as a tool I can offer to my client to think about their mental health in a structured way.
In the current therapeutic climate, CBT has become a very popular approach. This is mainly due to the emphasis the NHS placed on ‘results’, whatever that means. The IAPT system (which is the NHS based therapy), is entirely based on CBT. This is not just unfair to other approaches, but reduces the offer available to the public. IAPT, in my opinion, is also guilty of creating an over-simplified version of CBT.
The approach created by Aaron Beck, the father of behaviourism, is sophisticated and philosophically grounded. I think the IAPT is giving a very poor representation of what CBT could be.
CBT is a model that helps us make sense of the reality around us. To begin with, we divide reality in:
Thoughts: this is what I think about, in terms of content, as if it was a title, or a sentence. I know we don’t always think sentences, but for the purpose of this model we’re going to pretend we do. So an example would be, when I’m distressed my thoughts are: ‘I’m not good enough’, or ‘I can’t make it’
Physical sensations: This is what happens in my body. For instance when I’m anxious I might feel tight in my chest, my breathing might be shallow, I might feel my heart racing and so on. As well as physical sensations, we want to think about the lack of them. For example when we feel depressed, we tend to feel numb and disconnected to our body.
Emotions: this is about our feelings. I think it’s important to understand that anxiety and stress are not necessarily to be considered feelings; when I’m anxious I might be feeling scared, angry, frustrated, annoyed and so on. Again, we can also consider a lack of emotions, for example in the case of depression: lack of motivation, lack of enjoyment and so on.
Behaviour: this is what I do or I avoid doing because of my mood. For example, if I’m particularly anxious I might avoid crowds, I might bite my nails, I might ask for reassurance to people and so on. All of these examples are things that we do with our body, but other than physical behaviour, we need to consider cognitive-behaviour, this means things that I do with my thoughts. For example there are a lot of unhelpful thinking patterns we can fall into when we’re anxious: catastrophizing, jumping to conclusion, self-critique, worrying, repeating the same thought and so on. Classifying those as a behaviour, I think, it’s very important because it implies it’s something I have a degree of control over. And I do! I think my thoughts, whether I am conscious of it or not. Thoughts don’t just magically appear in my head, although sometimes it can feel like it. I think that, for example, thinking about worrying as an activity, enables me to think that I could potentially do something else with my thoughts. So categorising those unhelpful patterns as behaviours, it’s empowering.
I think this is a bit the point of CBT and the only way to deliver it in a relational way is to think about it as an empowering tool. I want my clients to feel empowered and enabled, so the CBT is a tool I can offer to support them.
A good place to start is:
Beck, A. (1967) Depression: Causes and Treatment. Philadelphia: University of Pensilvania Press.
One of my personal favourite CBT therapists is Frank Wills. I particularly recommend:
Wills, F. & Sanders, D. (1997) Cognitive Behavioural Therapy - Foundations for Practice. London: Sage.
Code of ethics and professional practice
In the past I was a member of the BACP, and more recently I moved to the UKCP.
In my work I consider both codes of ethics, as well as the Metanoia's Code for Ethical Practice.
© Matteo Francescon 2022