When addressing mental health, therapists often find themselves at the crossroads of human experience, confronting not just the symptoms of disorders but the existential realities that underpin them. From feelings of isolation to grappling with life and death decisions, clients bring a range of profound concerns to their therapy sessions.
A new study by Frediani and team at KU Leuven, Belgium, reveals how clinicians engage with these existential themes, uncovering the nuances of therapeutic encounters that go beyond traditional diagnostic frameworks.
This qualitative study, conducted with Belgian mental health clinicians, offers a groundbreaking perspective on the therapist-client dynamic. It focuses on how therapists relate to and process existential themes – ranging from the meaning of life and death to issues of identity and freedom – within the therapeutic context. The research highlights the need for clinicians to be deeply attuned to these existential aspects, suggesting that an effective therapeutic relationship requires an openness to these profound human experiences. As mental health care continues to evolve, this study points towards the importance of integrating existential approaches into clinical practice, ensuring that therapy addresses not just the symptoms but the existential underpinnings of mental well-being.
The researchers explain:
“Questions about the meaning of life and how to cope with finiteness and overwhelming experiences tend to fascinate people. This quest for answers has given birth to fields such as religion, philosophy, and humanistic and existential psychology. However, people are not always keen to be fully aware of the width and depth of their existence. A sudden rise in existential awareness can be a disruptive experience. It can be induced by limit situations such as traumatic experiences and can be accompanied by a loss of meaning, anxiety, and despair. However, existential awareness can also be triggered by peak experiences, exceptional positive life experiences, and awe.”
The authors described the ways in which people can problematically relate to existential reality, compromising their health and well-being and bringing them into therapy or counseling. For many people, expanded existential awareness can be distressing, such as experiencing death anxiety or having to search for meaning in life. Being unable to accept life’s existential givens can lead to conditions such as someone’s existential indifference to their lack of a meaningful life and poor psychological well-being or existential guilt for not living an authentic life.
When people discuss their mental health with a therapist, they may mention feeling sad or depressed, though such symptoms may arise from feeling isolated from other people and experiencing difficulties making meaningful connections with others. When making difficult life decisions talk to their counselor, people may struggle with questions about life and death that leave them distressed and overwhelmed.
In this study, clinical psychology researchers from KU Leuven, Belgium, led by Giana Frediani, studied mental health clinicians’ experiences with encountering clients’ existential concerns. Their results, published in Person-Centered & Experiential Psychotherapies, show that existential issues are a prominent and pervasive presence in clinicians’ care of their clients. To notice existential elements of clients’ experiences and to effectively be present with clients’ existential concerns, mental health clinicians need to be more attuned to these concerns.
This qualitative study aimed to explore the existential themes encountered by mental health clinicians in their clinical work, their attitudes, and interventions used to address their clients’ existential concerns, as well as their personal processing of existential material as therapists and people who share their humanity in common.
The researchers conducted this study with two groups of Belgian mental health clinicians.
- The participants in the first study were nine experienced humanistic therapists with varying levels of training in existential approaches who worked in private practice, public mental health clinics, and hospitals.
- The second study group comprised ten clinicians from various disciplines who provided counseling to couples considering pregnancy termination and were therefore very close to existential issues arising in their work.
The research team was composed of two therapists with a background in existential psychotherapy who were more attuned to existential phenomena in the analysis of participants’ interviews. Two psychology graduate students with no training or experience in existential approaches also interviewed participants and analyzed the data. Their presence was argued to counter possible biases of the more seasoned therapists’ description and interpretation of the data.
Each therapist participant was interviewed by one of the researchers about the existential themes they encountered in the session, how they dealt with them, their attitudes towards them, and the interventions they used to work with them. Participants were also asked how this had changed over the course of their careers and whether it influenced their existential reckoning. Audio recordings from the interviews were transcribed in Dutch and analyzed using a consensual qualitative research (CQR) design.
To identify existential themes in the text, the researchers used Irving Yalom’s four existential givens: (1) death and boundaries of life; (2) freedom, choice, and responsibility; (3) connection and isolation; and (4) meaning and meaninglessness. Identity, another domain of existential givens, was added based on recent research in existential psychology.
Researchers first independently analyzed the interview text, deductively sorted the interview text into these five domains, and then, using a consensus process, the researchers came together to determine core ideas among team members. The frequency of various categories of existential phenomena was counted to determine how typical these themes were across the interviews.
To improve the credibility and dependability of the study findings, the researchers had external auditors check the clarity, coherence, consistency, and completeness of the coding systems and provide feedback to the research team. The researchers also sent the findings to all 19 participants to provide feedback as a member check.
From these two studies, a meta-synthesis was completed by the first author, which compared the coding systems of these two groups of clinicians. While all clinicians frequently dealt with existential themes in treatment, they differed in their level of training and preparation in existential approaches to therapy and counseling. Existential themes emerged from the data analysis that did not fit the initial domains, which led researchers to inductively create new domains related to the way therapists relate to existential themes in therapy and their personal processes concerning these themes.
From this analysis, the researchers identified the existential themes of therapy, how the clinicians were relating to their client’s existential concerns, and how their work on these issues affected them. As part of the theme of death and boundaries of life, clinician participants discussed:
- How the finality of life showed up for their clients in sessions both in a literal sense (e.g., suicidal thoughts) and implicitly in attempting to avoid death anxiety. For counselor participants working in pregnancy termination care, the significance of death was most tied to helping clients reckon with the loss of pregnancy.
- Boundaries of life were often confronted with participants’ clinical work, as clients dealt with their own limitations and with the limitations of the therapist.
- The meaning of life and death was a recurrent theme in sessions across therapists, but with pregnancy termination counselors, the theme of what counts as life was especially poignant.
Existential themes of freedom, choice, and responsibility were common, as clients were described by participants as:
- In the process of choosing freedom while necessarily dealing with responsibility.
- For pregnancy termination counselors, deciding about life and death was a typical theme, as clients made heavy decisions about whether their unborn child should live or die.
- Many seasoned humanistic therapists noted how their clients experienced feeling a sense of agency, or a lack thereof, and how it impacted their treatment.
- Clinicians from both studies mentioned grappling with their responsibility in therapy with clients, sometimes countering notions about clients’ passive role and therapists’ active use of interventions.
Connection and isolation were a set of major existential themes that clinicians saw manifested quite frequently, such as:
- Clients’ loneliness manifested in a lack of social support, with participants referring to rare occasions of clients bringing up more fundamental existential isolation of realizing one must die alone.
- Only one stance across all participants was recounted in which a client discussed their relation to the self as estranged.
- However, participants described how their clients relate to others in increasingly meaningful ways as treatment progressed, from clients’ families and friends to the therapeutic relationship.
Participants reported often reflecting with clients about experiencing meaning in life, including:
- Clients’ loss of previously held worldviews as they came to realize the uncertainty of life. Seasoned humanistic therapists described many of their clients’ difficulties finding meaning.
- Clinicians across the two studies discussed clients’ reflections on the source of meaning in life and often mentioned spiritual and religious sentiments.
- Identity was brought up by a few participants when clients felt they were losing who they were and had to re-examine their life path.
As healthcare professionals, participants related to the existential themes their clients brought up, as researchers noted that:
“…nearly all participants from both studies underlined the importance of a supportive work environment and other kinds of connection. A warm work environment helps them to share experiences with colleagues. Supervision, intervision, and training were also mentioned as important supportive factors. In addition to colleagues, also friends and family members are, for certain participants, an important resource. Other supportive factors that were mentioned were: receiving enough time for sessions, self-care, and spending time to connect to what energizes them.”
In responding to clients’ existential concerns effectively, participants frequently mentioned:
- Their need for existential openness and empathy to effectively engage with their client’s existential concerns, stay present and resonate with them rather than try to change.
- Over time, they took a milder stance towards life and were grateful to share in their clients’ existential journey, letting go of their simplistic and judgmental notions of people’s life paths.
- Seasoned humanistic therapists reported feeling a sense of powerlessness when relating to clients’ existential struggles that had them questioning themselves.
When discussing specific therapeutic interventions, clinician participants from both studies mentioned:
- Active exploration with clients of existential themes and their experiences of coming up in treatment without trying to find a solution.
- Frequent use of validation to communicate that clients’ existential struggles were relatable and made sense.
- Pregnancy termination counselors occasionally used reframing to help clients view their existential concerns from another perspective.
Participants reflected on how their work with existential concerns affected them, saying they became aware of existential themes in their work more generally. This had them reflect more on how they played out in their personal lives, as well as being more conscious of when existential themes came up in therapy across clients. Working with clients’ existential themes in therapy also made participants live more consciously, being more in tune with the essence of existence and cherishing happy experiences in life that they felt enriched as people.
They also reported relating differently to existential themes as clinicians. Earlier in their career, they often had difficulty tolerating their clients’ existential struggles and moved quickly to problem-solving. However, over time they learned to be more present with their clients around these concerns. Some participants noticed that working with existential themes gave them more nuanced views on life matters and developed more complex understandings, especially for participants working with clients considering pregnancy termination.
This qualitative study laid out the various ways existential concerns play out in therapy and how these different clinician participants responded to them. Participants found existential themes to be ubiquitous within their clinical work, and that learning to effectively be present with clients’ existential concerns was contingent on their own ability to acknowledge their shared existential reality.
The value of such deductive research is to gather data through examples from clinical work that grounds theories of existential psychology. However, due to the amount of research being covered in the article, there is little room for expansion, with usually two, but more commonly, just one quote demonstrating any domain.
A deductive approach to research restricts what researchers perceive in data. Much of the findings confirm existing theories, so this analysis is arguably cyclical in that many of the participants would already be familiar with Yalom’s writings. While there was an inductive analysis done to clarify some of the domains, its utility as an exploratory method may not be as well-developed as if the study was more inductively driven from the beginning. The authors also caution regarding the generalizability of the study to other mental health clinicians:
“The findings of this study need to be understood within the context of experienced Belgian therapists and counselors, mostly female, mostly humanistic-experiential and existential in theoretical orientation, and mostly trained as psychologists.”
The authors did not provide much direction for future research. However, researchers could use more exploratory methods, such as grounded theory, to explore how mental health clinicians handle existential concerns both in and out of session and generate findings that help them effectively navigate existential themes in treatment with their clients.
If addressing existential concerns is important for mental health, therapists need to be able to work effectively with their clients on these issues. Therapists must understand the relevant existential concerns that people face and know how to interact with others who are acutely experiencing these existential realities. This requires therapists to acknowledge that they share these realities with their clients and to allow themselves to be open to them.
Patients have expressed the importance of therapists’ presence in treatment. Researchers have also demonstrated that the bond between the therapist and patient is a crucial element in treatment that helps patients find meaning in life, which is linked to higher levels of well-being and cognitive functioning.
The findings from this study, along with other research, provide evidence for the importance of training in existential approaches to psychotherapy to help clinicians work more effectively with existential concerns. However, therapists’ inadequacies in dealing with patients’ existential concerns can be addressed through fields such as clinical psychology embracing existentialism.
The study also raises critical questions about how existentially minded mental health services could be delivered in healthcare systems that have often failed to be person-centered. Research using intersectional approaches should study the systemic barriers that keep these vital concerns of mental health from being more fully acknowledged and addressed in psychotherapy and counseling. Previous research has shown a prevailing biomedical discourse in psychiatry, though many alternative models in psychiatry attempt to grapple with these structural issues.
A more compassionate and holistic approach to mental health ensures individuals grappling with existential concerns find solace and support in therapeutic spaces and helps foster genuine and meaningful human connections. Incorporating a more nuanced, existentially-aware approach within mental health services paves the way for future studies and enhancements in clinical practices.
In conclusion, this study demonstrates the profound and pervasive impact of existential concerns in the realm of mental health, underscoring the need for clinicians to navigate these concerns with sensitivity and attunement. This requires a deeper understanding of existential realities that are essential for effective therapeutic interventions with clinicians and clients embarking on a collective journey toward meaning, connection, and healing.
Frediani, G., Krieckemans, L., Seijnaeve, A., & Vanhooren, S. (2022). Engaging with the client’s existential concerns: The impact on therapists and counselors. Person-Centered & Experiential Psychotherapies, 1–20. https://doi.org/10.1080/14779757.2022.2133000 (Link)