Time and Existential TherapyHow We Live, NSPC Conference, British Library, 9th July 2016

Dr Neil Lamont, CPsychol, HCPC & UKCP regd.

Workshop Agendao Time and temporality

o Overview of existential time-limited therapy

o My research

o Group exercise

Time and Temporality

A Brief History of Temporality

E. Husserl (1859-1938):

Lived time is three-dimensional -

a ‘retentive’ (past) and ‘protentive’ (future) influences how we experience the current

A Brief History of Temporality

Martin Heidegger, 1962

‘the phenomena of the future, the character of having been, and the Present’ together constitute the ‘ecstases of temporality’

‘A unity of the ecstasies’ So we experience an amalgam of all three tenses – time is three dimensional and transient:

‘the unity of a future which makes present in the process of having been; we designate it as ‘temporality’ (Heidegger, 1962. p.326)

We are unique in having the ability to transcend the present and project towards the future where our possibilities, and the certainty of our death, reside.

My choice… 1. confront and embrace this transience > purposeful living

2. avoid and deny - the ‘never me’ strategy:

‘dominates everydayness so stubbornly that in Being with one another, the ‘neighbours’ often still keep talking the ‘dying person’ into the belief that he will escape death and soon return to the tranquillized everydayness of the world of his concern’ (ibid.p253)

Being towards Death ‘When Dasein concerns itself with time, then the less time it has to lose, the more ‘precious’ does that time become, and the handier the clock must be’ (ibid. p.418).

Relevance to Existential Therapy

Time-limited therapies

Defining characteristics Collaborative endeavour – ‘positive, strong, collaborative working alliance’ (Bor, 04)

Brief practitioner should actively challenge their client from the outset

Fundamental intention is for the client’s resourcefulness and autonomy to be encouraged and nurtured – instil self-reliance and self-confidence Small changes both a realistic aspiration and, crucially, sufficient to instigate a larger process of change which the client will continue once the therapy has ended

Defining characteristics Clear explicit contract re number of sessions (usu. 6-12)

Ending should always be present and discussed

Acknowledged as not suitable for all presenting issues (early life trauma/abuse)

Existential time-limited therapyLimited literature e.g. Bugental (1995) and Strasser & Strasser (1997) – seminal:

‘the one important distinguishing feature…is the limitation of time itself. So although the goal is to achieve the same kind of awareness as outlined in an open-ended approach, the aspect of time becomes a tool in itself’ (ibid, p.13) a ‘pressure’ is created for both client and therapist to become mindful of the limitations that they face and the objectives they aspire to meet ‘…the simple fact of knowing that there is an ending tends to evoke stronger emotions…such as fear, anger, sadness and the recollection of previous losses and rejections help clients to identify their value and coping strategies’ (Strasser & Strasser)

Existential time-limited therapy as with open-ended ET, clients values explored within the context of a life lived within the paradox of possibilities, limitations and choice; ‘to distinguish them from the limitations that they impose on themselves’

encouraging an engagement with the key existential concepts of responsibility, choice, temporality, the embracing of our limitations, possibilities and death within this particular context can facilitate a unique opportunity for a meaningful exploration of problems with living

My research

Is Time of the essence? Experiential accounts from existential time-limited therapy at an HIV counselling service

Existential time-limited therapy

My existential vantage point

client work

Prevalence of time-ltd therapy

What role for ETLT?

Research rationale and associated questions

Little knowledge of how ETLT is experienced by clients.Lack of ET practice evidence-base. Prevalence of time-ltd therapy.Is ETLT an effective therapy option for this client group?

1. Presenting issues and objectives – what were your hopes and expectations when you began ETLT?2. What actually happened during the ETLT?

3. Therapy outcomes – what was taken from the process, if anything?

Research design

Semi-structured interviews

Follow-up interviews – why?

Participant demographics

Alias Age Ethnicity HIV status

Sessions attended

John 38 White Irish HIV+ (<1yr)

12

Oliver 34 White British unknown

12

Jawaad 43 Zimbabwean British

HIV+ (>2yr)

12

Michael 36 White British HIV+ (>3yr)

12

Three key periods:

1. Beginning time-limited existential

therapy

2. A time-limited

existential exploration

3. Leaving a time-limited existential

journey

1. Beginning a time-limited existential journey:• ‘the tragedy of being a gay person – you’ll party

hard, you’ll get HIV…and you’ll die. I just felt like such a cliché…it represented punishment and oh judgment and fear of your own sexual desires’ (John)

A quest for acceptance and understanding

• ‘I may not be able to talk candidly about sex….because she is a woman she may not understand as well as say a gay male counsellor’ (Michael)

Obstacles en route to trust

• ‘I said I needed interaction…and I got a whole explanation about ET…all this nonsense…it is not going to make any difference to me’ (Jawaad)

Therapeutic substance over

style

2. A time-limited existential exploration• ‘She asked me ‘when you think of love, what does

it mean?’ and I said ‘unhappiness’…it was very useful…I realised that I am afraid of letting myself go because loving or being loved equates to being hurt’ (Jawaad)

A meaning revealing journey

• ‘Her personality, her manner, her warmth, her presence…her ability to relate to what I was saying and what I was feeling…sometimes she drew on personal experiences...It built the trust.’ (Michael)

How relational alliance is conduit for

change• ‘I think that if you want to kind of explore a

problem and look at it, examine it…to me (12 weeks) feels like the right amount of time…to open something up, look at it and deal with it’ (Oliver)

The opportunity of

the time-limited setting

2. A time-limited existential exploration

Challenging, confronting fears:

I think (counsellor) always *pause* always asking the question ‘well what do you think will happen if you do something you are frightened of doing?’ or ‘what will happen if you don’t do something you are frightened of doing?’. Making me articulate things and to focus on these different scenarios and and and erm cos I think everyone knows, you know the answers to those questions but it’s one thing to know it and another to say it, and get it out! Erm and really *pause* examine it, you know, looking right at it. Oliver, (II104)

Confronting fears:

This process of describing and meaning making engendered an early and welcome shift in his mood and attitude:

I went from a place of such isolation and loneliness and just ...terror in a way... I felt I was just breaking down and I just needed somewhere to go with that. And just to have that space and do that, describing how I felt, making sense of it, I quite quickly kind of started getting more happy again...and positive again, and felt much healthier and you know OK about myself and that probably happened in the first four to five weeks. (II67, Michael)

Early relationship…

Something has happened definitely. Because in the first 2 sessions I remember being in that desperate state and almost scared of (counsellor) in a way, not knowing, and almost apologising for me being there. But as the weeks progressed I became more and more animated and it was...it was a confidence building thing and maybe that was the relationship that was helping with that. (II199)

Substance and depth…

(It) did feel like a substantial bit of work, and I suppose in a way it did make me focus more...and after twelve weeks it would have gone deeper but we went quite deep anyway, it wasn’t on the surface. I've faced some painful and difficult things in the twelve weeks. (II138)

Value of good ending You know this is a relationship in the way that is ending in a way that I didn't want it to end and I quite enjoyed and looked forward to and now I won't have. So you know to have the sense of loss of that, that space. Yeah it's sad...I feel sad. But it's tolerable cos you know I can contain that and know that but it's kinda like I'd made a friend and they have moved on but I'm happy I had that time while I had it. That's what it feels like. (II55-7)

3. Leaving a time-limited existential journey:

• ‘You’re faced with your own mortality basically…but I can now see that how – and this will sound absolutely atrocious – but it has actually been my saving grace…I realise that now’ (Michael)

Purposeful living from adversity

• ‘This is…the conversation I wanted to have with the counsellor, but I avoided it because I thought ‘I shouldn’t really…don’t get too analytical…just go with it’’ (Oliver)

The value in taking stock

• ‘I think it has kicked-off something which I am continuing myself. I’ve really felt that – it hasn’t just stopped’ (John)

The beginning in the ending

Post therapy follow-upAnd there was stumbling blocks which I was really challenged by since the therapy that have really rocked me and I feared would put me back in that same place again...but they haven’t. And I suppose again it has challenged me to now make the changes that I am now aware that I need to make. I need to do it slowly but I will do it, the judgement has been removed I suppose, I’m not as judgemental on myself. John (FU14-15)

Value of post therapy reviewI am glad this has happened (interview), because it has kind of crystallised the whole process. But had you not been doing this…you are just left to get on with your life and it’s not... and it is that uncertainty, you know ‘what the hell just happened *laughs* for twelve weeks?!’ ‘What have I actually achieved if anything, what have I actually covered? Have I covered this, have I done this?!’ Michael (II143)

Beginning in the endingI think it (counselling) has erm kicked-off something which I am continuing myself. I've really felt that - it hasn’t just stopped…It's there with me and that's something that’s changed in me and that’s something I want to keep. I don’t want to lose that...I found something here in me that I want to keep. Oliver (FU143-4)

1. Relevance of the existential approach• Isolation, low self-worth, fear of

judgement and rejection• Shadow of HIV• Crises of being-in-the-world –

perception of unacceptability

Presenting issues

• Accepting relationship with self• More meaningful relationships with

othersObjectives

• Acknowledgement, Understanding, Respect

• Interaction and engagementTherapist

1. Relevance of the existential approach (contd)

Session features: descriptive, conversational, clarifying

Understanding emotions, deriving meaning

Outcome: enabling, empowering, purposeful living

3. The influence of the time-limited frame

Potential of a time-limited contract• Sense of urgency > engaged, focussed explorations – but

not ‘single issue’• Early establishment of alliance pivotal• Evidenced in potency of ending

Potential of post-therapy review• Sense of ‘after-care’, tailored• Opportunity to explore experience of ending and loss• Importance of this being external

Time-ltd setting as change initiator

• This was beginning of journey, work-in-progress – equipping and empowering

Some conclusions

ETLT in actionPresenting issues –

existential engagement

effective: self-acceptance and

empowering

Time-limited can be non-specific and achieve depth

12 sessions were enough for all – no plans to re-

apply

Relational attitude was key – insight into specifics

Taking stock – much value in time-limited setting (external reviewer esp

valuable)

Practitioners should be mindful of context of

minorities (BPS) and alert to triggers

Conclusion:

ETLT deserv

es a place

Client-centric

and empowering

Reflects

human conditi

on

Pluralism and

client choice