A Case Study Illustrating Existential-Humanistic Therapy
Chapter 16: World Handbook of Existential Therapy (2019)
Orah T. Krug, PhD
A case study is presented here to give the reader a vivid, lived experience of how E-H therapy actually unfolds between clients and therapists. The case by Orah Krug and her client Mimi illustrates how E-H therapists: a) develop responsiveness to clients’ feelings, experiences and protective patterns, b) develop collaborative and safe therapeutic relationships with clients, c) assess client motivation, level of functioning and capacity for presence and c) work with levels of self-protections and associated wounds by focusing on process over content. The case also illustrates how E-H therapists attain the goals of expanded experiential awareness and real therapeutic change by cultivating genuine encounters in which both clients and therapists are personally and relationally present.
E-H therapists cultivate presence to three dimensions of experience and process: a) the personal or subjective dimensions of both client and therapist, (i.e., a focus on “self”), b) the interpersonal or relational dimension, (i.e., a focus on the “in-between” field of client and therapist), and c) the ontological or cosmological dimension, (i.e., an existential focus on “the world”). Being present to all three dimensions of experience and process is crucial—all three dimensions are “actual” in the present moment and provide entry into the feelings and world of the client. Without presence there may be intellectual, behavioral or physiological change but not necessarily the sense of agency or personal involvement that “whole-bodied” transformation requires.
The Case Illustration of Mimi
The case study of Mimi, Orah Krug’s client demonstrates how E-H therapy is an experiential journey of personal discovery and embodied transformation (for the full case study see Schneider & Krug, 2010, p. 69). This case illustrates how an E-H therapist conceptualizes and facilitates change by being present to all three dimensions of experience and process. Three additionally significant aspects of E-H therapy are also illuminated in this case: a) how it can be tailored to be a brief therapy, b) how it can be the foundation upon which other approaches such as cognitive behavioral and EMDR therapy can be employed, and c) how it allows a therapist to enter the subjective world of her client even though she differs from the therapist with respect to country and culture.
This therapeutic encounter began with two people, Orah Krug, a therapist and Mimi, a client, who met in a therapy room several years ago. (Mimi is a composite of several clients with whom Orah worked). Mimi and I are centered in ourselves with a capacity to relate to the other. We relate to each other from our own personal contexts, which means that we are limited, to some extent, to be present and connected to ourselves and to each other. I had been an existential-humanistic therapist for over 20 years at the time; Mimi was a 29-year-old married woman, of Persian descent, who was 8 months pregnant with her second child. We agreed the therapy would be limited to eight sessions because of Mimi’s impending due date. Although not central to the therapy, Mimi’s Persian heritage, culture, and worldview factored in to the way I related and worked with her.
My first aim was to cultivate with Mimi a safe and collaborative therapeutic relationship. I also wanted to step into her experiential world so I could attune empathically to her feelings and experiences. By attuning to what was most alive in the moment whether it be within Mimi, me or within the interpersonal field, I could mirror the moment back, thereby supporting expansion of her experiential awareness. Why do E-H therapists work in this way? Because we believe that it is within a safe and intimate therapeutic relationship, co-created by therapist and client, that disowned experiences and relational patterns (of both client and therapist) can be discovered, integrated, or revised. We assume the client will relate to the therapist as he or she relates to others outside the therapy room because the client’s past is concretely alive in the present moment. Thus, as Yalom (2002) suggests, working in the here-and now is the “power cell” of therapy. By cultivating personal and relational presence, the therapist and client experience the client’s real (actual) but often out of awareness (unregarded) experiences and ways of relating. By illuminating these life stances carefully and respectfully, therapy becomes a project of experiencing one’s life instead of talking about one’s life. E-H therapists believe, as do the other experiential therapists that this is the basis for real and lasting life changes.
Mimi presented as a highly functioning, attractive, young woman, in deep distress—a woman significantly motivated to change, related in part, to her fast-approaching due date. Three weeks prior to this first meeting, a plane had crashed into her home when Mimi and her 3-year-old were eating lunch. I assessed that prior to the incident Mimi had felt generally happy and content with her life and marriage but now her sense of security was badly ruptured. Mimi was drained both physically and emotionally but very motivated to “get her old life back.”
In the first session, as I listened to Mimi tell her story, I attended not only to the content but also to how Mimi related her story. Being present to Mimi’s process, allowed me to hear and see Mimi’s life stance (her spacesuit) emerging in her vocal intensity, affect, body language, and attitude toward self and others. Mimi’s life stance was present (actual) but out of Mimi’s awareness (unregarded), expressed concretely in different ways, summarized here as: “If I’m good and do things right then good things will happen to me and to those I love.” Now Mimi’s stance obviously has positive value, i.e., Mimi believed in her agency and in taking responsibility for her life. Unfortunately, also implicit in Mimi’s life stance was her unmediated belief in the power of her personal control to keep herself and her loved ones safe—Mimi does not truly appreciate an existential axiom: one can influence but not control an outcome. So, when the plane crashed into Mimi’s home, her unmediated belief in her personal power was seriously shaken. Mimi’s typically self-assured and confident manner was only faintly present at the first meeting. Three weeks after the incident Mimi was still highly agitated and anxious. As Mimi told her story, she angrily repeated again and again, “it isn’t fair.” I sensed the phrase was rife with emotion-laden meaning given her life stance. I also sensed that she was “caught” in the experience, as if in the retelling the story she was relieving the experience.
My work with Mimi was an integration of behavioral strategies within an existential-humanistic context. Our goals, created together in the first session were to: a) address her PTSD symptoms, b) help her to be more present and calm, and c) incorporate constructively the traumatic experience into her life. In the first session I gave her an experience of how I work in the here and now. She experienced how experiential learning could help her develop deeper awareness of her thoughts and behavior patterns that might be blocking her healing process. I asked I she agreed to work with me in this way. She readily did. I began with Mimi, as I do with all of my clients to build the therapeutic relationship with my self-disclosures and “contracting” with Mimi on how our work will proceed. Getting Mimi to “buy-in” to my way of working gives me a place to stand with her and conveys to her my belief in transparency and collaboration.
In the first session I learned that in addition to the airplane incident, Mimi was stressed by the responsibility of caring for her elderly parents and sister dying of cancer. Mimi allowed that she was carrying a heavy load but said she was okay because it meant she was fulfilling her role in the family. I understood that Mimi’s cultural norm was to be “a good daughter” so I supported Mimi’s duties on the one hand acknowledging they gave her life purpose and meaning but noting how the duties seemingly added additional stress to her already stressed system. I framed Mimi’s situation in this way thereby allowing Mimi to feel supported and not judged. Eventually Mimi decided to delegate some of her duties to a visiting nurse.
With regard to the traumatic incident in the first sessions, I knew I needed to help Mimi out of her traumatizing loop enacted as she raged at the pilot’s stupidity saying, “it isn’t fair, I wasn’t prepared.” I intervened by noting to her repeated expressions of rage, saying, “once again, you say how unfair it is” or “can you hear yourself getting angry again as you tell me what happened?’ Fairly quickly she began to agree with my comment that her repetitive statements were gnawing away at her like the mice gnawing on her clothes in her now abandoned home. I tried to help her move out of her “stuckness” by suggesting that she employ a “Stop” technique (Penzel, 2000). Whenever she heard herself begin the repetitive litany, she was to say, “Stop, I don’t need to go down this road” and go to a place in her imagination where she felt safe and cozy. I asked her to practice the Stop technique as many times as she needed in between sessions.
At the next session, she reported that at first she struggled to stop her repetitive thinking but after using the technique for a while, she was able to stop reliving her plight and started to feel better. Given that Mimi was beginning to let go of her anger, now seemed an opportune time to help her experience other feelings associated with her trauma. Mimi was able to release her anger and her replay of the event, not by advising or suggesting, but by inviting Mimi to cultivate personal presence. I suggested she slow down and make space for the phrase, “It isn’t fair, I wasn’t prepared,” to simply reflect on the phrase, saying aloud whatever emerged. I invited her to “go slow” so she might deepen her experience of her anger, implicit in the phrase, and discover what lay behind it, which eventually emerged as her death terror, “There was no place to go and I thought we were going to die”—blocked from consciousness by her rage at the pilot for not “doing right” by her. This work allowed Mimi to be “with” her experience, and not “caught” in it. By connecting with her subjective experience, she was able to be both with the experience and stand back from it. She reported that she felt separate from her feelings for the first time. Now Mimi could begin to heal and loosen her stance towards life, a stance that had created a sense of invulnerability and specialness, that is, a belief that “bad things happen to everyone else but me.” When this traumatic event occurred, Mimi felt oddly betrayed because of this implicit belief, which was out of her conscious awareness. By encouraging Mimi to be more personally present she began to “shake off her spacesuit” and over the next few sessions she gradually shifted from a repetitive expression of anger to her real experience of impending death and associated powerlessness in a constructive and healing way.
I also invited Mimi to focus on interpersonal presence, asking her, “How was it for you to have me witness your exploration of your feelings?” She said she felt comforted by my presence and wondered if it was common for people to use anger to cover up feelings of helplessness. Interestingly, before she had raised that issue, I was aware of my own context and how I too have often “led” with anger to cover up my feelings of helplessness and powerlessness. When she turned to directly ask me if I ever did that, I told her I had. My transparency prompted a fruitful exploration of how we all develop self-protective yet constricting patterns, which we can get caught in during times of great stress.
Within the context of a safe therapeutic relationship, healing and change occurred. In each session I checked in with Mimi as to how we were doing, thereby giving Mimi an opportunity to share what was difficult and what was helpful. The “check-ins” also helped me know if I was staying aligned with her, given that our cultural differences could potentially result in misunderstandings. By working in this relational, collaborative way, I gauged Mimi’s sense of safety, knowing that the therapist’s most important goal is to create a safe and secure therapeutic relationship.
I helped Mimi dissolve her traumatic memories using a modified version of Eye Movement Desensitization and Reprocessing (EMDR), as developed by Shapiro (1998) by asking her to call up the memory and view it as if she were on a train and the landscape was moving past her. As she recalled the memory, I told her to tell herself, “this is just a memory, it’s in the past, I can let it go by and focus on my safe and cozy place.” Two weeks went by between sessions. Mimi walked in looking more relaxed and secure. She reported that she was no longer plagued by the memories and was beginning to feel more alive in her life. She reported that she was sleeping more soundly, was less irritable, and not jumping at loud noises.
Many therapists would be satisfied with Mimi’s reported improvement and would likely have no further aims other than to consolidate the learning. But as an existential-humanistic therapist, I sensed that one of the difficulties underlying Mimi’s symptoms was her inability to accept a crucial aspect of existence, namely that personal safety and security is an illusion—at any moment it can be shattered. I decided to use the two remaining sessions to help Mimi experientially face the existential reality that life will deal with her in the same harsh way it deals with others, helping her to work through her feelings of betrayal. We devoted a substantial amount of time working with Mimi’s inability to accept the contingencies of existence. As we explored Mimi’s feelings about life’s uncertainties, she began to realize how she typically coped with uncertainty-- by being self-sufficient and by trying to be in control, by being “on top of everything” and “keeping a lid on her feelings.”
Her phrase “it isn’t fair” re-emerged but now Mimi understood it as her unwillingness to face and accept the harsh contingencies of life. “Go slow” I suggested “and let yourself explore what it means now.” This time, as Mimi experientially reflected on it’s meaning, a deeper meaning emerged: “It isn’t fair that there is no plan, no structure or protection—anything can happen. I don’t like it but I guess that’s just how life is.” By relinquishing her illusion of personal protection, Mimi could now paradoxically accept her vulnerability and finiteness. Mimi let go of old meanings about herself and her world (e.g. “I’m safe if I do the right thing”) and made new ones, (e.g. “I’m vulnerable, anything can happen”) which allowed her to cope more consciously and effectively with the realities of life. The therapeutic journey of discovery and transformation for Mimi eventuated as a paradox—Mimi could only affirm her being by acknowledging her limitations. Mimi had to relinquish her illusion of “specialness” so she could embrace more life-affirming patterns.
Orah Krug’s therapy with Mimi illustrates how E-H therapists facilitate change in clients by (1) cultivating therapeutic presence, (2) activating deep experiential reflection, (3) identifying and illuminating polarized protective patterns, and (4) supporting the reclamation of disowned experiences, thus allowing for the creation of new meanings and more constructive ways of being. The net result for Mimi was an expanded sense of self, specifically, an enhanced capacity for intimacy with her husband and children, coupled with more joy and spontaneity in her life. Mimi succinctly summarized her therapeutic journey by exclaiming: “I’m like my old self but better!”
Most E-H therapists share four core aims: 1) to help clients to become more present to themselves and others; 2) to help them experience the ways in which they both mobilize and block themselves from fuller presence; 3) to help them take responsibility for the construction of their current lives; and 4) to help them choose or actualize ways of being in their outside lives based on facing, not avoiding, the existential givens such as freedom, finiteness, ambiguity, and anxiety.
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