Towards An Existential Cognitive Behavioural Therapy Model for Psychotherapy and Counselling
by
V.A. De Maynard
Recent
developments in Existential analysis has seen the introduction of a need to
develop psychotherapy that reflects changes in the ways people pay for their
therapy. Both Employers, and insurance companies do not seem to want to pay for
therapy that could, effectively, go on, indefinitely (EAP Practice, 1999, p4;
Samuels, 2001). However, if is argued that being-in-the-world, or being-there
(Da-sein) seems typified by a continual 'throwing of ourselves' into situations where the range of possible outcomes
present for us configurations of uncertainty; and hence, experienced
Existential angst, it could also be argued that the possible need to engage in
therapeutic encounter may arise in equal proportion. However, the cost of being
‘in therapy’, over time, does not seem to be a realistic option for the
majority of potential clients, and only those for whom accessibility and
availability of can psychotherapy and counselling seem to benefit from its
application in either the long-term, or short-term (Dryden and Feltham, 1994).
Existential Analysis has,
traditionally, been an therapeutic approach which like Psychodynamic analysis,
has required a considerable amount o personal investment in its application,
over time. It is argued that this implies that Existential Analysis may
not be a realistic option for the
majority of people who might wish to benefit from the application of
Existential Analysis within the course of their everyday lives. Therefore, some
attempt to make accessible and available Existential Psychotherapy and
Counselling a more realistic option for members of the public may need to be
considered in the here-and-now. Strasser and Strasser (1997), for example, have
devised a theoretical schema which addresses the issues of time, and cost,
(i.e. ‘Modular’ or ‘Open-ended’ Existential Time-limited Psychotherapy and
Counselling), but this paradigm fails
to embrace current thinking within the psychotherapeutic profession, and
establish themes within its exposition which may be similar, and ways in which
this paradigms might be different. This article is an attempt to initiate a
movement towards inclusion within the psychotherapeutic profession that seems
to be current thinking in psychological therapy.
My aim is not de-value, nor
dissolve Existential thought as represented within the ‘Society of Existential
Analysis’, but to discover whether there is anything within ‘Cognitive
Behavioural; Therapy (CBT)’ that seems ‘Existential’. One way of doing this is
to make movement towards an “Existential CBT”. Why? An “Existential CBT” would
take advantage of the wider society’s apparent acceptance of CBT as an
affordable option for psychotherapy and counselling, whilst allowing the
therapist to err towards interventions which are the less directive, non-authoritarian
stance typified within ‘Existential Analysis’, or ‘Existential Psychological
Therapy’ (Robbins and Hayes, 1993; Beutler et al, 2001, p159). For me, this
seems to be more a question of attitude, (i.e. the therapist’s attitude to
psychotherapeutic work, and their interpretation of the theory and what might
be expected of him/her as a psychological therapist). In this sense, CBT will
be presented as a personal interpretation of what the theory and its
application might mean to me, and accept that this might be different from
other practitioner’s interpretations.
Existential
psychotherapy seems to pride itself on the ability to apply the art of
phenomenology, or the art of reasoned inquiry, to the human condition; and
it’s, reluctance to accept the scientific approach to understanding human being
in-relation to, and with, the world-around (Husserl, 1913/1982; Idhe, 1986).
People like Lacan, who advocated short or brief therapy, have been asked to
leave the ‘International Society for Existential Analysis’. However, it must be
acknowledged that short/brief psychological therapy, and the ability to conduct
‘evidence-based’ interventions has become a social reality (Nelson-Jones, 2001;
Dobson et al, 2001). It reflects the changing nature of the society in which we
all live, and this may be reflected in the reduction in the acceptance of
psychological therapies that are unable to say when a ‘fund holder’ can expect
an improvement (Arthur, 2000). Brief Therapy, arguably, offers a greater
proportion of society the opportunity to evaluate the ways in which we are
‘free-to-be’ in-relation, and make changes within the context of their everyday
lives ‘as’, ‘when’, and ‘where’ necessary, and to so do within the changing
social constraints that appear to bind us all. This can only be a ‘good thing’
as it shows how, as tempero-spatial beings, we are all intertwined of, and
with, each other; and yet separate, and distinct. To pretend otherwise would be
like striving to become autonomous in isolation of a professional world that
seems to be enthused with ‘science’, and CBT; the avoidance of, and escape
from, which does not seem possible.
Conceptually, this should not be
possible. The aims, and purposes of therapy that is Cognitive-Behavioural, and
Existential, are different, arguably. (For review of Existential Philosophy,
and its application see appendix A). But are they? In what way is CBT less
human, more technical, less able to facilitate understanding, less
here-and-now, less questioning of our beliefs systems, and how they might be
applied within the context of our everyday lives, as opposed to Existential
Psychotherapy and counselling? Personally, I see little difference; except may
be on the level of abstraction that is often achieved in Existential
Psychotherapy, and the attitude reflected in the application of CBT by
individual practitioners (Beutler, 2001, p159).
Both approaches investigate the
client within the context of their everyday lives (Kirk, 1989). Both identify
an aspect of the client’s repertoire for being-in-the-world, and attempts to
‘shed light’ on the core beliefs, values, or sedimentations, that appear to
underpin our behaviour within a given situation. Both look for ways of being-in-the-world
that which ‘transcends’ a given everyday experience, or situation, and allow
for planning future interaction within a lived-world that appears peculiar to a
given individual. Both allow for the consideration of options when presented with
a dilemma, or paradox. We could ask whether it is necessary to deconstruct, and
hence categorise, our everyday experiences into variables which then become
‘measurable’. But having ‘separated-out’ our thoughts, feelings, and actions within a given context,
does not the relatedness between these variables, also, reveal themselves? It
does not seem, absolutely, necessary to then measure these variables, over
time, nor to impose one will as therapist over and above that of the client, as
may seem to be the case in the application of some therapists.
The structure of language
necessitates that we construct our sentences in a pre-specified way (Derrida,
1967). Therefore, deconstruction of events in this way would occur regardless
of our intention, or indeed, purpose; if only to make sense of the dialogue
that leaps into flame in the space in-between the client, and the therapist. In
fact, it seems to me that the only real difference between Existential Therapy
and Cognitive-Behavioural Therapy, seems to be a tendency in CBT to plan future
behaviour as a joint venture between the therapist and client, and to note the
consequences having decided that this is what you were going to do, (i.e. shown
intentionality during therapeutic encounter), and so do, purposefully.
This constitutes a difference in
attitude to psychological therapy between practitioners of these two
approaches. An Existential practitioner may make an intervention with conscious
intention, but this intention to be in-relation with the client in either this
way or that does not seem to be, purposeful at that time. On reflection, the
Existential Therapist may appear to be acting intentionally, and their
intervention may seem purposeful, but this seems difficult to deduce until
after the fact. Van Deurzen-Smith (1989) suggests that therapeutic ‘change’ in
the way a client experiences the world may be secondary observation, but it is
not the intention of the Existential therapist to change the client,
purposefully. Hence, this, with the application of techniques, ‘Self-help’
literature, and ‘homework’ are key features of CBT; and though not exclusive to
CBT; remain contrary to Existential therapeutic practice. However, on
reflection, the interventions of the Existential Practitioner seem no less
purposeful than those of the Cognitive-Behavioural Therapist, save to say that
the outcome of each intervention can not be known in either case until after
the fact. The CB therapist may argued that their interventions are design to
delver a specific predetermined outcome, and speak with some certainty as to
this outcome. But such claims seem difficult to verify until after the fact.
The CB Therapist may desire an outcome to be in either his direction or that,
but ultimately, is it not the client who choices whether or not to make the
movement. So, having decided that there are very few significant differences
between CBT, and Existential Psychotherapy, is it, now, possible to merge these
approaches to psychotherapy and counselling, theoretically?
Cognitive-Behavioural
Therapy: the movement towards constructivist psychotherapy
The first cognitive approach to generate interest among behavioural researchers may have been self-instructional training (Meichenbaum, 1975). The popularity of this approach was the identifiable similarity to the concept of coverant, or mental Operant, behaviour within ‘Operant Theory’. Meichenbaum suggested that changing the instructions that patients gave themselves could bring about behaviour change. Beck (1967) argued that negative thinking mediated the experience of depression. ‘Being depressed’ was something that the client does when confronted with events/situations which de-value his/her sense of self in-relation to the world-around. The client’s behaviour, (i.e. thoughts, feelings, and actions), seemed to maintain ways of being the seem ‘depressed’, overtime. Hence, it was believed that by changing the way the client ‘thinks’ about him/herself in-relation to his/her lived-world, (e.g. the experience of depression), it was thought that the client’s experience of being-in-the-world could be changed.
The idea that the way we think about ourselves in the ‘here-and-now’, often includes perceptions of self as we appeared to be in the past, appear to be in the present, and will appear to be in the future dimensions, seems to ensure that our view of self in the world takes on a global outlook. Beck (1976) showed how we distort our cognitions, (i.e. the way we think about the world), to maintain our own view of the world or worldview. The way we interpret our everyday experiences seems to show little variation, over time, suggesting that the meaning we attach to our interpretations are not readily changed. No matter how the content of our everyday experiences reflected in the descriptions of events/situations appear to differ, our interpretations of such events/situations seem to be essentially, very similar. This may suggest reasons for the experience of similar outcomes to these same events/situations. We seem to have become stuck, trapped, and unable to influence ‘how’ we could become in a positive way.
By identifying ways we in which we distort our cognitions, (i.e. the ways we think about ourselves in the world), we can begin to challenge the validity of the values, attitudes, core beliefs, sedimentations, or mineralisations that appear to underpin our behaviour within the context of our everyday lives. Ellis (1962) went one step further arguing that we become emotionally-distressed when our cognitions become ‘fixed, rigid, irrational, difficult to change, and persistent, overtime’. Somewhere between perception, and interpretation, the mind seems able to “conjure-up for itself” a situation that invites a particular way of being-in-the-world that seems indicative of what has become to be labelled as ‘mental illness’.
Characteristic of CBT design is there attempt to mimic a ‘case study experiment’ (Kirk, 1989). Each Client presents as a ‘case’, (i.e. person in their lived-world), to be discovered, and then studied or investigated. Already, we seem to have made a movement from the subjective, to the objective. Both the CBT therapist, and the client co-construct hypotheses/formulations from the information the Client has brought to the therapeutic encounter, and having collated this client-specific information, they both set out to ‘test’ the validity of these hypotheses within the context that is the client’s everyday life (Dobson et al, 2001). No attempt is made to superimpose our own prejudices, presumptions onto the client, nor vice versa. This would constitute a violation of the Client, and the therapist can not conclude within any certainty that his/her formulations about the Client are valid to any extent outside of the parameters that reveal themselves within these encounters. The Therapist’s interpretations remain without validity until tested in-relation with the client, and therefore, the application of information from other studies seems tentative; if, not a useless passion, as the Client seems to become lost in the rhetoric. ‘Therapeutic work’ is, therefore, collaborative; it seems co-constructed, and planning strategy to deal with the presenting difficulty takes place within the context of the developing ‘working alliance’ that seems best made specific to the presenting situation(s).
Therapy is time-limited in CBT, and seems directed towards the meeting of explicitly agreed goals (D’Zurilla and Goldfried, 1971; Spivack, et al, 1976). Does this in-itself constitute a movement towards the transcendent? The client does seem to made aware of the passage of time, and his ability to transcend his/her everyday experiences to adopt a way of being-in-the-world that s/he has not a yet experienced. In the first instance, there seems to be more explanation than exploration, but it could be argued that in order to understand the thing in-itself, (e.g. the presenting the psychological distress), some primary exploration is required. In saying that we are uncovering some explanation of the clients apparent depressed behaviour, something also needs be said about the depression, itself. In what way is the client behaving in a ‘depressed’ way, and what does this behaviour apparently signify? In-relation during therapeutic, both the Therapist, and the Client, can then set about deconstructing the Client’s lived-world, and looking at the relationship between what appears to be the antecedents to a given way of thinking about being-in-the-world, the underlying beliefs/values, their resultant behaviour, and the apparent consequences of that resultant behaviour.
Hence, explanation follows exploration, and establishes meaning, which then has the opportunity to become shared; and not imposed. We are reminded of the ‘pre-science, ‘science’ split, which for me, represents the juxtaposition of phenomenology, and science, respectively, and attempt to forge links between to two in constructive way. Again collaboration seems to be of the ‘essence’ of facilitated self-discovery. The Client needs to feel ‘safe enough’ to disclose important, and often distressing, information about himself or herself in-relation to, and with, his or her lived-world; and so do without risk of censure, and with someone who is empathic, and committed to helping and supporting the Client confront his/her difficulties as s/he struggles within context of their lived-world (Guidano, 1987). It seems to me that it is a misconception that having arrived at a diagnosis, that a prescribed form of treatment, then follows. This seems neither ‘experimental’, nor good science. Having formulated the ‘problems’, ‘issues’, ‘concerns’, and the context in which they arise, we can then go on to say something about how they might interfere with the Client’s everyday life. In exploration of the Client’s lived-world, he or she might frame their everyday experience having gained some understanding of CBT, and the Client’s role in the therapeutic process. Framing everyday experience in this way not absolutely necessary, but for me, it provides a good way of showing the possible relatedness of thought, feelings, and action within the Client’s everyday lived experience(s).
Further treatment remains tentative in spite of the amount of research that suggests one form of therapeutic intervention over, and/or above, another. To so do assumes that one Client live experience shows strong correlation with another, and the individual seems lost in this kind of discourse. Further, it remains difficult for anyone to know the outcome of intervention, until the outcome has been experienced within a given context. To this end, intervention seems person-specific, and context-specific, in-itself, and can not be pre-determined beyond the realm of possibility. To claim otherwise seems ‘unscientific’; if, not un-phenomenological.
Collaboration is emphasised within CBT such that treatment plans are reflective of the information that put into the ‘space in-between’ during the course of genuine meeting (Kirk, 1989; Buber, 1967). Only that which is disclosed within the therapeutic sessions is brought to bear on the presenting problem/issue. The boundaries within which the therapeutic session will take place need to be set, and adhered to. The therapist may bring to bear his/her own subjective view of the presenting situation, physiological states, cognition, interpersonal factors, as well as overt behaviours, such that clarification, and description facilitate mutual understanding. The difference between the use of prior knowledge for description and clarification, and for diagnosis and treatment, is an important distinction. In collaboration with the Client, the therapist may present a point of view of the Client that encompasses all the Client’s symptomatic behaviour, (i.e. how the Client appears to be in-relation with the Therapist), given their relation to the presenting problem statement; but, this in-itself remains tentative; and hence, not ‘fixed’, and ‘immutable’, as may be inferred from reading some of the Cognitive Psychology literature (Neimeyer and Raskin, 2000). It may be that some symptoms, (or ways of being-in-the-world), do not seem to be related to the primary problem statement, and further problem statements may need to be discovered, documented, and subjected to explorative investigation.
Ultimately, adherence to what appears to be fixed, and determinate, seems more reflective of how the Client appears to have been in past, or in the present, but suggesting that such formulations might be indicative of how the Client might become in the future seems, tentative. Thus Therapists who behave as if the information with which the Client presents enables them to predict ‘how’ the Client is likely to behave in the future, could appear to be behaving in ways that seem just as fixed, rigid, intolerant, and immutable as the purport their clients to be.
‘Mutual collaboration’ invokes an image of a therapeutic process that may be perceived as a joint project in which the Client is able to say something about how s/he might want to become at some point in the future. Up until now, the possibility of being in relation to a lived-world, differently, may have been out of the client’s own human experience (Guidano, 1991), and as such s/he may be required to take ‘a leap of faith’ (Kierkegaard, 1843; 1954). The therapist can help and support the client whilst s/he negotiates how s/he will endeavour to reach these goals having been offered the opportunity to consider the possible outcome of the client efforts within the context of his lived-world (Guidano, 1983; 144). Ultimately, both the therapist and the Client should be able to say to what extent a given difficulty may occur within given situations, overtime, having shown this to have been the case to date, in appearance. The Client may then given the opportunity to change the outcome of such situations by devising a plan of action aimed at creating, precisely, this.
Implicit within a given situation, where the outcome has been shown to be ‘predictable’ in reference to recent past experience, is the element of personal agency, and hence, some say in how this situation is experienced by the Client. By this I mean, that client can ‘control’ how s/he experiences, contextually, similar situations, which s/he has not experienced, previously. The reasoned argument being that, if, we know what is likely to happen within a given situation, we can take steps to change our experience of it. However, there is no certainty as to this, nor of the consequences of our interjections. We assume that the outcome will be this or that, but circumstances in which a specific response has been noted are unlikely to be exactly the envisage they might. We ourselves do not appear to be the same from one moment to the next. Likewise, the people with whom we intend to associate seem unlikely to be exactly the same from one day to the next. However, we behave as, if, our lived-world was fixed, and hence, predictable. We seem to imagine that our projects in the world will have predictable outcomes.
It could be argued that there are certain aspects of our self-of-the-human-person, which do not change, significantly, over time, and that it is these aspects of our self-of-the-human-person which we seem fixed, and hence, subject to scientific investigation and measurement. Guidano (1983; 1991) seems to alluding to this precept within his constructivist view of the human experience of being-in-the-world. But such aspects do not seem to be transmutable as being indicative of a way of being-in-the-world as this in-itself seems to subject to our own personal willpower (Nietzsche, 1968), and hence, our own courage to change for ourselves (Tillich, 1951). For me; change as in change in the way we appear to be in the world, seems to require a fundamental changes in personhood at this most basic level, and finding the courage to make such changes in-relation to a world that continues to challenge our understanding of the world seems to be the essence of being human, or being- there.
Psychologist and philosophers alike seem destined to uncovering what these aspects of being-there are, and what the myriad of possible responses to these aspects might be. Their projects in the world seem intentional; though psychologists might argue that his/her projects are both intentional, and purposeful. Separating out our own prejudices, and being non-judgemental in-relation with each others, ensures that nothing that appears to be unrelated to the issue in question is brought into the space ‘in-between’ during the genuine meeting of Client, and therapist. Discovery seems to require a continuous search for relatedness within the context of the client’s lived-world such that both the Client and therapist appears to be asking themselves what has this view or opinion, feeling, action, got to do with the case in question (Guidano, 1991).
Cognitive-Behavioural Psychological Models seem to be the same, generally, in so much, as they aim to identify, clarify, and evaluate, cognitive and behavioural ways of being-in-the-world that appear to be preventing, or interfering with, the client’s ability to reach specified goals or objectives s/he has set for him or herself (Dobson et al, 2001). This argument may, also, be proposed for those who seem unable to resolve their own issues concerns, paradoxes, or dilemma.
Cognitive models appear to be highly structured, and can seem directive when applied to a given situation; irrespective of due consideration to way in which this given context may well be different from the prior experience of the therapist. But the aim is to shed light on a presenting situation or issue/concern looking, intensively, at the way the client processes information. The therapist takes on a psycho-educational role by ‘teaching’ the client ways of testing the validity of their beliefs, and thought processes that underpin their behaviour, within the context of their everyday lives, (e.g. skills training, imagery, Socratic questioning, assignments, and other homework) (Dobson et al, 2001). The therapist is not required to impose his/her will over and above the client; though s/he may assume the role of ‘advocate’ in situations where the client seems either unable, or unwilling, to assume full responsibility for the life choices s/he may have to make within the context of their own lived-worlds. By this I mean, where there is a possibility of risk of harm to self, or to others, within the context of the Client’s lived-world the therapist attitude in-relation with the client may be one that denies the Client full autonomy, and hence, responsibility for the Client’s own actions.
Beck at al (1990) devised a way of working with clients based on the premise that the way people interpret their everyday experiences determines they way they behave. Behaviour, therefore, becomes consequential, and determined by the way we interpret our everyday experiences. Embedded within our schemata are our beliefs. When applied to the world-around, our beliefs seem to give our everyday experiences, meaning. Hence, to achieve changes in worldview, or outlook on life, or ways of doing things in general, it might be prudent to shed some light on the way we process information, cognitively, and organise this information within mental constructs referred to as schemas (Guidano, 1991). In evaluation of our information processes, we can shed some light on that which remains hidden, and automatically applied within the context of our everyday lives. We become emotionally distressed when the schemata representing a real or imagined scene become activated. As to whether we choose to reproduce a previously distressing experience, and to so do in ways which seem purposeful, seems debatable. But our responses to what appears to be ‘sensed’ in given situations, do seem to be indicative of action response mechanisms that do seem to pre-exist our current experience; insomuch, as clients on reflection do seem to have behaved in similar ways before the event under review in the here-and-now. This in-itself, suggests that “unspoken rules for being in-relation” derived from information acquired earlier in life do seem to be applied to the lived-world as experienced in the here-and-now in such a way as to induce vulnerability and sensitivity within us, and motivate us to take avoidant; if, not evasive, action.
For Ellis (1958), ‘Rational Psychotherapy’ was based on three hypotheses. The first was that thinking and emoting are, closely, related. The second was that thinking, and emoting, established a ‘cause and effect’ relationship between them. The third was that thinking, and emoting, takes the form of ‘self-talk’, or ‘internal self-statements’, and hence were capable of generating, and modifying our emotions. Ellis (1993) asks ‘what are the ‘rules’, hypotheses, or core beliefs, that are applied to a given situation’, and ‘how do these ‘rules’ appear to interfere with the achievement of a pre-stated goal, or objective?’ In other words what is the nature of ‘God’ within our own minds, and how does ‘God’ interfere with the achievement of goals we set for ourselves?
Ellis (1972; 1991) devised a scheme for categorising individual thoughts, emotions and actions, and placing them within a given event based on O’Leary and Wilson (1975) Antecedents (A), Beliefs (B), and Consequences(C) Model. This has become a widely used model, and proved most useful for understanding how the client is within a given situation. So:
A Activating
event perceived as aiding, confirming, or blocking/inhibiting goals
B Belief
system(s) invoked, and/or applied to a given situation
C Consequences of applying these
beliefs to a given situation, (i.e. what happened when thought felt in a
particular way;
Further categories were devised to
incorporate preferred ways of thinking and feeling about a particular event in
order to produce a different response, or change. Ellis (1991) suggests that
REBT has two goals the first is as stated above, (i.e. ‘to help people overcome
their emotional blocks and disturbances’). The second is ‘to help people become
more fully functioning, more self-actualising, and happier than they would
otherwise be’ (ibid, p7) – to help clients make a philosophical change from
their musturbatory to preferential thinking’, (ibid, p164). So:
D Disputing
irrational beliefs or rules that underpin our behaviour
E effective new philosophy which
deals with symptoms of emotional distress, or preferentially, with flexible, personal
reactions to everyday obnoxious activating events
Ellis (1991) lists several important
characteristics of fully functioning or ‘self-actualising’ people. These are:
Self-interest, Self-direction, social interest, tolerance, flexibility, commitment, creativity and originality, scientific thinking, self-acceptance, risk-taking, long-range hedonism, high frustration tolerance, self-responsibility disturbance.
Beck and Weishaar (1989) devised a list of
‘cognitive errors’, errors in information processing and/or storage, which seem
to interfere with ‘individual self-actualising’ and lead to emotional distress.
These are:
Dysfunctional beliefs, arbitrary
interference, selective attention/abstraction, overgeneralization,
magnification/ catastrophising, or minimisation, personalisation, dichotomous
thinking, tunnel vision, biased explanations, negative thinking, negative
labelling, mind-reading, subjective or emotional reasoning
These ‘cognitive errors’ may occur individually, or in multiples, and each tell us something about the way the client appear to be viewing the world-around. Through assessment, we can shed some light on these ways of being-in-the-world. But having identified, explored, and described these ways of being-in-the-world; we should not ‘sediment’ our interpretations of the other, (i.e. treat the other as if they were some fixed entity, and not subject to change). The client may appear to be ‘fixed/rigid; even mineralised, in their attitudes to their attitudes to the physical world, social world, personal world being-with-self, and spiritual world (i.e. being in ways that they have not as yet experienced )(Van Deurzen-smith, 1989). But this can not be representative of how the client is in the world beyond the point in time and space when they experienced their emotional distress, nor indicative of the extent to which they might be able to ‘transcend’ their everyday experiences, in totality (Husserl, 1923; Heidegger, 1966). To take such view would be to present oneself as being equally fixed, rigid, and not subject to change as the client! Therefore, information relating the client to the world-around, and collected from a number of different sources, can but a give a snapshot picture of how the client has been in-relation to their lived-world; and, not indicative of how they will be with any certainty in the future with or without therapeutic help and support.
If, we look at the way Cognitive-behavioural therapist make their assessments of clients that present with varying problems, issues, or concerns, it would seem that an understanding of the client’s world may be gleaned from the information that is shared, explored, and clarified within the context of the therapeutic encounter. Joan Kirk (1989, p22) lists the kinds of information that may be shared, and the kinds of methods that may be applied to facilitate this process. For example:
Modes of
Assessment:
Behavioural Interview
Self-monitoring
Self-Report
Information form other people
Direct Observation of Behaviour in clinical settings – role play; behavioural tests
Behavioural by-products
Physiological Measures
Stages of
Behavioural Interview
Brief Description of the Problem(s)
Development: precipitants; time course; predisposing factors
Description of Problem Behaviour: behavioural, cognitive, affective, and physiological
Who, What, Where when, and How - the effect
Contexts and Modulating Variables: Situational
Behavioural
Cognitive
Affective
Interpersonal
Physiological
Maintaining Factors: Situational (Describe the Context in which the problems arise)
Behavioural
Affective
Interpersonal
Physiological
Avoidance
Coping Resources and Other Assets
Psychiatric and Medical History
Previous Treatment: response
Current medication
Beliefs about the Problem
Engagement in Therapy
Mood/Mental State
Psychosocial Situations: Family
Psychosexual relationships
Occupation
Social relationships
Hobbies/interests
Preliminary Formulation
We can see that there appears to be as many different ways of being-in-the-world, as there are factors/variables, and that each may be identified, explored, and clarified to gain some understanding of what it might be like for the client to be in their lived-world - Dasein – ‘being there’ that is contextually-specific. The assessment give both the client and the therapist a snapshot view of the what it might be like being there for the client. Many therapists attach a label to the observed behaviour pattern, and forget that this label can not describe the client in totality. The assumption being that the client has expressed ways of being-in-the-world that are not indicative of mental illness prior to being in therapy, and may well develop new and different ways of being-in-the-world, in the future. The assessment is not supposed to be a definitive label that invites a response from those who are aware of that way of being-in-the-world, and its meaning. We can say that in a given situation this person appears to have behaved in either this way or that. There is some suggestion as to the predictability of behaviour that is reflected in the information shared between therapist and client, however, this seems tentative, and we would have to assume that the contexts in which the client has shown themselves to behave in either this way or that are persistent, overtime, and unchanging. As situations do not seem to reproduce themselves, and we seem to co-create situations by choosing to behave in one way or another, we can not say with any certainty that the client will, or will not, behave in either one way or another. Something could be said as to the probability that this client is likely to behave in either this way or that given the prevalence of a set of predetermined conditions, but such calculations seem pointless beyond considerations of risk of harm to self, or to others (Neimeyer and Raskin, 2001).
When we explore a client’s lived-world, we may often confronted with client responses, which do appear to be very similar. We might question whether the response was appropriate given the prevailing circumstances, but fundamentally, the client has decided that the situation warranted a response, which they themselves seemed to have reproduced in other situations where her/his interpretation of that evidence, real or imagined, appeared to warrant such as response. The therapist may fail to see the relatedness between, and within, these difference events, but on exploration their relatedness does seem to reveal itself.
As there seems to be no difference between a prima facie judgment, and all-things- considered’ judgement at a precise point in time and place, we are required to consider the extent to which the client’s perception of a given event, or situation, is shared within, and between, different events/situations. For instance, I was recently asked to consider the relationship between a sequence of events that happened in childhood, and one that happened in adulthood where the outcome appeared to be the same (Guidano and Liotti, 1983). The factor linking the client’s world view with his overt behaviour seemed to be related to the client’s perception and interpretation of the given event in the here-and-now. Even though the players, and the time and place of the event, did seem to be very different, the client seemed to be experiencing his lived-world in the present as if he were purposefully reproducing the event as it appeared to be when he was a child. It transpired that the outcome was the same because he had derived the same meaning from both events, and hence applied the same sedimentations, or core beliefs, to both situations. In translation, it appeared the Client appeared to be saying that, ‘in situations, where I cannot, or have no wish to, contain myself any longer I must be free to ‘relieve’ myself in this particular way’. In addition, the client seemed to be saying that, ‘You must accept what I can no longer hold for myself, by myself’, and ‘you must not criticise me for so doing’. Such demanding behaviour might prompt a Cognitive-behavioural response that would attempt to challenge such demands, but ultimately, is it not the Client who on reflection remains the chooses whether to he continued to reproduce his apparent demands, over time?
Analytically, the client appeared to be ‘constipated’, he needed to eject that, which he could no longer hold within himself, for himself. He wanted others to accept this ‘offering’ without criticism. This he failed to do. Others did not accept this demand for the acceptance of these offerings’. From an ‘Object Relations’ perspective, his part-object had become internally represented as a generalised self-statement, which exalted the client over and above the other, and de-valued the other in-relation. He himself had become ‘dirty’; instead of the ‘dirt’ being associated with that which he wished to ‘void’. In-relation with his partners, he anticipated their possible ridicule or criticism, in much the same way as he had done with his mother when he was a child, and he himself had sort to force the bearer of the ‘good breast’ accept whatever he had to offer, and in so doing, invite the other(s) to recreate the bad-breast in-relation with him.
From a CBT perspective, the core belief might be something like ‘the other should accept the inevitability in the way I have chosen to express myself’, seemed to reproduce itself in any situation where the possibility of being discovered as being ‘dirty’, arose. The Client had considered all things in that particular instant, and yet continued to make his demand for others to accept him in the way that her had presented himself. He seemed to invite criticism, and then criticise other when they appeared to refuse to meet his demands. There is no certainty about the outcome of such social interactions, but in the Client’s being in these ways seemed intentional, and purposeful, the possibility of his reproducing this critical experience seemed very high based on the evidence inherent within the Client’s own recounts or such events, phenomenologically.
From an Existential perspective, the Client described ways of being in-relation that prohibited the existence of the other to the extent that the other became annihilated in-relation with the Client. There seemed to be little authentic meeting of the other in genuine dialogue; merely the insistence that others accept him for the way he was in-relation.
From Constructivist perspective the client appeared to have constructed a worldview in which he perceived others as potential threats to his very being. The possibility of becoming somebody else was denied in-relation with others, (i.e. others appeared to, equally, restricted somehow in the ways they were allowed to express themselves in relation with the Client), and he himself saw nothing wrong, per se with the way he treated others, (i.e. he seemed to believe that he himself had been denied the right to express himself as he was in-relation with others).
In first instance, it would seem that this client’s ways of being in the world seemed fixed, rigid, and not subject to change, but it transpired through out the therapeutic process that the client could interpret his everyday experiences, differently, and therefore the application of a ‘label’ that described his behaviour could not be applied in ways that reflected the rigidity and inflexibility of the therapist. It was important to note that this behaviour did do harm both to the client and to his partners, but there was no evidence to support the view that this client was not capable of being different. CBT when done with conscious intention of testing the validity of the client’s interpretations of his/her everyday experience would show a shift in the way the therapist describes the client, and the ways the client describes themselves as a ‘subject engaged in his own projects in the world’ (Van Deurzen-Smith, 1997). Any attempts to reduce the client to an object should be resisted on the basis that such descriptions often can not be supported by evidence, over time.
Conclusion:
Ultimately, the Existential theory and practice and Cognitive-Behavioural Theory and practice have evolved, separately, and present distinct views and opinions as to what it means to be ‘human’, and what it means to be-in-the-world. However, through a process of deconstruction, it appears that the distinction between the therapist, and what the therapist may be observed doing, calls into question the extent of the difference between these two approaches to psychotherapy and practice. In this paper, this difference has been called into question, and attempts to make explicit the extent to which each approach may shown to be evolving in-relation to, and with, each other, has been demonstrated.
In CBT, both the therapist, and the client, engage in the development of a ‘working alliance’ within which the movement towards constructing a ‘treatment plan’ that enables the client to meet a desired outcome; or resolve an ongoing issue or concern for himself or herself, is made. Therapy takes the form of a ‘single-case experiment’ where the client is given the opportunity to explore, and investigate, himself. Factors which seem to influence the ways in which the client is ‘being there’ can be explored and described to varying depth such that both the client and the therapist can say that the client appears to have been this way or that within the context of their lived-world. S/he formulates hypotheses, which s/he tests for himself or herself, over time. S/he seems to validate or refute these self-statements, and thus assumes autonomy in deciding how s/he chooses become in the future. There seem to be no hard and fast rules about the findings of therapeutic interrelation. There is no certainty pertaining to the ‘how’ the client has shown himself or herself to be in-relation with their lived-world, only a statistical possibility, which in-itself may be significant, but not predictive of how the client is likely to become in the future. The participant-client takes a ‘lead role’ in deciding how s/he will deal with specific problems, rather than be told, directly, how best to live her/his life.
Success early on, reinforces the view that progress can be made in the right direction, and that the client need only persevere, over time, to reach their desired outcome, goal/aims, and objectives that s/he has set for themselves. Self-monitoring, in the form of homework are essential to ensure that the Client is able to continue with the Cognitive-Behavioural change in the absence of the therapist. Other family member may want to help and support the Client, but it is important to emphasise the Client autonomy in deciding for himself or herself how they intend to ‘transcend’ their everyday existence, and hence, who s/he will become in the future. This aims and objectives are not absent within the sessional notes of Existential practitioners; although, it may argued that the purpose of therapeutic intervention that appears to be intentional seems to be absent in the said notes. There is conscious intention towards the exploration and description of the client in their lived-world, but such intention remains without purpose in Existential therapy indicating that the motivation for deciding whether behavioural change, (i.e. immanent or transcendent), remains with the client, and not with the therapist, nor society as a whole.
References:
Arthur A., (2001) The EAP Debate . CPJ, Vol. 12, no.1. February 2001
Beck, A.T., Young, J.E., Shamma, K., (1979) Competency Checklist for Cognitive Therapies. Philadelphia, PA. Centre for Cognitive Therapy.
Beck, A.T., Weishaar M.E.,
(1989) Cognitive therapy. In, R.D. Corsini and R Wedding (eds.) Current
Psychotherapies (4th ed.), pp 285-320). Itasca, IL: Peacock
Beck, A.T.,
Freeman, A., & Associates,
(1990) Cognitive Therapy of Personality
Disorders.
New York: Guildford.
Buber,
M., (1923) ‘I and thou’, (trans.) W.
Kaufman. Edinburgh: T & T Clarke. 1970
Buber,
M., (1929) Between Man and Man (trans.) R.G. Smith. London Kegan Paul 1947
Binswanger, L., (1946) The Existential Analysis School Thought. In, R. May, E. Angel, and H.F., Ellenberger (eds) Existence. New York: Basic books.
Boss,
M., (1957) Psychoanalysis and Dasein Analysis. (trans.) J.B. Lefebre.
New York: Basic Books.
Derrida,
J., (1967) Writing and Difference, (trans.) 1978, Chicago: University of
Chicago Press
Dryden,
W., Feltham, C., (1994) Developing The Practice Of Counselling.
London: Sage Publications.
Dobson et al (2001)(eds.) Handbook of Cognitive Behavioural Therapies.
New York: Guildford
D’Zurilla, T.J., Goldfried, M.R. (1971) Problem-solving and Behavioural Modification.
Journal of Abnormal Psychology, 78, pp107-126.
Ellis,
A., (1958) Rational Psychotherapy,
Journal of General Psychology, 58,
pp 35-49.
Ellis,
A., (1962) Reason and Emotion in Psychotherapy. New York: Stuart.
Ellis, A., (1991) Achieving
Self-Actualisation: rational emotive approach (special Issue) Journal of Social
Behaviour and Personality, 6(5)
pp1-18
Ellis A., (1993) Changing Rational Emotive Therapy to Rational Emotive Behavioural Therapy. The Behaviour Therapist, 16, pp257-8
Guidano, V.F., Liotti, G., (1983) Cognitive Processes and Emotional Disorders: a structural approach of consulting and clinical psychology. New York: Guildford Press.
Guidano, V.F., (1991) The Self in Process. New York: Guildford Press
Husserl, E., (1913) Ideas Pertaining to A Pure Phenomenology and to a Phenomenological Philosophy. F. Kersten (trans.), The Hague: Martinus Nijhoff.
Heidegger, M.,
(1927) Being and Time. J. Macquarrie and E. Robinson, (trans.).
Oxford: Basil Blackwell. 1962
Idhe,
D., (1986) Experimental Phenomenology; an introduction.
Albany: State University of New York Press.
Jaspers, K (1951)
The Way to Wisdom. R. Manheim (trans).
New
Haven CT: Yale University Press
Kierkegaard, S.,
(1843) Fear And Trembling. Princeton NJ: Princeton University Press. 1954
Kirk, J., (1989) Cognitive-Behavioural Assessment. In, Keith Hawton, Paul Salkovskis, Joan Kirk, and David M. Clark (eds.,) Cognitive Behaviour Therapy for Psychiatric Problems: a practical guide. (pp13-51). Oxford; Oxford University Press.
Merleau-Ponty, M.,
(1945) Phenomenology of Perception. C.
Smith (trans.).
London: Routledge & Kegan
Paul.. 1962
Meichenbaum, D.H., (1975) Self-instructional Methods. In, F.H. Kanfer and A.P. Goldstein (eds) Helping People Change: a Textbook of Methods., pp 357-91.
New York: Pergamon.
Neimeyer, R.A., Raskin, J.D., (2001) Varieties in Constructivism In Psychotherapy.
In, Dobson et al (eds.) Handbook of Cognitive Behavioural Therapies.
New York: Guildford.
Nietzsche, F., (1895) The Will to Power. W. Kaufman and R.J. Hollingsworth(trans.)
New York: Vintage Books, 1968
Nelson-Jones, R., (2001) Counsellors, Psychotherapists and Research. CPJ, vol. 12, no.2, p6-9.
O’Leary, K.D., Wilson, G.T., (1975) Behaviour Therapy: application and outcome. N.J., Engelwood Cliffs: Prentice Hall,.
Samuels, A., (2001) Politics on the Couch. CPJ, Vol. 12, no.1. February 2001
Sartre, J-P.,
(1958) Being and Nothingness: an essay in phenomenological Ontology.
Hazel
Barnes, (trans.). London: Routledge
Sartre. J-P.,
(1939) Sketch for A Theory of Emotions.
London: Methuen. 1962
Spivack, G., Platt,
J.J., Shure, M.B., (1976) The Problem-solving Approach To Adjustment.
San
Francisco: Josey-Bass.
Tillich P., (1951)
The Courage To Be. New Haven CT:Yale University Press.
Van Deurzen-Smith,
E., (1997) Everyday Mysteries: Existential Dimensions of Psychotherapy. London: Routledge.
Yalom. I., (1980)
Existential Psychotherapy. New York: Basic Books.
Appendix A
There has been much talk, and
discussion about counselling and psychotherapy that is ‘evidence-based’,
recently, and those who have shown a preference for practicing counselling and
psychotherapy from an Existential perspective may need to consider to what
extent ‘Existential Psychotherapy and Counselling’ meets the criteria for being
a “valued” form of intervention for those who present in emotional difficulty.
Whilst it is not the intention to suggest that counselling and psychotherapy which
is evidence-based is in any way better than those psychological therapies that
are not, it may be useful to consider the possibility on comparative thought
about being ‘human’, and how human beings construe themselves, the world, and
the future, contextually.
Essentially, the idea that being, or our observed actions, may well be mediated by our thoughts or cognitions, and if, our cognitions are indicative of the way we construe ourselves, and others and beings-in-the-world, then it Existential philosophy, which is the investigation into what being-in-the-world might mean in general, may have an important contribution to make to the practice of Cognitive-behavioural Therapy.
‘Existential thought’ may be said to have grown out of a sense of ‘individual isolation and alienation’ in a world that seemed ‘hostile’. This statement puts the individual in context in much the same way as a psychologist might put the client in a situational context or environment that holds significant meaning for that client.
The individual within society becomes aware of ‘social rules’ within which s/he may be expected to function, and presents a ‘sense of self of being’ that appears to adhere to these ‘social rules’ to greater or lesser extent. This ‘sense of self’ may be observed in the individual’s overt behaviour: thinking, or cognition, may be considered within this concept of behaviour as something that we as human beings ‘do’ both actively, (i.e. purposefully), and passively, (i.e. inadvertently). The distinction is made between cognition that seems to be ‘done’ with intention and expressed as being purposeful, and cognition that shows intention but does not, necessarily, seem purposeful. However, determining to what extent any of us are, actually, alone/alienated remains difficult. Although you may accept that it is possible to feel isolated, and alienated, and for others to appear to be isolated and alienated, none of us actually exist in a social vacuum. Our whole being is dependent on being in-relation, and by the experiencing of others as being so different that the other constitutes somebody else. Therefore, whilst each individual may find it difficult being in a world that appears to be hostile: s/he is nothing without the anxiety, and the sense of guilt, that may be experienced when s/he chooses to behave in ways that appear to challenge/conflict with societal expectations.
Existential philosopher,
Kierkegaard (1954) construed the world from ‘a place of splendid isolation’.
Due to his own personal experiences of social constraints that bound his very
existence, he attempted to re-claim his subjectivity by purposefully engaging
‘anxiety’ that was ‘Existential’. He referred to the tension induced as one
denies sense of being that which is
desired. A similar tension that arises, as that which is desired is denied is
also inherent when he refers to the social constraints imposed by the very
nature of the society in which we live. Out of his own personal suffering, it
could be argued that he devised schemata to represent changes in his experience
of his own subjectivity. This developmental sequences or stages of life began
with an immediacy/vegetative stage, through an aesthetic/hedonistic stage, to
ethical/ moral stage, to thinking/cogniscent stage, and culminated in
Existential doubt/angst. At the final stage, the individual is required to make
a choice. S/he may either continue experiencing the angst inherent in simply
being; or take a ‘leap or faith’ into the unknown; or transcend this ‘ready-to-hand’
experience to conceptualise possibilities and limitations which had not as yet
been experienced. None of this seems possible unless the individual is prepared
to accept the existence of their inadequacies; that which gives angst; and
confesses to problems/issues/concerns.
The idea of being able to carry
‘burdens’; to identify and accept the pre-existence of difficulty; is visible
in Nietzsche’s work. Again the idea of realising one’s full potential, and
having the courage to be is operationalised within the concept of developmental
stages. He refers to the ‘Camel stage’ where the individual is required to
carry, unquestioningly, the burdens of life - to endure; the ‘Lion Stage’ where
one is required to develop the courage to assert oneself in the world; and the
‘Child Stage’ where one develops the ability to be optimistic and to enjoy life
in spite of experienced difficulties. Nietzsche’s ideas seem to have grown out
of the awareness of the ‘chaos’ that existed in Germany towards the end of the
19th century, and of the effect religiosity had had on people, overtime. He
argued that people followed blindly, like a herd of animals, unquestioning, and
reluctant to challenge the current hegemony - the herd instinct’. In renouncing
the very existence of God, he effectively renounced the dogma that goes with
adhering to any faith. In so doing, he separated himself from that which was
perceived to bind him; that which curbed self-expression; and, created for
himself a place of ‘nothingness’ in-relation. It was out of this ‘nothingness’
that he sought to create for himself a new person; a ‘super person’
(Ubermensch). Nietzsche transcended his old existence, and created for himself
a new world where all the rules were, essentially, created for himself by
himself. It must be said that Nietzsche’s rejection of the prevailing social
order would only be possible, if, he could isolate himself from existing within
any given social structure. It seems unlikely that such views could co-exist
without the deconstruction of that which bound society itself, and this poses
grave problems where one considers that which may arise out of the chaos, and
‘nothingness’ that arises when the prevailing social order is renounced.
Kaufmann (1970) in translating
Buber’s ‘Ich and Du’ (I and Thou) (written in 1923) seemed to be suggesting
that Buber differentiated between ‘I’; as in ‘me’; and, ‘I’; as in ‘you’. There
is a difference between how we perceive ourselves to be, and how others
perceive us. Buber argues that we are able to adopt two ways of being. ‘I-it’
describes the relationship between self and others where ‘I’ objectifies self
such that s/he response to the world in a ‘fragmented’ way: portraying only
fragments, or parts of self in reference to the demands of others. The other, ‘I-You’
is in contrast to ‘I-It’ where the individual quantifies self, and others, as a
‘whole’, and suggests that the relationship between self, and other is more the
presentation of self in partiality. The whole of one’s being is given over to
the experiencing of other, and Buber suggests that this is akin to a spiritual
experience between self, and others. Buber goes on to suggest that there is a
‘continuum’ of being between I-It, and the I-You, ways of being, and
acknowledges the difficulty that may be experienced when attempting to exist in
either extreme of being for any length of time.
In the face of adversity the
world appears to us, differently. As individuals we, arguably, present a sense
of ourselves to the world that is relating which is ‘I’ as an object to a
greater or lesser degree. The extent of this objectification seems to depend on
how threatening the world appears to us, and in defence of self we protect that
part of ourselves that may become disseminated as a result of our interactions.
Insofar, as autonomy is
concerned, it would seem that we make personal choices based on that which is
known to us, and believed to be true (James, 1920, pp147-8). Such
‘psychological facts’ (Sartre, 1939) serve as the basis for action; they
provide the grounds for future, past, and present interaction with the world.
But are these ‘facts’ not of our own making? Do we not represent the world,
internally, as it appears to us? Sartre would argue that this is the case, and
goes further to suggest that such ‘facts’; in themselves; are meaningless
without showing ‘how’ they may be related, and ‘what’ context in which they may
be shown to occur; even the degree of relatedness is, individually, determined.
We choose to view the world in particular ways; our worldview appears to be
preferential. We view the world through a ‘veil’, and ‘as if by magic’, the
world is transformed into something that is more reflective of what is known to
us as opposed to the reality that lies before us. But what is this reality? Who
are we to determine that which is true from that which is not? Do we not all
have a personal worldview? In which case, what are the grounds for action if
they are not personal? Herein lies a paradox, and ‘psychological facts’ are
nothing if it is not shown to what extent they are reflective of experience of
being-in-the-world. Sartre argues that without making explicit that, which is
signified, ‘psychological facts’ remain meaningless and life appears to be
‘groundless’.
The ‘angst’ that arises out of
this ‘groundless’; this uncertainty; it self makes explicit the difficulty that
may be experienced in problem solving, or decision-making. In the absence of
that which may be judged concrete’ in our lives we are doomed to remain in
state of permanent anxiety. At the same time we are aware of the passage of
time, and its finiteness, and make life choices in the hope that they will e
the right ones. Experiencing ‘Existential guilt’ when the choices we make fail
to have the desired effect. But Heidegger suggested that this 'thrownness' is
often denied, and in doing so, we deny ourselves autonomy, and the ability to
be perceived as behaving, authentically. This may be recognised in the way
people make excessive reference to the past, or future, fail to make life
choices, and the way we see others as being deterministic of our own
behaviours. He argued that when fail to see and accept our own role within the
context of our everyday experiences, we, also, refuse to embrace uncertainty,
anxiety, meaningless, and groundlessness. In asking ‘how’ a person is
‘in-the-world-around (Umwelt), ‘with-the-world’ (Mitwelt), ‘of-the-world’
(Eigenwelt), and ‘above-the-world’ (Uberwelt), you are asking a person to
describe what it is like ‘being-in-the-world’ in totality. Such concepts are
difficult to describe, and hence measure, without the deconstruction of the
presenting subject, and has tended to the construction of
psychological/statistical tools, (i.e. methodology), to determine to what extent
the person is being relational in the world. As the contexts in which we find
ourselves are so numerous and invariably different, life experience of a
statistically reliable grouping within any society is difficult beyond that
which shows no relation, and is without contextual relevance. Such findings
seem reflective of that which is ‘undifferentiate’: part of the ‘they’: and as
such lacks autonomy, individuality, and reflection.
Binswanger, a psychiatrist
working in Switzerland at turn of the 20th century developed Existential
analysis to show relatedness between the environment (Umwelt), and the world of
signals (Mitwelt), and a ‘world of actions’ (Alitheiawelt). He argued that we
are ‘thrown’ into the world in that we do not choose, but we are obliged to
accept this 'throwness' and derive meaning from that into which we are
‘thrown’. Out of ‘throwness’, and awareness of a relation that is
‘with-the-world’ (Mitwelt), it argued that we gain understanding of our
relationships with the world and that, which differentiates us from each other
(Eigenwelt). We seem to move from being ‘anonymous’, through a period where our
identity as part of a group, (e.g. the family), to assume individual identity
which separates us from the group. With further understanding we assume a ‘mode
of being’, which is reflective of our dual state of being, (i.e. both physical,
and spiritual). Ludwig Binswanger outlined this process of change in the case
study of ‘Ellen West’.
‘Ellen West’ was an only child
born to reasonably wealthy and authoritarian parents. Within the case notes
Binswanger was able to show how ‘Ellen West’s throwness, and inability to cope
with this throwness, made it very difficult for her to be part of the group;
her family; and seem to have led to the development of mental illness. Through
the process of anthropological description, it was found that Ellen seemed to
oppose the will of her parents, but seemed reluctant to give up her dependency
on them. She developed anorexia as she tried to ease the pain of her anxiety,
and separate herself, physically from a representation of womanhood that
Mitwelt would have conveyed to her. When she finally did experience ‘freedom’
whilst on holiday in Greece, she discovered an appetite for food; she put on
weight, and seemed happy for a short time. At least until she returned home and
others commented on how much weight she had put on. At which point she began to
despise herself. Again difficulty being in the world was represented,
physically, and she long for ‘freedom’ from the vessel that seemed to bind her
very spirit. At University she found someone who she could love, but who her
parents thought unsuitable. Ellen gave up her love, and in doing so appeased
her parents. But this ‘loss’ was, clearly, too great, and she, eventually,
committed suicide. This case illustrates the different modes of being, and how
we relate to others by attaching meaning to signals that are inherent in a
changing in environment. Our action are reflective of the meaning derive from
an interpretation of the signals which when internally represented, come to
symbolise the world around us (Umwelt). We seem to strive for a mode of being
that satisfies our spirit; that deters ‘spiritual tension’, and thwarts growth.
For some, existing in a world that denies such freedom of self-expression,
existing becomes an effort in itself, and they choose to only option available
to them: that being to ‘free themselves from that which binds’.
Again we hear the application of
‘Peripheric theory’ (William James) with attempt to uncover that, which seems
to be ‘hidden’. Maurice Merleau-Ponty transforms Peripheric theory into the
concept of ‘embodiment’ by relating that which is sensed (i.e. external to the
central nervous system), to that which is construed, mentally. This is more
than an internal representation of externally located symbols - the
world-around us. In his ‘Phenomenology of Perception', Merleau-Ponty,
dialectically, philosophises on the continuity of our sensual relationship with
the world; that within which we are embodied is always in connection with a
lived-world. What we know about the world is made possible by that within which
we are embodied. We do not ‘speak as we are spoken to’, we speak that which has
been transformed: that which is made explicit is a sedimentation of that which
has been deciphered. This is very similar to Sartre’s view of
being-in-the-world. The world appears viewed through a ‘veil’ that is of our
own making, and we choose through which veil to view the world from one moment
to the next, and to so do, with increasing speed and efficiency. But ‘who’ is
to say that we choose the correct veil; after all, does not the world seem full
of uncertainty?
During the therapeutic encounter, such
ambiguity becomes ‘a two-way process’ as we co-create existence in-relation to
the client’s interpretation of what it means for them to exist in world that
appears in either this way or that; existence in-relation with the client
becomes agreed, mutually. Through this process of dialectical debate we derive
meaning, and in so doing, become aware of our limitations, the strength of our
arguments, and the ability of others to present the world in ways which confuse
us, and from which we experience a created uncertainty (Jaspers, 1951; Van
Deurzen, 1997). We experience humility in the light of that which seems to be
the better argument. Medard Boss, another psychiatrist laid great emphasis on
the ‘uncovering of that which is hidden’ (Aletheia), and the derivation of the
‘confession’.
The ‘confession’ reflects an
expression of a self-of-the-human-person that accepts responsibility for our
own actions. It acknowledges our ability to experience doubt, anxiety and
existential guilt, and invites others to engage in a therapeutic encounter. The
‘confession’ illustrates ways in which being-in-the-world has proven difficult,
and through a process of interpretation, our behaviour is illuminated, and
‘brought forth into the light’. Paul
Ricoeur emphasised the value of the hermeneutic tradition in which our everyday
lives seem full of heuristics or ‘rules of thumb’, which are represented in the
ways in which we behave in certain situations. Such ‘rules of thumb’ may or not
be held by others, and gaining some incite into the meaning of others’
behaviour seems to require some knowledge and understanding of these rules.
Ricoeur proposed that deriving meaning for symbols we encounter in our everyday
lives invites thought. Hence, through a process of induction, hermeneutics
could show how different individuals interpret reality. It is possible for
different individuals to interpret, and hence derive meaning, from the same
event/situation, differently. There may be ‘many similarities’ between these
different interpretations, but each individual could effectively derive a different
‘subtext’ for the same event; subtext
or meaning that pervades several different contexts which would be reflective
of that individual’s understanding irrespective of the given event. Ricoeur
argued that we need to look ‘deeper’ to uncover the subtext; the underlying
structure inherent within our interpretation(s) of existence. There are no
right or wrong interpretations per se.
Each interpretation is simply, different.
Jacques Derrida acknowledges
that any ‘life story’; recount of events situations in which a person
experiences existential angst; the ‘text’ could give rise to multiple
interpretations, and multiple understandings, and as we have seen we are not in
a position to say which interpretations are either ‘right’, or ‘wrong’, per se,
Derrida advocates the ‘death of the subject’, and ‘working towards a
relativistic discourse’. He argues that we should get rid of the ‘primacy of
truth’; the dominance of God over our existence; the dominance of men over
women; the dominance of presence over absence’; speech over writing; to,
effectively, get rid of structuralism, and the view that the ways in which we
are in-relation to, and with, our ‘lived-world’ is "preordained", and
hence unavoidable. This view contradicts that of Ricoeur in so much as it re-emphasises
individual autonomy, and individual choice. But such views seem to ignore the
fact that we are in-relation, that much of what we believe we ‘know’ about
ourselves is ‘known’ in relation to our ‘lived-world’; and, that we are
required to exist within the boundaries that society sets for us on a
collective level, or pay the consequences for revolt. It seems to me that you
cannot have structuralism without de-structuralism the two seem to be
intertwined, and inseparable. They are the opposite sides of the same coin: the
‘Yin and Yang’ of existence. In discovering ‘self-reflective knowledge’ (Paden,
1998), we are doomed to accept that we are not ‘free-to-be’ for its own sake;
we are free-to-be’ in-relation. To choose otherwise would be not to exist at all.