ACT and Existential Therapy

Comparing the two approaches when working with death anxiety and meaninglessness

Arwa Hussein

Guy Mayer - "I've got you under my skin "
Guy Mayer - "I've got you under my skin "

Cognitive Behavioural Therapy (CBT) approaches traditionally have a limited place for exploring existential themes such as death anxiety and the meaning of life, instead preferring a goal-orientated focus. It is unclear whether CBT interventions can accommodate our existential anxieties (Prasko, Mainerova, Jelenova, Kamaradova, and Sigmundova, 2012), and yet the most common port of call when a client is referred by their general practitioner for psychotherapy is CBT (Wilhelm et al., 2005). In recent years, however, the question has arisen of whether or not some cognitive behavioural therapies, such as those emerging in the so-called “third wave” of CBT approaches, can be useful in tackling existential issues.* Acceptance and Commitment Therapy (ACT) is a third-wave behavioural therapy, which is specifically based on mindfulness (Hayes, Strosahl and Houts, 2005). It has endeavoured to overcome the traditional limitations of CBT by considering existential themes in practice (Bunting and Hayes, 2007). This essay will consider the similarities between existential therapies and ACT with particular reference to death anxiety and meaninglessness.

Existential-phenomenological therapy is a distinct model with its own principles, which differentiates it from other psychotherapies such as psychodynamic and behavioural therapies (Spinelli, 2014). It is firmly rooted in phenomenology, a realm concerned with subjectivity and the way a phenomenon is presented (Bullington, 2013). In applying the process of existential-phenomenology, therapists and clients work alongside each other to coherently map out the client’s experience and in doing so, heighten the client’s awareness of their life (Ramsey-Wade, 2015). However, attempting to define the existential model contradicts the underpinning philosophy of the model (McGinley, 2006). Existential therapy mirrors the process of becoming, an intersubjective and ever-unfolding concept with no construct (Spinelli, 2014). Research supports and advocates the importance of existential themes being considered in therapy, regardless of the model being used (Steffen and Hanley, 2014).

The existential psychotherapist Irvin Yalom addresses the topics of meaninglessness and death anxiety, stating that in the dynamic dimensions of existential therapy, we can aid the client’s journey towards understanding their existence (Cooper, 2003). Yalom argues that our existential givens play a fundamental role in human psychopathology and proposes four themes which are at the root of every individual’s anxieties. These are: death anxiety, meaninglessness, freedom and isolation. When we rely on non-adaptive defence mechanisms, we are attempting to steer clear of these essential existential anxieties, resulting in psychopathology (Yalom, 1980). Behavioural approaches such as CBT focus on finding new, more adaptive defence mechanisms that aid the client’s functionality, but without ever facing the pain of death anxiety and meaninglessness. Though this is useful to an extent, it does not reach the core of the problem, and more likely than not, the client will return for more psychotherapy.

In comparison to CBT, however, the empirical efficacy of existential therapies has only recently been considered (Vos, Cooper, Correia and Craig, 2015). In contrast, ACT has much stronger empirical backing (Powers, Vörding and Emmelkamp, 2009). Existential therapy is generally seen as irreconcilable with empirical research (Wilson et al, 2011), whereas ACT is research-driven, values the scientist-practitioner perspective in using appropriate terminology, and avoids oversimplifying existential experiences (Wilson et al., 2011). It is an empirically validated branch of psychotherapy that nevertheless incorporates existential concepts (Badiee, 2008). Numerous studies propose that ACT is the answer to overcoming the limitations traditionally associated with CBT, especially with regards to existential anxieties (Bunting and Hayes, 2007). Several of the fundamental processes included within ACT, such as acceptance, are referred to as mindfulness processes (Wilson and DuFrene, 2008). There is increasing literature discussing the parallels between mindfulness and existential therapy, which supports the concept that existentialism and ACT have a lot in common (Claessens, 2010).

ACT is rooted in Relational Frame Theory (RFT) (Day, 1969), which emphasises the human ability to utilise language as a tool for making meaning and to make links between concepts (Hayes, Strosahl and Wilson, 1999). Though ACT differs from second-wave CBT therapies such as RFT, it remains committed to building an evidence-base for itself, whilst appreciating the value of avoiding internal experiences that lead to psychopathology (Yovel and Bigman, 2012). According to RFT, humans are able to experience fear and anxiety in objectively safe situations due to our ability to establish language-meaning relationships. Anxiety can be triggered simply through making a connection between a thought or idea and a particular meaning.

The general objectives of ACT are twofold, firstly for clients to accept experiences within their lives that they have unsuccessfully modified, and secondly, focusing on goals that hold personal importance whilst accepting the experience of anxiety that goes alongside this. ACT aims to focus on reducing the impact of such thoughts and thwarting experiential avoidance through the development of psychological flexibility (Hayes, Strosahl and Wilson, 2012). To help clients work towards this psychological flexibility, ACT follows six core principles: diffusion, acceptance, contact with the present moment, self-as-context, values and committed action (Hayes, Strosahl, and Houts 2005). To briefly describe these principles, diffusion refers to learning to view cognitions (e.g. thoughts, memories, images etc) as a language process rather than an objectified truth. Acceptance refers to creating space for unpleasant feelings rather than avoiding them. Contact with the present moment refers to nurturing a conscious and open alertness to current experiences. Self-as-context means allowing the client to experience the difference between thoughts and the self that witnesses these thoughts. Values means the identification and exploration of the client’s values and sense of meaning (or meaninglessness). Lastly, committed action means supporting the nurturing of a value-guided approach (Hayes, Strosahl, & Houts 2005).

Research highlights distinct similarities between existential therapies and mindfulness-based approaches such as ACT (Badiee, 2008; Claessens, 2010; Ramsey-Wade, 2015). Particularly, Felder et al (2014) focus on the similarities between mindfulness meditation and the non-interfering meditative state of consciousness that the existential philosopher Heidegger encouraged. Furthermore, the concept of epoché, or bracketing one’s experience is similar to the idea of decentring from experience, which is found in mindfulness approaches (Nanda, 2010). In addition, both approaches establish a non-hierarchical relationship between therapist and client, rejecting the concept that therapists are experts (Madison, 2014).

Both ACT and existential therapies share the position that there is no need to pathologise human distress, which is ultimately essential for our growth (Nanda, 2010; Harris, 2013). Such distress may very well serve a positive function (Spinelli, 2014). There is therefore no focus on a reduction of negative thoughts and symptoms (Harris, 2013). Both existential therapy and ACT avoid the psychiatric framework that assumes suffering requires treatment (Bunting and Hayes, 2008; Sharp et al., 2004). Both ACT and existential therapy accept that suffering is part of our existence. If the underlying problem is not a pathological disorder, it may point towards the human struggle to live fully (Garcia-Montes and Perez-Alvarez, 2010). The increase of acceptance-based approaches within therapy highlights the problems associated with pathologising some of the difficulties humans face, in particular our existential anxieties. Suffering remains a basic human experience and maybe we should stop focusing on eradicating it and more on owning it (Sharp et al. 2004).

There is a clear focus on freedom and the value of making choices to improve quality of life within both ACT and existential therapies (Nanda, 2010). In ACT, values are viewed as ‘freely chosen’ and are not rationalised or explained through logic, which leads to entanglement and fusion (Yovel and Bigman, 2012). There is therefore a parallel between ACT and Sartre’s view that existence precedes essence. According to this view, freedom lacks foundation yet it forms the basis of our values, and avoiding our existential choices is seen to be at the core of problems that clients identify in therapy (Nanda, 2010). ACT focuses on identifying the client’s value-related goals and supporting the client to find meaning in their values. Meaning-focused work is more traditionally a focus associated with existential approaches rather than behavioural approaches such as CBT, but we can see it being demonstrated in ACT (Sharp et al., 2004). Existential therapy questions the notion of a fixed self and prefers to view being as something more fluid, essentially, being-always-becoming (Spinelli, 2014). This means that our behaviours and experiences develop from relatedness. ACT does not hold this view, but its position on relatedness is closer to existentialism than other approaches (Nanda, 2010). In ACT, the self is seen as a process-based perspective rather than a concrete ‘thing’ (Bunting and Hayes, 2008).

How are existential anxieties such as death and meaninglessness practically addressed in ACT? Harris (2010) considers two approaches to aid clients with death anxiety. Firstly, shifting focus from problem-solving to acceptance, although he is vague how this can be practically tackled. Secondly, he suggests that the therapist uses diffusion techniques, which support the client to understand their thoughts as processes of language rather than objective truths. Wilms (2016) conducted a study to investigate the way ACT therapists encounter existential themes and the strategies they use to deal with such themes. The study found that the majority of therapists were accustomed to clients struggling with death anxiety and/or meaninglessness in therapy. Death anxiety was mostly in relation to severe illnesses, panic attacks and the loss of loved ones, whilst meaninglessness was mostly in relation to depression and chronic pain. The ACT therapists’s strategies were compressed into several thematic categories, including but not limited to: diffusion and distancing from thoughts; exploring the client’s meaning-making; and exploring values.

However, Wilms’s (2016) study explores the therapist’s perception of existential themes but did not account for therapists who are unaware of existential themes during their practice. In these cases, it is probable that therapists will not highlight death anxiety and meaninglessness as important themes in the client’s therapeutic journey. Grober, Heidenreich and Rief (2016) emphasise that therapists should develop their own stance towards existential themes, even if they are not existentially trained, to act as a role model for the client. Thus, existential themes should be addressed in all psychotherapy training to help therapists detect existential themes throughout the unravelling of the client’s story (van Bruggen, Vos, Bohlmijer and Glas, 2013).

There is some disagreement regarding whether it is reasonable to explore death anxiety and meaning-making using RFT. Wilms (2016) finds that ACT therapists arrive at different interpretations and conclusions from the core assumptions of RFT. The conclusions made can be divided into two differing approaches. The first is a focus on diffusion techniques so as to avoid the client’s anxious meaning-making altogether, and the second is an exploration of death anxiety and meaning-making. Despite these different emphases within ACT, overall Wilms (2016) found similarities between existential therapies and ACT, supporting the findings of previous studies proposing that  ACT can be accommodating for clients in the exploration of existential anxieties (Claessens, 2010; Ramsey-Wade, 2015).

Although several similarities between ACT and existential therapies have been outlined, the difference in the root philosophies of the two approaches must not be discounted. Radical behaviourism and phenomenology differ greatly, although some of their roots overlap and connections can be made. Existential therapy is based on phenomenology, which focuses on lived experience and essentially brackets out empirical information, highlighting a major epistemological difference from ACT (Bullington, 2013). ACT appears to work with clients in an isolated and individualistic manner, falling into a dualistic trap that brings it closer to other, less relational therapeutic approaches. In contrast, existentialism proclaims that relatedness and intersubjectivity are core to our experience of life (Spinelli, 2014). Furthermore, differences lie within the therapeutic relationship. ACT is a more structured form of therapy, with the therapist holding a more active role, whilst still remaining an equal to the client. Existential therapy aims to avoid the therapist taking an active role. Rather, the work is in being present and attentive to the client throughout their journey (Spinelli, 2014).

Regardless of the differences and similarities outlined in this article, both ACT and existential therapy can benefit from one another. Cognitive behavioural therapies are not typically associated with being capable of addressing clients’ existential anxieties, but ACT offers a cognitive behavioural approach that reflects some of the philosophical principles of existential therapy. Similarly, in a time when existential therapy is sometimes seen as the “black sheep” amongst therapeutic approaches, it is to the benefit of existentialism to be associated with a form of psychotherapy that is more empirically driven.

 

*Third wave cognitive behavioural therapies focus more on the client’s relationship to their thoughts and emotions, rather than on identifying and changing maladaptive thought patterns (Hayes and Hofman, 2017).

Arwa Hussein is a trainee existential counsellor, who is currently in the third year of her doctoral studies at the NSPC. She has a great interest in culture and its role within our mental health. Arwa is also attracted to the topic of motherhood, and is writing her thesis on the experience of bi-cultured first-time mothers.

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