pragmatic existential therapy

8/9/2019 Pragmatic Existential Therapy

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Journal of Contemp orary P sychotherapy, Vol. 29, No. 1, 1999

Pragmatic Existential Therapy

Carl P Ellerman Ph D

A pragmatic m odel of existential therapy i s offered to support the thesis that brief,solution focused therapy is a clinical application of existential psychology. Su -perseding pioneering existential therapies more concerned w ith insight than withclinical technique, pragmatic existential therapy is a dynamic clinical interven-tionfacilitating in patients, decision, c hoice, self-commitment, an d concrete action,the goal of which is movement toward the future an d fulfillment of patients' la -tent po tentials. In addition to clarifying th e m odel's theoretical focus on (a) livedexperience, (b ) self-creation, and (c) existential anxiety, practical guides to briefexistential treatment ar e offered. Sources from existential philosophy an d psy-chology, as well as brief solution focused treatment, ar e used to evidence coreelements of an existential therapy that is not contemplative an d insight-focused,b ut pragmatic an d action-based.

INTRODUCTION

At first sight, brief solution focused therapy (BSFT) a nd existential psycho-logy appear to be strange bedfellows, not only to empirically-minded cliniciansperplexed by the obscure conceptual formulations of existential philosophy, bu talso to pragmatic clinicians who reject a tragic view of life that seems inimical tooptimistic approaches to solving human problems. Clearly seen, however, existen-tial psychology provides a meaningful theoretical grounding for BSFT, althoughexistential psychology was mistakenly presented by its originators as a philosophyof life and death that is "not a psychotherapeutic technique and makes no pretensesin that direction (Feifel, 1969, p. 62).

Contrary to the pioneering group of European and American practition-ers who developed a contemplative philosophical, rather than pragmatic clinical

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© 1999 H u m a n Sciences P ress, Inc.

Address correspondence to Carl P . Ellerman, Ph.D ., M edical Center East, 590 0 N o r th u r d i c k Street,East Syracuse, NY 13057.


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relationship to existential psychology, my work with patients in the outpatientclinic of an urban American hospital indicates that BSFT is a c linical applicationof existential psychology, while also showing that a revivified existential pointof view provides BSFT with a theoretical logic and a clinical rationa le heretoforelacking. Hope fully, a coherent account of the relationship of existential psychologyand BSFT will not only give therapists guiding principles lacking in the brief mod-els currently flooding the menta l health com munity, but also advan ce appreciationand use of a solution focused strategy.

PRAGMATIC EXISTENTIAL THERAPY

Clinical Context

M y revisionary work in existential therapy was motivated by a mandatedchange in the treatment philosophy of the urban hospital where an interdisci-plinary team of psy chiatrists, clinical psychologists, an d psych iatric social work-ers had been treating a full range of psychopathology in adult, adolescent, an dchildren's clinics. Spec ifically, the outpatient clinics initiated a proactive reversalof the traditional 50 -minute, weekly session standard that guaranteed interminablepsychiatric treatment to every ind ividual and family. A flexible triple-tier modelof short, intermediate, and long term care established the no rm of BSFT.

1. Individuals and families would be offered up to ten sessions, with clinicaltechnique and session spacing left to the disgression of the primary thera-pist. T he expectation was that 60-70% of the clinic 's population could betreated effectively by means of BSFT, with 20-30% requiring additional

intermediate care (primarily group therapy), and the remaining 10%—these being severely and persistently m enta lly-ill individ uals or chaoticfamilies—requiring comprehensive, long term ou tpatient care.

2. T he ten session standard was implemented in conjun ction with a solu-tion focused treatment approach, requiring a significant change in the wayclinicians perceived and practiced therapy. Generally, the interdisciplinarystaff w as not only trained to diagnose psychopatho logy, but conditioned tonurture long term clinical relationships, with the expectation tha t patientswould abreact trauma, achieve a modification of intrapsychic structuresand dynamics, and secure emotional hea ling. Given the mandated changein treatment philosophy, clinicians would now rapidly assess the life cir-cumstances of patients and w ork actively with individuals a nd families toco-create concrete solutions to palpable problems. Conceived as a practi-

cal tool used to generate constructive cha nge in the lives of patients, BSFTshifted therapeutic focus from pathology to patient com petence—a depar-ture from traditiona l practice that invited therapists to see themselves not ashealers of the soul or as specialists curing psychopatho logy, but as agents

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of change involved in short term relationships that nurture the patients'

ability to solve their own problems.Th e follow ing discussion is not an outcome study of the triple-tier strategy.

Rather, it is a report of how I revised an d practiced existential therapy within thistime-limited, solution-focused context. This is noteworthy because the originatorsof existe ntial psychology adm itted forthrightly that those who read w orks on ex-istential analysis as handbooks of tec hn iqu e... will not find specifically developedpractical methods" (M ay, 1967, p. 76). In fact, existential psychology was initiallyconceived a s a pure, rather than applied science, and many pioneering existentialanalysts were simply not concerned with clinical technique. This me thodologicallacuna notw ithstan ding , wh en peeled, pared, and boiled dow n to essentials, ex-istentialism contains three core elements that guide the practice of brief solutionfocused existential therapy (BSFET): a dynamic clinical intervention facilitating

in patients, decision, choice, self-commitment, an d concrete action, the goal ofwhich is movem ent toward the future an d fulfillment of patients' laten t poten tials.M indful that this triad does not exhaust the existential repertoire, B SFE T— whichI shall also refer to as pragm atic existential therapy (PET)— focuses on (1) livedexperience, (2) se lf-creation, and (3) existential anxiety.

Elements of Pragmatic Existential Therapy

Lived Experience

Existentialism commenced as a historical repudiation of abstract specula-tion about hu ma n beings, m ost notably, abstruse metaphysical specu lation tha t

failed to address hum ans concretely within the context of lived experience. P iquedby Hegelian abstraction, Kierkegaard (1846/1974) launched the existential re-volt, maintain ing that "modern philosophy ... ha[d] forgotten, in a sort of world-historical absent-mindedness, what it means to be a human being (p. 109). Onecentury later, this historical quest to address lived experience found summation inthe articulate voice of Camus (1942/1961), who argued boldly: There is but onetruly serious philosophical problem, and that is suicide. Judging whether life is oris not worth living amounts to answering the fund ame ntal question of philosophy.All the rest . . . are games (p. 3). Between 1846, when Kierkegaard inauguratedexistentialism, and 1942, w hen Camus summ ed-up the existential revolt, existen-tial analysts examined hu ma n persons phenomeno logically within the crucible oflived experience: death, anxiety, freedom, aloneness, self-estrangement and m ean-inglessness, were among the crucial experiences thematized. A lthoug h cont inen-ta l philosophers frequ ently expressed themselves in turgid prose that obfuscated,rather than clarified the hum an drama, their quest to un derstand lived experience b yexamining "the necessities of being in the world, of having to labor and to die there(Sartre, 1960, p. 303), remains a constant, core element of existential psyc hology.

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Recently, a renewal of the existential focus on lived expereince surfaced insolution-focused therapies critical of theoretical speculations about intrapsychiclife, particularly abstract metaphysical speculations that issue in interminable psy-choanalyses devoid of practical consequences. Regarding this contemporary cri-tique, it is instructive to reflect on Kernberg's (1975) analysis of ego weakness inborderline patients:

Th e failure of normal integration of the structures derived from internalized object rela-tionships ... interferes with ... neutralization and abstraction of both ego and superegofunctions. All of this is reflected in the reduction of the conflict-free e go sphere, clinicallyrevealed in the presence of nonspecific aspects of ego weakness, particularly a lack o f. ..developed subliminatory channels, (p. 79)

With due respect for Kernberg's seminal attempt to understand and treat bor-derline and narcissistic disorders, the lived experience of human beings appearsto have disappeared within th e labyrinthine passages of psychoanalytic mythol-ogy. Disappearing also, are practical solutions to demonstrable life problems whosepersistence commonly results in depression, explosive rage, an d sundry other com-plaints. Melioration of this state of affairs is the goal of BSFET: a pragmatic clinicalencounter in which the existential therapist remains "on the same plane with hispatients—the plane of common experience (Binswanger, 1962, p. 21).

Rather than speculating about the travails of a mythical psyche in the patient'smachine, a pragmatic existential therapist remains on a common experiential planewith patients by focusing o n palpable life problems. In practice, I begin by conceiv-ing lived experience as a series of concrete problems, while envisioning patientsas problem solvers and BSFET as a tool useful to some patients who have becomestuck in problem solving. This simple conception of lived experience is explicit inthe evolutionary psychologists' heuristic view of organismic existence as a series

of problems solved by the natural selection of biological adaptations (Barkow, Cos-mides, an d Tooby, 1992). Unfortunately, while many human beings adapt to thedemands o f their natural and social environments by confronting an d solving theirproblems, some get stuck in problem solving, while others are maladaptive prob-lem avoiders. From the perspectives of PET, avoiding or becoming stuck in solvinglife's problems is the royal road to the mental health clinic. As Peck (1978) notedinsightfully, many individuals attempt to avoid problems due to the emotional painthat results when problems are confronted directly; however, avoidance of life'sprimary problems often results in depression and in other more painful secondaryproblems that eventually bring individuals to the clinic. Moreover, avoidance ofth e legitimate suffering that results from confronting primary problems, results i nthe loss of personal growth that problem solving entails.

In order to generate a therapeutic encounter committed to solving the prob-

lems of lived experience, it is helpful to think of clinical interventions with refer-ence to simple dynamic images arising from common experience. For example, inthe snowbelt of Central New Y ork where winters are severe, autos often becomestuck in snowbanks; once stuck, an angry driver will si t inside the cab gripping the

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steering wheel tensely, wh ile depressing the accelerator in a futile effort to liberate

the snowbound vehicle. Like a rocking chair moving back and forth bu t neveractually getting its occupant anywhere, the car will spin its wheels, digging deeperand deeper into the sno wbank, becom ing more snowbo und than it was before. Forthe unfo rtuna te driver wh o happen s to be stuck, a push is required to get unstuck.

Trite as this image m ay seem, a pragm atic existential therapist can perform avital clinical function by effectively pushing a patient out of an entrenched positionthat precludes movement toward the future and fulfillment of latent potentials.Given the fact that a therapist can app ly direct or indirect, manifest or subtle, hardor soft pushes, the art of pushing is really a sophisticated activity, an acquiredskill wh ich increases with clinical experience. O ne example of a direct push is theclinical act of eng aging anxious patients in a death reflection (this is explainedmore fully in a later discussion of existential anxiety); an example of an indirectpush w ould be a casual comm ent about a patient's grooming or skill, strategically

offered to bu ild confidence or to suggest readiness for problem solv ing. Regardingbrief therapies currently informing the mental health community, th e dynamicimage of pushing a patient within a field of lived experience is notably congruentwith Gustafson's (1990) image of brief th erapists as architects of movem ent:

Th e complete game of brief psychotherapy concerns the entire field of small moves withlarge effects. Th e question is: How does a therapist make small moves with large effects inways that take [patients] swiftly from bad places to better places? ... Meeting the challengeof the case ... is to get movement on the field in question.

The first convention.. . consists of finding the best place to give the patient a push. Expertiseis knowing where, how, and when to push to get the most successful change, (pp. 408-409).

Whatever t he convention may be, a brief existential thera pist is focused on thepractical task of applying a simp le clinical strategy that will g et patients unstuck.

This pragmatic approach to help ing patients solve their primary life problems su-persedes the contemplative philosophical approach to clinical work advanced bythe originators of existential psychology. Indeed, when M ay (1967) imaged exis-tential therapists as Socratic m idwives facilitating the birth of insight in patients,he said that "the central task an d respon sibility of the therapist is to ... understandthe patient" (p. 77); he also claimed th at the main purpose of existential therapy isto help patients become aware of their existence, "which includes becoming awareof... potentialities and becoming able to act on the basis of them" (p . 85). Altho ughM ay's clinical midwife w as able to help patients give birth to self-understanding,his midwife seems to have no effective clinical approach to actually facilitatingfulfillment of the potentials broug ht to awareness in therapy. To be sure, M ay'simage of mid wifery is consistent with Socrates bringing w isdom to birth in per-plexed dialogical partners, b ut the image has little clinical utility— a serious de ficitevidenced by M ay's frank admission that when editing their pioneering volumeon existential psychology, he and his colleagues "had difficulty piecing togetherinformation about what an existential therapist would actually do in any givensituations in therapy" (p. 77).



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Departing from a contemplative tradition that spawned protracted psychother-

apies such as Yalom's (1980) insight based existential therapy, PET is not primarilyconcerned with bringing insight to birth in unenlightened patients; in fact, whilefixed o n lived experience, problem solving, and patient competency, PET is notcontemplative and insight focused, but dynamic and action based. This is consis-tent with the meaning of pragmatic, a term derived from the Greek pragma, act ordeed; it is also congruent with the existentialist thesis that in hum an affairs, there ishope only in action (Sartre, 1960). Against this background, a pragmatic existentialtherapist generates future driven clinical encounters animated by solution-directedacts that enable patients to move forward meaningfully in life. In this dynamiccontext, the art of clinical midwifery may be likened to pushing patients out of astuck position b y coaxing, teasing, drawing or pulling out o f potentia decisions,choices, self-commitments, an d concrete actions that involve patients in adaptiveproblem solving, while bringing to birth life affirming self-creation.

Needless to say, BSFET may not resonate with clinicians seeking to reparentpatients by means o f protracted clinical relationships. B eneficently conceived an dpracticed, however, BSFET moves patients into the position of learning to takeresponsibility fo r life—a necessary part of growing-up. I have revealed this hard-minded existential attitude to patients quite candidly, with reference to Frankl's(1965) keen observation that the sort of person one becomes is often the resultof an inner decision regardless of physical or sociological circumstances, even ifthe circumstances happen to be a savage death camp—this having been Frankl'slived experience. O f course a patient's inner decision to survive, to become self-responsible, to gain control of difficult circumstances, to learn from mistakes, toproject a future an d give shape to experience, even to find meaning in suffering,is only a necessary first step in the adaptive work of problem solving and of get-ting on with life. In the end, a s Frankl observed pragmatically: Our answer mustconsist, not in t a lk . . . , but in right action— Life ultimately means taking theresponsibility to find the right answer to its problems and to fulfill the tasks whichit constantly sets for each individual (p. 122). In the context of PET, the essentialtask turns upon self-creation.

Self-Creation

Attempting to clarify the notorious notion that existence precedes essence,Sartre (1960) declared: man is nothing else but that which he makes of himself(p. 291). In the light of molecular biology and the cumulative evidence of geneticresearch, Sartre appears to have overstated his first principle of existentialism,defining human beings in terms of total freedom, thereby failing to author a deci-sive role for the genes in determining human identity. Heidegger (1927/1962) wascloser to contemporary constructions when he defined self-creation a s finite free-dom meaning that individuals are free to create themselves with reference to thebiological, historical, and cultural context in which they are thrown. Having been

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born into a specific existential situation—possibilities of being predetermined by

one's biological, historical, and cultural legacy—an individual is free to constructa self by fulfilling possibilities that are inherited, yet chosen.The philosophical dispute between Heidegger and Sartre brings into relief

the central thrust of existential psychology: human beings become who they arethrough decisions, choices, self-commitments, and actions. This pivotal idea in-heres in the core concept exist, a verb derived from the Latin existere meaning toemerge or come into being. Fleshing this out, May (1967) claimed that cliniciansunderstand patients existentially when they see what patients are becoming, in thesense of projecting potentia in action. In BSFET, this entails shifting attentionfrom past to future time, thereby transcending a sedimented psychoanalytic tradi-tion that h as taught generations of ardent clinicians to analyze childhood eventsand ensuing life history in order to understand the foundational relationship of thepast to current psychopathology.

To shift from the archaeological model (Spence, 1984) of digging in the pastto excavate layers of deformed life history, to an existential model o f engineeringthe future an d liberating self-creation, is to design roads an d bridges that provideconcrete ways for patients to get movement in the field of lived experience. In orderto actually design therapeutic roads and bridges, I continually: (a) translate negativetalk about the past into positive talk about the future; (b ) transmute demoralizingfeelings o f powerlessness into concrete action by pushing a patient to identify an dtake small achievable steps in the direction of confronting an d solving a specificproblem; (c) conceive an d openly define patients with reference to potentials andcompetency, rather than interpreting patients in terms o f psychiatric constructionsthat n ot only pathologize personality an d behavior, but fix humans in reified cate-gories of symptoms and diagnoses difficult for therapists and patients to transcend.Regarding the latter, not only have Nietzsche (1886/1966) and Heidegger (1962)argued a compelling case for the role of interpretation in human experience, butmore recently—while commenting critically on the psychiatric construction o fbehavior as internal pathology requiring long term reparative therapy—Weakland(1990) reaffirmed the existentialist thesis that we do not live by realities, but byinterpretations: We humans make complex problems out of originally rather sim-ple, if difficult situations.... What is a large or serious problem is not a given ...bu t . . . a matter of our interpretation (p. 104).

Epistemology aside, the existential strategy of engineering th e future an dquickening self-creation is congruent with the strategies of other brief therapies.One pregnant example is the clinical work of Gilligan (1990), who declared thattherapists should orient to the future (p. 364). In practice, Gilligan uses briefinterventions to experientially activate both the future an d self-creation by hyp-notically hallucinating an d working with a patient's future self:

Conversation ... [is] guided by the general underlying question What does your desiredfuture self look, sound, an d feel like? Once the future self is hallucinated, I treat it as anactual living presence and try to develop a balanced experiential connection between it,the client, and me (pp. 364-365).

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Putting this experiential strategy into an existential frame, I normally engagepatients as though the future self activated during BSFET is authentic or inauthen-tic: a future self that actualizes a patie nt's legitimate p otentials, or a future self thatis lost in accidental possibilities, or ways of being a self that others have chosen.Frequently, the clinical activation of an authentic future self includes protectingpatients from wandering beyond t he limits of their existential situation. Alth oughrespecting a patient's wishes and dreams, engineering the future does not entaila gratuitous wand ering—o f patient or therapist—beyond appropriate limits of fi-nite freedom determined by the patient's biological, historical, and c ultural legacy.As Binswanger (1967) noted in his pioneering essay, "Extravagance," authenticchoice has to do with rising or lifting oneself above one's cu rrent situation; butrising upward as an authentic self issues from matu ration and self-realization, notfrom being carried along willfully by gratuitous fantasies, wishes, or dreams. Ac-cordingly, PET has the goal of safeguarding patients from extravagance, while

midwifing self-creation.In practice, I remain focused on the fact that a patient has become stuck inlife, mired in self-defeating ways of existing, prisoned by negative patterns ofthinking, feeling, an d beh aving that paralyze the w ill, shrivel the spirit, and petrifyself-creation. H elping a patient become unstuck, reinvested in life, an d willingto undertake self-creation by confronting an d solving life's primary problems,is the basic challenge of PET. Often, meeting the challenge requires flexibilityand a willingness to experiment with a variety of strategies to discover a clinicalintervention th at works; sometimes this involves a brief adven ture into the symbolicworld of dreams.

Case Study. A 37-year-old single female presented with depression and anx-iety. Obese and on public assistance since age 18, Peggy complained of asthma andan arthritic ankle that precluded em ployment. Following the death of her m other—

with whom she had a conflicted relationship)—P eggy continued to live with he rfather, achieving neither emancipation nor autonomy. U nable to say "no," she be-came the family drudge, forsaking whatever she was doing for herself to f u l f i l lthe needs of a multitude of family members who called upon her continuously forassistance. Summarizing her existential situation at the end of our first session,P eggy stated sim ply: "I don't have a life " D uring our second session, however,P eggy reported the recurring dream of being a seven year old child dro wnin g in aswimming pool. Significantly, he r mother stood at the edge of the pool looking on,without responding, while Peggy neither asked for help nor attempted to help her-self. In so far as this disturb ing nightm are vividly symbolized h er stuck position,I decided to experiment with the dream to get P eggy unstuck.

I moved the dream imagery forward, while initiating Peggy's effort to helpherself, by teaching her to program herself to have a new dream in which she asksher mother to help her out of the pool. D uring our third session, P eggy reportedthat he r mother laughed maliciously, while remaining unresponsive, when she

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dreamed of asking her for help. After Peggy flatly rejected my suggestion that

her dream mother was waiting benignly for Peggy to help herself, I suggestedanother dream in which Peggy tries to climb out of the pool without her mother'shelp. Session four included Peggy's report that when she tried climbing out of thepool, her mother pushed her back into the pool forcibly. After exploring variousoptions, including the choice of remaining in the pool forever, stuck in the act ofdrowning, Peggy accepted my cavalier suggestion of a new dream in which sheforcibly pulls her mother into the pool and then climbs out. Our fifth session wasconclusive: Peggy dreamed that her deceased cat attacked her mother at the edgeof the pool, enabling Peggy to climb out. After escaping through the back door ofa neighboring house, Peggy came out the front door as an adult and found herselfdriving a car with the cat on the seat beside her.

Continuing to push Peggy forward, I interpreted this dream positively, using afew simple Jungian conventions. Interpreting the whole dream sequence as a sym-

bolic story of Peggy's transformation—from powerless childhood to competentadulthood—I portrayed the final dream as a friendly guide, leading her onward,showing he r that she was no longer stuck, that she had a new life rich with pos-sibilities, although she had some important choices to make. Disclosing the caras freedom of movement, I interpreted the escape dream as a vivid symbolizationof the fact that Peggy was now in the driver's seat, able to take herself wherevershe chose to go. While explaining that dream animals often represent disownedparts of ourselves, the cat was interpreted as Peggy's shadow—disowned powersh e needed to integrate in order to become a confident, successful woman. I furtherexplained that Peggy's cat solved the problem presented in the dream, because sheha d disowned her power to solve life problems, although the cat's power was avital, unused part of her nature. When she asked how to integrate the cat, I claimedthat this would happen naturally as she begins to assert herself by setting bound-aries and acting on the basis of choices and decisions that are consistent with herpotentials and her best long term interests.

Translating dream into reality during this pivotal fifth session, I asked Peggyto imagine that she was driving the car depicted in the escape dream. As shedrove aimlessly, I asked her to decide exactly where she wanted to go, and shedrove herself to school. After giving her a formal application for state supportedvocational/educational services during our sixth session, I involved her in thecontinuing generative work of hallucinating a future self who was: (a) doingwell in school, (b) dieting and exercising, (c) wearing more fashionable clothing,(d) gainfully employed, and (e) living in her own apartment. Meanwhile, herimaginary as if self was reinforced by concrete action: in addition to carrying out atreatment assignment to telephone the state attorney general for help in rectifyinga costly telephone scam she fell victim to, due to intense anxiety when using thetelephone, she began to set boundaries with her family, saying no to some oftheir outlandish requests.



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I have seen Peggy seven times, and her presenting symptoms appear to have

remitted. She reports being hopeful about life, she is dieting, and is progressingtoward vocational/educational rehab ilitation. Un fortunately , BSFET is not alwayseasy, for there is an obdurate obstacle to self-creation, a fierce deterrent to movingtoward the future—something akin to the formidable giant Jack confronted afterdeftly climbing the beanstalk during archetypal rites of passage. By all accounts,anxiety is the unbridled obstacle, the principal reason why individuals becomepetrified and unw illing o exist toward the future in meaningful acts of self-creation.

Existential Anxiety

Traditionally, existential psychologists have construed anxiety as a profoundlydisquieting lived experience in volv ing an immin ent threat of death and subsequentconstriction of self-creation. Accordingly, while using PET to teach anxious pa-

tients, behavioral and cogn itive techniqu es that mitiga te disabling symptom s, Ialso engage them with the understanding that "anxiety actually is at bottom al-ways fear of death, fear about existence and fear of its annihila tion" (Boss, 1962,p. 180). The clinical thrust o f this existentialist understanding is to encourage anaffirmation of life by means of reconciliation with death, with the goal of liberatingself-creation. Ultimately, anxious patients must take some risks, for the death ofold ways of existing and of being a self must be accepted before self-creative actsof rebirth or reintegration are set in motion.

When Freud (1920/1938) analyzed anxiety (Angst) in his introductory lec-tures, he claimed that the meaning of the term—a narrow place or strait—character-ized a tightness of breathing in real life situations. Conceiving the experience ofbirth as the prototype of anxiety, while commenting on an infant's separationfrom the mother as mo num enta l, Freud argued th at birth involves a disturbanceof internal respiration, as well as other painful bodily sensations repeated in allsubsequent life endangering situations. He also observed that the repetition ofprototypic somatic disturbances during an intense anxiety episode results in "themaddest precautions (p. 341).

Following Freud, clinical observation reveals that it is common for patientsdiagnosed with anxiety disorders to complain of choking; in fact, the feeling ofchoking, trouble swallowing, or the sensation of having a lump in one's throat andof smothering are diagnostic symptoms of an anxiety disorder. Interestingly, theLatin anxius is an adaptation of angere, choke ; furthermore, anguish, angst, an -goisse and angustia—metaphors used to elucidate the lived exp erience of anxietyby American, German, French an d Spanish philosophers respectively—are devel-opments of the Latin angustus, narrow, tight, formed on the Latin angere andthe Greek ankhein, squeeze, strangle, choke. Although I am acutely awareof the fact that etymological research will never mitigate anxiety, the etymology o fanxiety is clinically relevant, for it brings into relief the strategic existential v iewthat the feeling of chok ing and the sensation of having a lum p in one's throat durin g

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an anxiety episode are embodiments of self-creation being chok ed-off, p otentiali-ties of being having been strangled, movement toward the future being constrictedor narrowed dow n, the capacity for decision, choice, self-commitment, and actionhaving become squeezed or smothered by an ominous threat of self-annihilation.

This classic existential view of an xiety originated in Kierkegaard's seminalanalysis of dread or anxiety. Particularly important is Kierkegaard's (1844/1970)brilliant heuristic insight that the object of anxiety is "nothing," and that anxietyand nothing correspond regularly. D eveloping these insights, Heidegger (1962)advanced the pivotal notion that anxiety is an acute estrangement that ruptures asecure sense of being-in-the-world, thereby confrontin g an estranged individualwith the nothing of the world and with the possible im possibility of existence.Although not characterized as an existentialist, Ra nk (1936/1964) arrived at similarinsights, viewing h um an beings as oscillating between fear of life and fear of deaththroughout the life cycle. The ultimate payment for being alive, Ra nk claimed, is

death; seeking to avoid this final payment, m any individuals attempt to delay orto control death by engaging in a constant self-inhibiting life restriction. "Theneurotic gains from all the p a i n f u l . . . self-punishments no positive pleasure, butthe ... advantage of avoiding a still more painful pun ishm ent, namely fear ofdeath (p. 271).

Consistent with existential theory, patients commonly report that when anx-iety strikes, as if suddenly remo ving firm ground beneath th eir feet, it yanks themout of an incognizant absorption in everyday concerns, thereby nullifying the tran-quilizing illusions of crowd and culture: all the sheltering fictions that make lifeendurable for a paradoxical creature who possesses the gift of anticipating thefuture, while existing consciously toward the indefinite certainty of death. Awak-ening them rudely to the fact that neither human relationships nor involvementwith material things can save them w hen death comes calling, existential anxiety

brings disillusioned individuals face to face with the nothing of the world, andwith the disquieting possibility of the impossibility of existence.

Although clinicians outside the existential tradition may scoff at the sugges-tion that anxious patients may be likened to archetypal heroes, BSFET is facil-itated by treating anxious patients as if they were archetypal heroes undergoingself-annihilative rites of passage. Rather than pathologizing patients, the positivesymbolism of the hero archetype suggests that the lived experience of anxiouspatients is a compelling adventure which presents them with a series of difficultproblems to be solved during the current stage of trials and tribulations. Acco rdingto the archetype—who se standard formula is separation (death), initiation (trialsan d tribulations), and return (rebirth, reintegration, or renewal)—when mytholog-ical heroes leave the security of home and cross the threshold of adventure, therebyseparating themselves from the world of ordinary experience, they have accepteda call to venture into an unknown region, where they will undergo a severe test oftheir power during a confrontation with a formidable obstacle (Campbell, 1967).Significantly, every threshold crossing may be seen as a risky self-annihilative



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experience in which the hero submits to the death of previous forms of life andself. Similarly, clinical observation reveals that anxiety is often triggered whenan individual's secure sense of being-in-the-world is threatened by an awarenessof some new possibility of living, of being a self, of projec ting the future. This"alarming possibility of being able (Kierkegaard, 1970, p. 40) , is a terrifying indi-vidualization that accompanies the lived experience of freedom—particularly thelonely act of choosing to be or of fleeing from oneself. U nfortu nately , self-evasionis common, for existential anxiety is often "the dizziness of freedom ... [in which]freedom succumbs" (Kierkegaard, p. 55).

Just as a frightened mythological hero may refuse the call to adventure andremain home safely, anxious individuals commonly shrink from rites of passage,hoping to avoid the difficult life problems that anxiety discloses. Having spurnedenlivening experience, thereby cho king self-creation, they become stuck in life—unwilling to risk themselves in existential action that would advance the process

of self-creation un derly ing a dizzy ing anxiety episode. Once stuck in a constrict-ing life position, clinical disorders are sure to follow, with somatic complaintsbeing comm on. Believing these secondary problems are primary , wh ile avoidingconfrontation with real life problems, anguished hum ans arrive at the door of themental health clinic seeking symptom relief, unaware of the fact that symptomsare vivid expressions of the problems of lived experience. As M edard Boss (1951)asserted in a pioneering existential study of somatic disorders:

Vegetative and metabolic processes... [are] special ways and means by whichthe business of being alive ... is expressed in bodily phenomena ... Patients ...unable to m aintain ... relationships with the world and its people,... bog down intheir own bodily m anifestations, which become inflated an d distorted into m orbidsymptoms. (pp. 52-53)

In order to get existentially anxio us patients u nstuc k, I guide them into a posi-

tive confrontation w ith death during BSFET. I use this strategy discrimina tively, inorder to awaken a new appreciation of life and a keen awareness of the preciousnessof present and future time, all the while pushing patients in the direction of ac-cepting the adventure of solving their primary problems. Often, a simple questionabout death will stimulate a fruitful discussion of life. For example, w hen a patientis ripe and it is clinically appropriate, I will ask: "If you learned tha t you had onlynine months to live, exactly wh at would you do with your remaining time?" T hisprovocative qu estion is not asked in a heavy-handed way th at encourages m orbidintrospection; rather, it is posed empathically to promote a realistic appraisal ofwasted time, life's opportunities, and the identification o f achievable goals. If apatient engages the question, in the fashion of an archetypal hero undertaking ritesof passage, a carefully employed death reflection can effectively activate pragmaticaction resulting in problem solving and authentic self-creation.

Guiding patients into a constructive death reflection is one of those smallclinical moves that may have large effects, especially if it triggers a decisive

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affirmation of life in the face of death referred to existentially as "the courage

to be" (Tillich, 1959). However, even careful employment of this clinical strat-egy may leave vulnerable patients in the position of living without tranquillizingillusions; and this may be countertherapeutic Regarding this exposed con dition ,N ietzsche (1966) not onl y articulated the hum an need to falsify reality by means ofvital lies and myths and fictions, but empirical research has led cognitive psychol-ogists to confirm the existential philosopher's belief that healthy hum an minds arethose that promote be nign fictions about self, world, and future . For example, wh ilenoting that depressed ind ividuals lack the positive illusions informing the cogni-tive set of individu als who are not mood disordered, Taylor (1989) m aintained thatan accurate view of reality—a depressive realism—describes the cognitive set ofmood disordered patients.

In as much as the most empathic death reflection may dispel tranquilizingillusions, leaving a patient more vulne rable than wh en treatment began, the decision

to use this strategy requ ires sound clinical jud gm ent. Suffice it to say, whenev er apatient deflects the qu estion of death, in the fashion of an archetypal hero refusing acall to ad venture, the better part of wisdom is to not push in that direction. A lthou ghthe anx ious patient has spurned the opportunity fo r self-creation, the therapist hasplanted a seed that may germinate and grow and be harvested after BSFET ends.

In the absence of a meliorative death reflection, a useful clinical strategywould be to work with patients to replace destructive fictions with ne w life af -firming deceptions. This strategy is congruent w ith Y alom's (1980) belief that aprincipal function of existential therapy is to provide patients with a sense of per-sonal mastery by means of fictional interpretations that catalyze a dormant will;this strategy is also consistent with evolutionary psychology's formative thesisthat self-deception and the ability to deceive others are biological adaptations en-hancing reproductive success (N esse & Lloyd, 1992). Although a clinician maybe accused of disdaining truth, a brief existential therapist must develop a sharpeye for the "cash value" of ideas (James, 1966); in this pragmatic context, vitallies and fictions are treated as instruments of therapeutic action. In fact, creativefictions that facilitate adaptation, imaginative m yths that activate choice an d com -mitment, positive illusions that liberate self-creation may be promoted d uring PETbecause they have the virtue of enabling some demoralized patients to: (a) experi-ence increased self esteem, (b) develop m astery and control of life circumstances,(c) project positive future outcomes of action. In short, clinical experience withBSFET indicates that the co-creation of illusion enables some patients to experi-ence a happier, healthier, more meaningful life.

W hile existentialists are responsible for disclosing the imp ortance of mea ningin human experience—not only conceiving meaninglessness as a pathologicalcondition, but also claim ing that the quest for meaning m otivates hum an action—given a tragic view o f hum an existence, unen cumbered happiness has not figuredprominently in existential lore. In fact, existentialists have been more com fortable



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with Sisyphusean images of absurd happiness, in which a life of futile labor is

coupled with an heroic acceptance of tormenting terms of existence (Camus, 1961).Nevertheless, when developing strategies of BSFET, an optimistic clinician maywish to integrate empirical evidence supporting the hypothesis that,

positive illusions abou t one's personal qualities, degree of control, and likely f u t u r e appearto promote happiness. P eople who have high self-esteem and confidence in their abilitiessay that they are ha pp y, .. . People who believe that they have a lot of control in their livesand who believe that the f u t u r e will bring them even more happiness are happier by theirown reports than people who lack these perceptions. (Taylor, 1989, p. 49)

Needless to say, some therapists may be uncomfortable with a pragmaticapproach to clinical work; some may even hold a more traditional view of mentalhealth, thereby premissing clinical strategy upon the suppression of falsehood asa necessary part both of reality testing, and of healthy human functioning. Fromthe perspectives of PET, however, a clinician is free to use whatever tools willwork to responsibly midwife the self-creation of petrified patients who are stuckin life. This may entail a strategy of hardminded realism (Ellerman, 1997), or itmay necessitate artistic experimentation (Ellerman, 1998). Whatever strategy isadopted dur ing BSFET, the task of midwifing self-creation remains as complexas human existence. Regarding this complexity, Boss (1962) concluded wiselythat existential anxiety may be an inseparable part of life not to be eliminated bypsychotherapy. Comparing anxious patients to the perishing old skin of a snake inthe act of sloughing, Boss observed that the casting of a skin is ... a catastrophicevent.. . fear[ed] as its final destruc tion. ... Ye t . . . the sloughing process is thecontrary of a dying; it is the creating of a more vital space for the animal to go ongrowing and maturing (p. 184).

SUMMARY AND CONCLUSION

There are countless ways of conceiving therapy—as many ways as there areclinicians practicing this experimental art. For the art of therapy covers a vast can-vas on which both simple sketches and highly imaginative masterpieces have beenpainted. Whatever artistic experiment has prevailed within the clinic since Freudconstructed his psychoanalytic experiment in free association one hundred yearsago, from time to time, therapists are given to believe that their successful inter-ventions have something to do with magic (de Shazer, 1990). In fact, there is anarguable sense in which patient change is magical: a metamorphosis of thinking,feeling, and behaving whose elan remains inscrutable. Still, seasoned practitionersmay view an impressionistic sketch of clinical magic rather skeptically; for what-ever magic has begotten demonstrable change in a patient's life, a therapist haslabored hard in the vineyard—like Van Gogh in Aries, Auvers, and Saint Remy—working diligently, despite unfavorable elements, to fashion clinical techniquesand ways of being present that liberate human potential.

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