Working with Fear and Sadness: Existential methodology VS Cognitive-Behavioural approach.

Introduction

Following Freud’s popularisation of psychoanalysis, his successors found that the approach they had been taught did not, fully satisfy the needs they were confronted with. Although psychoanalysis is preoccupied with past events, the subconscious, the intangible which lies below the surface of consciousness, it did not deal with the immediacy of the present, such as those experiences that preoccupy the day-to-day life reality of people seeking therapy. New theories and new approaches to counselling emerged in response, some with philosophical roots such as existential therapy, and others backed by scientific research such as cognitive-behavioural therapy. With an emphasis on the present and the future rather than the past, Existential therapy was developed at the dawn of the 20th century and refined in the last 30 years, stemming from ideas of existential philosophy from the 19th century onwards. Similarly preoccupied with resolving immediate psychological problems, Cognitive-Behavioural Therapy (CBT) focuses on dealing with the management of symptoms. Emerging from theories on cognitive and behavioural approaches, it evolved as a therapy method thanks to the work of Beck (1976) on the cognitive theory of emotion (Beck, 1976). This essay will discuss these two approaches by comparing and contrasting them in relation to understanding fear and sadness, starting with a summary of each and a discussion of their similarities and differences, merits and flaws, concluding with an explanation of why an evidence-based approach, such as CBT, is more adequate in understanding anxiety and depression.

The Existential Approach

Existentialist philosophy focuses on the individual’s responsibility to existence, freedom and choice. When, in the 19th century, Kierkegaard proposed that the responsibility of finding meaning in life lies with the individual, he did so to counter the prevailing thought of the time, dominated by the hierarchical doctrine of Christianity (Stanford University, 2016). This idea on the individual’s responsibility is what led Nietzsche and other philosophers to build upon it and develop it to its current form, highlighting the importance of acknowledging the inevitability of the “human condition” and one’s own fate. These ideas then influenced the development of the existential approach to therapy by Ludwig Binswanger and Medard Boss in the early 20th century as an alternative to the psychoanalytic model, which they both had been trained in, and by the work of Emma Van Deurzen and Ernesto Spinelli in recent years, with their further contribution in refining the method of practice(as cited in Langdridge, 2016). This therapeutic approach focuses on the phenomenological method, which aims to understand the world as it appears to the client, without prejudices. This method engages in a process known as epoché and is divided into four parts, beginning with bracketing where the therapist attempts to better understand the world of the client by setting aside prejudices and preconceptions during an initial assessment. This leads to the building and developing of an understanding of the client’s state of mind from their point of view allowing for an authentic relationship to form during therapy. Following this, the next step is to describe the world as it is, rather than seek reasons and explanations as to why things are the way they are, empathising the experience of the world, rather than its meaning. Once the experience is described, the step that follows is to horizontalize it, so as to avoid placing hierarchical importance when compared to other events. In the mind of the counsellor, during this step, all events and experiences described by the clients are of equal importance. Finally, the counsellor will seek to verify their understanding of the client’s experience to ensure its description accurately reflects their reality by engaging in a conversational approach focusing on the what and how. During the process, the counsellor is highly engaged and entertains a dialogue with the client, where ideas from existential philosophy are occasionally used as tools to bring self-awareness to one’s self, as well as awareness of the world as it is. This awareness, both of the self and the world, can then be directed towards the realisation of the client’s potential and freedom to choose their own path, as existential therapy aims to eradicate what obstacles that lead to it.

The Cognitive-Behavioural Approach

In the 1960s, following the research on behaviourism led by Skinner which built upon the work on conditioning by Pavlov, theories of cognitive and behavioural approaches emerged in response to the dissatisfaction and inadequacy offered by traditional psychoanalysis in the 1960s. However, these ideas on their own did not offer a useful approach method (Salkovskis, 2016). When Arron Beck, a trained psychoanalyst, was conducting research on dreams, he noticed how the thematic content did not reflect the existing notion in psychoanalysis of wish fulfilment (as cited in Salkovskis, 2016). As Salkovskis (2016) notes, those dream accounts involved more of the everyday experience, daily concerns and fears of people, rather than their subconscious desires (Salkovskis, 2016). This led Beck (1976) to develop his theory of cognitive emotion (Beck, 1976). This theory proposes that it is not so much the events causing an emotional response but the meaning attached to it. Beck’s theory suggests that the meaning an individual assigns to any given event is the result of a complex interaction between that person’s mood state, context and personal history. As Salkovskis (2016) notes further, “Often the meanings are conscious, sometimes there are not, but with careful questioning they can be identified” (Salkovskis, 2016). This therapeutic method involves identifying the client’s issues and obstacles so as to find ways to overcome them by offering alternative narratives, often challenging a pre-existing belief. The approach begins with an initial assessment where clients are asked about how their psychological problem or problems are affecting their lives and identifying what coping mechanisms they have devised to overcome them. Outlining the goal sought by the client in terms of short, medium and long term, helps design the trajectory of the therapy sessions as well as provide realistic objectives. The relationship that builds between the counsellor and the client is akin to an alliance, where an emphatic response to the client’s experience helps build the trust necessary throughout the process. Following this, a more specific assessment takes place where the counsellor works with the client to understand how the problem works, identify a recent occurrence, and work through understanding the process by deconstructing it. This leads to a formulation in which the vicious cycle is broken into easily identifiable parts, with an emphasis on the cognitive mechanism which feeds the intrusive or negative thoughts and the safety-seeking behaviour. This formulation is then put forward to the client as a theory to the problem, followed by a discussion leading to an alternative interpretation of the stressful event. Understanding the client’s own coping strategy is key to the process and leads to the development of an alternative theory in an attempt to break the cycle. Throughout the course of the therapy, the client will be encouraged to engage in behavioural experiments so to determine what works and what does not. This offers the client an opportunity to evaluate their own belief and to consider alternative cognitive behaviours to take outside of the therapy.

Existential vs Cognitive-Behavioural Approach

Fear and sadness, respectively an extension of anxiety and depression, are interpreted differently by each approach. Kierkegaard saw anxiety as the price to pay for freedom and Martin Heidegger described it as a fundamental feature of human existence (as cited in Langdridge, 2016). Furthermore, Langdridge (2016) goes on to explain that existential psychotherapy sees fear as a form of anxiety, better understood as a universal aspect of existence rather than a diagnosis (Langdridge, 2016). Similarly, sadness and depression are interpreted in the existential approach, as a consequence of a person’s restricted understanding of the world and thus unable to be truly free. Eugene Minkowski proposed that depression is the manifestation of an unfulfilled or unrealised potential leading to existential guilt. This notion leads to entrenched beliefs which, in turn, work towards reinforcing it. Thus, the phenomenological method helps identify which aspects of the world are being ignored and which are instead being embraced. Whereas in CBT, fear and anxiety are viewed within a cognitive framework, where meaning is attached to what is happening and thus, can be changed by proposing alternative ways of thinking. Similarly, sadness and depression are also viewed as problems to be tackled by behavioural experimentation: a process aimed at breaking the pattern of behaviour that leads to the reinforcement of the psychological problem. Both approaches acknowledge the vicious cycle of negative thought and offer different ways to counter it. As described above, breaking from traditional psychoanalysis, both approaches are not preoccupied with the past in their treatment methods, but instead focus on how to empower the individual to move forward. Albeit in different ways, they both aim at an awareness of the client of how things are so that to help understand how the world works. Existential therapy seeks to help the client by raising self-awareness as a means to cope with the inevitability of existence. CBT, on the other hand, is more concerned with the attributed meaning of events, finding ways to challenge preconceived beliefs in order to alter the self-reinforcing pattern of negative behaviour. In the methodology of existential therapy, all events are dealt with as equally important whereas in CBT the focus is on the most recent occurrence of the problem that is to be resolved. Both approaches aim at empowering the client to choose their own path, thus both approaches can be said to be neither directive nor non-directive but rather directional. Critically, however, CBT is an evidence-based approach where behavioural experiments play a key role during the therapeutic process; on the other hand, existential therapy, although based on a significant body of work, lacks empirical evidence and does not offer reliable methods of quantifying progress during the process. Moreover, the existential approach to therapy relies heavily on the ability of counsellors and their knowledge with a considerable intellectual toll, as philosophical ideas must continuously be engaged with, outside of the therapeutic sessions and developed to fit the client’s needs during the process (Langdridge, 2016). Both approaches do require a level of high engagement with the client, as in both cases the process is based strongly on a relationship built upon trust and understanding. A criticism that both approaches face is the risk that such therapy may resolve in worsening the condition of the client, as the process can potentially feed the pre-conceived notion and negative thought into the intrusive pattern which leads to the psychological problem.

Conclusion

In conclusion, an evidence-based approach is, in my opinion, more equipped, than one lacking empirical evidence on its benefits, to understand how to better deal with fear, sadness, anxiety and depression. Although, there are undeniable merits to the existential approach to therapy, such as when assisting terminally ill patients (Spiegel, 2015), it may lack day-to-day practicality when dealing with issues that a client suffering from anxiety or depression encounters, as it appears too abstract in its interpretation. Furthermore, there is evidence that CBT does alter brain connectivity over time (Liam Mason, et. al 2017). Also, CBT has been proven to be an effective method of treating phobias via the method of graded exposure (Salkovskis, 2016). It is indeed due to the growing amount of empirical evidence that CBT is rapidly evolving, making it an increasingly effective treatment alternative to a pharmacological approach (Kathryn McHugh, et. al 2013). Moreover, it is worth noting that neither approaches are set in stone nor are their methods definitive. Both existential therapy and cognitive-behavioural therapy are still evolving, often one borrowing ideas from another. As discussed, Freud’s psychoanalyst approach was unsatisfactory for the 21st century, leading to the emergence of alternative therapies and approaches, such as the humanist and the more recent mindfulness approach. The tools and technology available to contemporary research are helping, now more than ever to determine which is more effective, but not necessarily excluding one over the other. In my opinion, cognitive-behavioural therapy is a more effective approach because of its roots in the scientific method as well as the growing evidence of its effect on the wiring of the brain, thus leading me to conclude that it is a more efficacious approach in understanding fear and sadness.

References

Beck, A. T. (1976). “Cognitive Therapy and the Emotional Disorders”. New Yotk: International Universities press.

Langdridge, D. (2016). Existential Psychotherapy. In T. O. University, Understanding Counselling and Psychotherapy (pp. 125-143). London: The Open University.

Mason, L. Peters, E.Williams, S.C. and Kumari, V. (2017). “Brain connectivity changes occurring following cognitive”. Translational Psychiatry, 7. doi:doi:10.1038/tp.2016.263. Online, accessed on January 28, 2017. Available at http://www.nature.com/tp/journal/v7/n1/full/tp2016263a.html#aff2

Kathryn McHugh, R. Sarah W. Whitton, Ph.D., Andrew D. Peckham, B.A., Jeffrey A. Welge, Ph.D., and Michael W. Otto, Ph.D (2013). “Patient Preference for Psychological vs. Pharmacological Treatment of Psychiatric Disorders: A Meta-Analytic Review”. The Journal of Clinical Psychiatry, 74(6), 595-602. doi:10.4088/JCP.12r07757. Online, accessed on January 28, 2017. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156137/

Salkovskis, P. M. (2016). Cognitive-Behavioural Therapy. In The Open University, “Understanding Counselling and Psychotherapy” (pp. 145-166). London: The Open University.

Spiegel, D. (2015). “Existential Psychotherapy for Patients”. JOURNAL OF CLINICAL ONCOLOGY, 33(24). Online, Accessed on January 28, 2017, from http://ascopubs.org/doi/pdf/10.1200/JCO.2015.62.2365

Stanford University. (2016, July). “Søren Kierkegaard”. Online, accessed on January 28, 2017, from Stanford Encyclopedia of Philosophy: https://plato.stanford.edu/entries/kierkegaard/

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