Keywords

In anxiety one feels ‘uncanny’ Here the peculiar indefiniteness of that which Dasein finds itself alongside in anxiety, comes proximally to expression ‘the nothing and the nowhere’. But here ‘uncanniness’ also means ‘not-being-at-home’. (Heidegger, 1962, p. 233)

1 CBT and Existentialism: An Uncanny Relationship?

Can existentialism, or existential thinking (a broader term I use to encompass existential philosophy as well as existential therapy), be said to have a ‘home’ in contemporary CBT? Or is it more accurate to suggest that CBT has, as one of its original homes, existential philosophy? For some, the juxtaposition of CBT and existential thinking may itself appear ‘uncanny’ and disorienting as they represent fundamentally different and opposed ways of understanding human experience and psychological distress. Much of course depends upon how one defines and delineates the nature of ‘existentialism’ and ‘CBT’. Both of these terms are in their own ways contested and unclear. Can it be said that CBT exists? It is often noted that CBT is in fact not a unitary school unless a stance is taken to limit the definition of CBT to include only a set range of perspectives, research projects, commitments and practices.

Salkovskis (2002), surveying the development of the field, defined CBT as ‘a set of empirically grounded interventions’. This definition would initially seem to imply that CBT is essentially a set of ‘tools’ that are ready to hand and are primarily to be thought about in terms of whether they are good tools, appropriate for some tasks and not others, depending also on the skilfulness of the person wielding the tool. This would also seem to indicate that the foundation stone for CBT therapists is the empirical method itself (which is of course also in need of clarification and by no means anywhere a settled issue). So, for example, even if CBT therapists may adopt different positions regarding the direct causal role of cognition in psychopathology, they would nevertheless agree on how such questions should be approached through the experimental method. However, CBT as a whole does not endorse the idea that it can be defined principally in terms of techniques and the extent to which they are empirically supported. Beck et al. (1979), Clark (1995) and Salkovskis (2002) have strongly argued that it is not possible to define Cognitive Behavioural Therapy simply in terms of its technical interventions. Rather, a wide range of interventions can be employed to the extent that these interventions make sense in terms of the CBT model. That is, it is the conceptual and theoretical aspects of the cognitive behavioural model, which remain contested and subject to debate, that define it. It follows from this that any consideration of the relationship between existentialism and CBT cannot simply be at the level of techniques, as in ‘are there technical procedures that may be employed to address existential issues in CBT’ (although this is of course not irrelevant). The relationship between CBT and existentialism must also be explored at a conceptual, theoretical and indeed philosophical level.

And what of existential philosophy and existential psychotherapy? As the previous chapter demonstrated, while ‘existentialism’ is clearly identifiable as one of the most important and influential philosophical movements of the twentieth century, its defining features and key arguments have always been subject to heated division, debate and revision (Cooper, 1999). Indeed, if one were to imagine all the key existential thinkers were able to meet together in one place, a café perhaps, to discuss their thinking, most likely, the one thing that they would each agree on is that all the others present in the room have substantially misunderstood and misrepresented the views being presented.

CBT therapists, seeking to gain inspiration or guidance from existential philosophy, also need to contend with the fact that there are already a substantial number of ‘existential psychotherapies’ (Cooper, 2003). These have ranged from approaches that have worked out the therapeutic implications arising from the work of a single philosopher, such as the work of Medard Boss who developed ‘Daseinsanalysis’ with the direct collaboration of Martin Heidegger (Boss, 1963) to those approaches that draw inspiration from a diverse range of existential philosophers (see, for example, van Deurzen et al., 2019). It is also the case that existential philosophy has had considerable impact across a diverse range of psychotherapies. This includes a wide range of humanistic psychotherapies and existential-humanistic psychotherapies (Schneider, 2008), as well as forms of psychoanalysis that have attempted to rework fundamental psychoanalytic ideas such as the unconscious and transference through the lens of existential philosophy (Stolorow et al., 2002). All of these forms of inspiration and integration are themselves subject to controversy and critique. Currently, there exists no widely held agreement as to what constitutes an appropriate or indeed ‘authentic’ application, or thinking through of the implications, of existential philosophy for therapeutic practice.

2 Existential Issues Versus Existential-Phenomenological Thinking

The most straightforward and accessible discussion of existential philosophy and its relevance to and place in CBT would be one that highlights a range of ‘existential issues’ and topics and explores how CBT therapists, and CBT as a model, might incorporate or address these issues. In this regard, the work of Yalom (1980) is highly useful in that he has identified four such ‘fundamental existential concerns’ and clearly demonstrates how a wide range of clinical and experimental evidence supports the role of these concerns in different forms of psychological distress as well as the practice of therapy. The four existential issues that Yalom identifies are death, meaninglessness, isolation and freedom. Each of these themes and concerns can indeed be found in a range of existential philosophies. Equally, as potential ‘transdiagnostic’ issues, each of these themes lends themselves quite readily to a range of CBT conceptualisations and interventions. ‘Death’, for example, or at least ‘fear of death’ and ‘death anxiety’ can be a legitimate focus for CBT and may substantially enrich CBT practice. There is in fact a very substantial range of empirical literature to support the notion that concerns around death feature very heavily in differing forms of psychopathology and that there may be CBT-specific forms of intervention that can usefully address this (see Menzies et al., 2018, as well as chapters in the present volume). Equally of course, these concerns lend themselves to forms of analysis and interventions arising from a wide range of different theoretical perspectives including the humanistic and psychoanalytic. Issues around death, and indeed the hypothesis of a ‘death drive’, are featured prominently in Psychoanalysis (Freud, 1920/2003).

Arguably, taking such a ‘thematic’ focus to existential issues, while legitimate and potentially highly productive, constitutes only the most superficial engagement with existential thinking. Why might this be so? While Yalom’s (1980) discussion is original, engaging and useful, it remains the case that there are a wide range of other existential issues and concerns that can be presented as equally primary but have somehow not made it onto this list of ‘the big four’. To identify an issue or concern as being ‘existential’ is to suggest that this issue is in some way rooted in, and an expression of, some fundamental ‘given’ aspect of what it means to be human. The issue is somehow essential, unavoidable and constitutive of human existence itself. Without it, human existence would not be what it is. Additionally, and unfashionably, to identify an issue or factor as existential is to argue that this is in some way universal and that it finds expression and can be discerned cross-culturally and across time.

3 Identifying the ‘Existentials’

The range of relevant existential ‘givens’ can in fact be seen to be quite wide, and what should and should not be included in any such description is a subject for debate. Medard Boss (1963), for example, based upon the work of Martin Heidegger, has argued that our ‘dreaming existence’ is a fundamental aspect of what it is to be a human being. In a manner that CBT therapists may initially find difficult to appreciate, Boss describes our experience of dreaming as in a sense ‘equal’ to, although different from, our waking existence. To be human, for Boss, is to live in dreaming and to be in the world through and as dreaming. Additionally, Boss (1963) discusses how human existence is always fundamentally an embodied existence. Embodiment, existence through ‘being-a-body’, is so fundamental that it is difficult to appreciate the emphasis on death awareness and death anxiety other than through an appreciation of the fundamentally embodied nature of human existence. In addition, drawing on Heidegger, Boss argues that human existence is always characterised by some ‘mood’. Human beings are said to be ‘attuned’ to the world via mood as an ‘atmosphere’ that, rather than being seen as simply the outcome of cognitive processing, is fundamental to the way human existence reveals the world itself. The most fundamental of moods for existential philosophers is that of anxiety. Existential anxiety is in this sense basic to human existence, and we are anxiety. Existential anxiety reveals human existence as always ‘open’, ‘unfinished’ and as always a being-towards-death (Heidegger, 1962). Additionally, human existence is seen as inevitably always ‘guilty’. Rather than this indicating some form of moral lapse or sin, existential guilt refers to the fact that, as limited beings, we are always already ‘behind’ our possibilities for being. Any choice we make, and we are always inevitably making such choices, involves an implicit or explicit ‘no’ and letting go of other known and unknown possibilities for being.

A further addition to this list of ‘existential givens’ is suggested by the existential therapist Hans Cohn (2002) who has convincingly argued that sexuality is fundamental to human existence. Sexuality is existential in the sense that each human being responds to and takes up a stance towards the ‘possibilities of being sexual’ and that this stance is an expression of their manner of relating to self, others and world. Existential sexuality is a primary means of relating to and revealing a world.

4 Existential Uncertainty

Spinelli (2015), in his original take on existential psychotherapy, has suggested that one of the most central existential concerns, or rather ‘principles’ to arise from existential-phenomenological philosophy, is that of ‘uncertainty’. This emphasis on ‘principles’ is important as it suggests that many of the themes and dimensions discussed above will also be seen to be expressions of and to include a ‘reference to’ such principles. Existential guilt, for example, can only be fully understood to the extent that this expresses a response to, and is revealing of, existential uncertainty. According to Spinelli (2015), the principle of existential uncertainty asserts that:

I can never fully determine with complete and final certainty or control not only what will present itself as a stimulus to my experience, but also how I will experience and respond to stimuli. An immediate consequence of this stance is that even how I will experience myself under differing stimulus conditions cannot be predetermined. (2015, p. 22, emphasis in original)

At the same time, the principle of uncertainty is also contextualised by the fact that human existence is always, using Heidegger’s language ‘thrown’, that is, that human beings ‘always already’ find themselves in a context and situations over which they exert little control and yet must in some way respond to. Such contextual givens such as racism, inequality and the vagaries of a global pandemic provide the background conditions from within which the principle of uncertainty arises. The principle of uncertainty in existential phenomenology also reveals itself to be paradoxical in that any statement such as ‘all is uncertain’ reveals itself as a statement of certainty (Spinelli, 2015). Thus, rather than a fixed position of the certainty of uncertainty, existential phenomenology challenges us to consider the uncertainty of certainty and the uncertainty of uncertainty. In regard to the latter possibility, this would, for example, encourage a CBT therapist to consider each new instance of ‘a client presenting with panic attacks and thus appropriate for treatment X with manual Y’ as potentially novel, unpredictable and uncertain. The manual need not necessarily be thrown away as an inauthentic expression of certainty, but rather, the question becomes, What new uncertainties may be revealed by the attempt to understand how the manual and model both throws light upon and obscures the client’s experience of problems in living that have been described as ‘panic attacks’?

Recently, CBT therapists who have turned their attention to the task of identifying ‘transdiagnostic factors’ have argued that ‘intolerance for uncertainty’ is potentially one of the most significant factors implicated in a range of different forms of psychological distress. McEvoy and Erceg-Hurn (2016) have argued that intolerance for uncertainty may constitute both an important transdiagnostic factor and a ‘trans-therapy’ factor. That is, intolerance for uncertainty may be a key factor that is altered by a range of differing therapies even when this is not an explicit target of those therapies. As such, they consider it to be a potential ‘universal process’.

5 Existential Relatedness

As Spinelli (2015) has argued, possibly the most foundational principle of existential phenomenology is the principle of ‘existential relatedness’. This is also, unfortunately, the principle that is the most difficult to grasp and keep hold of due to the extent to which it challenges typical Western assumptions that can most certainly be seen to be present in most forms of psychological practice including CBT. Martin Heidegger’s (1962) expression ‘being-in-the-world’ attempted to express this fundamental relational nature of human existence. This is also elaborated as ‘Dasein’, which describes the nature of human being as ‘being-there’ or alternatively ‘the “there” where being reveals itself’. Unfortunately, despite the use of hyphens that are intended to express the extent to which being and world are a unitary phenomenon, it can be so easy to read this expression as indicating the existence of two separate aspects ‘being’ and ‘world’ that somehow enter into or create a relationship.

In much psychology, based as it is on a ‘Cartesian’ perspective that separates subject from object and ‘inner’ from ‘outer’, and certainly in much CBT, there are a range of apparent ‘splits’. Consider the distinctions between cognition and behaviour or cognition and emotion or indeed between ‘situation’ and ‘response’. Related distinctions can be identified in terms of body and mind, self and other, and ‘cognitive representation’ and ‘outer reality’. The existential-phenomenological principle of relatedness can be seen to challenge each of these apparent separatist distinctions and to instead propose that while we may indeed experience and report upon seemingly more isolated phenomena such as ‘my self’, ‘my freedom’, ‘my body’ and so forth, each of these more subjectively grounded descriptions in fact emerge from a more foundational relatedness. It is more existentially adequate to speak of ‘body-mind’ and ‘lifeworld’. Thus, issues and dilemmas such as ‘freedom’ and ‘choice’ cannot be adequately considered from the more typical individualistic and separatist position or must at least be considered as highly limiting.

A typical misunderstanding of existential thinking is that it emphasises the primacy of the ‘lone individual’, isolated in their own inner emotional experience, condemned to create their own individual and unique life project in the face of the absurdities of existence. Such a view can of course be found but must be contextualised within a more thoroughly relational perspective. In such a perspective, the experience of an individual unique self is seen as an outcome of relatedness, and each existential choice can be seen as implicating others and the world and as having unpredictable and uncertain consequences for others and the world. Thus Yalom’s (1980) emphasis on isolation could be more adequately understood as a polarity with ‘being-with-others’ on one end and ‘isolation’ on the other. The following quote from Merleau-Ponty serves well to express this central principle of relatedness:

True reflection presents me to myself not as idle and inaccessible subjectivity, but as identical with my presence in the world as to others, as I am now realising it: I am all that I see, I am an intersubjective field, not despite my body and historical situation, but, on the contrary, by being this body and this situation, and through them, all the rest. (As quoted in Friedman, 1964, p. 201)

The principle of existential relatedness can be seen as having many radical consequences for the practice of therapy, and any consideration of the place of existential thinking in CBT needs to grapple with such consequences. Existential thinking, therefore, is not identifiable by its specific focus on themes such as death, meaning, isolation and freedom, but rather, that such concerns are explored in terms of their grounding in relatedness.

6 The ‘Way’ of Existential Thinking: Phenomenology

In the sections above, I have attempted to show that while it is a valid undertaking to identify and explore a range of existential issues such as death, meaninglessness, isolation and freedom, there is nothing uniquely existential about any exploration that considers these themes. I have also briefly shown that each of these themes needs to be more thoroughly contextualised within the existential-phenomenological notions of relatedness and uncertainty. Prior to considering what place such ideas might have in CBT, it is also necessary to briefly consider the particular method and stance that existential thinkers such as Heidegger, Sartre and Merleau-Ponty adopted in order to approach such issues. This concerns the philosophy and method of ‘phenomenology’.

Phenomenology can be considered primarily as a way of doing philosophy rather than a set and agreed-upon philosophical system. It is a practice and a way of exploring and describing experience. The term ‘phenomena’ is understood as ‘that which appears’, and as such, phenomenology becomes the exploration and description of ‘what appears in the way that it appears’ (Moran, 2000).

Spinelli (2015) has described the phenomenological method in terms of three overlapping and interdependent phases or steps. A phenomenological investigation of any phenomena, such as the experience of ‘being anxious’, or ‘being depressed about the economy’, involves the following interdependent overlapping steps:

  1. 1.

    The phenomenological reduction: Here, the researcher, philosopher or therapist is required to identify and to make an attempt to set aside any preconceptions, personal biases or theoretically based views regarding the nature of the phenomena under investigation. This includes hypotheses about causal factors involved in its generation or maintenance. This step is often regarded as the most challenging aspect of the method as frequently, assumptions and preconceptions remain unreflected upon. The task of the reduction remains an attempt at introducing an unusual degree of experiential openness to whatever arises, not unlike some descriptions of mindfulness. In therapy, this step requires of the therapist a willingness to set aside any notions of being a ‘change agent’ or ‘educator’ in favour of a stance that attempts to ‘stay with’ the lived experience of the client as it reveals itself in the immediacy of the therapeutic conversation. If there is something that can be said to express a degree of ‘competence’ here, it is this very willingness and ability to stay present and open to the client’s experience as well as the experience of the therapist as they attempt this unusual form of intense listening, seeing and sensing.

  2. 2.

    The rule of description: The second step can be summarised as ‘describe don’t explain’. The therapist or investigator is encouraged to attempt a descriptive clarification of the phenomena under investigation: How is ‘being anxious’ experienced? What does it entail? How is this experienced bodily and within the world? Again, these descriptions should be as free of ‘causal scientific hypotheses’ as possible.

  3. 3.

    The rule of ‘equalisation’: In this final step, the investigator or therapist is required to avoid placing any ‘hierarchies of significance’ on the descriptions that were obtained. Thus, a client’s reports of a sense of ‘feeling small and insignificant’ or ‘like my heart will explode’ or that ‘the space between my door and the stairs seems infinite and uncrossable’ are each regarded as potentially equal in their meaningfulness and relationship to the phenomena of being anxious.

The descriptive phenomenological method presents itself as a clear alternative to the typical hypothesis testing approach of CBT whose intent is often to construct a causal model to explain the development and maintenance of a psychological problem. Nevertheless, a number of CBT-oriented researchers have seen in the phenomenological method a useful tool that has potential in the training of CBT therapists, particularly in regard to all frequent temptation to ‘jump to conclusions’ regarding the nature of a client’s difficulties (O’Conner, 2015).

In summary, it has been argued above that existential thinking and existential phenomenology present CBT therapists with a significantly expanded and deepened description of ‘what it means to be human’. It raises issues such as death, meaninglessness, isolation and freedom but does so in a novel way that seeks to highlight the irreducibly relational and contextual basis of human experience and existence. Existential thinkers have argued that such issues are best approached from a phenomenological perspective, and this perspective is one that makes unique demands on the therapist or investigator, which in large part rest upon the willingness to ‘let go of’ much of the theoretically derived assumptions regarding ‘what it means to be a therapist’. In what way can these ideas and perspectives have any place within a CBT that presents itself as the project of developing a scientific understanding of human distress and the practice of therapy? In the sections that follow, I outline a variety of ways in which different versions of CBT have both points of contact as well as points of divergence with some of the existential principles and methods described above.

7 Standard ‘Beckian’ CBT and Existential Thinking

One does not need to dig too deep in order to find clear evidence of a place for existential thinking in what might be regarded as ‘standard’ Beckian CBT. In what might be regarded as the foundational CBT text, Beck and his colleagues acknowledge the influence of the existential and phenomenological philosophies of Heidegger and Husserl as well as the contributions of the phenomenological studies of Jaspers, Binswanger and Strauss (Beck et al., 1979). More recently, Clark et al. (1999) have stated that the philosophical perspective that most clearly is in tune with and captures the central concerns of CBT is existential phenomenology. Moss (1992), writing from a more traditional existential therapy perspective, has argued that Beck and other cognitive therapists have effectively given a greater degree of respectability and legitimacy to existential ideas and have succeeded in ‘smuggling’ insights from existential phenomenology into the respectable halls of academia via the ‘back door’.

A strong case can be made that Beck and his colleagues are correct when they seek to characterise CBT as being consistent with existential phenomenology. The focus on forms of meaning that are in principle directly accessible by the therapist and client alike, as opposed to an emphasis upon the role of the therapist as ‘interpreter’ of the client’s statements in terms of hypothesised ‘underlying’ or ‘unconscious’ factors, provides a clear point of contact between CBT and existential psychology. Beck’s description of a cognitive triad of self-world-future also seems consistent with a range of existentially derived analyses regarding the centrality of meaning. Beck’s description of the process of ‘guided discovery’ could also be interpreted as a form of structured phenomenological exploration. Therapist questions that arise from a guided discovery standpoint are those that ‘stay close’ to the client’s experience but may direct their attention to aspects of this experience that they are not currently attending to in order to widen the client’s perspective. If Beck’s cognitive therapy is presented as a framework for the therapeutic exploration of meaning, it could also be easily argued that many of the thematic focus points of existential phenomenology, death, isolation, freedom, choice and meaning, are a legitimate topic for CBT therapists to the extent that these themes present themselves in clinical work. Indeed, the recent contributions of ‘experimental existential psychology’ (Greenberg et al., 2004) that have presented quantitative data that support the hypothesised role of ‘death anxiety and defences’, for example, may provide substantial support for CBT therapists to consider the role of these existential themes.

In addition, the so-called ‘disorder-specific’ models of CBT that have focussed on identifying the specific cognitive content and processes maintaining specific difficulties can also be read as highly informative, phenomenologically rich and clinically helpful analyses of the manner in which the clients presenting problems are in fact best thought of as their ‘attempted solutions’ to universally experienced aspects of existence such as anxiety.

The work of Robert Leahy (2015), which represents a further elaboration of an essentially Beckian CBT perspective, has drawn explicitly on existential philosophy and has sought to highlight the more ‘tragic’ aspects of existence as well as the need for competent CBT therapists to develop the capacity to ‘stay with’ expressions of distress that arise from encounters with inevitable aspects of existence, such as death and loss, rather than attempting to ‘reconstruct’ the client’s cognitions.

Drawing directly on the philosophies of Heidegger and Sartre, Leahy suggests that:

individuals struggle with their freedom of choice, often having difficulty with the “given” that is arbitrarily part of their everyday lives, while recognising that the choices people face often involve dilemmas or tradeoffs that are emotionally difficult. Choice, freedom, regret, and even dread, are viewed as essential components of life in this model, and these “realities” cannot simply be eliminated by cost-benefit analysis, rationalization, or pragmatism. (2015, p. 10)

At the same time, however, there remain significant points of difference and potential conflict. Most significant is the reliance of standard Beckian CBT that can be described as a ‘correspondence theory of truth’ based upon assumptions of the separateness of cognition, emotion, behaviour and world (no matter how closely entwined and interactional these elements are regarded as being). The correspondence theory of truth holds that the truth of a client’s cognitive representations, which are in some way ‘internal’ and separate from the world, can be evaluated in terms of the degree to which they correspond with the way the world ‘really is’. That CBT, in its standard version, can be seen to embrace both a ‘rationalist’ stance, and a correspondence theory of truth can be clearly seen in the following quote that is from an article whose explicit purpose is to clarify perceived misconceptions regarding the CBT model:

Standard cognitive therapy is a structured, time-limited, problem-oriented psychotherapy aimed at modifying the faulty information processing activities evident in psychological disorders like depression... The therapist and patient collaborate to identify distorted cognitions, which are derived from maladaptive beliefs or assumptions. These cognitions and beliefs are subjected to logical analysis and empirical hypothesis testing which leads individuals to realign their thinking with reality. (Clark, 1995, p. 155)

Existential phenomenology, with its emphasis on the inherently relational nature of human existence, challenges the model of truth implicit in the above quotation. With it, the possibility of a therapist identifying and challenging distortions or errors in thinking is challenged as is the assumption that therapeutic encounters are primarily to be seen as forms of ‘treatment’ for identified psychological ‘disorders’. As noted above, the phenomenologically based perspective of existential thought suggests that therapists are more likely to gain a more adequate understanding of a client’s experience to the extent that they are able, initially at least, to ‘set aside’ notions of treatment or psychoeducation.

8 Schema Therapy: Working with the ‘Depths’ of Meaning

While the concept of ‘schema’ features clearly in standard CBT, the use of this concept has been considerably expanded by Young et al. (2003) and others who have developed ‘schema-focussed’ approaches that seek to understand client distress and change in terms of ‘deep’ cognitive structures that are often, in their content, clearly related to and expressive of fundamental existential issues.

Young et al. (2003) argues that traditional CBT assumes that clients will be able to directly change distorted cognitions and unhelpful behaviour through rational-logical strategies such as empirical analysis, logical discourse, gradual behavioural exposure tasks and experimentation. Young et al. (2003) argue that for many clients, this is not the case and that their distorted cognitions and behavioural patterns are highly resistant to change even after months of sustained intervention. Young et al. argue that for many such clients, their distorted cognitions and unhelpful behaviours are ego-syntonic, that is, they are experienced as central to the client’s identity and that ‘to give them up can seem like a form of death- a death of part of the self’ (2003, p. 4). This understanding of the uncertainty and potential losses associated with meaningful cognitive change is very much in tune with the perspective of existential phenomenology where individual’s ‘world views’, their beliefs, explicit and implicit are seen as in many ways expressive of efforts to cope with the given existence and to provide a degree of predictability and certainty in the face of inevitable uncertainty.

Young et al. (2003) has also suggested that the origin of schemas lies in the frustration of a number of core emotional needs in childhood. Such needs are seen by Young et al. (2003) as ‘universal’ aspects of human experience and development. These needs include:

  1. 1.

    Secure relationship attachments that provide safety, stability, nurturance and acceptance

  2. 2.

    Autonomy and sense of competence and individual identity

  3. 3.

    Freedom to express valid needs and emotions

  4. 4.

    Spontaneity and play

  5. 5.

    Realistic limits and self-control

Young et al. (2003) regard ‘schema healing’ as the ultimate goal of schema therapy. The process of schema healing, however, is seen as long and often arduous. They argue that individual will often resist the process of schema change as:

Patients resist giving up schemas because the schemas are central to their sense of identity. It is disruptive to give up a schema. The whole world tilts. In this light, resistance to therapy is a form of self-presentation, an attempt to hold onto a sense of control and inner coherence. To give up a schema is to relinquish knowledge of who one is and what the world is like. (2003, p. 32)

A number of features of the schema approaches seem to allow for a greater degree of appreciation for existential issues in a broadly CBT perspective. The focus on ‘deeper’ levels of meaning would appear to open up the possibility of working with more existential aspects of meaning and experience. Ottens and Hanna (1998) have argued for an integration of cognitive and existential perspectives on the basis of this shared, focused-upon meaning at a schematic level. These authors argue that many of the schemas identified by CBT theorists are inherently ‘existentially constituted’ as they refer to basic fundamental aspects of a client’s identity, essence and validity in the world. Indeed, it may be possible to identify explicitly existential schemas such as ‘my existence is wrong or should not be’, ‘my existence is a burden and is damaging to others’ and ‘my existence is vulnerable and not real’. Schema therapy also seems to express a greater appreciation for the dilemmas and challenges of change that is in tune with existential thinking. Any potential movement towards changing a schema, while it may open up greater and more positive possibilities, is also unpredictable in its implications. This perspective on change, that change is often a question of trade-offs and ‘workability’ rather than ‘rational correspondence with reality’, is also of central concern to those versions of CBT that have described themselves as ‘constructivist’.

9 Constructivist and ‘Post-rational’ CBT

A key concern for a range of ‘constructivist’ approaches is the question of ‘epistemology’ that is ‘how we come to know what we know’. These approaches have tended to contrast themselves with what they regard as the more ‘objectivist’ and ‘rationalist’ approach of standard CBT. In the so-called objectivist approach, knowledge is regarded as ‘representation’ of an external world and where such representations can be tested as to their degree of accuracy. By contrast, the constructivist sees knowledge as a product of social construction, negotiation and co-construction. Lincoln and Hoffman (2018) have suggested that existential phenomenology and constructivism converge on taking seriously the philosophical and epistemological basis of therapy and psychological theory. Additionally, they can both be understood as challenges to the limits of modernism in psychological theory and practice and emphasise multiple ‘ways of knowing’ and the extent to which personal and cultural assumptions may condition and constrain knowing and action.

A diverse range of ‘narrative’, ‘constructivist’ and postmodern approaches to CBT have been proposed that on the whole have not greatly influenced the mainstream of CBT practitioners but that nevertheless represent important developments. Social constructivism as a philosophy has had a wide-ranging influence over differing psychotherapies and academic disciplines. In some respects, it represents a development of certain strands of existential phenomenology. Important theorists who have attempted to develop a more constructivist version of CBT include Guidano (1991) and Mahoney (2003).

Guidano (1991) explicitly contrasts what he regards as a ‘post-rationalist’ cognitive therapy with rationalist (standard) CBT that he positions as inevitably being focussed upon ‘control’:

the therapeutic relationship established in rationalist and objectivist psychotherapy cannot become other than an instrument- a more or less authoritarian instrument- for the reestablishment of a rational, realistic, and otherwise socially dictated order. (Guidano, 1991, p. 100)

Guidano argues that for the constructivist, rationality is inherently relativistic. There is no ‘God’s-eye view’ from which a therapist is in a position to judge the irrationality or otherwise of a client’s thoughts. Guidano’s post-rationalist cognitive therapy focusses upon the gaps and incongruities that inevitably exist between the individual’s ongoing, embedded, acting, experiencing ‘I’ and their sense of self that continually emerges from abstractly self-referencing this ongoing experience—the observing and appraising ‘me’ (alternatively phrased as the self as subject ‘I’ versus the self as object ‘me’). Guidano emphasises that the experiencing I is always ahead of and not equivalent to the reflecting Me. Guidano draws upon attachment theory as a resource to help theorise the difficulties and distortions that arise in the ability of the reflecting Me to adequately capture the experiencing I. ‘Normal functioning’ is regarded as being equivalent to a personal meaning organisation that is capable of evolving towards greater complexity via assimilation of contradictions in experience and construction. In psychotherapy, the experience of emotion is regarded as central in promoting reorganisation of self-constructs and emotion schemas.

Key to Guidano’s (1991) constructivist perspective is an understanding of the nature of resistance to change as being essentially about the inherent need for individuals to maintain the coherence and stability of their current meaning constructions. Those constructions that are more ‘core’ to the sense of self are highly resistant to change, and as such, resistance is seen as essentially expressive, self-protective efforts at maintaining coherence and identity rather than expressing poor motivation or non-compliance.

Mahoney’s (2003) version of constructivist psychotherapy also focusses on ‘deep’ tacit core-organising principles and uses a wide range of strategies to assist clients in increasing their awareness of these. He describes strategies such as the ‘life review’ that focuses on the elaboration of a life narrative as well as ‘mirror time’, which is a mindfulness-based intervention involving the client being able to become aware of and stay with emotions, memories and thoughts that arise as they view their own face in a mirror for a specified period of time.

Key to the therapeutic application of these constructivist principles is a preference for a more unstructured therapeutic process, a lessened focus on highly specified treatment targets and a focus on the therapeutic relationship and the accessing and exploration of emotional embodied experience as key processes of change (Mahoney, 2003). Additionally, in contrast to an attempt at the identification and ‘correction’ of cognitive distortions, these approaches advance what they refer to as an ‘almost reverential’ appreciation for clients’ meaning-making processes.

As with many apparent polarities, the contrast between so-called objectivist and rationalist CBT and constructivist CBT may be much less stark as many have proposed. In fact, standard CBT appears to contain many elements that fit more easily within a constructivist perspective than a rationalist one. Consider, for example, strategies to alter ‘rules for living’. Seldom is this done via appeal to logic alone. Most often, this is addressed through an open dialogue regarding the possibilities and limitations of any change in such ways of being. This consideration of the pros and cons of change and the recognition that change may at times lead to unexpected, unpredicted consequences is a feature embraced by both standard CBT as well as existential and constructivist thinking. The constructivist strand of CBT has on the whole had a limited impact, and the most recent elaboration of the standard CBT model by Beck and Haigh (2014) has incorporated a much greater focus on constructivist aspects while still maintaining an overall rationalist perspectives. It appears that the pragmatic and clinically focussed CBT is capable of embracing and living with the apparent contradiction between these two philosophical polarities. By far the most interesting development, in terms of potential for contact with existential themes, within the family of CBT therapies has been the development of a range of ‘third-wave’ CBT therapies. These approaches are often characterised by a renewed interest in the philosophical underpinnings of the approach. Possibly the most important of these approaches, in terms of existential issues, is Acceptance and Commitment Therapy or ACT, to which we now turn.

10 Acceptance and Commitment Therapy: An Existential CBT?

Of all approaches, ACT possibly comes closest to constituting an ‘existential CBT’. At the same time, as will be discussed below, there remain significant points of disagreement and difference that should not be glossed over or ignored.

According to Yalom (1980), existential psychotherapy may not constitute a specific school of therapy at all and that what it represents is more of an attitude or position towards the nature of psychological suffering and the process of therapy. This basic existential attitude contends that human difficulties are expressions of individuals attempt at responding to the nature of existence itself. Hence, psychological disturbance and distress is to some degree inevitable and unavoidable. Most human difficulties are thus issues ‘to be lived’ as opposed to ‘problems to be solved’ in any final sense. Existential thinking can be said to embrace what the philosopher Miguel De Unamuno (1954) has referred to as a ‘tragic sense of life’. This contrasts clearly with the apparent optimism of much CBT that sees the possibility of ‘a CBT’ for most human difficulties. ACT, on the other hand, appears to embrace a much more existentially attuned tragic sense of life. Hayes et al. (1999), in their original presentation of ACT, distinguish between what they refer to as the ‘assumption of healthy normality’ and the assumption of ‘destructive normality’. Hayes et al. (1999) argue that the ‘psychological mainstream’ (including CBT) has adopted the assumption that the natural state of human existence is one of health and that, by corollary, the experience of abnormality, in the form of psychological distress, is a form of disease. That is, the common assumption amongst clients as well as therapists is ‘I am meant to be happy, and if not, there is something wrong that can and should be fixed’. ACT, by contrast, asserts that psychological distress and difficulty are inevitable aspects of human existence principally due to the manner in which language works and the extent to which we become ‘entangled’ with language.

While the connection between ACT and existential phenomenology may seem to be most obvious in regard to the ACT emphasis on issues of mindful acceptance and ‘values’, the connection actually runs much deeper and ultimately arises from the fact that ACT represents an evolution of a radical behavioural approach that can be traced to the work of Skinner.

Numerous authors have highlighted points of convergence between Skinner’s version of behaviourism and existential phenomenology. Principally, this is due to the fact that Skinner proposed a more contextual and less mechanistic science of behaviour. Kvale and Greness (1990), for example, have pointed to some surprising points of convergence between the psychology of Skinner and the existential philosophy of Sartre. This convergence rests upon the rejection of the Cartesian notion of the a ‘dual world’—an inner world of thoughts and emotions versus an outer world consisting of environmental stimuli. Two quotes from the respective authors seem to point towards an essential agreement on the notion that behaviour should be understood only in terms of acting-within-context and without recourse to notions of ‘inner states’ or cognitive representations:

Our “perception” of the world- our “knowledge” of it- is our behaviour with respect to the world. (Skinner, 1953, p. 90)

The point of view of pure knowledge is contradictory; there is only the point of view of engaged knowledge. This amounts to saying that knowledge and action are only two abstract aspects of an original, concrete relation. (Sartre, 1956, p. 30)

Hayes et al. (1999) describe the philosophy of functional contextualism as deriving from the pragmatism of William James as well as other influences. In contextualism, the basic unit of analysis becomes the ‘act-in-context’ with the hyphens serving to emphasise that this must be understood in terms of a ‘whole event’ including its historical and situational context. Parts or elements (such as a specific behaviour of an individual) are only abstracted in accord with a specific purpose or goal of analysis. Thus, contextual analyses are viewed as being inherently relational.

Within ACT, ‘truth’ is a matter of pragmatism, and a psychotherapeutic theory is true to the extent that it is effective in supporting the attainment of its specified goals. Hayes (2016) asserts that the goals that are chosen by a researcher or a therapist and client together can only be stated and ‘owned’ and that the results of any particular analysis or therapeutic intervention do not in themselves justify the choice of that goal. Following Skinner, the stated goal of contextual behavioural science, of which ACT is an expression, is ‘the prediction and influence of behaviour with precision scope and depth’ (2016, p. 20). Hayes (2016) acknowledges that ACT, as a form of functional contextualism, overlaps with other forms of contextualism that he labels as ‘descriptive contextualisms’. Existential phenomenology is a clear example of a descriptive contextualism. Descriptive contextualism, while sharing many core assumptions of functional contextualism, starts from a different goal. The goal of descriptive contextualism has been stated in terms of the search for ‘understanding’ as opposed to the search for the means to exert influence or achieve predictive precision.

In the application of a contextual behavioural science approach to psychological therapy, many further points of contact with existential approaches to therapy can be seen. ACT proposes that therapy should not principally be focussed on the attempt at controlling or eliminating unwanted psychological phenomena such as anxiety or depression. Rather, such efforts at control are seen as themselves as constituting the main difficulty. ACT suggests that therapy can more effectively be reconfigured to support clients in clarifying for themselves key values, that is, ‘What do you want to stand for? What do you want your life to “be about” regardless of whether or not you continue to experience these distressing phenomena?’ The central aim of ACT is also described as the effort to support ‘psychological flexibility’, which has been defined as contacting the present moment fully as a conscious human being and, based on what the situation affords, changing or persisting in behaviour in the service of chosen values (Hayes et al., 1999).

ACT has the potential to renew an interest within CBT regarding issues that are in essence philosophical. Hayes et al. (1999) argue strongly that it is important for therapists to be clear on the philosophical assumptions that they are embracing. As noted above, Hayes (2016) has suggested that such assumptions can be clarified and owned. Existential phenomenologists, on the other hand, might present the challenge that such assumptions can also be questioned. From an existential perspective, the chosen value of moving towards the possibility of ‘prediction and control’ remains problematic to the extent that this value may serve to introduce a significant degree of bias and distortion in terms of a therapist’s ability to ‘stay with’ phenomena as they reveal themselves. In the conduct of therapy, this may express itself in terms of a therapists’ attempt to ‘shape’ a client, even if this is done in a flexible and paradoxical manner, towards a predefined ideal of psychological flexibility. Contrast the emphasis on prediction and control, in essence a desire to move towards certainty, with the existential-phenomenological embrace of uncertain certainties and uncertain uncertainties. The ACT therapist’s frequent use of experiential techniques of defusion, mindfulness and committed action may run the risk, from an existential-phenomenological point of view, of detracting from the therapist’s and client’s ability and willingness to ‘stay with’ phenomena as and how they reveal themselves in the therapeutic conversation.

11 Summary: Finding a Place for Existential Thinking in CBT

The above, admittedly superficial and incomplete, exploration of where existential thinking may have points of contact and divergence with various forms of CBT has hopefully demonstrated that there may be interesting and productive points of dialogue and debate between these differing perspectives. From an existential perspective, committed as it is to the embracing of a phenomenological stance, there is a grave risk that CBT therapists may seek to ‘technologise’ existential issues. Thus, ‘death anxiety’, ‘meaninglessness’, ‘existential choice and responsibility’ and, even worse, ‘relatedness’ could become just additional variables or factors in an increasing ‘set’ of ‘transdiagnostic issues’ that will attract researchers into devising specific interventions for their ‘overcoming’, resulting in that most despair and angst inducing eventuality of the development of ‘yet another manual’. There is of course nothing inherently wrong with attempting to explore such existential issues from a more empirical standpoint. However, the risk is that in doing so, some of the more disturbing, challenging and demanding aspects of existential thinking is lost.

Cohn (2002) has emphasised a very useful distinction that CBT therapists could keep in mind. This is the difference and relationship between what has been referred to as the ‘ontological’ and the ‘ontic’. The ontological refers to aspects of being itself, essential and fundamental givens of existence. The ontic, on the other hand, refers to our everyday experience of existing. Cohn, drawing off the work of Heidegger, emphasises that the ontological can be seen as being included in the ontic. It does not need to be seen as somehow behind the ontic or causal of the ontic. Thus, a client who presents with a phobia of snakes, for example, need not be principally approached in terms of this ‘all being about the fear of death’. Similarly, a client presenting with OCD that expresses great difficulties with the issue of responsibility need not be seen as principally struggling with a case of ‘excessive existential responsibility and guilt’. These clinical presentations should not be seen as being principally caused by these existential concerns with the notion that delineating, formulating and designing interventions to more effectively target these existential dimensions will lead to a better therapeutic result. Instead, if these existential dimensions are in fact ontological, aspects of existence itself, then they are present at all times and in all situations. Thus, my writing this paper is itself expressive of my attempts at responding to both my ‘being-towards-death’—there is a ‘deadline’ for its completion, which I have now missed, and my choice to attempt its completion also contains within it my stance towards ‘existential responsibility and guilt’; my choice necessarily entails saying no to other possibilities of being. My award-winning novel remains, alas, unwritten.

Existential dimensions of existence cannot be seen as being either pathological or healthy, and therapists are encouraged instead to remain at an ontic level but with the possibility of developing ears that are able to discern the presence of existential dimensions in many clinical presentations, as well as in their own experience as a thread that at times may be useful to clarify and explore. How might this ‘existential competence’ be developed? I would suggest that in the training of CBT therapists, other than didactic explorations of existential literature, principally, this can be supported by experiential practice exercises that focus on the capacity for ‘deep listening’ and ‘staying with phenomena as and how they reveal themselves’. Below, I have outlined several of these exercises in the hope that some may prove enticing and productive for reflection.

12 Exercises in Phenomenological Listening

The following exercises are offered as possibilities for CBT therapists in training regardless of their preferred version of CBT. The intention is not to practice these exercises as forms of ‘skill’ that relate directly to CBT interventions. They are not opportunities for ‘role play’, and they are not intended as practice runs for how CBT therapists should work with their clients. Rather, they are designed to allow the possibility of the therapist in training to ‘gain a sense’ of what phenomenological listening might be like and what it might be like to allow ‘existential issues’ to present themselves in the way they present themselves without the need for these to be ‘assessed’, ‘formulated’ or ‘intervened’ with.

In each exercise, there are three ‘positions’, that of therapist, client and observer. Ideally, each participant takes a time in each role. There is no set time limit for these exercises, but in general, between 10 and 15 minutes per interaction should be sufficient.

Exercise 1: ‘Just’ Listening

In this exercise, the ‘client’ is asked to describe a recent experience where they had some form of emotional experience, be it positive or negative. The client is simply asked to describe, ‘What was this experience like for you?’ The task of the ‘therapist’ is to remain completely silent throughout and to attempt to listen in a way that allows them as full a sense as possible of what this experience was like for the client. No questions or redirections are allowed. At the end of the exercise, each participant is asked to describe what this experience was like—was it interesting, frustrating, enjoyable, anxiety provoking, etc.

Exercise 2: Listening to Myself Listening to You

In this exercise, the ‘client’ is again asked to describe in detail a recent experience where they felt a strong emotion. The ‘therapist’ is again asked to remain silent and to focus on listening in depth to the client. However, on this occasion, the therapist is also asked to listen intently to their own experience of attempting to listen to the client: ‘What is it like to attempt to enter into the experience of the client in the manner that the client has this experience. What images, memories, emotions, body sensations, etc., arise when this attempt is made?’ Again, after each exercise, each participant is asked to describe what occurred for them and their reflections about this.

Exercise 3: Clarification of Embodied Emotional Experience

In this exercise, the therapist is at last allowed to speak! However, their task is to remain one of attempting to gain as adequate as possible understanding of the client’s experience as and how it presents itself. In this exercise, the therapist is permitted to ask for clarifications and further description; however, such clarificatory questions should be limited to questions that are attempts to gain further descriptions of the clients’ ‘embodied emotional experience’. There should be no attempts made to identify and separate ‘key cognitions’, nor should there be any attempts to steer the conversation towards problem solving or towards alternatives that the client has not already engaged with. Again, reflection and discussion are invited after each exercise.

Exercise 4: Existential Observations

This exercise is principally focussed upon the ‘observer’ position. In this exercise, the therapist and client proceed as above for Exercise 3 (there is a second run of Exercise 3 with these additional instructions). The observer is asked to listen intently to both the therapist and client as they are engaged with each other and to also note their own experience while doing so. In addition, the observer is asked to see if they can discern the presence of any ‘existential dimensions’ that arise within the dialogue. What is it like to simply note the presence of these dimensions in the manner in which they present without these necessarily being ‘targeted’? Again, reflection and discussion are invited following the completion of the exercise.

13 Conclusion

This chapter has endeavoured to show how existential thinking and existential issues ‘show up’ in a variety of forms of CBT. There is no doubt that existential thinking is fundamentally a different form of human enquiry than the scientific, evidence-based methodologies favoured by CBT theorists and therapists. Nevertheless, there are significant points of contact and convergence that are worthy of further dialogue and debate. It is possible that for CBT to maintain its commitment to an empirical hypothesis testing, problem-solving perspective, the existential thinking will remain primarily at the level of suggesting a range of themes that may lead to the identification of important ‘transdiagnostic factors’. Where existential thinking is engaged with more fully, including an engagement with phenomenological methods as well as the conclusions and findings of phenomenological investigations, it remains the case that CBT therapists and theorists are presented with a rage of highly significant challenges that again raise the old as yet still open and unresolved question regarding the best way to understand the relationships between cognition, emotion, behaviour, other ‘selves’ and world.