Existential-Humanistic Therapy in the Age of COVID-19 in Vulnerable Populations

• Challenges
• Existential-Humanistic Therapy
• The Case of Michael
• Concluding Thoughts

Challenges

COVID-19 has been a sudden, unexpected, and existentially shattering experience for many individuals, resulting in their questioning their sense of safety and security in the world. Whether facing actual illness or loss, fear of getting sick or infecting others, forced isolation, lack of personal space, or economic hardship, people have now been facing unprecedented stressors for close to a year. With a second wave upon us and new variants emerging, there may be a sense that anyone is vulnerable. While vaccine distribution offers promise for individual immunity, there is protracted uncertainty about the duration of the crisis and its psychological, economic, political, and societal consequences.

These COVID-19 phenomena may exacerbate challenges for individuals with a history of chronic medical conditions and trauma, including feelings of vulnerability, stigma, and lack of control. Having previously confronted and accepted existential truths such as life’s uncertainty, the random nature of events, and the inevitability of death, these individuals may, at the same time, be better equipped to cope with aspects of the pandemic (Gordon, 2020). Existential-Humanistic (E-H) therapy can provide effective therapeutic interventions to aid vulnerable populations in optimizing adjustment, coping, and quality of life during the COVID-19 pandemic.

Existential-Humanistic Therapy

Developed in the 1960s, E-H therapy consolidates central ideas from European existential philosophy—the power of self-reflection, taking responsibility for decisions, and confronting freedom and death—with the American tradition of spontaneity, pragmatism, and optimism (Schneider & Krug, 2017). E-H therapists emphasize several core aims that enable patients and therapists to become more present in the moment: increasing awareness of self-protective patterns that block and restrict presence and personal agency; taking personal responsibility for the construction of one’s life and self-narratives; and choosing or actualizing ways of being in the world that are consistent with values. E-H therapy strives to be a catalyst for individuals to develop their level of curiosity, generate experience that is felt to be enriching, and expand their capacity for personal agency, commitment, and action.

The model emphasizes the “whole-bodied” (e.g., cognitive-affective-kinesthetic) ability to choose, within limits, who one will become, and that fundamental change takes place through experiential learning. Bugental (1987) depicted resistance as analogous to wearing a spacesuit which helps sustain life but also narrows one’s experience of the world. E-H therapists believe that when life-constricting protections are reduced, more meaning, purpose, and joy can emerge. E-H therapists focus on the here-and-now experience of the past as manifested in the present moment, including the patient’s body posture, level and quality of presence, tone or voice, and self-protective patterns.

Viktor Frankl (1992), an Austrian psychiatrist and Holocaust survivor, observed that we do not get to choose our difficulties and challenges, but do have the ability to select our attitudes and responses, decide what we make of them, and maintain a sense of dignity. Rollo May (1985) believed that it takes courage to move forward in life despite adversity.

An E-H theme developed by Irvin Yalom (1980) is the idea that individuals have a basic need to construct meaning through tolerating uncertainty, a passionate engagement in life, and living in the moment. He describes existential anxiety as the result of the confrontation with the givens of existence, including death, freedom, isolation, and meaninglessness. Existential anxiety occurs because of the conflict between these challenges and a desire for its opposite. These universal conflicts include the awareness of death and the desire for immortality, a sense of groundlessness and the wish for structure to provide safety and security, feeling of isolation and the need for connection, and the awareness of meaninglessness of life and the need to construct meaning. As a result of facing death, individuals experience the urgency of time and setting priorities. For Yalom, psychotherapy during times of crisis can heighten existential awareness and help clients put current and ongoing life crises into perspective.

Yalom incorporates the concept of “rippling” into his many writings on existential therapy. This is the notion that we pass parts of our self onto others, even to others we never met, much like the ripples caused by a pebble in a pond—whether a personality trait, an act of kindness, a quote or saying, the impact of our work—which tempers the pain of transiency. Along related lines, Hoffman (2021), guided by the work of Rollo May, discussed the existential guilt that accompanies failure to live up to one’s potential or taking responsibility, while in contrast finding that meaning can transform pain. And finding this meaning, according to Remen (2000), does not require us to live differently, but instead to see our lives differently.

It is in this context of seeing life differently that I ask you, as we might ask our clients, to imagine the consequences of living in a house with only one window. For all intents and purposes, the view from that window will define your reality. Only by experiencing the view from a new window, built perhaps on the other side of the house, will you gradually internalize a degree of perspective and relativity, a sense that vision and meaning involve choice and agency. And with that, I now offer the case of Michael.

The Case of Michael

Michael is a 35-year-old aspiring artist who was referred to me for psychotherapy to develop effective coping skills in his adjustment to his recent diagnosis of Multiple Sclerosis (MS). MS is an autoimmune disease that attacks the central nervous system, which can cause a variety of symptoms, including numbness, fatigue, vision loss, and walking difficulty. He was living with his grandmother and mother and had a strained relationship with his father, whom he had never lived with. He entered therapy three months before COVID-19 rattled the city and shut down services.

At the beginning of treatment, Michael reported multiple symptoms, frequent incidents of falling and losing his balance, a long-standing history of anxiety and panic attacks, and inhibitions in his ability to commit himself to intimate relationships and professional goals. Since his adolescence, his anxiety had often resulted in shortness of breath that triggered fears of a heart attack and impending death. He was particularly worried that his physical symptoms would continue to get worse and that he would be totally dependent on others for his physical care.

During his initial sessions, he expressed a great deal of frustration that it took a number of years to get a definitive diagnosis of MS. He felt his family and friends thought he was exaggerating his symptoms to avoid pursuing his educational and vocational goals, which resulted in lack of confidence and trust in expressing his own feelings, needs, and opinions. Even when he was given a definitive diagnosis six months before entering treatment, he experienced others as not fully understanding the impact of his “hidden disability.” He was angry that he developed his medical condition at such an early age, started to doubt his belief that “bad things do not happen to good people,” and felt that he was being punished for his lack of motivation and accomplishments.

Capitalizing on meaning-centered and post-traumatic growth perspectives, therapy began by exploring his strengths—deep-seated values and qualities that did not change due to his medical condition—in order to help him feel more empowered. He identified his compassion for others, creativity, and a sense of humor that could help him cope with his multiple challenges. The only moments when he felt passion in life were when painting or taking pictures of landscapes and city architecture.

In these initial sessions, Michael was able to express a deep sense of loss and sadness over his physical functioning, as he felt his athleticism had formed a core component of his identity during his adolescence and young adulthood. He grieved the loss of not being able to play sports with his children, if he became a father in the future. These feelings of sadness triggered memories of his paternal grandfather, who had died of cancer during his adolescence. He was one of the few figures in his life who had confidence in Michael’s talent as an athlete and that he would succeed in the future. Michael identified his grandfather’s resiliency and perseverance in the face of his terminal illness as two of his special qualities. The sessions involved asking Michael open-ended questions, including “What advice would your grandfather give you right now in how to handle your MS?” and “How are you similar to your grandfather?” Michael became more aware of feelings of gratitude toward his grandfather and that he too was a survivor and a determined individual.

When the news of the spread of COVID-19 in March 2020 caused a city-wide lock down, Michael agreed to continue sessions via telehealth. At that time, now on top of his anxiety, panic, and fears of dependency resulting from his medical condition, he identified the virus as compounding his fears of dying or becoming totally dependent on others. Shortly after, Michael recalled a series of unsettling dreams. He reported that since his diagnosis of MS approximately nine months before, he had a recurring dream where “Martians shot people and then placed them in upright coffins. They had blank faces and appeared as if in an altered state and could only move their hands in front of them.” Michael’s associations to the dreams were fears of not being able to move, ending up in a wheelchair, and being totally dependent on others. He was asked to retell the dream in the present tense and how he would want the dream to end in order to develop a sense of agency. He said he wanted to be able to fight the Martians like his grandfather had fought his cancer and scare them away.

Two weeks later, Michael reported another frightening dream where he was “trapped in a glass cube in [his] home that was invaded by bad guys who were pumping gas into the cube, and [he] had no way out.” He said he felt terrified of dying and feeling helpless. He was asked to visualize and re-experience how he felt in the dream. He recalled that he felt trapped, his lungs were burning, and he was going to suffocate to death. Michael then spontaneously recalled a memory of escaping from the scene of the World Trade Center Attack. He was at breakfast in a diner across the street and saw the plane hit the building. Michael was numb and could not process what had happened. He was paralyzed by fear, but eventually ran down the street when told to leave by a security guard. He did not remember what happened next, but eventually arrived home covered in ashes and debris, and had difficulty breathing and sleeping for several days. He had not thought about this traumatic event in years.

During this phase of treatment, Michael became more aware of how this traumatic confrontation with the possibility of dying, which occurred shortly after his grandfather’s death, contributed to his panic attacks and fears of dying during his adolescence, which in turn impacted his ability to pursue his educational, vocational, and interpersonal goals. Michael became more aware that his strong needs for safety, security, and protection inhibited his pursuit of taking risks in many aspects of his life. Michael further realized that his avoidance of taking chances and exposing himself to failure and rejection was, as Bugental reminded us, analogous to wearing a spacesuit which is life-affirming but also narrows and inhibits one’s experience of the world.

A major focus of the middle phase of therapy involved his fears of dying and what was meaningful in his life. Michael acknowledged that part of his death anxiety was that he had wasted many years avoiding pursuing his goals of being an artist and having close relationships. When asked to project himself a year from now and what new regrets he might accumulate, Michael tearfully stated, “Not completing my college degree and becoming an art teacher, and not living up to Grandfather’s belief in my potential.”

This was a pivotal point in Michael’s treatment, which brought him to enroll in a local college, where he took and succeeded in a number of online courses. He continued to realize on a more experiential level that he had been fearful of taking risks and failing since his adolescence, but that he was paying a significant price for pursuing his strong need for security. When asked “What have you discovered about yourself through the challenge of the pandemic?” Michael reflected that, while the pandemic had added new layers of anxiety, it also had provided him with the space to step back and evaluate what really mattered to him. Rather than continuing his past patterns of avoidance, self-doubt, and comparing himself unfavorably to others, he was determined to focus on his creativity and having an impact on others through teaching. He also realized that his previous contemplation of death anxiety and perseverance in coping with his MS served as protective factors in dealing with COVID-19.

Within a few months, Michael transitioned from feeling overwhelmed and vulnerable in the storm of his MS symptoms and COVID-19 threat to feeling more focused, determined, and resilient. Although he had to maintain cautiousness due to his medical condition and COVID-19, he was able to take the initial steps in pursuing a meaningful career that was consistent with his values and identification with his grandfather. Through the therapeutic process, he came to recognize his own power to choose how he wanted to view and respond to life’s major challenges, including his MS.

Concluding Thoughts

This essay describes my flexible application of E-H approach to psychotherapy when working with a patient with a chronic medical condition and a history of trauma during COVID-19. The case vignette highlights different aspects of the E-H approaches, including cultivating presence in the moment, choosing one’s attitude toward challenge and adversity, increasing awareness of what is most meaningful in life, living in manner consistent with one’s values, and expressing gratitude toward others.

For patients who have chronic and life-threatening medical conditions and a history of trauma, COVID-19 may increase their level of anxiety, fear, vulnerability, and social isolation. On the other hand, these individuals may have developed a degree of psychological protection and resiliency in having already experienced a prolonged sense of insecurity and uncertainty involving fears of body integrity and mortality.

In my therapeutic work, E-H therapy provides a safe place for patients to reflect on how COVID-19, while frightening and potentially traumatic, is changing them in unanticipated positive ways, including living life with greater meaning, purpose, and sense of urgency. It is my hope that in reading this, that you may experience this new context as an opportunity to explore existential issues such as uncertainty, vulnerability, meaning in life, and death anxiety with patients in deeper ways than before.


References

Bugental, J. F. T. (1987). The art of the psychotherapist. Norton. https://doi.org/10.1037/h0085349

Frankl, V. (1992). Man’s search for meaning (4th Ed.). Beacon Press.

Gordon, R. M., Dahan, J. F., Wolfson, J. B., Fults, E., Lee, Y. S. C., Smith-Wexler, L., Liberta, T. A., & McGiffin, J. N. (2020). Existential-humanistic and relational psychotherapy during COVID-19 with patients with preexisting conditions. Journal of Humanistic Psychology. Published online: November 2020, https://doi.org/10.1177/0022167820973890

Hoffman. L. (2021). Existential-Humanistic therapy and disaster response: Lessons from the COVID-19 pandemic. Journal of Humanistic Psychology, 61, 33-54. http://doi.org/10.1177/0022167820931987

May, R. (1985). The courage to create. Bantam Books.

Remen, R. N. (2000). My grandfather’s blessings: Stories of strength, refuge, and belonging. Riverhead Books.

Schneider, K. J. & Krug, O. T. (2017). Existential-humanistic therapy (2nd Edition). American Psychological Association. http://dx.doi.org/10.1037/0000042-000

Yalom, I. D. (1980). Existential psychotherapy. Basic Books. 

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