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Theory and Practice of Existential Group Psychotherapy

Death – Freedom – Isolation – Meaninglessness… these words can’t conveniently package a product like existential psychotherapy.  “Existentialism is a philosophy that addresses what it means to be human.”  (Gladding, 2008, p. 352)  We would be hard pressed to find “heavier” content to try to assemble and process against the backdrop of group theory and process.  I choose to start with one word.  Why?  That simple word serves as the underlying premise on which a rewarding existential dialogue can be constructed in a group setting, and the foundation on which this essay is constructed.

Why draw attention to death and death anxiety?  Human beings are unique because they strive to persist in the physical world, yet they are aware of the inevitably of death for the majority of their natural lives.  The terror of death is ever-present and of such enormity that a considerable portion of one’s “oomph” is consumed in the practice of denying death.  (Yalom, 1980, p. 41)  How can we combat death anxiety in the group therapy environment?  “A person cannot bear to face the prospect of inevitable death unless he has had the experience of fully living.”  (Yalom, 1980, p. 208)  Existential group psychotherapy aims to provide that experience.

Patients, given the slightest encouragement, will bring in an extraordinary amount of material related to a concern about death.  They discuss the deaths of parents or friends, they worry about growing old, their dreams are haunted by death, they go to class reunions and are shocked by how much everyone else has aged, they notice with an ache the ascendancy of their children, they occasionally take note, with a start, that they enjoy old people’s sedentary pleasures.  They are aware of many small deaths: senile plaques, liver spots on their skin, gray hairs, stiff joints, stooped posture, and deepening wrinkles.  (Yalom, 1980, p. 57)

Why freedom?  Why responsibility?  “As long as patients persist in believing that their major problems are a result of something outside their control- the actions of other people, bad nerves, social class injustices, genes- then we therapists are limited in what we can offer.”  (Yalom, 1995, p. 139)  Although we almost universally attribute a positive connotation to the word “freedom,” existential psychotherapists recognize and emphasize that freedom comes with a tremendous responsibility.  The burden of structuring our individual lives, and taking responsibility for all our choices- past, present, and future- is not a trivial event.  “One is wholly responsible for one’s life, not only for one’s actions but for one’s failures to act.”  (Yalom, 1980, p. 220)  We yearn for autonomy, but we recoil from its inevitable consequences.  Acknowledgement that we are free to choose comes with an embedded acknowledgment that if we have the power to change our circumstances in the present, we also had the ability to make those same changes in the past.  Where did all that time go?  Existential guilt is created because we come to realize that we have consciously chosen not to free ourselves, to keep ourselves in bondage.  We come to the realization that despite our wish for the future to be different, we must mount sufficient will to traverse the chaotic ocean of uncertainty.

A client drove this concept recent.  This particular client suffered from a traumatic brain injury as a young child.  She was diagnosed with a pervasive developmental disability due to the injury and committed to take up residence in a group home setting for people with developmental disabilities.  It would suffice to say that this individual was very angry with the situation and had an exceptionally difficult time dealing with her persistent desire to live independently.  Although the supporting staff had clearly designated the goal as “a free and autonomous life without need for support” it was clear that the individual served didn’t feel that way.  The individual coveted the luxuries independence, but there was an underlying existential concern that stood opposed to that goal… “if I recover, I will no longer get the support she have become accustomed to.”  The checks from the state will stop.  No more safety-net.  If she fails- she fails and suffers the consequences of failure like everyone else – and that was a scary concept.  Despite repeated encouragement that she was “high functioning enough” to live independently, and reassurances that the agency wasn’t just going to “shove her out the door,” that underlying fear of freedom led to repeated incidents of aggressive behavior that served to insure that the individual would never been removed from the support of the state or the agency entrusted with her care.  The individual “cursed the safety net” while simultaneous embracing it.  She demanded more autonomy and fewer restrictions, yet refused move in that direction for fear that she might appear to be “too competent.”  Real freedom means she had the freedom to fail- and that was unacceptable.  I submit that this cycle of learned helplessness occurs more often than we are willing to admit, especially in the context of supporting individuals with developmental disabilities.

Why existential isolation?  There are three types of isolation: interpersonal, intrapersonal, and existential.  Interpersonal isolation is typically experienced as loneliness, and generally refers to the isolation from other individuals.  (Yalom, 1980, p. 353)  Conversely, intrapersonal isolation takes place when we stifle our feelings and subsequently accept “oughts” or “shoulds” (borrowed from Rational Emotive Behavior Therapy and Dr. Albert Ellis) as our own wishes.  (Yalom, 1980, p. 354)  Existential isolation refers to the most fundamental isolation – isolation both from creatures and from the world.  It is the “unbridgeable gulf between oneself and any other being” or thing.  (Yalom, 1980, p. 355)  Our wish to be part of a larger whole hangs in the balance.  No one captures the spirit of existential isolation like Yalom (1980) when he wrote:

We are all lonely ships on a dark sea.  We see the lights of other ships- ships that we cannot reach but whose presence and similar situation affords us much solace.  We are aware of our utter loneliness and helplessness.  But if we can break out of our windowless monad, we become aware of the others who face the same lonely dread.  Our sense of isolation gives way to a compassion for the others, and we are no longer quite so frightened.  (p. 398)

I am wholly in agreement with Yalom (1980) that the best way to combat isolation in all its forms, at least within the context of group therapy, is to foster genuine relationships.  “This requires the therapist to approach the patient without presuppositions, to focus on the project of sharing the patient’s experiences without rushing in to judge or stereotype the patient.”  (Yalom, 1980, p. 409)  In the selfless act of genuine caring the therapist emits “non-conditional” love that transcends “rebelliousness, narcissism, depression, hostility, and mendacity.  In fact, one might say that the therapist cares because of these traits, since they reflect how much the individual needs to be cared for.”  (Yalom, 1980, p. 408)  This concept translates easily into the group therapy environment.  It has been said that “a freely interactive group, with few structural restrictions, will, in time, develop into a social microcosm of the participant members.”  (Yalom, 1995, p. 28)  If an individual group member chooses to stub out anything that resembles an interpersonal supporting structure in their real lives, it should come out in the group.  It is the responsibility of the existential group leader to embolden members to accept personal responsibility for the choices that have led to interpersonal isolation – to provide tools to evade mechanisms of intrapersonal isolation – and to underscore the importance of a “here-and-now focus” through “process illumination.”  (Yalom, 1995, p. 139)

Why do we live?  How shall we live?  Making meaning matter.  The existential dynamic conflict of meaninglessness is fueled by meaning seeking human beings who are inescapably thrown into a universe that is devoid of meaning.  Some of the world’s finest minds have approached it from various positions in effort to reveal its raw materials.  Among them, Jung suggests that meaning is merely the recognition of patterns of order.  (Storr, 1983, p. 26)  Gabriel Marcel sits in communion – a valiant effort to protect his subjectivity from annihilation at the hands of materialism.  Jean-Paul Sartre is nauseated by the transcendent cup of consciousness he called – “other.”  Nietzsche’s dead gods yearn for their will to power.  Søren Kierkegaard leaps into a subjective faith while Dostoevsky enlists spiritual values in a timeless war against the hands of evil.  Kafka’s pen drips with characters discovering the depths of alienation and persecution.  Yalom stares at the sun.

What we must do is plunge into one of the many possible meanings, particularly one with a self transcendent basis.  It is engagement that counts, and we therapists do most good by identifying and helping to remove the obstacles to engagement.  The question of life is, as the Buddha taught, not edifying.  One must immerse oneself into the river of life and let the question drift away.  (Yalom, 2002, p. 135-136)

What populations do existential groups NOT work for?  Existential groups come with some limitations that are inherent in the underlying philosophy, and other limitations that are specific to individual participants in the group.  First among them is a concern that existential groups only benefit members who are verbal, communicative, and unafraid to confront painful issues.  (Gladding, 2008, p. 357)  Tackling concepts like death and the meaning of life aren’t for the faint of heart.  Because of the primacy and intimacy of the content, use is primarily confined to counseling and psychotherapy settings.  Existential concerns are wholly inappropriate for most psycho-educational, task, or work groups.  The approach takes considerable amounts of maturity, life experience, and close supervision and is not recommended which presents a significant obstacle for developing group leaders.  Finally, existentialism and existential groups are characterized as being broadly based because they generally don’t deal with specific behaviors or concerns.  As a result, “group members who need information or immediate answers are not good candidates for these groups.”  (Gladding, 2008, p. 358)

“It’s complicated.”  Let us, if we can, bring this conversation back down to earth and use a concrete example – a group activity focused on defining our relationship with our significant other.  It’s complicated is an existential group activity that forces participants to qualitatively explain and justify the relationship status that they pick on Facebook.  It’s based on a very fundamental concept – the relationships we keep are chosen by us, not for us.  The options are many – single, engaged, married, widowed, separated, or divorced.  Perhaps it’s just a relationship, open or otherwise, that defies all of the above.  It could be labeled a civil union, or a domestic partnership.  Last, but certainly not least, there is the most popular choice… “It’s complicated.”  Existential group psychotherapy was tailor-made for “it’s complicated.”  The beauty of the search is that the journey is as important as the destination, and the process of getting there is much more enriching than actually arriving (if that is even possible).

What differentiates existential psychotherapy from other theories?  Yalom defines existential psychotherapy as “a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence.”  (Yalom, 1980, p. 5)  Like its Freudian psychodynamic predecessor, existential psychotherapy moves under the tacit assumption that there are “forces” that exist at assorted levels of awareness.  It’s a precious gift of insight surrounded by layer upon layer of repression, denial, displacement, and symbolization.  It’s learning to make choices under the eternal auspice of the future becoming the present.  It’s a royal road that can be traversed in “deep reflection, dreams, nightmares, flashes of profound experience and insight, psychotic utterances, and the study of children.”  (Yalom, 1980, p. 6) 

Comparatively speaking, behavioral psychotherapists rely primarily on what and when questions that focus on the environmental conditions that exist before, during, and after a behavioral episode.  They would much prefer to avoid the question of why.  The question why tends to evoke “mentalistic explanations that are of little value” to a behaviorist who is attempting to understand the behavior of interest.  An existential line of questioning that demands an inquiry into the reason why could be viewed as encouraging “motivational” reasons that are “usually uninformative” to a behaviorist.  (Cooper, Heron, & Heward, 2007, p. 50)  Generally speaking no existential psychotherapist is going to avoid or evade questions about what and when, but I wonder if I am the only one who sees some irony in the dichotomy.  Surely if you ask a behaviorist why someone behaves the way they do they would provide you with an answer, yet they evade motivational questions to which they have no behavioral solutions.  A stalwart behaviorist doesn’t care why because he thinks he knows why.

“A real change occurring in the absence of action (behavior) is a practical and theoretical impossibility.”  (Yalom, 1980, p. 287)  Behaviorists prefer to define behaviors functionally.  “Functional definitions are often simpler and more concise than topographical definitions, leading to easier, more accurate, and more reliable measurement.  (Cooper et al., 2007, p. 66)  Herein lays the problem – “The precision of the result is directly proportional to the triviality of the variable studied.”  (Yalom, 1980, p. 24)  I challenge any behavior oriented therapist to functionally define a concept like love, for example.  “The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection.  I hate to be love’s executioner.”  (Yalom, 1989, p. 17)  I’m not suggesting that it’s not worthwhile to document the antecedent, behavior, and consequences of a given behavior- I am suggesting, however, that there are a limited number of conclusions that can be definitively drawn from the discriminated operant and three-term contingency embodied in the antecedent, behavior, and consequence model of behaviorism.  Theory grounded in applied behavior analysis will freely admit that behavior repertoires can appear quickly.  Behavior can spontaneously erupt with little or no direct conditioning.  Behaviorism can offer no real explanations in matters of the heart, and I submit to you that matters of the heart are where the bulk of our work resides.  The opportunity that lurks in the darkness of the unconscious mind cannot reason with our feelings, thoughts, or behavior.

References

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Gladding, S. T. (2008). Groups: A counseling Specialty (6th ed.). Upper Saddle River, NJ: Pearson Education.

Storr, A. (1983). The essential jung. Princeton, NJ: Priceton University Press.

Yalom, I. D. (1980). Existential Psychotherapy. New York: Basic Books.

Yalom, I. D. (1989). Love’s executioner (Harper Perennial ed.). New York: HarperCollins.

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: BasicBooks.

Yalom, I. D. (2002). The gift of therapy (Harper Perennial ed.). New York: HarperCollins.