Journal of Contemporary Psychotherapy, Vol. 29, No.

1, 1999

Pragmatic Existential Therapy

Carl P. Ellerman, Ph.D.

A pragmatic model of existential therapy is offered to support the thesis that brief,
solution focused therapy is a clinical application of existential psychology. Superseding pioneering existential therapies more concerned with insight than with
clinical technique, pragmatic existential therapy is a dynamic clinical interventionfacilitating in patients, decision, choice, self-commitment, and concrete action,
the goal of which is movement toward the future and fulfillment of patients' latent potentials. In addition to clarifying the model's theoretical focus on (a) lived
experience, (b) self-creation, and (c) existential anxiety, practical guides to brief
existential treatment are offered. Sources from existential philosophy and psychology, as well as brief solution focused treatment, are used to evidence core
elements of an existential therapy that is not contemplative and insight-focused,
but pragmatic and action-based.

INTRODUCTION
At first sight, brief solution focused therapy (BSFT) and existential psychology appear to be strange bedfellows, not only to empirically-minded clinicians
perplexed by the obscure conceptual formulations of existential philosophy, but
also to pragmatic clinicians who reject a tragic view of life that seems inimical to
optimistic approaches to solving human problems. Clearly seen, however, existential psychology provides a meaningful theoretical grounding for BSFT, although
existential psychology was mistakenly presented by its originators as a philosophy
of life and death that is "not a psychotherapeutic technique and makes no pretenses
in that direction" (Feifel, 1969, p. 62).
Contrary to the pioneering group of European and American practitioners who developed a contemplative philosophical, rather than pragmatic clinical
Address correspondence to Carl P. Ellerman, Ph.D., Medical Center East, 5900 North Burdick Street,
East Syracuse, NY 13057.

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relationship to existential psychology, my work with patients in the outpatient

clinic of an urban American hospital indicates that BSFT is a clinical application
of existential psychology, while also showing that a revivified existential point
of view provides BSFT with a theoretical logic and a clinical rationale heretofore
lacking. Hopefully, a coherent account of the relationship of existential psychology
and BSFT will not only give therapists guiding principles lacking in the brief models currently flooding the mental health community, but also advance appreciation
and use of a solution focused strategy.

PRAGMATIC EXISTENTIAL THERAPY

Clinical Context
My revisionary work in existential therapy was motivated by a mandated
change in the treatment philosophy of the urban hospital where an interdisciplinary team of psychiatrists, clinical psychologists, and psychiatric social workers had been treating a full range of psychopathology in adult, adolescent, and
children's clinics. Specifically, the outpatient clinics initiated a proactive reversal
of the traditional 50-minute, weekly session standard that guaranteed interminable
psychiatric treatment to every individual and family. A flexible triple-tier model
of short, intermediate, and long term care established the norm of BSFT.
1. Individuals and families would be offered up to ten sessions, with clinical
technique and session spacing left to the disgression of the primary therapist. The expectation was that 60-70% of the clinic's population could be
treated effectively by means of BSFT, with 20-30% requiring additional
intermediate care (primarily group therapy), and the remaining 10%
these being severely and persistently mentally-ill individuals or chaotic
familiesrequiring comprehensive, long term outpatient care.
2. The ten session standard was implemented in conjunction with a solution focused treatment approach, requiring a significant change in the way
clinicians perceived and practiced therapy. Generally, the interdisciplinary
staff was not only trained to diagnose psychopathology, but conditioned to
nurture long term clinical relationships, with the expectation that patients
would abreact trauma, achieve a modification of intrapsychic structures
and dynamics, and secure emotional healing. Given the mandated change
in treatment philosophy, clinicians would now rapidly assess the life circumstances of patients and work actively with individuals and families to
co-create concrete solutions to palpable problems. Conceived as a practical tool used to generate constructive change in the lives of patients, BSFT
shifted therapeutic focus from pathology to patient competencea departure from traditional practice that invited therapists to see themselves not as
healers of the soul or as specialists curing psychopathology, but as agents

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of change involved in short term relationships that nurture the patients'

ability to solve their own problems.
The following discussion is not an outcome study of the triple-tier strategy.
Rather, it is a report of how I revised and practiced existential therapy within this
time-limited, solution-focused context. This is noteworthy because the originators
of existential psychology admitted forthrightly that "those who read works on existential analysis as handbooks of technique... will not find specifically developed
practical methods" (May, 1967, p. 76). In fact, existential psychology was initially
conceived as a pure, rather than applied science, and many pioneering existential
analysts were simply not concerned with clinical technique. This methodological
lacuna notwithstanding, when peeled, pared, and boiled down to essentials, existentialism contains three core elements that guide the practice of brief solution
focused existential therapy (BSFET): a dynamic clinical intervention facilitating
in patients, decision, choice, self-commitment, and concrete action, the goal of
which is movement toward the future and fulfillment of patients' latent potentials.
Mindful that this triad does not exhaust the existential repertoire, BSFETwhich
I shall also refer to as pragmatic existential therapy (PET)focuses on (1) lived
experience, (2) self-creation, and (3) existential anxiety.

Elements of Pragmatic Existential Therapy

Lived Experience
Existentialism commenced as a historical repudiation of abstract speculation about human beings, most notably, abstruse metaphysical speculation that
failed to address humans concretely within the context of lived experience. Piqued
by Hegelian abstraction, Kierkegaard (1846/1974) launched the existential revolt, maintaining that "modern philosophy ... ha[d] forgotten, in a sort of worldhistorical absent-mindedness, what it means to be a human being" (p. 109). One
century later, this historical quest to address lived experience found summation in
the articulate voice of Camus (1942/1961), who argued boldly: "There is but one
truly serious philosophical problem, and that is suicide. Judging whether life is or
is not worth living amounts to answering the fundamental question of philosophy.
All the rest... are games" (p. 3). Between 1846, when Kierkegaard inaugurated
existentialism, and 1942, when Camus summed-up the existential revolt, existential analysts examined human persons phenomenologically within the crucible of
lived experience: death, anxiety, freedom, aloneness, self-estrangement and meaninglessness, were among the crucial experiences thematized. Although continental philosophers frequently expressed themselves in turgid prose that obfuscated,
rather than clarified the human drama, their quest to understand lived experience by
examining "the necessities of being in the world, of having to labor and to die there"
(Sartre, 1960, p. 303), remains a constant, core element of existential psychology.

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Recently, a renewal of the existential focus on lived expereince surfaced in

solution-focused therapies critical of theoretical speculations about intrapsychic
life, particularly abstract metaphysical speculations that issue in interminable psychoanalyses devoid of practical consequences. Regarding this contemporary critique, it is instructive to reflect on Kernberg's (1975) analysis of ego weakness in
borderline patients:
The failure of normal integration of the structures derived from internalized object relationships ... interferes with ... neutralization and abstraction of both ego and superego
functions. All of this is reflected in the reduction of the conflict-free ego sphere, clinically
revealed in the presence of "nonspecific" aspects of ego weakness, particularly a lack of...
developed subliminatory channels, (p. 79)

With due respect for Kernberg's seminal attempt to understand and treat borderline and narcissistic disorders, the lived experience of human beings appears
to have disappeared within the labyrinthine passages of psychoanalytic mythology. Disappearing also, are practical solutions to demonstrable life problems whose
persistence commonly results in depression, explosive rage, and sundry other complaints. Melioration of this state of affairs is the goal of BSFET: a pragmatic clinical
encounter in which the existential therapist remains "on the same plane with his
patientsthe plane of common experience" (Binswanger, 1962, p. 21).
Rather than speculating about the travails of a mythical psyche in the patient's
machine, a pragmatic existential therapist remains on a common experiential plane
with patients by focusing on palpable life problems. In practice, I begin by conceiving lived experience as a series of concrete problems, while envisioning patients
as problem solvers and BSFET as a tool useful to some patients who have become
stuck in problem solving. This simple conception of lived experience is explicit in
the evolutionary psychologists' heuristic view of organismic existence as a series
of problems solved by the natural selection of biological adaptations (Barkow, Cosmides, and Tooby, 1992). Unfortunately, while many human beings adapt to the
demands of their natural and social environments by confronting and solving their
problems, some get stuck in problem solving, while others are maladaptive problem avoiders. From the perspectives of PET, avoiding or becoming stuck in solving
life's problems is the royal road to the mental health clinic. As Peck (1978) noted
insightfully, many individuals attempt to avoid problems due to the emotional pain
that results when problems are confronted directly; however, avoidance of life's
primary problems often results in depression and in other more painful secondary
problems that eventually bring individuals to the clinic. Moreover, avoidance of
the legitimate suffering that results from confronting primary problems, results in
the loss of personal growth that problem solving entails.
In order to generate a therapeutic encounter committed to solving the problems of lived experience, it is helpful to think of clinical interventions with reference to simple dynamic images arising from common experience. For example, in
the snowbelt of Central New York where winters are severe, autos often become
stuck in snowbanks; once stuck, an angry driver will sit inside the cab gripping the

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steering wheel tensely, while depressing the accelerator in a futile effort to liberate
the snowbound vehicle. Like a rocking chair moving back and forth but never
actually getting its occupant anywhere, the car will spin its wheels, digging deeper
and deeper into the snowbank, becoming more snowbound than it was before. For
the unfortunate driver who happens to be stuck, a push is required to get unstuck.
Trite as this image may seem, a pragmatic existential therapist can perform a
vital clinical function by effectively pushing a patient out of an entrenched position
that precludes movement toward the future and fulfillment of latent potentials.
Given the fact that a therapist can apply direct or indirect, manifest or subtle, hard
or soft pushes, the art of pushing is really a sophisticated activity, an acquired
skill which increases with clinical experience. One example of a direct push is the
clinical act of engaging anxious patients in a death reflection (this is explained
more fully in a later discussion of existential anxiety); an example of an indirect
push would be a casual comment about a patient's grooming or skill, strategically
offered to build confidence or to suggest readiness for problem solving. Regarding
brief therapies currently informing the mental health community, the dynamic
image of pushing a patient within a field of lived experience is notably congruent
with Gustafson's (1990) image of brief therapists as architects of movement:
The complete game of brief psychotherapy concerns the entire field of small moves with
large effects. The question is: How does a therapist make small moves with large effects in
ways that take [patients] swiftly from bad places to better places? ... Meeting the challenge
of the case,... is to get movement on the field in question.
The first convention... consists of finding the best place to give the patient a push. Expertise
is knowing where, how, and when to push to get the most successful change, (pp. 408-409).

Whatever the convention may be, a brief existential therapist is focused on the
practical task of applying a simple clinical strategy that will get patients unstuck.
This pragmatic approach to helping patients solve their primary life problems supersedes the contemplative philosophical approach to clinical work advanced by
the originators of existential psychology. Indeed, when May (1967) imaged existential therapists as Socratic midwives facilitating the birth of insight in patients,
he said that "the central task and responsibility of the therapist is to ... understand
the patient" (p. 77); he also claimed that the main purpose of existential therapy is
to help patients become aware of their existence, "which includes becoming aware
of... potentialities and becoming able to act on the basis of them" (p. 85). Although
May's clinical midwife was able to help patients give birth to self-understanding,
his midwife seems to have no effective clinical approach to actually facilitating
fulfillment of the potentials brought to awareness in therapy. To be sure, May's
image of midwifery is consistent with Socrates bringing wisdom to birth in perplexed dialogical partners, but the image has little clinical utilitya serious deficit
evidenced by May's frank admission that when editing their pioneering volume
on existential psychology, he and his colleagues "had difficulty piecing together
information about what an existential therapist would actually do in any given
situations in therapy" (p. 77).

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Departing from a contemplative tradition that spawned protracted psychotherapies such as Yalom's (1980) insight based existential therapy, PET is not primarily
concerned with bringing insight to birth in unenlightened patients; in fact, while
fixed on lived experience, problem solving, and patient competency, PET is not
contemplative and insight focused, but dynamic and action based. This is consistent with the meaning of "pragmatic," a term derived from the Greek pragma, act or
deed; it is also congruent with the existentialist thesis that in human affairs, there is
hope only in action (Sartre, 1960). Against this background, a pragmatic existential
therapist generates future driven clinical encounters animated by solution-directed
acts that enable patients to move forward meaningfully in life. In this dynamic
context, the art of clinical midwifery may be likened to pushing patients out of a
stuck position by coaxing, teasing, drawing or pulling out of potentia, decisions,
choices, self-commitments, and concrete actions that involve patients in adaptive
problem solving, while bringing to birth life affirming self-creation.
Needless to say, BSFET may not resonate with clinicians seeking to reparent
patients by means of protracted clinical relationships. Beneficently conceived and
practiced, however, BSFET moves patients into the position of learning to take
responsibility for lifea necessary part of growing-up. I have revealed this hardminded existential attitude to patients quite candidly, with reference to Frankl's
(1965) keen observation that the sort of person one becomes is often the result
of an inner decision, regardless of physical or sociological circumstances, even if
the circumstances happen to be a savage death campthis having been Frankl's
lived experience. Of course a patient's inner decision to survive, to become selfresponsible, to gain control of difficult circumstances, to learn from mistakes, to
project a future and give shape to experience, even to find meaning in suffering,
is only a necessary first step in the adaptive work of problem solving and of getting on with life. In the end, as Frankl observed pragmatically: "Our answer must
consist, not in talk..., but in right action Life ultimately means taking the
responsibility to find the right answer to its problems and to fulfill the tasks which
it constantly sets for each individual" (p. 122). In the context of PET, the essential
task turns upon self-creation.
Self-Creation
Attempting to clarify the notorious notion that existence precedes essence,
Sartre (1960) declared: "man is nothing else but that which he makes of himself"
(p. 291). In the light of molecular biology and the cumulative evidence of genetic
research, Sartre appears to have overstated his first principle of existentialism,
defining human beings in terms of total freedom, thereby failing to author a decisive role for the genes in determining human identity. Heidegger (1927/1962) was
closer to contemporary constructions when he defined self-creation as finite freedom, meaning that individuals are free to create themselves with reference to the
biological, historical, and cultural context in which they are "thrown." Having been

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born into a specific existential situationpossibilities of being predetermined by

one's biological, historical, and cultural legacyan individual is free to construct
a self by fulfilling possibilities that are inherited, yet chosen.
The philosophical dispute between Heidegger and Sartre brings into relief
the central thrust of existential psychology: human beings become who they are
through decisions, choices, self-commitments, and actions. This pivotal idea inheres in the core concept "exist," a verb derived from the Latin existere, meaning to
emerge or come into being. Fleshing this out, May (1967) claimed that clinicians
understand patients existentially when they see what patients are becoming, in the
sense of projecting potentia in action. In BSFET, this entails shifting attention
from past to future time, thereby transcending a sedimented psychoanalytic tradition that has taught generations of ardent clinicians to analyze childhood events
and ensuing life history in order to understand the foundational relationship of the
past to current psychopathology.
To shift from the archaeological model (Spence, 1984) of digging in the past
to excavate layers of deformed life history, to an existential model of engineering
the future and liberating self-creation, is to design roads and bridges that provide
concrete ways for patients to get movement in the field of lived experience. In order
to actually design therapeutic roads and bridges, I continually: (a) translate negative
talk about the past into positive talk about the future; (b) transmute demoralizing
feelings of powerlessness into concrete action by pushing a patient to identify and
take small achievable steps in the direction of confronting and solving a specific
problem; (c) conceive and openly define patients with reference to potentials and
competency, rather than interpreting patients in terms of psychiatric constructions
that not only pathologize personality and behavior, but fix humans in reified categories of symptoms and diagnoses difficult for therapists and patients to transcend.
Regarding the latter, not only have Nietzsche (1886/1966) and Heidegger (1962)
argued a compelling case for the role of interpretation in human experience, but
more recentlywhile commenting critically on the psychiatric construction of
behavior as internal pathology requiring long term reparative therapyWeakland
(1990) reaffirmed the existentialist thesis that we do not live by realities, but by
interpretations: "We humans make complex problems out of originally rather simple, if difficult situations.... What is a large or serious problem is not a given ...
but... a matter of our interpretation" (p. 104).
Epistemology aside, the existential strategy of engineering the future and
quickening self-creation is congruent with the strategies of other brief therapies.
One pregnant example is the clinical work of Gilligan (1990), who declared that
therapists should "orient to the future" (p. 364). In practice, Gilligan uses brief
interventions to experientially activate both the future and self-creation by hypnotically hallucinating and working with a patient's future self:
Conversation ... [is] guided by the general underlying question "What does your desired
future self look, sound, and feel like?" Once the future self is hallucinated, I treat it as an
actual "living presence" and try to develop a balanced experiential connection between it,
the client, and me (pp. 364-365).

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Putting this experiential strategy into an existential frame, I normally engage

patients as though the future self activated during BSFET is authentic or inauthentic: a future self that actualizes a patient's legitimate potentials, or a future self that
is lost in accidental possibilities, or ways of being a self that others have chosen.
Frequently, the clinical activation of an authentic future self includes protecting
patients from wandering beyond the limits of their existential situation. Although
respecting a patient's wishes and dreams, engineering the future does not entail
a gratuitous wanderingof patient or therapistbeyond appropriate limits of finite freedom determined by the patient's biological, historical, and cultural legacy.
As Binswanger (1967) noted in his pioneering essay, "Extravagance," authentic
choice has to do with rising or lifting oneself above one's current situation; but
rising upward as an authentic self issues from maturation and self-realization, not
from being carried along willfully by gratuitous fantasies, wishes, or dreams. Accordingly, PET has the goal of safeguarding patients from extravagance, while
midwifing self-creation.
In practice, I remain focused on the fact that a patient has become stuck in
life, mired in self-defeating ways of existing, prisoned by negative patterns of
thinking, feeling, and behaving that paralyze the will, shrivel the spirit, and petrify
self-creation. Helping a patient become unstuck, reinvested in life, and willing
to undertake self-creation by confronting and solving life's primary problems,
is the basic challenge of PET. Often, meeting the challenge requires flexibility
and a willingness to experiment with a variety of strategies to discover a clinical
intervention that works; sometimes this involves a brief adventure into the symbolic
world of dreams.
Case Study. A 37-year-old single female presented with depression and anxiety. Obese and on public assistance since age 18, Peggy complained of asthma and
an arthritic ankle that precluded employment. Following the death of her mother
with whom she had a conflicted relationship)Peggy continued to live with her
father, achieving neither emancipation nor autonomy. Unable to say "no," she became the family drudge, forsaking whatever she was doing for herself to fulfill
the needs of a multitude of family members who called upon her continuously for
assistance. Summarizing her existential situation at the end of our first session,
Peggy stated simply: "I don't have a life!" During our second session, however,
Peggy reported the recurring dream of being a seven year old child drowning in a
swimming pool. Significantly, her mother stood at the edge of the pool looking on,
without responding, while Peggy neither asked for help nor attempted to help herself. In so far as this disturbing nightmare vividly symbolized her stuck position,
I decided to experiment with the dream to get Peggy unstuck.
I moved the dream imagery forward, while initiating Peggy's effort to help
herself, by teaching her to program herself to have a new dream in which she asks
her mother to help her out of the pool. During our third session, Peggy reported
that her mother laughed maliciously, while remaining unresponsive, when she

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dreamed of asking her for help. After Peggy flatly rejected my suggestion that
her dream mother was waiting benignly for Peggy to help herself, I suggested
another dream in which Peggy tries to climb out of the pool without her mother's
help. Session four included Peggy's report that when she tried climbing out of the
pool, her mother pushed her back into the pool forcibly. After exploring various
options, including the choice of remaining in the pool forever, stuck in the act of
drowning, Peggy accepted my cavalier suggestion of a new dream in which she
forcibly pulls her mother into the pool and then climbs out. Our fifth session was
conclusive: Peggy dreamed that her deceased cat attacked her mother at the edge
of the pool, enabling Peggy to climb out. After escaping through the back door of
a neighboring house, Peggy came out the front door as an adult and found herself
driving a car with the cat on the seat beside her.
Continuing to push Peggy forward, I interpreted this dream positively, using a
few simple Jungian conventions. Interpreting the whole dream sequence as a symbolic story of Peggy's transformationfrom powerless childhood to competent
adulthoodI portrayed the final dream as a friendly guide, leading her onward,
showing her that she was no longer stuck, that she had a new life rich with possibilities, although she had some important choices to make. Disclosing the car
as freedom of movement, I interpreted the escape dream as a vivid symbolization
of the fact that Peggy was now in the driver's seat, able to take herself wherever
she chose to go. While explaining that dream animals often represent disowned
parts of ourselves, the cat was interpreted as Peggy's shadowdisowned power
she needed to integrate in order to become a confident, successful woman. I further
explained that Peggy's cat solved the problem presented in the dream, because she
had disowned her power to solve life problems, although the cat's power was a
vital, unused part of her nature. When she asked how to integrate the cat, I claimed
that this would happen naturally as she begins to assert herself by setting boundaries and acting on the basis of choices and decisions that are consistent with her
potentials and her best long term interests.
Translating dream into reality during this pivotal fifth session, I asked Peggy
to imagine that she was driving the car depicted in the escape dream. As she
drove aimlessly, I asked her to decide exactly where she wanted to go, and she
drove herself to school. After giving her a formal application for state supported
vocational/educational services during our sixth session, I involved her in the
continuing generative work of "hallucinating" a future self who was: (a) doing
well in school, (b) dieting and exercising, (c) wearing more fashionable clothing,
(d) gainfully employed, and (e) living in her own apartment. Meanwhile, her
imaginary as if self was reinforced by concrete action: in addition to carrying out a
treatment assignment to telephone the state attorney general for help in rectifying
a costly telephone scam she fell victim to, due to intense anxiety when using the
telephone, she began to set boundaries with her family, saying "no" to some of
their outlandish requests.

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I have seen Peggy seven times, and her presenting symptoms appear to have
remitted. She reports being hopeful about life, she is dieting, and is progressing
toward vocational/educational rehabilitation. Unfortunately, BSFET is not always
easy, for there is an obdurate obstacle to self-creation, a fierce deterrent to moving
toward the futuresomething akin to the formidable giant Jack confronted after
deftly climbing the beanstalk during archetypal rites of passage. By all accounts,
anxiety is the unbridled obstacle, the principal reason why individuals become
petrified and unwilling to exist toward the future in meaningful acts of self-creation.
Existential Anxiety
Traditionally, existential psychologists have construed anxiety as a profoundly
disquieting lived experience involving an imminent threat of death and subsequent
constriction of self-creation. Accordingly, while using PET to teach anxious patients, behavioral and cognitive techniques that mitigate disabling symptoms, I
also engage them with the understanding that "anxiety actually is at bottom always fear of death, fear about existence and fear of its annihilation" (Boss, 1962,
p. 180). The clinical thrust of this existentialist understanding is to encourage an
affirmation of life by means of reconciliation with death, with the goal of liberating
self-creation. Ultimately, anxious patients must take some risks, for the death of
old ways of existing and of being a self must be accepted before self-creative acts
of rebirth or reintegration are set in motion.
When Freud (1920/1938) analyzed anxiety (Angst) in his introductory lectures, he claimed that the meaning of the terma narrow place or straitcharacterized a tightness of breathing in real life situations. Conceiving the experience of
birth as the prototype of anxiety, while commenting on an infant's separation
from the mother as monumental, Freud argued that birth involves a disturbance
of internal respiration, as well as other painful bodily sensations repeated in all
subsequent life endangering situations. He also observed that the repetition of
prototypic somatic disturbances during an intense anxiety episode results in "the
maddest precautions" (p. 341).
Following Freud, clinical observation reveals that it is common for patients
diagnosed with anxiety disorders to complain of choking; in fact, the feeling of
choking, trouble swallowing, or the sensation of having a lump in one's throat and
of smothering are diagnostic symptoms of an anxiety disorder. Interestingly, the
Latin anxius is an adaptation of angere, "choke"; furthermore, anguish, angst, angoisse and angustiametaphors used to elucidate the lived experience of anxiety
by American, German, French and Spanish philosophers respectivelyare developments of the Latin angustus, "narrow," "tight," formed on the Latin angere and
the Greek ankhein, "squeeze," "strangle," "choke." Although I am acutely aware
of the fact that etymological research will never mitigate anxiety, the etymology of
anxiety is clinically relevant, for it brings into relief the strategic existential view
that the feeling of choking and the sensation of having a lump in one's throat during

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an anxiety episode are embodiments of self-creation being choked-off, potentialities of being having been strangled, movement toward the future being constricted
or narrowed down, the capacity for decision, choice, self-commitment, and action
having become squeezed or smothered by an ominous threat of self-annihilation.
This classic existential view of anxiety originated in Kierkegaard's seminal
analysis of dread or anxiety. Particularly important is Kierkegaard's (1844/1970)
brilliant heuristic insight that the object of anxiety is "nothing," and that anxiety
and "nothing" correspond regularly. Developing these insights, Heidegger (1962)
advanced the pivotal notion that anxiety is an acute estrangement that ruptures a
secure sense of being-in-the-world, thereby confronting an estranged individual
with the nothing of the world and with the possible impossibility of existence.
Although not characterized as an existentialist, Rank (1936/1964) arrived at similar
insights, viewing human beings as oscillating between fear of life and fear of death
throughout the life cycle. The ultimate payment for being alive, Rank claimed, is
death; seeking to avoid this final payment, many individuals attempt to delay or
to control death by engaging in a constant self-inhibiting life restriction. "The
neurotic gains from all the painful... self-punishments no positive pleasure, but
the ... advantage of avoiding a still more painful punishment, namely fear of
death" (p. 271).
Consistent with existential theory, patients commonly report that when anxiety strikes, as if suddenly removing firm ground beneath their feet, it yanks them
out of an incognizant absorption in everyday concerns, thereby nullifying the tranquilizing illusions of crowd and culture: all the sheltering fictions that make life
endurable for a paradoxical creature who possesses the gift of anticipating the
future, while existing consciously toward the indefinite certainty of death. Awakening them rudely to the fact that neither human relationships nor involvement
with material things can save them when death comes calling, existential anxiety
brings disillusioned individuals face to face with the nothing of the world, and
with the disquieting possibility of the impossibility of existence.
Although clinicians outside the existential tradition may scoff at the suggestion that anxious patients may be likened to archetypal heroes, BSFET is facilitated by treating anxious patients as if they were archetypal heroes undergoing
self-annihilative rites of passage. Rather than pathologizing patients, the positive
symbolism of the hero archetype suggests that the lived experience of anxious
patients is a compelling adventure which presents them with a series of difficult
problems to be solved during the current stage of trials and tribulations. According
to the archetypewhose standard formula is separation (death), initiation (trials
and tribulations), and return (rebirth, reintegration, or renewal)when mythological heroes leave the security of home and cross the threshold of adventure, thereby
separating themselves from the world of ordinary experience, they have accepted
a call to venture into an unknown region, where they will undergo a severe test of
their power during a confrontation with a formidable obstacle (Campbell, 1967).
Significantly, every threshold crossing may be seen as a risky self-annihilative

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experience in which the hero submits to the death of previous forms of life and
self. Similarly, clinical observation reveals that anxiety is often triggered when
an individual's secure sense of being-in-the-world is threatened by an awareness
of some new possibility of living, of being a self, of projecting the future. This
"alarming possibility of being able" (Kierkegaard, 1970, p. 40), is a terrifying individualization that accompanies the lived experience of freedomparticularly the
lonely act of choosing to be or of fleeing from oneself. Unfortunately, self-evasion
is common, for existential anxiety is often "the dizziness of freedom ... [in which]
freedom succumbs" (Kierkegaard, p. 55).
Just as a frightened mythological hero may refuse the call to adventure and
remain home safely, anxious individuals commonly shrink from rites of passage,
hoping to avoid the difficult life problems that anxiety discloses. Having spurned
enlivening experience, thereby choking self-creation, they become stuck in life
unwilling to risk themselves in existential action that would advance the process
of self-creation underlying a dizzying anxiety episode. Once stuck in a constricting life position, clinical disorders are sure to follow, with somatic complaints
being common. Believing these secondary problems are primary, while avoiding
confrontation with real life problems, anguished humans arrive at the door of the
mental health clinic seeking symptom relief, unaware of the fact that symptoms
are vivid expressions of the problems of lived experience. As Medard Boss (1951)
asserted in a pioneering existential study of somatic disorders:
Vegetative and metabolic processes... [are] special ways and means by which
the business of being alive ... is expressed in bodily phenomena ... Patients ...
unable to maintain ... relationships with the world and its people,... bog down in
their own bodily manifestations, which become inflated and distorted into morbid
symptoms. (pp. 52-53)
In order to get existentially anxious patients unstuck, I guide them into a positive confrontation with death during BSFET. I use this strategy discriminatively, in
order to awaken a new appreciation of life and a keen awareness of the preciousness
of present and future time, all the while pushing patients in the direction of accepting the adventure of solving their primary problems. Often, a simple question
about death will stimulate a fruitful discussion of life. For example, when a patient
is ripe and it is clinically appropriate, I will ask: "If you learned that you had only
nine months to live, exactly what would you do with your remaining time?" This
provocative question is not asked in a heavy-handed way that encourages morbid
introspection; rather, it is posed empathically to promote a realistic appraisal of
wasted time, life's opportunities, and the identification of achievable goals. If a
patient engages the question, in the fashion of an archetypal hero undertaking rites
of passage, a carefully employed death reflection can effectively activate pragmatic
action resulting in problem solving and authentic self-creation.
Guiding patients into a constructive death reflection is one of those small
clinical moves that may have large effects, especially if it triggers a decisive

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affirmation of life in the face of death referred to existentially as "the courage

to be" (Tillich, 1959). However, even careful employment of this clinical strategy may leave vulnerable patients in the position of living without tranquillizing
illusions; and this may be countertherapeutic! Regarding this exposed condition,
Nietzsche (1966) not only articulated the human need to falsify reality by means of
vital lies and myths and fictions, but empirical research has led cognitive psychologists to confirm the existential philosopher's belief that healthy human minds are
those that promote benign fictions about self, world, and future. For example, while
noting that depressed individuals lack the positive illusions informing the cognitive set of individuals who are not mood disordered, Taylor (1989) maintained that
an accurate view of realitya depressive realismdescribes the cognitive set of
mood disordered patients.
In as much as the most empathic death reflection may dispel tranquilizing
illusions, leaving a patient more vulnerable than when treatment began, the decision
to use this strategy requires sound clinical judgment. Suffice it to say, whenever a
patient deflects the question of death, in the fashion of an archetypal hero refusing a
call to adventure, the better part of wisdom is to not push in that direction. Although
the anxious patient has spurned the opportunity for self-creation, the therapist has
planted a seed that may germinate and grow and be harvested after BSFET ends.
In the absence of a meliorative death reflection, a useful clinical strategy
would be to work with patients to replace destructive fictions with new life affirming deceptions. This strategy is congruent with Yalom's (1980) belief that a
principal function of existential therapy is to provide patients with a sense of personal mastery by means of fictional interpretations that catalyze a dormant will;
this strategy is also consistent with evolutionary psychology's formative thesis
that self-deception and the ability to deceive others are biological adaptations enhancing reproductive success (Nesse & Lloyd, 1992). Although a clinician may
be accused of disdaining truth, a brief existential therapist must develop a sharp
eye for the "cash value" of ideas (James, 1966); in this pragmatic context, vital
lies and fictions are treated as instruments of therapeutic action. In fact, creative
fictions that facilitate adaptation, imaginative myths that activate choice and commitment, positive illusions that liberate self-creation may be promoted during PET
because they have the virtue of enabling some demoralized patients to: (a) experience increased self esteem, (b) develop mastery and control of life circumstances,
(c) project positive future outcomes of action. In short, clinical experience with
BSFET indicates that the co-creation of illusion enables some patients to experience a happier, healthier, more meaningful life.
While existentialists are responsible for disclosing the importance of meaning
in human experiencenot only conceiving meaninglessness as a pathological
condition, but also claiming that the quest for meaning motivates human action
given a tragic view of human existence, unencumbered happiness has not figured
prominently in existential lore. In fact, existentialists have been more comfortable

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with Sisyphusean images of absurd happiness, in which a life of futile labor is

coupled with an heroic acceptance of tormenting terms of existence (Camus, 1961).
Nevertheless, when developing strategies of BSFET, an optimistic clinician may
wish to integrate empirical evidence supporting the hypothesis that,
positive illusions about one's personal qualities, degree of control, and likely future appear
to promote happiness. People who have high self-esteem and confidence in their abilities
say that they are happy,... People who believe that they have a lot of control in their lives
and who believe that the future will bring them even more happiness are happier by their
own reports than people who lack these perceptions. (Taylor, 1989, p. 49)
Needless to say, some therapists may be uncomfortable with a pragmatic
approach to clinical work; some may even hold a more traditional view of mental
health, thereby premissing clinical strategy upon the suppression of falsehood as
a necessary part both of reality testing, and of healthy human functioning. From
the perspectives of PET, however, a clinician is free to use whatever tools will
work to responsibly midwife the self-creation of petrified patients who are stuck
in life. This may entail a strategy of hardminded realism (Ellerman, 1997), or it
may necessitate artistic experimentation (Ellerman, 1998). Whatever strategy is
adopted during BSFET, the task of midwifing self-creation remains as complex
as human existence. Regarding this complexity, Boss (1962) concluded wisely
that existential anxiety may be an inseparable part of life not to be eliminated by
psychotherapy. Comparing anxious patients to the perishing old skin of a snake in
the act of sloughing, Boss observed that "the casting of a skin is ... a catastrophic
event... fear[ed] as its final destruction.... Y e t . . . the sloughing process is the
contrary of a dying; it is the creating of a more vital space for the animal to go on
growing and maturing" (p. 184).
SUMMARY AND CONCLUSION
There are countless ways of conceiving therapyas many ways as there are
clinicians practicing this experimental art. For the art of therapy covers a vast canvas on which both simple sketches and highly imaginative masterpieces have been
painted. Whatever artistic experiment has prevailed within the clinic since Freud
constructed his psychoanalytic experiment in free association one hundred years
ago, from time to time, therapists are given to believe that their successful interventions have something to do with magic (de Shazer, 1990). In fact, there is an
arguable sense in which patient change is magical: a metamorphosis of thinking,
feeling, and behaving whose elan remains inscrutable. Still, seasoned practitioners
may view an impressionistic sketch of clinical magic rather skeptically; for whatever magic has begotten demonstrable change in a patient's life, a therapist has
labored hard in the vineyardlike Van Gogh in Aries, Auvers, and Saint Remy
working diligently, despite unfavorable elements, to fashion clinical techniques
and ways of being present that liberate human potential.

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Regarding therapeutic presence, my experience with PET has reinforced the

importance of inspiring patients. Unfortunately, the ability to inspire is an existential quality within the therapist of which little can be said, except to suggest
that the gift of inspiration may be the magic often mentioned when clinicians
have difficulty understanding how patient change occurs. Sometimes, the magical
ability to inspire issues from Rogersian authenticity and the quality of being a
transparently real person to the patient. On other occasions, it results from clinical crazinessthe freedom to be a spontaneous, non-rational, creative therapist
(Warkentin, Felder, Malone, and Whitaker, n.d.). Whatever therapeutic presence
obtains during BSFET, inspiration often rests upon the clinician's ability to impart
an appreciation for the absurdities of human existencean appreciation for and
acceptance of the contradictions, paradoxes, and impotencies informing the lived
experience of patient and therapist alike. In the end, the ability to induce a smiling
awareness of the absurd, may be that final soft push that brings a patient into accord
with existence. For a pragmatic existential therapist, this simple harmony between
a patient and existence is the cash value of happiness.
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