- Orah Krug
Ethical Issues in Existential-Humanistic Psychotherapy
Orah T. Krug and Troy Piwowarski
A set of principles underlie Existential-Humanistic (E-H) therapy and guides the therapeutic change process. These principles uphold the ethical values of dignity of human beings and the sanctity of human connections. Moreover, their implementation, it is presumed, effectively transforms lives. The practice of E-H therapy presents ethical challenges for its practitioners because it relies not on a medical treatment model but rather on an existential-humanistic healing model. This model does not focus on diagnosing and treating symptoms. Instead, it supports an understanding of how each client is uniquely coping with his or her existence. Practicing therapy in this way, may be more challenging ethically, precisely because there are no standardized protocols or treatment interventions to rely upon. In the first section of this chapter, four ethical principles of E-H therapy are paired with several potential ethical challenges arising from them. In subsequent sections, these principles and related challenges are explored more extensively, illuminated with relevant case vignettes.
Keywords: Existential-Humanistic psychotherapy, cultivation of presence, meaning making, therapists’ personal contexts, self-constructed worlds, Existential-Humanistic healing model of therapy, relational intimacy and authenticity, experiential learning, Existential-Humanistic model of supervision, existential issues in therapy.
“It takes outward courage to die; but inward courage to live.”
-- Lao Tzu
How shall we live? How are we living in this moment? What really matters to us? How do we find meaning and purpose? Existential-Humanistic (E-H) therapy is an experiential and relational therapy, which assumes that if life-limiting patterns are faced and dissolved, more joy, satisfaction, meaning and purpose will emerge. At its essence, E-H therapy is more than a therapeutic orientation—it is also an ethical endeavor to assist each client in their search for the good life (see Engelhardt 1973). As such, E-H therapists are less inclined to guide clients toward pre-set goals or ideals. We are less focused on helping clients reach concrete goals or reduction of symptoms, preferring instead to help our clients gain the clarity needed to more fully realize who they deeply are, the multitude of choices available to them, and how to live a life with fuller conscious consent. Far from a dry philosophical exploration, E-H therapy is a concrete, embodied search that requires client and therapist to grapple with the deepest foundations of life itself and how we are willing to live it. As Lao Tzu suggests, awareness of our existence requires an inward courage to face life—not avoid it. E-H therapy aims to help clients, through experiential reflection, understand how they miss a fuller life by constricting their living. A re-claiming of one’s life is the ultimate goal, but this cannot be achieved until one knows what has been disowned. Though symptom relief often occurs along the way, this kind of change takes place in the core of one’s being; it is “whole-bodied” and transformative.
An E-H Theory of Human Change Processes
E-H practitioners base their understanding of human change processes on suppositions regarding human nature, human experience, and human functioning. Human beings are understood to be always in the process of becoming, situated as beings-in-the-world—relating to their physical, personal, and social worlds. Human beings are not simply a collection of drives and behavior patterns within encapsulated selves— human beings are more than the sum of their parts. Human beings continually shape their experiences because they are capable of self-reflection and subjective meaning making. Hence human beings have agency: they are free to change, to make new meanings—yet are bound by the givens of existence and their unique personal, cultural, and historical contexts. We are both free and determined (Krug 2016, Schneider and Krug 2017)
Consequently E-H practitioners focus on clients’ (and at times their own) actual, lived experiences. We desire to know our clients’ subjective meanings directly, as opposed to projecting onto them abstract models of human behavior such as behavioral or psychoanalytic theory. To this end, we enter our clients’ self-constructed worlds, using our own personal contexts to develop responsiveness to our clients’ feelings, experiences and protective patterns (see Krug and Schneider 2016).
The cultivation of therapeutic presence is both the ground and the method of this approach, supporting authentic human connections (Krug 2016, Schneider and Krug 2017). Experiential reflection and relational enactment are “presencing” methods that illuminate the clients’ (and at times), the therapists’ own protective patterns and core wounds. Experiential reflection involves the therapist illuminating that which is implicitly and explicitly present in the client’s own process at each critical juncture of the therapy; relational enactment is calling attention to what is implicitly or explicitly present in the relationship between therapist and client (Schneider and Krug 2017). We presuppose that greater personal freedom is paradoxically found through an encounter with the ties that bind. Consequently, we encourage clients to experience and attune to their polarized, limiting protective patterns and their underlying traumas, fears and anxieties. In so doing, clients reflect upon, as opposed to react against, evocative material. This work typically results in clients appreciating the “functionality” of their symptoms and experiencing their polarized protection patterns as restrictive or self-limiting. Thus, by encouraging clients to experientially embody their restrictive patterns, they are more able to face and accept the givens of existence previously avoided, denied, or repressed. However, for the E-H practitioner, clients taking responsibility for themselves is not sufficient—it is simply preparatory for substantive change evidenced when clients first make new meanings about themselves and then choose more life-affirming patterns for themselves and with others (for an expanded perspective see Krug 2016).
A set of ethical principles underlies E-H therapy and guides the therapeutic change process (see next subchapters). We adhere to these principles because they uphold the dignity of human beings and the sanctity of human connections. Moreover, their implementation effectively transforms lives. The authors of this chapter presuppose that E-H therapists and supervisors adhere to the core ethics of every good therapy and training, that is, to protect the welfare and to promote the rights of clients and trainees.
Why would the practice of E-H therapy present ethical challenges for its practitioners? The reason is related to differing models of therapy. E-H therapy is not founded on a medical treatment model but rather on an existential-humanistic healing model. Specifically, E-H therapy comes from the philosophical traditions of secular humanism and existential philosophy (for an expanded explanation see Krug 2016, Schneider and Krug 2017). Ethical challenges and issues may arise, in part, because of each psychotherapy model has a different structure and method. The E-H model’s structure is not hierarchical but collaborative. Its methods do not focus on treating the DSM symptoms but on healing the distinctive person. Instead of reifying the status quo, the E-H model supports an examination of possible alternatives. As such, the E-H model of healing emphasizes a whole-person approach over compartmentalizing clients in terms of symptoms and diagnoses.
Consequently, the ethical principles of E-H practice are not defensive, risk-management maneuvers but instead are ways to understand how each client is uniquely coping with his or her existence. Based upon their unique needs, we create therapies, tailor made, for each client that don’t rely on a “cookbook” of standard ethical recipes. Instead, our attunement to clients’ personal and interpersonal experiences becomes our compass, guiding our therapeutic course. We listen not only to the content of clients’ stories but also listen for the meanings and feelings underlying the content. Listening for the “music of the story,” or the underlying process helps us appropriately respond to clients. Consistent “check-ins” with clients such as “how was that to tell me just now?” or “how are we doing?” adds to this empathic mix, helping clients feel seen and accepted. Practicing therapy in this way, may present E-H therapists with more ethical challenges, precisely because there are no standardized protocols and treatment interventions to rely upon. But the challenges are well worth the price when the benefits include genuine encounters and lasting therapeutic change. The next section outlines the four ethical principles of E-H therapy paired with some potential ethical challenges arising from them. In subsequent sections, they will be explored more deeply, illuminated with relevant case vignettes.
The Principles of E-H Therapy and Related Ethical Challenges
1. The cultivation of presence is a primary cornerstone of E-H therapy, and a cornerstone of ethical practice within an E-H framework. It is an empathic, experiential way of being and relating that attends to and illuminates what is most alive in the moment, whether that be within the client, within the therapist or within the relational field. We hold up an imaginary mirror to personal and interpersonal processes, encouraging awareness of constricting protective patterns. Recognition of personal responsibility for one’s life usually follows, paving the way for actualizing more liberated ways of living.
While the experiential intervention of cultivating presence may not be appropriate for some clients, it is for the vast majority. However, one must gauge the speed with which one intervenes. Some clients are ready to “jump right in” whereas others need more time to acclimate. Sensitive therapeutic attentiveness and responsiveness to clients’ feelings help gauge readiness. For example, check-ins such as: “How are we doing right now?” cultivates safety, intimacy and a conversational space to address concerns. If attentiveness and responsiveness are absent or insufficient then clients may feel overwhelmed, ashamed or criticized when engaging in experiential approaches.
2. The creation of authentic, intimate and safe therapeutic relationships is another significant cornerstone of E-H therapy and E-H ethical practice. Attentiveness and responsiveness to clients’ experiences and feelings are crucial therapeutic qualities that cultivate genuine human connections and make healing and change possible (see Krug and Schneider, 2016). The greater presence the therapist and client can cultivate in their relationship, the likelier they will be able to remain sensitized to the ongoing impact of the therapeutic work is having, and to be able to make adjustments as needed. Appropriate therapeutic transparency germinates not only relational intimacy but also relational authenticity. Conversely, excessive or inappropriate transparency may result in violating boundary intrusions, which may gratify the therapists but harm the clients (see Bugental 1976). To complicate the subject even more, the absence or insufficiency of transparency and self-disclosure may result in hierarchical rather than collaborative interactions, causing clients to experience their therapists as dominating or as unsafe (see vignette by Troy Piwowarski below).
3. A focus on therapists’ personal contexts and worldviews is a third principle of E-H therapy. In E-H trainings and supervisory sessions, participants explore how their own personal contexts and worldviews may be affecting their abilities to be attentive and responsive to their clients (see Krug and Schneider 2016). While this focus may set us apart from other models of therapeutic education, it simultaneously invites us to address an important ethical issue: the teach/treat boundary. A clarification of this boundary and the related ethical challenges will be described in an upcoming section.
4. Attention to existential issues, a fourth principle, sets E-H therapy apart from medical models of therapy such as cognitive-behavioral or psychoanalytic. The invitation to explore the existential dimension of presenting problems is rooted in the therapy’s philosophical tradition (Schneider and Krug 2017). For example, a wish to relinquish responsibility may be underlying a desire to merge; or an unwillingness to accept uncertainty and contingency may be underlying panic attacks. Facing these and other existential givens paves the way to wrestle with and eventually incorporate the avoided existential given and its related existential anxiety not in an atrophied defensive pattern but in an open and accepting way. However, if clients are not given opportunities to wrestle with their existential nemeses, their avoidant or constrictive patterns may simply morph into different avoidant patterns. Presenting symptoms may be relieved but in time, may give rise to new symptoms. Has substantive transformation occurred? We think not, which is why we explore the existential issues related to presenting problems, and why the absence of such exploration might be considered unethical, as we have left important stones unturned which have the potential to continue constricting our clients’ capacity to live a fuller life. One famous illustration by Martin Buber of the dire consequences of such a missing of deeper existential implications can be found in Existential-Humanistic Therapy (2nd Edition) by Schneider and Krug (2017).
Ethical issues can also result when therapists haven’t sufficiently addressed their own existential nemeses. A therapist who has not fully faced her own terror about death may be unconsciously inclined to collude with a client who avoids acknowledging the role of death anxiety in their own life. If this happens, then clients may miss engaging in necessary therapeutic work while their therapists remain oblivious to a vital therapeutic dimension.
The preceding section outlined four principles of E-H practice paired with some potential ethical challenges arising from them. In the remaining sections, these principles and paired ethical challenges will be elaborated upon, using relevant case vignettes to illustrate their most significant aspects. The vignettes are derived primarily from full-length case studies written by Orah Krug in Existential-Humanistic Therapy (2nd Edition) (Schneider and Krug 2017). These cases of “Claudia,” “Hank” and “Mimi” do not depict specific individuals but rather are compilations of various clients seen by Dr. Krug.
Ethical Challenges of Cultivating Therapeutic Presence
E-H therapists aim to know the individual who comes for therapy at an experiential level, to enter his or her personal, subjective world of thoughts and feelings so that the individual’s uniqueness can be felt and hopefully understood. If therapists can connect with clients in this way, then clients can come to know themselves, in this same way. This relates directly to the ethical principles of beneficence and non-maleficence: we attempt to help our clients better their lives in a way that accords with their own sensibilities. We believe that to help a client simply do away with an inconvenient behavior or cognition without bringing awareness to the existential implications of such a change could lead the client to further disown an important part of self. Ethically responsible E-H therapy requires that we cultivate personal and relational presence that implicitly conveys a “being with,” not a “doing to.” Presence involves aspects of awareness, acceptance, availability, and expressiveness in both therapist and client. Clients’ behavior patterns and attitudes are respectfully reflected back so their unacknowledged feelings, thoughts and limiting protective patterns may be experienced. Our intention is to understand clients as individuals and not as diagnoses. We believe an individual’s uniqueness is often lost when they are categorized and labeled by their symptoms. Moreover, curiosity is often absent when abstract models of human behavior or clinical diagnoses are projected onto clients. Another difference is how we relate to clients’ symptoms. They are understood not as problems to be eliminated but rather as methods of self-protection. They invite E-H practitioners to wonder: “Why has this symptom “shown up” now, and what does the symptom want “to tell” my client?”
Although E-H therapists value the content (or explicit features) of clients’ experiences, they are acutely and simultaneously attuned to the process or implicit aspects of those experiences. They wonder, “How is my client telling me his story?” “Is his voice flat and unemotional or filled with trembling emotion?” “Does he look at me or does he turn away as he tells me his story?” They may also attend to how the client occupies personal space---with confidence and ease or with hesitation and constraint? They may comment on clients’ relational ways of being, i.e., “You seem to not like what I just said.” Or they may simply attend to how clients relate to them—in engaged, open ways or in a detached, aloof ways?
Why is that? E-H practitioners assume the past is alive in the present moment, meaning practitioners understand the therapeutic relationship as a microcosm of the client’s personal and relational worlds. The therapeutic encounter is consequently a “living laboratory,” whereby the therapeutic process refers not only to immediate interactions between client and therapist, but also refers to the underlying personal and relational processes of both client and therapist. E-H therapists, will usually explain, in the first session this “microcosm assumption” and this relational way of working in the “here and now” and get consent to proceed with this therapeutic method. Even with their clients’ “buy in,” E-H therapists move slowly in order to determine their clients’ capabilities and readiness for deeper work. E-H therapists must be sensitive to the potentially “exposing experience” of intimate mirroring (sometimes referred to as tagging) of clients’ implicit personal and relational ways of being. The reason being that they are concretely actual but are often out of the clients’ awareness, such as habitual foot tapping. A check-in usually follows the mirroring to mitigate any shame, felt judgments or criticisms. The following vignettes from Dr. Orah Krug’s work with “Hank” and “Claudia” help to illustrate.
Fairly early in my work with Hank, I decided to tag two evident, but unnoticed aspects of his behavior: his mechanical way of relating to himself and to me, and his repeated late arrival. I understood his behaviors not as problematic symptoms but as protective patterns, inviting my curiosity. I went slowly with Hank, first simply noting them, then, later working more relationally with them, always checking in with Hank regarding his experiences of the interventions. Our work helped Hank recognize how his unregarded behaviors were deeply entrenched relational patterns (employed not only with me but with everyone in his life) that protected him from anticipated rejection: “If I don’t fully show up, I won’t be rejected.”
With “Claudia” who for several years spent her sessions curled up at the end of the couch, silently facing the windows, I went even slower, recognizing Claudia’s need to stay hidden because of her shame. Claudia’s silence was a reflection of her shameful beliefs: “I’m too much” and “You will reject me.” For this reason, I carefully engaged Claudia, and even with that care, Claudia often projected onto me her shame-based assumption that I didn’t want her to show-up because she was too much. I quickly understood that my acceptance of her cancellations: “ok, see you next time,” only reinforced this assumption. Thereafter, following any cancelation, my call urged her to come in: “You don’t have to speak—just be here with me.” Adjusting my therapeutic frame to address Claudia’s self and world constructs, helped dissolve her belief that: “I’m too much for you.” Moreover, it illustrates how E-H therapists tailor the therapy to meet the particular needs of each person.
Healing and change happen as protective patterns are mirrored back to clients allowing them to experience how their patterns are embodied and enacted within the therapeutic relationship. With Claudia for example, after we identified the protective nature of her silence, and her core wound as “I’m too much,” I would doggedly check in when she lapsed into that familiar silence. “Are you imagining you’re too much for me right now? Would you like to check it out with me?” My sensitive attunement to Claudia’s easily triggered shame helped her feel safe and seen in our relationship.
By mirroring back self-protective patterns, clients can eventually reflect on their protective life stances (their spacesuits) instead of being unaware them. For example, Claudia eventually recognized: “I’m imagining I’m too much, and fear Orah will reject me, so I go silent,” and Hank recognized: “There I go again, showing up late to our session.” Using the therapy as a living laboratory and mirroring back ways of being, helps our clients feel the pain of a wound, no longer numbed by the protective pattern. The belief about self finds expression: Claudia, “I’ve never felt worthy of being cared for—I’m damaged, that’s why I don’t reach out to you.” Or, Hank, “I feel unlovable—I’m afraid if I engage with you and let you matter to me, you’ll reject me.” To the extent appropriate, meanings made about self, others, and world, and the associated hurt and pain are felt and worked through at an embodied, not cognitive level in the safety of the therapeutic relationship. By supporting clients to experientially embody their self-restrictive patterns, clients can face and accept the givens of existence and their core decisions and wounds that may have been avoided, denied, or repressed. Together past relational patterns can be dissolved and new ones developed.
Ethical Challenges of Intimate Therapeutic Relationships
As “fellow travelers” navigating the same ambiguous existential terrain as their clients, E-H therapists understand that they are in a better position to ethically work with their clients when they can own their flaws, uncertainties, and to the degree that it’s possible, biases that distort the therapist’s view of the client before them. E-H therapists see the relationship as the foundation for ethical practice. As Yalom (1980) and others (see Norcross and Lambert 2011, Schneider and Krug, 2017) have indicated, the relationship is itself a powerful source of healing. We would add that it is the relationship that engenders transparency, intimacy and safety that optimally heals, and is most likely to avoid inadvertent harm to the client.
Therapeutic relationships inherently carry a set of ethical boundaries in the form of confidentiality, payment, limits to time, a focus on primarily the client’s concerns over the therapist’s, and the like. Within the boundaries that delimit the ethical frame of all therapies, E-H therapists strive to collaboratively cultivate a real relationship with their clients. What does it mean to be real in the therapeutic context? The question itself contains a paradox. If therapists were to bring their uncensored thoughts, feelings, and perspective to bear, this could easily lead to clients feeling violated, or lead therapists to lose track of who is truly client and therapist. E-H therapists are ethically guided by a principle of “authentic to this particular context,” (Krug and Schneider, 2016) meaning that they simultaneously hold the delimited therapeutic frame while attempting to bring themselves as fully and presently to the engagement as possible. If I am noticing that I’m feeling bored with my client, it is incumbent upon me to pay attention to that signal, and to find out what it is that’s boring me. In the case that I choose to share my experience of boredom with my client, I would do so with the intention of helping my client, rather than to simply unburden myself of the boredom.
What it means to bring oneself fully to the encounter varies widely based on the personality, relational style, and comfort of the therapist, and often depending on the way the therapist and each client’s subjectivities come together in the encounter. Whereas I (Dr. Piwowarski) may feel comfortable being quite transparent with one client—freely offering an anecdote from my own experience to help my client hear a perspective that had not occurred to her—I may feel more reserved with another client, initially inclined to share mostly thoughts and feelings that pertain directly to my here-and-now experience of my client with them. This variation in relational style with each client is evidence that a new therapy is being created, based on this client’s unique existence, and on the genuine relationship that is unfolding before us. E-H therapists hold a delicate ethical balance between meeting clients where they are and challenging them to see ways that they limit themselves from living and relating to their fullest potential. Again, the barometer for when to support and when to challenge exists within the relationship itself. I often check in with my clients following a more challenging exchange, asking “how was it for you to experience me challenging you a moment ago?” This creates a feedback loop, a way to “test the waters” of the relationship together.
]At times, a significant ‘pull’ in the therapeutic relationship can draw the therapist towards stretching or constricting the frame, towards over-accommodating or being overly rigid about scheduling, towards being a “watch dog” responsible for keeping tabs on the client’s well-being, towards attempting to convince the client of some insight or change the therapist wants for the client, or towards getting lost in a client’s storytelling, keeping client and therapist from addressing difficult feelings.
These examples of potential enactments in the relationship underline the importance of two other guiding E-H principles discussed in this chapter, (1) bringing a grounding of presence and attunement to the unique living world of each client (including the therapy relationship), and (2) attending to the therapist’s socio-cultural context through reflection and consultation.
The following vignette, an amalgam of clients from Dr. Piwowarski’s practice, underlines some key facets of attending to the relationship from an E-H perspective, and how one might navigate an ethical gray area with an eye toward transparency and collaboration.
It was toward the end of my third session with David. Things were going remarkably well this early in our work together, and I was feeling optimistic about the direction of our work. In a short period of time, we had established a trusting relationship, and despite David’s outward shell of self-sufficiency, he allowed himself to drop into vulnerability in each of our first three sessions. I found it easy to be with David; even with his sharp edges, I did not struggle to find moments that I could help him begin to look at disowned aspects of himself.
As David began rustling with his bag in preparation to leave, he off-handedly mentioned, “So I’ll be seeing another therapist for the first time this week as well, and figured you might want to know that, since I’m still deciding who I want to work with.” I immediately felt a pang of something—was it jealousy—or perhaps a blend of rejection and irritation? After recovering from the surprise and rush of feelings at this last-minute announcement, I replied that I was not aware that he was meeting with another therapist, nor that he was still in the process of deciding. “Yeah, I’m just not sure who the right therapist is for me yet.”
With only a minute to respond, I thanked David for letting me know, and made him aware of my ethical responsibility not to duplicate services with another therapist (see APA Ethics Code 10.04: Providing Therapy to Those Served by Others). David was taken aback by this: “That would mean that if I see one of you for a while and I decide you’re not the right person for me, I have to start all over with someone new?”
In our next session, David did not bring up the matter of the other therapist spontaneously. With 15 minutes remaining, I found a way to bring it back up. “I’ve been thinking more about this dilemma about you seeing two therapists at the same time and thought we should take some time to talk more about what it means for our work together.” David launched into his invective about the “ridiculous” code for a good while. I noted how much feeling there was behind this for David, but for the moment, I chose to respond only to the content. “I’ve given this some thought too, and I agree that in this situation, it might make sense to offer you some leeway to feel things out. At the same time, I’m aware that this puts me in a tricky situation with my own ethical obligations. I’m willing to give you some time, but I’m not willing to keep going indefinitely this way—you’ll need to decide relatively soon.” David nodded in agreement, seeming to understand and showing no outward concern.
In the week that followed, my mind kept wandering back to those last few remarks I made to David, and how little he said in reply. Upon reflection, my tone struck me as much terser than usual. I began to search my own context for clues as to what might be triggering me. It occurred to me that I was operating out of a fear that “if I give him an inch, he’ll take a mile,” a belief borne out of earlier life experiences at a time when I had very little capacity to stand up for myself when I felt like someone was crossing a line with me.
Then I flashed back to the growing boil of frustration as an inexperienced therapist in my first practice in Michigan, begrudgingly waiving the fee for yet another last-minute cancellation and then neglecting to bring it up in the following session, for fear of the conflict that might ensue. I’ve come a long way with learning to draw good boundaries since then, but the fear that I felt about entering an ill-defined gray area with David was setting off old alarms in me. It clicked that I was attempting to ward off resentment toward David by drawing a hard line in the sand.
On the day of our next session, David emailed to let me know that he was unsure whether we would be a good fit, largely due to my discomfort with allowing him the time he needed to make his decision. At the end of the email, David asked whether I thought it would be good for us to meet once more before ending, to which I replied “yes, I think that would be a good idea.” During my lunch break before the appointment with David, I spent some time revisiting our dilemma. The thing was, I had not stopped to consider what I would be comfortable offering him. I was leaning on the ethics code as a convenient excuse, rather than taking responsibility for handling the situation according to my internal ethical compass. I had also failed to thoroughly explore with David what was important to him about having additional time to decide.
When David sat down on the couch, I launched right in: “I’m really glad you decided to come in today, because I’ve been reflecting on your email, and I wanted us to have a chance to talk it through. I recognize that the way I presented my boundaries about our dilemma last week was more rigid than I needed to be. I think there’s something about entering gray areas in my own history that can get my own anxiety up, and my way of shoring up anxiety can be to get rigid. From your email, I’m guessing you picked up on that and took it to mean that I wasn’t willing to be flexible about how long I would see you while you’re deciding who to work with?”
David nodded. With some hesitation at first, he began to share his own vulnerability. “To be honest, when you said that, I felt really unsafe. It really sucked, and it felt like you were getting rid of me.” I empathized with David and began to explore with him his own specific way of interpreting my statement, knowing I wanted to be able to continue our work together, which I also shared with him. David was eventually able to recognize old narratives that were playing out for him in this process, which were playing a part in both his insistence on being allowed to take more time to make his decision, and his quick leap to “you’re getting rid of me.”
This acknowledgement of our mutual enactment—mine out of the wounds of resentment from lacking the capacity to stand up for myself as a child and young adult, his of an unpredictable childhood that made it difficult to know when he was safe—was the beginning of a deep working-through of childhood injuries and the meanings David made about them. One of those beliefs was that David could not really trust his instincts in moments of uncertainty, which he was undergoing when he was trying to decide which therapist he wanted to work with.
Throughout the weeks that followed this pivotal session, I tended to my own anxieties and ethical concerns through consultation, and simultaneously helped David explore the deeper meaning of our enactment. David later told me that my willingness to be flexible gave him the time he needed to find his own metric of certainty in his choice of therapist and created a greater sense of safety. In the end, David chose to work with me.
From an E-H perspective, presence is at the foundation of working through relational enactments—presence to one’s own context, presence to the client’s, and presence to the unique way the contextual and relational pulls manifest in the room. This vignette illustrates the importance to all three. This vignette also illustrates one way of bringing oneself into the relationship through appropriate transparency, following the guideline of being authentic to the context of therapy. By sharing my own part of the enactment, that is, owning my rigidity, I modeled vulnerability that allowed David’s guardedness to immediately soften. Only then was he able to acknowledge his own vulnerability of feeling discarded and not wanted.
By acknowledging my responsibility in co-creating a relational impasse, I gave myself the option to revisit my original statement and collaboratively create a concrete, but more flexible timeline that met both of our needs. Adjusting the relational frame in the direction of greater attunement to the client’s needs often cultivates a deeper sense of safety and intimacy. Making these adjustments provides greater safety to explore what got triggered, as with the meaningful work that unfolded in David’s therapy following our adjustment of the frame.
Attending to Therapists’ Contexts: Ethical Boundary Lines in Supervision
Dr. Piwowarski’s vignette in the section above vividly illuminates how E-H therapists might ethically work with their personal contexts to understand unconstructive responses and behaviors, i.e., their enactments with clients. Participants in E-H trainings and supervisory sessions commonly explore therapeutic breaches, impasses, excessive accommodations, rigidities, or even experiences of boredom as possible indicators of “being triggered in their context.” This type of educational focus, such that participants’ personal, social and/or cultural contexts are investigated, requires E-H educators to explain the teach/treat boundary. This is of paramount importance in teaching E-H therapy principles, as we believe that experiential learning is the best way to learn how to be an E-H therapist.
Research has shown that therapist qualities such as empathy, attunement, acceptance, and congruence are some of the most powerful predictors of therapeutic effectiveness (Elkins, 2015). These qualities are not only conducive to effective therapeutic healing, but as the previous two sections underlined, they are the cornerstones of ethical E-H practice. The co-authors believe “we are the tools of our trade” and consequently hold the personal growth of supervisees to be integral to professional competency. How do we cultivate these qualities? The intimate journey of life-changing therapy requires supervisees to trust the subjective and the intersubjective realms, and to cultivate fluid access to both realms. An outward focus on techniques and treatment plans does not promote this subjective and inter subjective awareness. On the other hand, a focus on one’s personal, cultural and social contexts does.
In addition to enhancing access to both realms, a focus on personal context also helps to cultivate personal qualities such as empathy and compassion. Within the safety of the supervisory relationship, supervisees explore their protective patterns or life stances, and how they may be hindering their ability to engage effectively with their clients. Sometimes supervisors will point out how supervisees’ protective patterns are manifesting concretely in the supervisory relationship. For example, a supervisee may have a “rescuing type of relationship” with a child client that is out of awareness. This “rescuing behavior” may manifest in the supervisory relationship leading the supervisor to illuminate it, and then explore with the supervisee how it may be manifesting in her therapeutic relationships. Role-playing a client is another way for supervisees to grasp the lived experiences of their clients and to understand how they may be triggered by their clients’ ways of being. A byproduct of this exploration often elicits within the supervisee greater empathy, appreciation, and acceptance of the protective patterns and life stances of their clients.
In my supervisory role, I (Orah Krug) have shared with my supervisees some of my own therapeutic challenges and missteps. For example, my misstep with Diana (see Schneider and Krug 2017). In my rush to soothe Diana when her shame, triggered by feelings of dangerous self-exposure threatened to overwhelm her, I inadvertently deprived her of an opportunity to explore her immediate experience of shutting herself down. I caught myself in time to invite Diana to stay with her shameful feelings of: “I’m stupid, I don’t know what I’m talking about.” By making space for these shameful feelings, Diana came to appreciate how often she shuts herself down to avoid the anticipated criticism—a protection shaped by her consistently critical father. I shared with Diana how my own context had gotten triggered; being the one in my family whose job was to make everyone “happy.” Diana told me that my transparency helped her have more empathy for herself. When I have shared this misstep with my supervisees, they express appreciation for hearing how “even Orah” is not immune to being “caught in her context.” I want my supervisees to understand that I too, am a fellow traveler, earnestly working, but sometimes failing to understand the lived experiences of my clients because of my own context.
Clearly, we believe that a focus on personal, cultural and social contexts helps therapists consulting with us develop sensitive attunement and responsiveness, greater empathy and self-compassion. We do not consider this focus a breach of the “teach/treat” boundary but rather a valuable aspect of developing supervisees’ emotional maturity. What does the term “teach/treat” commonly mean? The term refers to the intention of the typical supervision model, which is to teach the theory and practice of a particular approach and to not cross the boundary into “treating the supervisee.” However, in the rush to not violate this boundary, what often gets ignored are ways to help supervisees understand how their own personal challenges and protective patterns may be impeding therapeutic progress.
In contrast, E-H supervisors, because they value developing the emotional maturity of the therapist do engage with supervisees in this way. This work is not seen as a breach of the teach/treat boundary, as we said, but rather an intention to develop therapists who can engage their clients in life-changing therapy. We understand that individuals always make contact with others from their personal, cultural, social context. In other words, contact is always contextualized, and therefore presence is to some extent compromised. For this reason, we help supervisees explore their contexts. Our research supports this intention: if supervisees are helped to understand how their context is influencing their contact with clients, then they will be more therapeutically effective with clients (see Krug and Schneider 2016).
E-H supervisors distinguish between not crossing a treatment boundary line (for example we would not engage a supervisee in an exploration of a deeply embodied trauma) but we would definitely engage a supervisee (as we did with Troy) in an exploration of a disowned or unrecognized aspect of self that is impeding or perhaps derailing the therapeutic work. Engagement in this type of exploration allowed Troy to be conscious of his protective rigidity so that he no longer enacted it with his client. Several quotes from our therapists in training suggest how supervisory education, focused not only on skill building but also on personal growth, results in transformative change (Krug and Schneider 2016):
“I am now aware of how my clients’ ways of relating may trigger some of my personal issues and how to use this constructively to assist my clients.”
“The issue I was having with my client was clearly relational, but I was not seeing just how much judgment I had toward this client. You invited me to bring into the room the judgments that felt so terrible in my head, and allowed me the space to sort out how those were contributing to the huge relational block I was having with her. The work I did with her after that was more profound than I could have imagined…I knew I would not have been able to do that without first acknowledging and working through all the things I hated about her!”
“I’ve seen my work improve tremendously. I’m more spontaneous, more authentic and more attuned to my clients. I’m able to respond to their body language in a new way. I’m braver about bringing up what’s actually happening in the room. I’m also more relaxed and trusting myself more.”
Of course, there may be times where a supervisee’s personal concerns overwhelm the parameters of the supervisory relationship. Because E-H supervisors keenly attune to their supervisee’s process it is quite likely that a supervisor would readily recognize a supervisee’s emotional overwhelm and quickly work to calm, soothe and reduce it. Once the supervisee is more settled, the supervisor would suggest that further exploration of such personal concerns be handled within a therapeutic context. If the supervisee is not currently in therapy, the supervisor would do all he or she could to provide appropriate referrals to the supervisee, particularly with some E-H oriented therapists.
To sum, if supervisors place a significant value on developing supervisees’ emotional maturity, then the supervisees will likely develop the personal qualities that determine therapeutic effectiveness. If a supervisee is unwilling to engage in this more personal exploration, then the supervisor is challenged to convince the supervisee of its value. We have been fortunate to have few, if any, students unwilling to engage in such an exploration. We value the presupposition that Carl Rogers (1961) made about therapists and readily apply it to the intention of E-H supervisors: supervisors are like gardeners, they can’t make something happen, but they can provide a soil, rich in experiences, that supports and nurtures the personal growth of their students.
Exploring Existential Issues and Related Ethical Challenges
Attention to existential issues sets E-H therapy apart from medical models of therapy such as cognitive-behavioral or psychoanalytic. The invitation to explore the existential dimension of presenting problems is rooted in the therapy’s philosophical tradition which presupposes that human beings are both free and determined: a paradoxical premise with roots tracing back to the Greek philosopher Heraclitus. Humans are free because they make meanings from their experiences, and they are determined because these meanings are limited by natural and self-imposed limitations. In other words, our subjective freedom—that is, our freedom to form attitudes, meanings and emotions about an experience—is limited by the objective facts of the experience and our subjective personal, cultural and historical context. Objective awareness pertains to measurable facts; subjective awareness pertains to feelings and experiences. They are not in opposition; rather they form a paradoxical unity of human experience. Human beings, unlike most organisms, have the remarkable capacity to make meaning and create an experiential world that is unique and personal, a world that includes both subjective and objective awareness.
Rollo May (1980) considered this paradox of human experience as the human dilemma; one that should not be resolved because choosing to emphasize one pole to the exclusion of the other can result in behavior that is either too expanded or too limited. Many people come to therapy suffering from an over-emphasis of one pole, such as the emotionally repressed, objectively focused intellectual (too limited), or the pleasure seeking, subjectively focused risk-taker (too expanded). E-H therapists are sensitive to this human dilemma, so they encourage a way of being that supports the development of both—objective and subjective awareness. The ability to move between the subjective and the objective pole is the source of human creativity and energy, but it is also deeply challenging.
In Courage to Be (1952) Paul Tillich brilliantly articulated this fundamental challenge of living courageously—to face the reality of our “finite freedom,” without avoidance, denial, or repression. It takes courage to be fully present in life, to face the “givens” of life and of one’s personal experiences and limitations. The choices we make determine who we become.
Irvin Yalom (1980) in Existential Psychotherapy describes four “givens” of human existence: death, freedom, isolation, and meaninglessness. Yalom asserts that the extent to which we are able to confront these givens will determine the extent of the dynamic conflict. If we need, for example, to deny the reality of death, we may cope by developing over-expanded, extreme risk-taking behavior, or we may cope with over-constricted, excessive rule-bound behavior. But if we are able to face these givens sufficiently, our lives will be more balanced, free, honest, and congruent. Here again, E-H therapists must hold a delicate moral line between meeting the client where they are in a deep way—over-expanded or over-restricted, and all of the self-protective behaviors that come with these states—while also holding the possibility for the client to gain greater access to disowned aspects of self.
Thus, the central aim of therapy is to “de-repress” and re-acquaint the individual with something she or he has known all along. This consists of two parts. The following vignette of Dr. Krug’s work with Mimi (for the complete case study see Schneider and Krug 2017) vividly illustrates these two parts. The first part involves encouraging the individual to engage in experiential self-reflection and attend to his or her existential situation. As Mimi faced her existential situation it paved the way for her to wrestle with and eventually incorporate the avoided existential given and its related existential anxiety not in an atrophied defensive pattern but in an open and accepting way. Although painful, this confrontation allowed Mimi to accept responsibility for shaping her life. But responsibility assumption was only the first step. For real change to occur, Mimi had to behave differently, which she spontaneously did, without my asking either implicitly or explicitly if she was satisfied with how her life was unfolding. Mimi’s spontaneous engagement with new ways of living indicated a ready willingness to transform her personal dissatisfaction into constructive action.
However, if clients are not given opportunities to wrestle with their existential nemeses, their avoidant or constrictive patterns may simply morph into different avoidant patterns. Presenting symptoms may be relieved but in time, may give rise to new symptoms. Has substantive transformation occurred? We think not. E-H therapists value an exploration of underlying existential issues related to presenting problems. Moreover, one could argue that the absence of such an exploration might considered unethical, in that a core concern that is driving the client’s problems has been missed. Ethical issues can result when therapists haven’t addressed sufficiently their own existential nemeses. If this happens, then clients may miss engaging in necessary therapeutic work while their therapists remain oblivious to a vital therapeutic dimension.
As alluded to in preceding paragraphs, the vignette of Mimi describes how I (Orah Krug) helped Mimi become re-acquainted with something she had known all along. The “something” had to do with an existential given, blocked from awareness by her protective life stance. Our therapy was short term, limited to eight sessions because of Mimi’s due date. Mimi was a 29-year-old married woman, of Persian descent, 7 ½ months pregnant with her second child. Although not central to the therapy, Mimi’s Persian heritage, culture, and worldview were aspects of her context that impacted how I related to and worked with her. I aimed to participate in Mimi’s experiential world by attuning empathically to what is most alive in the moment. By cultivating personal and relational presence Mimi’s actual but often out of awareness experiences and ways of relating could be felt. If we can illuminate these life stances carefully and respectfully, therapy becomes a project of experiencing one’s life instead of talking about one’s life.
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. As I listened to Mimi tell her story, I was able to hear and see Mimi’s life stance 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 believes she has agency and she takes responsibility for her life. Unfortunately, also implicit in Mimi’s life stance is her unmediated belief in the power of personal control to keep her and her loved ones safe—Mimi does not truly appreciate that one can influence but not control an outcome. This was the “something” (an existential given that was out of her awareness) that shattered her protective life stance when the plane crashed into her home. 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 (an indication that something had been shattered). 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.
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 a 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 decision to fulfill her role, acknowledging that the role gave her life purpose and meaning. But I also noted her recognition of the role’s additional stress to her already stressed system. My appreciation of Mimi’s need to “do her duty” normalized her decision instead of challenging it, consequently helping Mimi to feel supported and not judged. Eventually it enabled her to delegate some of the duties to a visiting nurse.
With regard to the traumatic incident, I helped Mimi release her anger and her constant replay of the event by inviting Mimi to “go slow” to make space for her phrase: “It isn’t fair.” I suggested she repeat the phrase and see what thoughts, feelings associations emerged. I imagined what lay behind the phrase, but I trusted that through this process she’d discover her truth—and she did: “I thought I was going to die.” Her death terror had been blocked from consciousness by her rage at the pilot for not “doing right” by her. Mimi’s stance towards life 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 that was out of her conscious awareness.
Within the context of a safe therapeutic relationship, healing and change occurred. I consistently checked in with Mimi about our work, giving her an opportunity to share what was difficult and what was helpful. The “check-ins” also helped me know if we remained aligned well, given our cultural differences. By working in this relational, collaborative way I hoped to maintain a safe and secure therapeutic relationship. I helped Mimi experientially “de-repress” and face the existential reality that life will deal with her in the same harsh way it deals with others. Mimi felt betrayed as her sense of “specialness,” a commonly held illusion, was ripped away. I helped her to work through these feelings of betrayal: a few weeks into the therapy, we revisited the phrase, “it isn’t fair.” This time, as Mimi experientially reflected on its meaning, a revelation spontaneously emerged: “It isn’t fair that there’s no plan, no structure or protection—anything can happen. I don’t like it, but I guess that’s just how life is.” Mimi was facing and accepting the existential given of contingency. By relinquishing her illusion of personal protection, she could 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.
By the end of our eight weeks together Mimi reported feeling more aware and open to life. A few months after the birth of her child Mimi checked in as I had suggested. She shared her satisfaction and joy in feeling closer to her family and being more spontaneous in her life. She said she would call me if she felt the need for further therapy. I heard from Mimi a year later, she said she felt great, exclaiming: “I’m like my old self but better!”
My work with Mimi illustrates how E-H therapists can facilitate “de-repression” and acceptance of the existential givens. Many therapists, from other orientations might have only understood the work as simply trauma work. But my orientation allowed me to appreciate the possibility of an existential concern underlying the trauma. My mentor, Irvin Yalom trained me well to appreciate this possibility, but even more significant was having addressed my own death anxiety issues in therapy. Consequently, with Mimi, I could be as Virgil was with Dante, a fellow traveler walking confidently by her side, helping her navigate the treacherous terrain.
One could make the case that working at such a deep existential level might not be ethical given the time constraints. However, I would argue that it was not my decision to go deeper but rather it was Mimi’s. I only held the awareness that Mimi might have such an underlying concern. I had no need or goal to go deeper. Mimi’s readiness to go deeper can be seen in her decision to go deeper. In my experience if Mimi wasn’t ready to go deeper, she would have stopped herself. I trust my clients’ abilities to decide what they need as long as I’m clear about my intentions. Another indication of Mimi’s readiness can be seen in her response to her self-discovery. Mimi was relieved not agitated. As we reviewed and processed it in the next session, Mimi described herself as feeling unburdened and excited about her realization. The follow up with Mimi confirmed to me that the deeper existential work had unblocked Mimi, allowing her to feel freer, more loving and spontaneous with her loved ones.
In this chapter, we outlined E-H therapy as itself an ethical endeavor aimed at assisting clients toward a whole-bodied search for their unique sense of “the good.” A set of principles also underlie E-H therapy, guiding the therapeutic change process. In this chapter, we explored 1) the cultivation of presence, 2) the creation of authentic, intimate and safe therapeutic relationships, 3) a focus on therapists’ personal contexts and worldviews, and 4) attention to existential issues as four ethical cornerstones that set E-H therapy apart from medical models of therapy such as cognitive-behavioral or psychoanalytic. These principles uphold the ethical values of dignity of human beings and the sanctity of human connections. Moreover, their implementation, it is presumed, effectively transforms lives, in addition to avoiding inadvertent harm to clients.
The practice of E-H therapy presents ethical challenges for its practitioners because it relies not on a medical treatment model but rather on an existential-humanistic healing model. This model does not focus on diagnosing and treating symptoms. Instead, attunement to clients’ personal and interpersonal experiences becomes the compass, guiding the therapeutic course, illuminating how this particular client is uniquely coping with his or her existence. Practicing therapy in this way may be more challenging ethically, precisely because there are no standardized protocols and treatment interventions to rely upon. E-H therapists may find themselves at odds between two opposing values, such as when Dr. Piwowarski found himself caught between a professional ethical code and an opposing interpersonal ethical value. At other times, E-H therapists may feel conflicted between the ethical principle of transparency and the desire to support the client where they currently are.
As this chapter unfolded, it became apparent to its authors that this project was more than a description of E-H principles of practice and the related ethical challenges. Unexpectedly, the chapter became an articulation of our values on the crucial elements of effective therapy and how these values translate into the ethics of our practice. This is reflective of E-H ethical principles, themselves embedded a philosophy that is based not on technique or rubric, but on an attitude toward existence that holds deep reverence for following what is alive in ourselves and our clients.
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