Existential-Spiritual Techniques for Fostering a Healthy Perspective on Aging

• Introduction: The Existential-Spiritual Model
• Initial Phase: Processing Unprocessed Grief and Loss
• Middle Phase: Establishing a New Sense of Self Through Existential Approaches
• Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values
• Concluding Thoughts: What is Psychological Health When Working with Older Adults?

Introduction: The Existential-Spiritual Model

The case vignette that I will share presents the application of an Existential-Spiritual model of coping when working with patients experiencing the natural inevitability of aging and the “normal” responses associated with it. The integrated model includes six intervention practices: self-compassion and mindfulness, discovering meaning in life, prayer, creativity, expressing gratitude, and being open to a sense of awe. Existentialism poses universal questions and concerns, while spirituality provides space to process grief and loss and create meaning in life (1). The aims of spirituality include having compassion for others’ pain and suffering, advocating for social justice, and gaining awareness of and learning from the tragic dimensions of existence, thereby enhancing an appreciation for and valuing of life. This case of Jonathan highlights how dreams can be a valuable resource in gaining a deeper understanding of an individual’s attempts to deal with their existential and spiritual challenges, as well as finding passion and purpose in life (2).

Initial Phase: Processing Unprocessed Grief and Loss

Jonathan is a 68-year-old male who entered individual psychotherapy for the first time. He reported that he has been married for 40 years and has a married adult daughter and two grandchildren, ages 8 and 12, who live nearby. He had retired just one year prior to the pandemic. Jonathan, who majored in English literature, pursued a law degree for financial stability and a personal value of and commitment to social justice. After law school, he worked in his father’s medical supply business to support his father’s declining health due to numerous medical problems and an early death from diabetes at age 56.

Jonathan expressed concerns of feeling “empty inside” and experienced lack of direction, meaning, and purpose in life since his mother died approximately five years ago, just six months after his retirement. He reported feeling numb and indifferent over the wars in Ukraine and Gaza/Israel, and the intensified polarization of political discourse he observed during his extensive time watching cable news. Given his commitment to social justice, these feelings were different for him. In addition, a close friend had died early on in the pandemic, but he was unable to visit him in the hospital or attend his funeral due to COVID-19 safety restrictions.

Jonathan wanted to work with a psychotherapist experienced in Existential-Humanistic approaches based on his longstanding interest in the existential writings of Tolstoy, Sartre, and Camus. During his initial psychotherapy session, Jonathan reported a disturbing dream from the night before. He was in a building with a male colleague and his own daughter trying to find a pool. His colleague pointed to some skin lesions on Jonathan’s body; one had rows of 20 elevated dots that looked like shingles. There was another area that had been festering for some time. He was preoccupied by his skin condition in the dream and when he looked up, his colleague and daughter were no longer there.

Jonathan frantically searched the building asking for help in finding his colleague, daughter, and the pool. He recalled walking into an office with an elderly woman who was volunteering in the building. She was unable to provide any guidance as to his colleague’s or daughter’s whereabouts. Jonathan felt anxious about missing out on seeing them and the opportunity to swim. He woke up feeling worried and not knowing what to do.

I used several existential approaches, including Jonathan telling the dream in the present tense to develop a sense of presence and agency. I asked him what he thought the dream meant and inquired about his main feelings in the dream. Jonathan responded that he felt that something was missing in his life and “life was passing me by.” Jonathan associated the dream skin lesions with his mother’s fatal skin melanoma. He also described the colleague in the dream as confident and adventuresome, much like his recently deceased friend. I wondered if the dream reflected Jonathan’s hope that his therapy would help reduce his anxiety, but also his fear of what his treatment would uncover.

When asked to elaborate on the circumstances of his mother’s death, Jonathan expressed that she had been living in an assistive living facility in Florida for three years with a full-time aide. He then expressed guilt that he only visited her a few times a year due to his busy work schedule. He said he felt emotionally overwhelmed being with her as she did not recognize him during his last few visits, and she needed everything repeated numerous times. Jonathan said he was actually relieved when she passed away but felt ashamed for having these feelings and did not share them with anyone.

To further his sense of agency, I asked Jonathan, “What is the existential message that can be taken from the dream?” He responded, “I need to stop avoiding making a medical appointment with my dermatologist because I am scared of what it could be” and that he might be paying a price for not processing his numerous losses. I then asked Jonathan, “If you could continue the dream, how would you want it to end?” After struggling with an answer, he said he missed seeing his colleague at work, swimming, and spending time with his daughter and grandchildren.

The initial phase of psychotherapy focused on his unprocessed grief and loss over his mother’s and close friend’s deaths, reflecting on the impact of the COVID-19 pandemic, and clarifying his values. He expressed resentment that he and his wife, who were eagerly looking forward to his retirement, were unable to fulfill longstanding travel plans to Asia, South America, and Alaska during the pandemic. Jonathan felt it unfair that he had sacrificed being a lawyer to help run his father’s medical supply business, and that he historically had placed others’ needs above his own.

He felt that it was unfair that these losses happened to him now, just as he was on the verge of finally pursuing his own dreams. He also felt that his mother’s and friend’s deaths, as well as the social isolation during COVID-19, were disruptions of the life “he was supposed to have,” rather than inevitable parts of anyone’s life. He wondered if he was being punished for not being compassionate and supportive of his mother at the end of her life. I suggested using self-compassion statements to soften some of the self-critical attitudes, such as how he should have grieved his mother’s passing.

Jonathan and I explored how his sense of guilt, regret, and shame over his mother’s death had drained his coping skills and flexibility to deal with his mourning process. We discussed how some of his basic assumptions of the world — such as “The world is fair,” “bad things should not happen to good people,” and “there is a reason for everything that happens,” — were shattered and left him “drifting at sea without a paddle,” not knowing what to do. We explored how these feelings were similar to how he felt at the end of his initial dream and how these factors may have impacted — and could continue to impact — his ability to mourn and grieve. Jonathan gradually was able to acknowledge, but not accept, that the world is unfair and unpredictable, and that random events can happen to good people.

I asked Jonathan to describe in more detail his last visit with his mother. He recalled her sitting up in bed requiring her full-time aide to feed her pureed food. She was staring out the window as if she was already in a different place. Jonathan said she was there physically, but in some ways she had died psychologically. I suggested that he was experiencing an ambiguous loss, making it challenging to start grieving her passing because she was still there physically. He tried to imagine what she might have been experiencing looking out of the window, and he wondered if she was scared of dying and being forgotten by others.

The next session included recalling positive memories of his mother — what kind of person she was before her Alzheimer disease diagnosis, and what values she lived by. He brought in photographs including her wedding picture and one where she was holding his daughter when she was an infant. His mother’s eyes in the second picture conveyed a warm, loving glow, which was comforting to Jonathan. He also recalled how she went back to school to become an elementary school teacher when Jonathan and his younger sister were in high school, and how much he enjoyed hearing stories about her work. He realized that his mother was more than his memory of what she was like at the end of her life.

Jonathan also discussed how his best friend, Michael, passed away three months into the pandemic. They had become best friends in 8th grade, and even though his friend moved out West after college, they maintained regular contact, including yearly visits. Michael was adventurous, loved hiking and fishing in the Pacific Northwest, and enjoyed talking to strangers. I suggested to Jonathan that the colleague from his initial dream might symbolize this friend, perhaps indicating a desire to emulate his confidence and adventurous spirit.  

Jonathan fondly recalled that the conversations he had with his friend always had the quality of picking up right where they left off. His beloved friend Michael, a social worker, always provided a listening ear and would ask challenging, but supportive questions. He was non-judgmental and helped Jonathan with various struggles. When asked what he missed most about his friend, he replied, “I could talk about anything without feeling judged, and he treated everyone with respect, always seeing the best in others.” When asked what Michael would say to him now in terms of how he should handle all his losses, he replied, “Just savor the preciousness of each moment, don’t take anything for granted, and take some risks.”

On top of these two significant losses, Jonathan felt that the pandemic was a very isolating and frustrating experience. His retirement dreams were put on hold, leading him into several unhealthy patterns, such as excessively, or perhaps obsessively watching cable news, growing more irritable with others, and being intolerant of conversations with friends and family members with opposing political viewpoints. His main pleasures during the pandemic were his weekly Zoom meeting with his daughter’s family, reading, and taking daily walks.  

I asked open-ended questions at this time, including: “What sustained you during the pandemic?” “What did you learn about yourself?” and, “Where did you find the strength?” Jonathan felt that his longstanding interest in Buddhism and the Jewish value of healing the world (tikkun olam) provided a sense of stability. Specifically, Buddhism stressed the importance of not getting too attached to things, the importance of just “being” and accepting things as they are. Although these beliefs provided some degree of intellectual comfort, they did not have a major impact on his actions or his self-confidence.

In order to provide Jonathan with a deeper foundation and sense of direction, I asked Jonathan to describe his core values, which he identified as supporting his family, treating others equally and with respect, and pursuing excellence in whatever he did. Since his retirement, he felt that part of his identity had been lost even though his career was never in line with his values of social justice and being a lawyer, leaving him lacking passion and direction. He was encouraged to explore if these values were still effective and whether he needed to reconsider refining them in some way. Jonathan was gradually able to realize that although he did not need to financially support his daughter and grandchildren, he could model for them how to handle adversity and aging in a graceful way, as well as find other ways to channel his need to treat others equally and with respect. I stressed that values are not fixed in nature but can be created. At this point in therapy, he was also encouraged to practice mindfulness exercises and self-compassion to increase his level of self-reflectiveness, to be less judgmental of his struggles, and to recognize that his feelings are transient.

Middle Phase: Establishing a New Sense of Self Through Existential Approaches

Four months into treatment, Jonathan reported a vivid dream where he was walking in New York City trying to get to a meeting in his office on the East Side. He was waiting with a group of people in a building near Central Park. Some of the people were taking too long so he decided to leave to make it to the 3:00 meeting. He was trying to find a cab, but they were all full. He walked down an area in midtown that was sectioned off with small houses that one would typically see in the suburbs. One of the buildings had a large window where he saw a group of people relaxing and socializing.

Jonathan realized he had to get to the office, so he finally got into a cab and saw he only had a $10 bill to pay for the short trip to the office. The traffic was slow, so he decided to get out of the cab to walk the remaining distance. There were long, winding, hilly sidewalks that are not typical of the city, and he realized that he was on the opposite side of Manhattan from his office. He sensed he would miss his meeting as he saw trains passing by near the Hudson River. He then found himself walking down a long, beautifully constructed road with tall, shady trees leaving the city through a tunnel. He woke up feeling that he wanted to stay in the city and that going through the tunnel was potentially dangerous.

Jonathan felt the dream meant that he was struggling to find a new path in life, that he had lost a core part of his identity in his retirement, and that he lacked a sense of community. Like in the Robert Frost poem, The Road Not Taken, he feared making the wrong choice, reminiscent of his decision not to pursue his dream of becoming a lawyer. He was asked to visualize what it would be like going through the tunnel. Jonathan imagined it would be dark, claustrophobic, and scary to walk on the narrow sidewalk with a guardrail with all the cars driving by fast. He felt that he would eventually be able to get to the other side, but it would take a great deal of effort and time. He was asked to imagine what it would be like if he went further into the tunnel to the other side.   

Jonathan struggled but was eventually able to say that he wished his parents and best friend were on the other side to greet him, saying how proud they were of him and the sacrifices he made for his family. He cried and realized that he had taken them for granted when they were alive. I acknowledged Jonathan’s determination, courage, and perseverance despite his anxiety and that the dream reflected his progress in therapy. At the end of the session, I asked him to think about if he was currently taking anything else for granted in his life. The following session, he mentioned that he felt gratitude that his family was healthy, that he had a few close friends, and that he could still give to others and pass on his knowledge and insights to his grandchildren. I then suggested that at the end of each day he write down what he was grateful for.

Consolidation Phase: Integrating Spirituality and Creativity and Reevaluating Values

In the subsequent sessions, I asked a number of open-ended questions to further work through Jonathan’s grief and mourning including, “Are there any ways you can honor your parents and friend by living out the values and causes they believed in?” Jonathan felt that his parents were generous in giving to those less fortunate, and that his mother had volunteered in a pediatric clinic at a local hospital after her retirement. Jonathan was also determined to honor his friend’s life for the years he did not get to experience by being more adventurous and taking more chances, including planning a trip with his entire family out west to a national park. He felt that identifying these values and living them out would be a way of honoring their memory and remaining close to them even after they passed.

Jonathan returned to the next session visibly shaken by an encounter at a supermarket the day before. He noticed a homeless man desperately wanting some food. The people in line were rude and impatient with him, avoiding eye contact as if they felt disgust at his condition and shame for looking away. Jonathan quickly went to the cashier and offered to pay. Jonathan’s and the man’s eyes met, and Jonathan felt that this was something his parents would have done without any recognition for it. He felt that this small moment of compassion was a way of honoring his parents’ values. He eventually decided that he wanted to volunteer in a nearby soup kitchen one day a week and to tutor local elementary school children in reading and writing.

The final stage of psychotherapy included a number of significant events and choices. Jonathan took a trip with his entire family to Yosemite National Park. While looking at the Sequoia trees with his family, he felt a deep sense of connection to his friend, Michael, and a feeling of awe in being in a place so vast and mysterious. He subsequently began to pray more consistently, to be more courageous and adventurous like his friend, gradually releasing his fears of the unknown and uncontrollable. Jonathan appreciated that although someone dies, the relationship does not end and can continue to evolve (3).

Upon return from his trip, Jonathan reported a dream where he was walking a tall winding staircase at a water amusement park. He recalled looking down and realized that he could seriously hurt himself if he fell. Despite his anxiety, he kept on walking up and was securely placed in a luge headfirst while lying on his back. He felt scared and excited about what it would feel like going fast down the waterslide. Jonathan woke up feeling energized and proud of his courage like he did on his recent trip with his family.

Jonathan began to read and write poetry, which he shared with his grandchildren. The poems reflected themes of savoring the moment, particularly in nature and while listening to music, avoiding getting lost in trivial complaints, and expressing gratitude for what one has. Jonathan felt that his creative writing was the beginning seeds of his own legacy.

As the psychotherapy concluded, Jonathan acknowledged how his parents’ and friend’s values and personal qualities had a significant impact on his life and that he shared these values of promoting the growth and well-being of the next generation. Generativity became a new core value that provided a sense of purpose and meaning in his life (Buechler, 2019).

Concluding Thoughts: What is Psychological Health When Working with Older Adults?

The case vignette highlights the benefits of integrating existential and spiritual interventions when working with older patients. Jonathan needed to gradually process his unresolved guilt, regret, and shame regarding his mother’s and friend’s deaths before he could fully experience joy, vitality, and meaning in life once again. His mourning process was further consolidated by honoring his parents’ and friend’s values, the causes they believed in and how their good qualities had changed him for the better (4). He recognized that he shared these same values, which was fulfilling for him in maintaining a deep connection to them even when they were no longer physically present. Jonathan was able to acknowledge the legacy he received from his parents and began to integrate the value of generativity in his life.

The theme of giving to others less fortunate become a unifying thread in his life narrative. While he could not prevent or slow down the inevitable tragedies in life and the regrets over past choices, the thread provided a meaningful foundation and compass in navigating new, turbulent challenges in life. When reflecting on his treatment, Jonathan recalled that his brief interaction with the stranger in the supermarket may have impacted the person’s life, and Jonathan experienced a sense of their shared humanity.

From a meaning-centered psychotherapy lens, Jonathan not only acknowledged the historical meaning of continuing his parents’ values and legacy, but also started creating and experiencing other sources of meaning in life (e.g., experiencing connection and awe in Yosemite (experiential) and deciding to embark on more adventures and being courageous in creating new experience himself (creative source of meaning)). Jonathan’s experience of awe enabled him to deepen his awareness of life’s fragility, resiliency, and sense of wonder (5). His involvement in reading and writing poetry facilitated a change in his attitude and perspective on life. His daily practice of mindfulness provided a safe space to observe his thoughts and feelings in a nonjudgmental and self-compassionate manner, while practicing gratitude increased his appreciation for the gifts of life and the legacy of those who passed before him. Prayer facilitated his ability to let go of his need to control life and provided a sense of safety in letting go of his fear of the unknown (6).

Jonathan’s journey highlights that psychotherapy with an older adult can bring “a heightened existential awareness…a new appreciation of the preciousness of life… (and the ability) to trivialize the trivialities” (7). At this development stage, there is a degree of comfort, meaning, and purpose that one’s actions, deeds, and values can have a known or unknown rippling effect on one’s family and others (8).

Questions for Thought and Discussion

What are your impressions about an existential-spiritual approach to therapy?

In what ways was this author effective in working with Jonathan?

Might you have worked differently with this particular client?

References
(1,6) Gordon, R. M., Groth, T., Choi, E., Galley, J., Marcantuono, J., & Kulzer, R (2023b). An Existential-Spiritual model for coping during and after COVID-19. Spirituality and Clinical Practice. Published online: December 11, 2023.

(2) Gordon, R. M. & Groth, T. D. (2023a). Relational and existential supervision and therapy for adolescents with life-threatening illness. Journal of Infant, Child, and Adolescent Psychotherapy, 22(4), 311-322.

(3) Buechler, S. (2019). Psychoanalytic approaches to problems in living. Routledge.

(4) Kessler, D. (2019). Finding meaning: The sixth stage of grief. Scribner.

(5) Schneider, K. J. (2004). Rediscovery of awe: Splendor, mystery, and the fluid center of life. Paragon House.

(7) Yalom, I. D. (1996). Lying on the couch. Basic Books.

(8) Yalom, I. D. (2008). Staring at the Sun: Overcoming the terror of death. Jossey-Bass.   

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