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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
CBT and EXISTENTIAL PSYCHOLOGY Explore the possibilities and challenges of bringing two highly diverse disciplines--CBT and existential therapy--into dialogue In CBT and Existential Psychology: Philosophy, Psychology and Therapy, distinguished clinical psychologist Dr Michael Worrell delivers a singular exploration of the relationship between diverse forms of contemporary cognitive behaviour therapy and existential phenomenology. Written for both experienced and beginning CBT therapists, as well as therapists who practice from an existential perspective, this book clarifies and discusses the potential and challenges presented when these two different schools of thought and practice are brought into dialogue. The author outlines, in accessible fashion, the implications and possibilities offered by the combination of CBT and existential practice. He also presents a series of discussions with the highly experienced CBT therapists, researchers, and trainers, Tomas Heidenreich and Alexander Noyon, and existential therapy leader Ernesto Spinelli. The book includes a series of "existential reflections" and experiential exercises to allow the reader to develop an understanding of descriptive phenomenological approaches to therapeutic conversations. Readers will also find: * A thorough introduction to existential philosophy, psychology, and therapy, including the theory and practice of existential therapy * Comprehensive discussions of cognitive and behavioural psychotherapies, including Beckian CBT, schema-focused therapies, and constructivist, narrative, and postmodern CBT * In-depth explorations of existential challenges and contributions to therapy, including discussions of anxiety, possibility, and uncertainty * Enlightening dialogues on CBT and existential psychology with Tomas Heidenreich, Alexander Noyon, and Ernesto Spinelli Perfect for beginning and advanced CBT and existential therapists, CBT and Existential Psychology: Philosophy, Psychology and Therapy will also earn a place in the libraries of trainee clinical and counselling psychologists, as well as integrative and humanistic psychotherapists.
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Seitenzahl: 586
Veröffentlichungsjahr: 2022
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Table of Contents
Cover
Title Page
Copyright Page
Dedication Page
About the Author
Contributors
Contributors
Preface
1 Introduction
Existential Therapy and CBT: An Interrupted and Incomplete Dialogue
Aims of This Book
Part 1: Existential Philosophy, Psychology and Therapy
2 Existential Philosophy
A Lightning Tour of Existential Philosophy
Precursors
Phenomenological Foundations
Existential Phenomenological Philosophers
Other Contributors
Contemporary Developments
Key Propositions of Existential Phenomenology
Phenomenology
Is Your Coffee the ‘Real Thing’?
The Phenomenology of Existence
Relatedness and Being‐in‐the‐World
Being and Being‐with‐Others
Meaning and Meaninglessness
Freedom and Limitations
Embodiment and Emotion
Existential Anxiety
Existential Guilt
Time
The Ontic and the Ontological
3 Existential Psychology
Experimental Existential Psychology
Existential Phenomenological Research Within CBT
Existential Phenomenological Research Methods in CBT
4 Existential Therapies—Theory
Daseinsanalysis
Logotherapy
Existential–Humanistic Therapy
Existential Phenomenological Therapy
R.D. Laing and Ontological Insecurity
5 Existential Practice
Principles of Existential Phenomenological Therapy
The Principle of Uncertainty
The Principle of Anxiety
The Nature of Psychological Problems
The Aims of Existential Phenomenological Therapy
Authenticity as an Aim in Existential Therapy
The Therapeutic Relationship
Frameworks for Descriptive Exploration
Part 2: Cognitive and Behavioural Therapies
6 Beckian Cognitive Therapy
Principles of Cognitive Therapy
Defining Procedural Aspects of Standard CBT
Some Unresolved Questions
7 Schema Therapies—The Depths of Meaning
Young’s Schema Therapy
8 Constructivist, Narrative and Postmodern CBT
Forms of Constructivism and Constructionism
Safran’s Integrative, Interpersonal, Emotion‐focussed Perspective
Guidano and Liotti’s Developmental‐constructivist, Post‐rationalist Cognitive Therapy
Narrative CBT
A Postmodern and Post‐rationalist CBT?
9 Mindfulness, Acceptance and the Third Waveof CBT
Mindfulness‐Based Cognitive Therapy (MBCT)
Dialectical Behaviour Therapy
Metacognitive Therapy MCT
Compassion‐Focussed Therapy (CFT)
Behavioural Activation (BA)
Functional Analytic Psychotherapy (FAP)
Acceptance and Commitment Therapy (ACT) and Contextual Behavioural Science
10 CBT and Existential Psychology—Convergenceand Divergence
Standard CBT—Points of Convergence
Points of Divergence
Schema Therapies—Existential Dimensions of Meaning
Constructivist and Post‐rational CBT
Mindfulness, Acceptance and the Third Wave of CBT
Summary
Part 3: Existential Challenges and Contributions
11 The Therapeutic Relationship
Is CBT A ‘Non‐relational’ Form of Therapy?
Doing and Being in the Therapeutic Relationship
Existential Views of the Therapeutic Relationship
‘Qualities of Being’ and the Aims of Existential Therapy
Acceptance in the Therapeutic Relationship
12 Anxiety, Possibility, Uncertainty
CBT Perspectives on the Nature of Anxiety
Existential Perspectives on Anxiety
Possibility and Choice
Existential Guilt
‘Problems’ as Attempted Solutions
13 Dreaming and Describing
Dreams in CBT
Existential Perspectives on Working with Dreams
Dreams in Supervision
14 Towards an Existentially Attuned CBT
Tuning an Existential Ear
Existence Themes and Ultimate Concerns
Temporality and Being Towards Death
Meaning and Meaninglessness
Isolation and Being‐with‐Others
Freedom, Choice and Facticity
Existential Challenges—A Human Science Approach to CBT?
Part 4: Dialogues on CBT and Existential Psychology
15 Thomas Heidenreich and Alexander Noyon
16 Ernesto Spinelli
References
Index
End User License Agreement
List of Tables
Chapter 8
Table 8.1 Contrasting Assumptions Between Objectivist and Constructionist A...
List of Illustrations
Chapter 3
Figure 3.1 A model of existential anxiety.
Guide
Cover Page
Title Page
Copyright Page
Dedication Page
About the Author
Contributors
Contributors
Preface
Table of Contents
Begin Reading
References
Index
WILEY END USER LICENSE AGREEMENT
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CBT and Existential Psychology
Philosophy, Psychology and Therapy
Michael Worrell
Consultant Clinical Psychologist
Central and North West London Mental Health NHS Trust
United Kingdom
Including dialogues with Thomas Heidenreich, Alexander Noyon and Ernesto Spinelli
This edition first published 2023© 2023 John Wiley & Sons Ltd
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Library of Congress Cataloguing‐in‐Publication Data applied forPaperback ISBN 9781119310969
Cover Design: WileyCover Image: © BlueOrange Studio/Adobe Stock Photos
This book is dedicated to my sons, Tomas and Danieland to Anna
About the Author
Michael Worrell, PhD, is a Consultant Clinical Psychologist and leads the Central London CBT Training Centre, within Central and North West London Foundation NHS Trust. He is accredited as a CBT Therapist, Supervisor and Trainer with the British Association for Behavioural and Cognitive Psychotherapies and is registered as an Existential Psychotherapist with the United Kingdom Council for Psychotherapy. He is a visiting professor at Regents University London.
Contributors
Professor Thomas Heidenreich, PhD, is a psychologist and a psychotherapist. He has worked as a scientific assistant at the Departments of Psychology and Psychiatry of the Frankfurt Goethe University. Since 2006, he has been a professor of Psychology for Social Work and Nursing at Esslingen University. He is an experienced CBT therapist and has numerous publications on existential issues over the past 15 years. He has worked as a lecturer and supervisor in several institutes for psychotherapy training. In 2019, Thomas was co‐chair of the scientific committee for the 9th World Congress of Behavioural and Cognitive Therapies in Berlin.
Professor Alexander Noyon, PhD, is a psychologist and a psychotherapist. He has worked in hospitals and, as a scientific assistant, at the Frankfurt Goethe University. Since 2000, he has worked as a therapist in private practice. Since 2007, he has been Professor for Psychology in Social Work at Mannheim University of Applied Sciences. He is an experienced CBT therapist who has also trained in existential psychotherapy (Logotherapy). He is also a lecturer and clinical supervisor.
Professor Ernesto Spinelli, PhD, is an existential phenomenological psychotherapist in private practice. He has published many papers and books on various aspects of existential therapy and has provided training workshop in the approach around the world. He was the Chair of the Society for Existential Analysis between 1993 and 1999. He is a Fellow of the British Psychological Society (BPS) and the British Association for Counselling and Psychotherapy (BACP). In 2000, he was the recipient of the BPS Division of Counselling Psychology Award for Outstanding Contribution to the Profession.
Contributors
I am grateful to Wiley and, in particular, to Monica Rogers, for her patience, support and enthusiasm for this project. I would like to thank Professor Ernesto Spinelli, Professor Thomas Heidenreich and Professor Alexander Noyon, for their willingness to engage with me in dialogue on this topic. I have also benefitted from many extensive and challenging discussions with Ernesto regarding the relationship between CBT and existential therapy and he has provided feedback and suggestions on many chapters. I would also like to thank the fantastic group of trainers and supervisors with whom I had the good fortune of learning existential phenomenological therapy in the 1990s including Professor Ernesto Spinelli, Professor Emmy van Deurzen, Lucia Moja‐Strasser (who continues to both support and challenge my therapeutic practice), The late Dr Hans Cohn (who would have raised an eyebrow and asked some very difficult questions about this whole project), and the late Dr Freddie Strasser, by far the coolest existential therapist I have ever met.
I would also like to thank the team of clinical psychologists and CBT therapists who I have the great pleasure of working with at the London CBT training Centre particularly Dr Rita Woo, Dr Rita Santos, Tamara Cilliers, Dr. Alexander Margetts and Dr Louise Payne. I would also like to thank Philip Tata for supporting me in my career in the NHS despite his concern, now possibly realised, that I was in fact ‘a rogue priest’. I would also like to thank Dr Carlton Coulter for the challenging, philosophically, and clinically rich discussions, attempting to clarify what we think we mean by the many terms we are using, as well as for constructive feedback on several chapters. Thanks also to Dr Anna Streeruwitz and Dr Stephen Adams‐Langley for their willingness to read and share their reflections and suggestions on the book. Additionally, I would like to thank the many trainees in CBT who have responded warmly and with considerable patience during my overly enthusiastic lectures on why they immediately need to read as much existential therapy literature as possible to become better CBT therapists. I think I might even have convinced one or two.
Michael WorrellLondon, 2022
Preface
This book is perhaps an unusual one for a text with ‘CBT’ in the title. In most cases, CBT texts are of the form of ‘CBT for X’, where ‘X’ stands for a wide range of specific and diagnosable forms of psychological suffering. The content of such texts normally would cover interventions that are based upon research evidence, and which are promoted as ‘evidence based’ strategies for ‘overcoming’ the particular condition. As I have been involved in the training and supervision of CBT therapists, as well as clinical psychologists, counsellors, psychotherapists, psychiatric nurses, and others interested in CBT for over 25 years, I am well acquainted with literature of this type. While I was trained in, and have practiced, applied behavioural analysis and CBT, I have had a long‐standing interest in Existential approaches and have trained in existential phenomenological therapy at what has become known as the ‘British School’ of Existential Analysis in the early 1990s. During my training in existential therapy, I was often struck by the points of contact and agreement with various perspectives within behaviour therapy and CBT. And yet very little was written of this, as existential therapy was mostly developed in dialogue, and at times conflict, with psychoanalysis. As will be seen, there is an existing literature that attempts to create such a dialogue between CBT and existential therapy, however it is scattered and incomplete. This book is an attempt to take this dialogue forward. In my view, the insights and methods of existential therapy are of immeasurable value in this current climate of evidence‐based practice, disorder‐specific interventions and manualised therapies.
Almost a half of this book was written during the COVID‐19 pandemic, an event that the existentialists would regard as an ‘ultimate situation’ or ‘boundary situation’. Such situations, bring us into direct, disturbing and anxiety provoking awareness of the ‘givens of existence’. The pandemic is most certainly an expression of, as Heidegger (1962) would have it, our ‘thrownness’. Our vulnerability to the virus arises from our fundamental relatedness to each other and the natural world. Our way of coping, the enforced, or embraced, strategies of ‘distancing’ and ‘isolation’ also bring us into contact with our ultimate separateness and existential isolation. The multiple, and extreme forms, of conspiracy theory that have arisen, are also a disturbing reminder of the ‘drive to meaning’ that is fundamental to human experience. This book focuses upon the relevance of existential thought for our practice as therapists and I invite you to reflect upon your own experience of the givens of existence as a reference point. Existential thinking and methods ultimately need to be embodied and ‘lived’ for their full meaning and implications to be revealed.
1Introduction
The quest for certainty blocks the search for meaning.
—Erich Fromm.
Cognitive behavioural therapy (CBT) has established itself as the dominant force in western psychotherapy. It has been identified as the treatment of choice by a range of health agencies, such as the UK National Institute of Clinical Excellence (NICE), for many of the most commonly encountered forms of psychological distress. In the United Kingdom and elsewhere, training in CBT has greatly expanded in an effort to increase public access to this form of evidence‐based therapy. This has caused considerable alarm to proponents of non‐CBT models, some of whom have taken a highly critical and challenging stance to what they perceive to be ‘the CBT tsunami’ (Dalal, 2018). Others have become so alarmed that they fear the advance of CBT will lead to the prospect of ‘100 years of psychotherapy wisdom’ being lost (Lees, 2016). During the 1990s, there appeared to be the possibility of further developments towards more integrative ways of practising. Indeed, one view of CBT has always been that it was intended to be a form of integrative therapy (Alford & Beck, 1997). In the current situation of the rapid expansion of CBT, there appears to be a hardening of views, with critical discussions around CBT appearing to have a limited impact due to their tendency to adopt and then attack ‘straw man’ versions of CBT that the CBT practitioner is unable to recognise (see the collection of papers in House & Loewenthal, 2008, for a range of both straw man and reasoned critiques).
From the outside, it can appear as if CBT is sitting proudly, if unjustifiably, on its laurels and is immune to any form of challenge. At the same time, within CBT there remains a range of unresolved clinical, empirical, theoretical and philosophical dilemmas and controversies. It is widely accepted that, rather than being a unified school of therapy, CBT is in fact a diverse range of therapies and theories that display both a family resemblance and significant points of disagreement. In a controversial paper, Hayes (2004) argued that there exists three generations, or ‘waves’, of CBT. The first wave, originating in the 1950s, focused on the identification and application of basic principles of learning. The second wave, originating in the work of Beck and Ellis, as well as the social learning theory of Bandura, shifted the focus to cognitive mediation of behavioural and emotional change. Hayes (2004) argues that the second wave also involved the loss of a strong link between the applied techniques of CBT and basic laboratory‐based science on fundamental principles; instead, the second wave favoured a more clinical approach to the evaluation of efficacy of treatment packages for specified diagnoses, formalised as treatment manuals. The third wave, according to Hayes (2004), came to fruition in the late 1990s and has involved an emphasis on assisting clients to change their relationship with cognitions and other distressing psychological experiences—instead of direct cognitive change efforts, mindful awareness and acceptance of distressing experience is promoted along with the identification of forms of value consistent behaviour.
Given the diversity and controversy described earlier, what is the basis of the family resemblance? At a fundamental level, despite differences in technique and concept, diverse forms of CBT agree that the overall project is one of developing a form of psychotherapy based upon scientific principles and validated via the scientific method of experimentation. The basic notion is embodied to such an extent in classical Beckian CBT that the metaphor offered to the client is one of ‘learning to become one’s own therapist by adopting the scientific‐experimental method to one’s beliefs’ (Westbrook et al., 2017). However, some of the controversies that exist in the field are expressive of basic philosophical differences in how the activity of ‘science’ should be understood, carried out and evaluated.
Consider the still unresolved question of the relationship between thoughts, emotions and behaviours highlighted above. While classical Beckian CBT maintains that the mediating factor in achieving beneficial outcomes is cognitive change, and that it makes sense to differentiate cognition from emotion and behaviour, acceptance and commitment therapy (ACT) asserts that beneficial outcomes are more likely when both the therapist and client step away from direct attempts at achieving cognitive change and instead focus on the possibility of acceptance. Furthermore, ACT disputes that cognitions can be separable from behaviour in any meaningful sense. They also cannot be regarded as being causal. More recently, additional controversy has arisen from the fact that both groups of researchers and practitioners claim empirical support for their positions, in contrast to those of other CBT perspectives, from the very same experimental research findings. This dilemma has led some to propose that different versions of CBT do not simply represent a range of opposing techniques and concepts but are in fact expressions of entirely different philosophical worldviews (Herbert et al., 2016).
Contemporary practitioners of CBT, and new practitioners in particular, are thus faced with a bewildering range of theories and strategies and, at times, competing propositions of how best to be of service to their clients. The forms of CBT favoured in government‐funded services, however, have tended to strongly emphasise the delivery of the so‐called second wave ‘disorder specific’ and manualised interventions. This has led to criticism from outside CBT (House & Lowenthal, 2008) that CBT is in essence a quasi‐medical approach, reliant upon diagnostic classification, that attempts to ‘remove symptoms’ and ‘adjust’ clients to the prevailing socio‐political ideology of neo‐liberalism. The apparent success of the CBT for x approach covers over the fact that, in the history of cognitive and behavioural therapies, there has always been a strong tradition of challenging the necessity, usefulness, reliability and validity of psychiatric classification as a basis for providing therapy. This challenge has arisen again as erstwhile opponents in the behaviour‐versus‐cognition wars have called a truce and proposed that further developments in CBT may be dependent on moving away from any reliance or endorsement of psychiatric classification of mental disease entities, and moving towards an approach that emphasises the identification of key processes, such as attentional fixation, cognitive fusion, rumination, avoidance and negative affect that are common across different forms of psychological suffering. These researchers suggest (Hayes & Hoffmann, 2018, p. 15): ‘This approach might counter the drawback of training clinicians in disorder‐specific CBT protocols, which often leads to an oversimplification of human suffering, inflexibility on the part of the clinician and low adherence to evidence‐based practices’. Furthermore, these authors suggest that an approach based upon the identification of key psychological processes and upon the development of evidence‐based ways of working with these processes that rely upon the intensive exploration of the experience and context of the unique client—an approach that abandons the psychiatric‐medical system of diagnosis—may lead to the eventual ‘death’ of CBT as a distinct approach; Hayes and Hoffmann (2018, p. 436) state:
This will not occur because all evidence‐based methods will be shown to emerge from CBT. Rather, as CBT reorients towards issues that were previously the focus of other therapy traditions, there will be fewer and fewer reasons to distinguish CBT from analytic, existential, humanistic, or systemic work.
These authors, who identify themselves as leaders of both the cognitive and contextual behavioural science wings of contemporary CBT, thus appear to re‐open the possibility of dialogue with alternative perspectives, including that of existential therapy.
Existential Therapy and CBT: An Interrupted and Incomplete Dialogue
At first glance, existential therapy seems the most unlikely of partners in any dialogue that has even the faintest hope of identifying areas of convergence and agreement with CBT. Nevertheless, the suggestion that various forms of CBT and existential phenomenology may have points in common, and may potentially enrich and challenge each other, is by no means a new one. As early as 1963, a symposium considering the relative strengths and limitations of behaviourism and phenomenology was held at Rice University (Day, 1969). In addition, the possibility that phenomenology and radical behaviourism, particularly the psychology of B.F. Skinner, share points of contact has been noted numerous times in the literature (e.g. Butcher, 1984; Fallon, 1992). Clark et al. (1999), writing from a more cognitive perspective, suggested that the philosophical perspective most consistent with the practice of CBT was existential phenomenology. In fact, as will be discussed further, Beck et al. (1979), in their seminal text on cognitive therapy for depression, acknowledge Ludwig Binswanger, an early proponent of existential therapy, as an inspiration for the development of cognitive therapy. More recently, Corrie and Milton (2000) have called for greater dialogue between the approaches. Additionally, Fewtrell and O’Conner (1995) and O’Conner (2015) have explored the possibility of incorporating phenomenologically derived perspectives into CBT. The possibility of finding ways to integrate forms of CBT with existential perspectives has also been advanced by Edwards (1990), Ottens and Hannah (1998) and Sotskova et al. (2016).
Existential therapy tends to distinguish itself from other models by virtue of it being an explicitly philosophical approach to therapy, as opposed to a scientific or medical one (van Deurzen‐Smith, 1997). Existential therapy gains its distinctive flavour through its concern with issues of being and existence, that is, the meanings we construct, or find, regarding our lives and how these meanings relate to various forms of psychological, behavioural and relational distress. As Cohn (1997) explains, the term ‘existence’ can be understood as the human being’s quality of standing out. In existential philosophy, this sense of standing out also connotes a special way in which human beings are said to, alone in existence, have an awareness of and openness towards Being. Also, according to this philosophy, human beings are best understood in terms of a fundamental inter‐relational grounding expressed in the notion of ‘Being‐in‐the‐world’. Existential psychology and therapy, drawing upon insights from a range of existential and phenomenological philosophers, propose that many of the dilemmas and concerns that clients bring to therapy are expressive of basic and universal aspects of existence itself. Such fundamental aspects of existence include the finite nature of human life, the ubiquity and inevitability of anxiety and uncertainty and that human existence is always embodied and temporal. In this approach, the problems that clients bring to therapy are often conceptualised as problems in living rather than necessarily being expressive of forms of psychopathology. The question follows: How can such an approach offer anything to therapists interested in developing a form of psychotherapy based on scientific principles?
In answering this question, much may depend on one’s understanding of the nature of science and the scientific worldview that is embraced. O’Donohue and Ferguson (2016) have noted that while the project of developing a scientifically based form of psychotherapy is defining for CBT therapists, the understanding of what is meant by science and what versions of scientific activity are appropriate to CBT remains an unanswered question. Existential therapists are by no means hostile towards scientific understandings and approaches to therapy; however, they trace their stance towards questions of science to a distinction made by the psychologist and philosopher Wilhelm Dilthey (1833–1911). Dilthey contrasted what he referred to as the explanatory natural sciences, naturwissenschaften, and the descriptive or interpretative sciences, geisteswissenschaften, also referred to as the human sciences. In brief, Dilthey advocated for a form of psychology based upon a human science which was understood as being inherently historical and contextual and concerned with issues of meaning and understanding rather than causality and prediction (Burston & Frie, 2006). The human science perspective, a form of ‘descriptive contextualism’, can be seen as a philosophical worldview as Hughes (2018, p. 26) defines it: ‘A philosophical worldview can be defined as the coherent set of interrelated assumptions that provides the preanalytic framework that sets the stage for scientific or therapeutic activity’.
From a human science perspective, it is as possible to be methodologically rigorous, structured and focused, and as concerned with empirical phenomena, as it is in natural science. However, from a human science perspective, concerns regarding causality, explanation and prediction are seen as extraneous and likely to significantly bias the conduct of any effort at research and understanding. Efforts at descriptive and contextualised understanding constitute the goal of human science projects. As Cohn (2005, p. 222) has stated, this concerns: ‘the slow process of exploring and clarifying the many‐stranded tangle of a life situation that can never be complete and does not lead to final answers’. For Cohn (2005), understanding involves a ‘broadening out of contexts’ rather than a targeted and reductive ‘narrowing down’:
The perceived phenomenon gains clarity, richness and meaningfulness whenever a new aspect of its totality is discovered. The concern is always with amplification and exploration rather than explanation
(2005, p. 224).
Existential therapy embraces this perspective and, as such, can also be understood as allied to a human science approach as much as it can be understood as a particular expression or application of existential philosophy. As applied to therapy, a human science perspective suggests that the goals of therapeutic conversations are more directed to the possibilities of dialogue and understanding rather than psychoeducation, cure or the technical overcoming of difficulties or, indeed, the prediction and control of behaviour.
Hughes (2018) argues that it is an invalid and pointless exercise to evaluate the results of work from one philosophical worldview against the criteria embraced by another philosophical worldview. Instead, what can be embraced is an attempt at entering into that alternative worldview in order that its possibilities and limitations can be considered. This has relevance for the discussion presented in this book as I will often be drawing the reader’s attention to the implications of an existential perspective that may be very challenging or alien for a CBT therapist to consider. In short, I will be drawing on a distinction made by existential therapist Ernesto Spinelli (2015) that I feel to be both valid and useful. Spinelli suggests that the insights and arguments of existential philosophy and therapy can be considered at two levels. The first level considers the various themes identified by existential philosophers, psychologists and therapists, such as death, isolation, meaning, freedom and choice. As argued by Yalom (1980)—possibly the most well‐known and widely read existential therapist—any therapeutic approach that is able to thoughtfully consider such universal themes can be considered an existential approach. As will be shown throughout this text, many versions of CBT do indeed consider such themes, or have the potential to do so, in meaningful and productive ways, and, as such, CBT can be considered, as Spinelli has it, to be a form of existentially attuned therapy. The second level, however, is by far more challenging as it involves a more thoroughgoing encounter with the underlying philosophical worldview of existential phenomenology; this encounter is likely to challenge and bring into question the more typical philosophical worldview implicitly or explicitly embraced by different forms of CBT.
In my view, Clark et al.’s (1999) suggestion that existential phenomenology is consistent with CBT is highly instructive and one that this book intends to elaborate upon. Contemporary standard CBT (the most commonly practised form of essentially cognitively based CBT), at the level of scientific investigation and validation of its methods, expresses a worldview best understood as either positivist or post‐positivist (Hughes, 2018). This worldview is essentially a reductionist and mechanistic one that asserts that there is an external reality governed by natural laws that can be systematically studied. Scientific models (as well as an individual’s beliefs/their personal worldview) are valid to the extent that they are in correspondence with the actual nature of the external world. At the level of practice, however, CBT therapists find themselves drawing upon significantly more constructivist notions (which are themselves derivations and developments of existential phenomenological views). It appears that in many respects, contemporary CBT mixes aspects of positivist and constructivist worldviews and that it would be of some benefit to explore the implications, challenges and dilemmas that this produces. The same is not the case for other versions of CBT, most notably ACT, which expresses and maintains a pragmatic‐contextualist worldview in both theory, research and practice. This contextualist perspective, as will be shown, also has substantial points of contact with, as well as difference from, existential phenomenological views.
Aims of This Book
This book aims to take the dialogue between existential phenomenology and CBT forward. In doing so, I am also aiming to include as much of the current breadth of CBT thinking and practice as is possible and practicable in a text of this type. My principal aim is to convince adherents of CBT that there is much within existential thinking to enrich, challenge and support their therapeutic practice. Because CBT was developed in a way that acknowledges the significance of existential therapy, well trained and critically informed CBT therapists should be aware of this and be able to draw upon this rich and varied literature. My second aim is to convince those therapists aligned with existential therapy to take a second and even a third look (or wave) at CBT. In my experience, the ability of existential therapists to take a constructively critical view of CBT has been severely hampered by a limited understanding of, and contact with, diverse forms of CBT. There is much within contemporary versions of CBT that existential therapists could potentially find of value, as well as much with which they will undoubtedly disagree. Much of the discussion to date has focused on the adequacy, reliability and validity of the empirical research held to support a view of CBT as the treatment of choice to the exclusion of other modalities. This book is less concerned with the issue of the adequacy and appropriateness of empirical research methodologies, as it is with the underlying worldviews characteristic of CBT and existential therapy.
As my principal aim is to promote a constructive, if challenging, dialogue, it is important to clarify from the outset what this book is not attempting to achieve. I am not proposing a new form of therapy called ‘existential CBT’. Rather, I will attempt to show how various forms of current CBT are already, in at least some respects, existentially attuned. I am also not suggesting that the contributions of existential thought can simply be integrated easily and fully within existing forms of CBT. So, there is no manual being presented here. The attempt is to provide the basis for a constructive and challenging dialogue—as challenging of existential therapists as of CBT therapists—one that avoids the pitfall of straw man versions of either approach. As I have trained, practised and provided teaching and supervision from the perspective of both approaches, I am hopeful that I am able to do this task some justice. It is of course for the reader to decide to what extent I am successful in this as undoubtedly there will be aspects of what I present that both CBT therapists and existential therapists disagree with and dispute. This is, of course, what true dialogue will allow and promote.
Structure of This Book
This book is presented in four parts. In Part 1, I introduce the reader to existential thinking in the form of existential philosophy, existential psychology and existential therapy. At times, I use the term ‘existential psychology’ to cover both philosophy, psychology and therapy, an obviously academically unacceptable practice that I adopt simply for convenience. There are many excellent texts available that provide a comprehensive introduction to the key existential philosophers and the fundamental arguments of existential thought. What is needed for my purpose here is a brief overview that identifies the key themes and figures in a way that sets the scene for what comes later. Chapter 2 therefore is a brief and incomplete overview of existential philosophy as philosophy. Many writers within the existential field have assumed that the key themes and ideas of existential thinking are unsuitable for the methods of experimental science—such an attitude would immediately create a barrier for those coming to the field with an interest in experimental science, as this book would then only be concerned with questions of philosophical worldview and therapeutic practice. However, a number of researchers have in fact made important contributions to a natural science focused approach to existential themes and issues, and this field of work is discussed in Chapter 3 on existential psychology. Additionally, Chapter 3 reviews some of the research that has been conducted within CBT but from a standpoint more in tune with the concerns of a human science approach. This will also allow for the presentation of the phenomenological method, a fundamental aspect of the human science approach of existential therapy. Chapters 4 (theory) and 5 (practice) are focused on the theoretical ideas, assumptions and ways of working within the many different versions of existential therapy. It will be clarified that just as there is no single unified school of CBT, the same is true of existential therapy.
In Part 2, I review what would be considered to be the major versions of contemporary CBT. The starting point in Chapter 6 is standard Beckian CBT, the most commonly practised form of CBT worldwide. It will be seen how this form of CBT converges with existential thinking by virtue of its focus on meaning, while at the same time significantly diverging via its adoption of a more Cartesian notion of an information processing system. Chapter 7 will consider the development of schema‐focused approaches that significantly deepen questions of meaning, while also widening the view of the role and significance of emotion and the therapeutic relationship in a way that opens up lines of possible convergence with existential therapy. Chapter 8 considers the wide range of constructivist and postmodern versions of CBT that in some ways constitute an unofficial and incomplete fourth wave of CBT. In many respects, these versions of CBT draw upon ideas and arguments that are direct developments and elaborations of existential phenomenological thinking. Chapter 9 considers the development of third wave CBT approaches that focus on issues of acceptance, mindfulness and inter‐relation that again substantially converge with existential therapy. This is especially the case with ACT where there is a substantial convergence in underlying philosophical worldviews, but where the difference in these worldviews also provides considerable scope for debate and disagreement. In Chapter 10, I attempt to draw together the various strands and points of contact, disagreement and potential dialogue between these different versions of CBT and existential perspectives.
Part 3 of this book considers a range of phenomena and issues where an existential perspective may be of value. Chapter 11 discusses the role of the therapeutic relationship and how an existential view provides a number of significant challenges to CBT. Chapter 12 considers the issue of existential anxiety, a theme that will be addressed at various points, and the extent to which the so‐called clinical expressions of anxiety have their basis in a more fundamental and shared existential anxiety. Chapter 13 considers the phenomena of dreams and how these may be worked within CBT, enriched by both existential perspectives on the nature and significance of dreams, as well as structured phenomenological ways of working. Chapter 14 is an inconclusive conclusion that attempts to clarify the various levels at which CBT and existential therapy can both enrich and challenge each other.
At various points in the book, I will discuss a range of clinical examples that seek to illustrate the various existential themes being discussed. Existential therapists are likely to have an immediate conditioned negative emotional response to the term ‘clinical’, so I invite these readers to substitute the term ‘therapy story’ to help reduce their subjective units of discomfort to a tolerable degree. These examples are drawn from my own experience working as a therapist—to protect the confidentiality of former clients, I have changed identifying information to the extent that these examples are more constructions than ‘reports’, and as such they implicate and express my own concerns and thinking more than they do the issues of any particular individual.
The essence of therapy from an existential perspective is dialogue or conversation. In keeping with this, the Part 4 of this book is a series of dialogues on the issue of the inter‐relation of CBT and existential thinking and therapy. The first dialogue is a three‐way conversation between me and two highly experienced CBT therapists, Thomas Heidenreich and Alexander Noyon, who also have a long‐standing interest in existential thinking and who incorporate existential views into their practice as CBT therapists, researchers, trainers and supervisors. The second dialogue is with Ernesto Spinelli, an internationally recognised authority in existential therapy. I hope these dialogues will inspire the readers’ engagement, conversation and wrestling with the issues and ideas raised in this book.
Part 1Existential Philosophy, Psychology and Therapy
2Existential Philosophy
Over his friend, Enkidu, Gilgamesh cried bitterly, roaming the wilderness.
‘I am going to die! —am I not like Enkidu?!
Deep sadness penetrates my core,
I fear death, and now roam the wilderness—’
—The Epic of Gilgamesh Tablet IV (somewhere between 2750 and 2500 BCE).
CBT practitioners, by nature pragmatic and empirically inclined, when presented with the possibility of an existentially attuned form of CBT, are likely to ask: ‘What have the existentialists ever done for us?’ In this book, it is argued that existential philosophy, psychology and therapy can offer much to CBT therapists. To explore this, it is necessary to have some grounding in the various perspectives and ideas of the existential philosophers. Rather than review in depth, the thinking of specific existential philosophers, which would require a single text of considerable length to even approach adequacy, an overview is presented of the field as a whole and, following this, key concerns and themes of existential philosophy are discussed.
A Lightning Tour of Existential Philosophy
The boundaries around the field of existential and existential phenomenological philosophy are nothing if not blurry. If the central issue is to explore philosophical perspectives that address what it means to live as a human being, then it is possible to claim that the views of western philosophers from antiquity, beginning with the Greek stoics and sceptics, and a diverse range of non‐western philosophies should all be considered (van Deurzen‐Smith, 1997). It is clearly true that such contributions are worthy of serious consideration; however, the more specific form of philosophy that is of interest here concerns not only various themes or dimensions relevant to an understanding of human existence but also the manner in which these themes were and are addressed. The discussion is therefore restricted to philosophers identifiable in some fashion with existential phenomenology. The philosophical perspectives identifiable within this grouping attempted to address key aspects of the nature of human existence, as clarified by phenomenological description and analysis. To place these in context, it will be useful to identify several important precursors, as well as a range of related voices and contributions that were/are in some form of dialogue with the existential phenomenological thinkers.
Precursors
The two most influential thinkers that are precursors to contemporary existential phenomenological perspectives are the contributions of Soren Kierkegaard and Friedrich Nietzsche. Kierkegaard (1813–1855) was a Danish Christian philosopher who is now regarded as the father of existentialism. Reacting to what he saw as the dry, abstract and totalising philosophy of Hegel, he forcefully argued that philosophy must remain focused on the existing individual. He is most appreciated for his contributions to understanding the nature of anxiety as an inherent and unavoidable aspect of human existence. Nietzsche (1844–1900) was a German philosopher (in)famous for his pronouncement that ‘God is dead’. Highly provocative in his style, he criticised what he regarded as the slave mentality of conventional society and urged people to become supermen, meaning autonomous individuals living embodied lives of passion and power. Nietzsche’s work is as relevant to the development of psychoanalysis and postmodernism as it is to existential philosophy (see Bazzano, 2019, for an in‐depth discussion of the impact of Nietzsche’s thought on psychotherapy).
Both philosophers were highly influential for a range of existential phenomenological philosophers. Concerns around issues of authenticity and anxiety are traceable to their ideas. At the same time, their philosophies appear to emphasise the centrality of an isolated individual as the source point for experience and value. Existential phenomenological philosophers, by contrast, have emphasised an irreducible relational foundation of human existence that is substantially at variance with the notion of the primacy of the existing individual (Spinelli, 2016).
Phenomenological Foundations
Although the term ‘phenomenology’ predates his work, Edmund Husserl is nevertheless credited as being the founder of phenomenology. Husserl (1859–1938) developed phenomenology as a radical new approach to philosophy that was also intended to provide solid foundations for the empirical sciences. Husserl’s phenomenology focused on the question of consciousness and emphasised the notion of ‘intentionality’, that is, that consciousness has a quality of directedness, that it is always consciousness of something. Husserl’s work was of prime importance to the existential phenomenological thinkers that followed him, even in their serious disagreements with him on central aspects of the phenomenological project. Key insights as well as aspects of phenomenology as a method are discussed further.
Existential Phenomenological Philosophers
Karl Jaspers (1883–1969) was a German philosopher and psychiatrist who developed descriptive studies of psychopathological states in his General Psychopathology (1963) and suggested that symptoms of mental illness should be diagnosable via their form rather than their content. His philosophical work, drawing on Kierkegaard and Nietzsche, emphasised the issue of individual freedom as well as the inevitable ‘boundary situations’ that human beings face, such as death and loss.
Martin Heidegger (1889–1976), a German philosopher, is widely considered as the most significant and influential existential thinker, let alone one of the most important philosophers of the twentieth century. Heidegger’s focus was on the issue of Being itself, asking ‘What does it mean that there is something rather than nothing at all?’ In his magnum opus Being and Time (1962), Heidegger argued that human beings have a fundamental pre‐understanding of the nature of Being and that the nature of their own being remained an issue for them. His descriptions of the fundamental dimensions of human existence—including the existential nature of anxiety and guilt, the notion of the human being as ‘thrown’, and being‐towards‐death—have been greatly influential for most existential therapists. At the same time, he remains a controversial figure due to the fact that he was in the 1930s a member of the Nazi party and did not subsequently publicly account for this. This raised the issue of the extent to which his political actions are consistent with or a betrayal of his philosophy as well as the question of to what extent a form of psychotherapy can be developed based upon his philosophy (see Cohn, 2002 for a discussion of this issue).
Jean‐Paul Sartre (1905–1980), a French philosopher, writer and playwright, is possibly the philosopher most clearly identifiable as being an existentialist. Sartre remains a highly influential philosopher and social critic who emphasised the centrality of human freedom and responsibility. His descriptions of forms of ‘bad faith’ are highly psychologically acute and revealing of the various ways in which human beings tend to avoid an awareness of, and responsibility for, choice. Sartre proposed a form of ‘existential psychoanalysis’ and also provided an analysis of the nature of emotions as being forms of meaning (emotions clarify for us in what way ‘things matter’) and are a ‘magical’ means by which people ‘transform their world’. Betty Cannon (1991) has developed a form of existential psychotherapy based principally on the work of Sartre and how his philosophy can be read as providing alternative understandings of the psychoanalytic notions of the unconscious and transference.
Maurice Merleau‐Ponty (1907–1961), a French philosopher, made particularly valuable contributions to an existential phenomenological understanding of embodied relational experience. While a number of existential phenomenological philosophers are notable for their hostility to psychology as a discipline, Merleau‐Ponty made use of the findings of contemporary psychologists, such as the findings of the Gestalt school.
Other Contributors
There is a wide range of other philosophers whose work has not been mentioned above, including, for example, Simone de Beauvoir (1908–1986), Paul Tillich (1996–1965) and Gabriel Marcel (1889–1973). Their absence is not due to their lower status, but due to the need for brevity. Three additional philosophers are, however, important to briefly describe due to the significant challenges and correctives they offered that served to emphasise the relational nature of human existence.
Martin Buber (1887–1965) was an Austrian Jewish and Israeli philosopher and theologian whose work has been highly influential among many existential and humanistic psychotherapists; he is known in the world of psychotherapy for having engaged in a dialogue with Carl Rogers (Anderson & Cissna, 1997). Buber’s work emphasises the fundamentally relational nature of human existence, and he challenged what he saw as an emphasis on ‘individuals’ in other perspectives. He is best known for his descriptions of I‐Thou versus I‐It forms of relating, both of which are essential aspects, or forms, of human dialogue.
Emmanuel Levinas (1906–1995), from Lithuania, is known as a French philosopher who prioritised ethics and the status of ‘the other’. For Levinas, the other is not knowable and cannot be made into an object of the self. Levinas provides a highly demanding philosophy in which the other holds primacy in a face‐to‐face encounter and in which ‘responsibility for the other’ is foundational for our existence (see Heaton, 2014).
Hans‐Georg Gadamer (1900–2002) was a German philosopher whose work on hermeneutics dealt with the nature of human understanding. Hermeneutics is concerned with the issue and methodology of interpreting texts. He was critical of the work of empirically minded researchers who sought an objective understanding of human action. In his major text, Truth and Method (2004), he described the process of interpreting the meanings of a text in terms of a ‘fusion of horizons’ in which both the text and the interpreter of the text always find themselves within a particular historical tradition and language. For Gadamer, the hermeneutic process is one of dialogue and conversation, and the meanings to be found in a text will change depending upon the questions asked of it.
Contemporary Developments
The existential philosophical movement was itself overtaken by developments in post‐structuralism and postmodernism. Many contemporary existential therapists are thus as influenced by the works of philosophers such as Foucault (1980) and Derrida (2001) as they are by the philosophers mentioned above. Nevertheless, there continue to be developments within philosophy that are, in important respects, continuations of central existential phenomenological themes, or that are important reinterpretations and elaborations of these. In this respect, the work of Hubert Dreyfus (1929–2017) is of particular relevance. Dreyfus, an American philosopher, used the central insights of Martin Heidegger to critique dominant models of cognitive psychology, as well as research into artificial intelligence (AI) (Dreyfus, 1972). Opposing current models of human information processing as being ‘computer like’ and based on processing of internal cognitive representations via ‘if‐then’ rules, Dreyfus argues that human consciousness is always an embodied consciousness‐in‐the‐world. In order to approach the form of intelligence most characteristic of human intelligence, argued Dreyfus, AI devices would need to be based on the key aspect of what it is to be human, namely, they would need to be embodied in such a way that ‘things matter’. Of interest too is the work of Dan Zahavi (1967–), a Danish philosopher whose work has focused on a phenomenological analysis of pre‐reflective consciousness and which has addressed the topics of shame, shared emotions and experiences of ‘we’ (Zahavi, 2015).
Key Propositions of Existential Phenomenology
If one were expecting that the field of existential philosophy would present itself as a coherent and consistent view of human existence—a view that could find easy or, indeed, manualisable application to the field of psychotherapy—then disappointment, dread and despair are the most likely consequences. Most of the existential philosophers discussed above would have refused the title existential philosopher and had the possibility of a symposium been presented, one in which they could compare and contrast their views, the most likely point of agreement would be that each philosopher had misunderstood or misrepresented what the other had intended. Cooper (2003) acknowledges that existential philosophy is, as a field ‘difficult, contradictory and ill‐defined’. For CBT therapists, the language used by existential philosophers, as well as existential therapists, can be alienating. Some philosophers, such as Kierkegaard, often make their arguments indirectly, using pseudonyms to express points of view and arguments that are not actually those of the writer. Others, such as Heidegger, either invent new terms or use ordinary (German) language in a manner that is substantially different from ordinary usage and that relies on an understanding of etymology. Cohn (2002) describes how in Heidegger’s classic and unavoidable work Being and Time (1962) there is no sustained clear argument that leads to a conclusion, and he suggests that Heidegger’s thinking can be compared to a musical score in which Being is the recurring theme.
Macquarrie (1973) asserts that existentialism is more a style of philosophising than a set of agreed philosophical doctrines, a style that is concerned with concrete realities of human existence, such as death, freedom, guilt, responsibility and the like. Similarly, Friedman (1991, p. 3) suggests that existentialism is best characterised as a mood that he understands as consisting of ‘a reaction against the static, the abstract, the purely rational, the merely irrational, in favour of the dynamic and the concrete, personal involvement and engagement, action, choice and commitment’.
In contrast, Cooper (1999) has argued that the main existential thinkers are identifiable as belonging to the same family, not on the basis of a style or mood but rather because they would all have at some point, as philosophers, subscribed to what he identifies as an ‘existentialist manifesto’. This manifesto is centrally concerned with an understanding of how human beings and the world are related to each other. Cooper argues that existentialism is often misunderstood as presenting a view of human beings as always isolated and alienated from the world. This view, while often an accurate portrayal of how some individuals may experience their existence, is based upon a misunderstanding. Existentialism, argues Cooper, asserts that human beings and the world are fundamentally a single unitary phenomenon. This notion of human existence as always Being‐in‐the‐world can be difficult to grasp—but before attempting to discuss what this might mean, it is important to clarify the manner in which this question is asked and explored by existential philosophy. This then brings us to the significance of phenomenology.
Phenomenology
Phenomenology aims at gaining a descriptive understanding of the nature of phenomena rather than a causal or explanatory analysis. Cerbone (2015) has provided a useful orientating experiential exercise that allows an approach to the key concerns and methods of phenomenological analysis. Consider the experience of holding a cup of coffee in one’s hands. We will take responsibility for this example and imagine that it is a regular ‘flat white’ (a form of coffee claimed to have been invented in Australia, but whose origins remain contested) that we are holding while sitting in an Italian café in Hammersmith underground station in London. The café advertises itself as serving ‘the best’ Italian coffee in London. The waiting staff come from various nationalities and the décor, intended to evoke the unique, relaxed but sophisticated vibe of an Italian city, has existed for less than 12 months and is but one of a, for the most part identical, chain of cafes. As Cerbone (2015) notes, a wide variety of questions could be asked regarding this experience. For example, a behavioural psychologist might enquire into our reinforcement history so as to address the question of the likely probability of future purchases of similar flat whites. Such an enquiry might be productive in that it may emerge that in fact the claims of perfect coffee are somewhat inconsistent with past experience such that a variable schedule of reinforcement has been set up. The sufficiently high ratio of excellent flat whites may have led to a high probability of future purchases (further reinforced by the application of the notorious behavioural strategy known as ‘the loyalty card’—a strategy that I consistently resist in an act of absurd existential defiance).
Alternatively, a postmodern or narratively informed psychologist might be most interested in the wide range of referential signs intended to evoke authenticity, sophistication and the like, and might inquire into the possibility that purchasing and consuming regular flat whites is a performance of identity, a caffeinated punctuation of existence that asserts a shallow and unstable individuality in a manner authorised and approved by a late (latte?) capitalist neo‐liberal ideology. A physiologically or biologically oriented researcher may be interested in the effects of caffeine on the brain or in the neural pathways activated by the touch of the cup and its emanating heat, as well as the visual pathways that provide the possibility for the cup to be registered in the brain as an internal representation of a flat white. All of these questions, and more, may be of interest. However, none of them are central to the project of phenomenology. Phenomenology, understood as an effort to study phenomena as ‘that which appears’, would seek to enquire into the question of how the flat white presents itself as what it is. That is, phenomenology seeks a descriptive clarification of how the phenomena presents itself and is experienced. This might include the observation, for example, that when slowly turning the cup in my hand, I am only ever presented with one side of the cup and yet, at the same time, I apprehend the cup as a whole cup of coffee. Furthermore, it presents itself as ‘about to be enjoyed’—the experience of ‘bitter‐smoothness’ already present within the anticipation.
