An Existential Approach: An Alternative To The AA Model of Recovery

Maria A. Rogers Debra Cobia Auburn University

schizophrenia, for example, they have a 47% lifetime history of substance abuse Abstract or dependence (Regier,et al. 1990).

Alcoholics Anonymous (AA) is the most In the past, it has been noted that mental widely used organization for the health professionals have not performed treatment of alcoholism. AA’s well in their treatment of substance philosophy has changed how many abuse disorders (Brown, 1985; people view themselves and their Khantzian, 1985; Vaillant, 1995). substance use. The majority of Professionals argued that the spread of substance abuse programs in the United self-help groups such as Alcoholics States use the 12 steps, either by making Anonymous (AA) occurred because of them the basis of their treatment the ineffective responses by mental program, or by introducing AA to clients health professionals to substance abuse as a means of recovery. Research is not problems (Khantzian, 1985). According clear, however, as to whether working to Shaffer (1986), professionals were the AA program is helpful in achieving confronted with an array of treatment sobriety. Based on a review of the models, professional and self help, for literature, this article examines substance abuse problems, and none of differences between AA and them appeared to demonstrate a high professional counseling, and explores degree of effectiveness. Additionally, AA’s philosophy. An existential some reviews of the history of the approach to therapy is reviewed with treatment of substance abuse have regard to case conceptualization, argued that the traditional assessment and interventions in treating psychodynamic approach to treating individuals suffering with alcohol- individuals with substance abuse issues related issues. as a symptom of an underlying psychiatric disorder has been especially Regardless of their area of expertise, ineffective (Polcin, 1997). According to counseling professionals will most Velleman (1989), there is no single certainly be faced with clients who approach or one agency that can help present with substance use disorders those individuals who suffer with (Polcin, 2000). Numerous studies substance abuse problems, and he suggest a lifetime prevalence rate of 8%- indicates that accurate assessment of 14% for alcohol dependence (American individuals is essential; professionals Psychiatric Association, 1994), and it must match the client with the best appears that at least 29% of clients who possible service. Beck, Wright, present with a current mental health Newman and Liese (1993) stated there is problem are also plagued with a history no conclusive evidence about the most of substance use disorder, and in such effective treatment for all people with populations as clients with a diagnosis of alcohol problems, and concluded that ExistentialExistential Approach Approach 60 treatment outcomes for individuals with less clearly codified. These entities alcohol-related problems are determined seem to be increasingly defined by by a number of aspects that include: the professional and commercial interests process of treatment; post-treatment and not by clinical science (White, adjustment; the characteristics of those 1998). individuals seeking treatment; the nature of the presenting problem, and the In a review of self-help and support interactions between these variables. It is groups, Kurtz (1997) highlights the recognized that in the United States, a distinctions between treatment and majority of professional programs for mutual-aid groups. Kurtz explains that substance abuse use the 12 steps, either self-help and support groups focus on by making them the basis of their the mobilization of resources within the treatment programs or by introducing self, within the family, and the wider them to clients as a means of recovery community. These groups are personal, (Bradley, 1988). The use of AA by egalitarian, and anti-bureaucratic and professional treatment programs is seen shun expert advice in lieu of personal as beneficial to the clients (Hulbert, and collective experience. According to 1992; Irwin & Stoner, 1991; Miller & Kurtz, many practitioners in the field Mahler, 1991). have some difficulty in distinguishing among self-help, support, or The purpose of this article is to provide psychotherapy groups, and she explains an overview of the fundamental that the most distinct difference between differences between Alcoholics self-help and support groups is that self- Anonymous (AA) model of recovery help groups aim at effecting change. and professional substance abuse Since both self-help groups and treatment, and also to examine the psychotherapy groups help their philosophy of AA. Additionally, an members achieve personal change, they existential approach to substance abuse differ by the inclusion of a professional treatment as an alternative to the AA therapist and not relying on the group. model of recovery for treatment of alcohol abuse will be investigated as a White (1998) offers elaborations on the process for helping addicted clients sort points made by Kurtz (1997) and adds out and clarify ways in which they additional reflections on the differences construct meaning in their lives. between AA and professional treatment in numerous areas. According to White, An Overview of the Differences between professional treatment services take AA and Professional Treatment place within the context of a business environment; AA-directed recovery The differences between AA and takes place within a voluntary social and substance abuse treatment could easily spiritual community. The field of be drawn if the boundaries of both of professional treatment is tied together by these separate units were clearly defined. professional and institutional self- While AA’s boundaries are defined by interest; AA is bound together by what the Twelve Steps and the Twelve White has called a “kinship of common Traditions, the professional boundaries suffering.” Theories underlying of what makes up “treatment” are much alcoholism treatment begin with

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 61ExistentialExistential Approach Approach different conceptions of the etiology of relationship in which the professional is alcoholism and proceed from these obliged to take on special ethical and conceptions to numerous derived legal duties and obligations for the care treatment strategies; AA simply says to of the client. The treatment relationship the alcoholic, “Stop drinking and here is is hierarchical whereby it is assumed that how to avoid taking the next drink.” control resides in the therapist and the Professional treatment asserts that it is institution. On the other hand, AA rooted in psychology and medicine, relationships are equal and have a sense while AA claims to come from medicine of reciprocity, and assume that strengths and religion. The focus of treatment is and vulnerabilities are shared by all characterized as a process of “getting members, and that the members are there into oneself”, self-exploration and self- because they need to be there. healing. AA is about the individual Treatment relationships are time-limited; getting outside oneself and focusing on relationships in AA are open-ended, and resources and relationships beyond the have the potential of being life-enduring. self. Treatment involves self- In substance abuse treatment, clients development; AA is about self- receive a service; in AA one receives transcendence. Treatment involves membership in a recovering community. discovery or initiating sobriety while the In treatment a diagnosis is made by one goal of AA is recovery or sustaining or more trained professionals of the sobriety. With respect to locus of nature of the problems presented by the control in addiction treatment, it is often person seeking help. The professionals difficult for the client to have control are aware that errors in diagnosis can over the degree of intimacy in the client- result in harm done to the clients, and therapist relationship, because of the the professional possesses substantial inherent inequality of this relationship; power, and the client who is being in contrast, AA members, every day, diagnosed brings significant decide if, when, where, how long, and at vulnerability to the diagnostic event. what level of intensity contact with AA The emphasis in AA is on self-diagnosis. will occur. In addiction treatment the “experts” credentials are measured in the degrees, The degree of invasiveness is reduced in licenses, and certifications awarded by AA through such mechanisms as the governmental and private authorities. It discouragement of cross-talk and is assumed that the professional avoiding taking other people’s possesses special knowledge and skill “inventories.” In treatment a high level that the client lacks. In AA, the experts of personal self-disclosure is are measured by the credentials of encouraged. Treatment seeks specific personal experience and the experience details related to the problem; AA asks is based on one’s sobriety today, one’s for conclusions. The story model of AA sobriety date, and one’s degree of is a life summary; the story model of actualization of the values of AA. When treatment is an expression of the participating in AA, members with particular aspects of how one came to be professional credentials must take off wounded. Relationships in substance their professional “hats.” Because abuse treatment are professionally credentialing is nonexistent in AA, this governed; a fiduciary service reduces disparities in power and helps to

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 62 create a foundation of universal sacred and spiritually protected. Finally, vulnerability. White states that it is the practice of institutions and treatment programs to Additionally, significant amounts of maintain extensive records on those who money are paid for professional seek their services. There are no treatment services, thus, treatment individual records in AA. involves an exchange of money for services. These fees paid by the addict White (1988) explains that when AA is or someone else help to reinforce the compared to professional treatment, the non-reciprocal character of the client- comparison is not being made between therapist relationship and the inequality two types of treatment; the comparison of power within the relationship. AA is between professional treatment and involvement calls for voluntary financial something else. AA is not a treatment contributions, in small amounts, to help for alcoholism. AA is a spiritual support the group. These contributions community of individuals that share are optional for membership. Addiction similar experiences. AA is a “way of treatment involves addiction-specific living and being.” The primary intervention technologies that target the functional linkage between AA and cravings and compulsions that drive alcoholism treatment is that both claim addictive behavior, to include the to have one driving mission, and that is consequences of addiction. Treatment to help alcoholics, and how and why focuses on the core of addiction to these missions are achieved could not be include its antecedents, consequences, further apart. White states that putting co-morbidities and obstacles to recovery. AA and alcoholism treatment in the AA has one focus, the achievement of same basket misunderstands them both. sobriety one day at a time through a This is not an error of mistaking “apples spiritual program of daily living. With for oranges”, two objects from the same respect to the ethical and legal guidelines family; it is similar to comparing “apples associated with treatment, relationships and automobiles.” are guided by professional codes of ethics to which each individual Seeking clarification in the differences practitioner is bound, as well as between AA and alcoholism treatment is licensing and accreditation standards to not a meaningless exercise and failure to which treatment institutions are bound. recognize the distinctions or the loss of These legal standards were conceived these distinctions has significant and exist in order to govern the delivery implications for the individuals seeking of addiction treatment services, because help for their addiction. Personal safety harm to the public might result from the of individuals requires an understanding delivery of fraudulent or incompetently of, and adherence to the code of ethics, delivered services. Disclosures in and the principles and boundaries that treatment are confidential as well as govern professional and personal legally protected. There are no legal relationships. If alcoholism treatment regulations governing AA because the becomes nothing but an undeclared AA public perceives no similar threat meeting, it stops being treatment; to call resulting from involvement in mutual- twelve-step work alcoholism counseling aid activity, and disclosures in AA are violates the AA traditions and the

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 63ExistentialExistential Approach Approach discipline of addiction counseling. and formed an alliance to obtain and Reflections about the differences maintain sobriety. Both men, known between AA and professional treatment now to AA as Bill W. and Dr. Bob, had are offered as opening observations in been through years of compulsive, heavy what will be a continuing discussion of drinking, and had tried to stay sober with the historical depictions of AA and the aid of the Oxford Group, an professional addiction treatment (White, evangelical non-denominational 1998). Christian organization. From those beginnings, AA has grown into a world- Philosophy of Alcoholics Anonymous distributed social organization consisting of autonomous local groups. An unusual Lemanski (2000) posits that today one institution, the only membership can join a twelve-step program for requirement is a desire to stop drinking. probably any self-defeating or AA charges no dues or fees from compulsive behavior, and some popular members and keeps no membership lists. twelve-step programs include: Narcotics AA exists in and through local meetings Anonymous, Cocaine Anonymous; and the interpersonal relationships Debtors Anonymous, Gamblers between members. AA in the United Anonymous, Nicotine Anonymous, States and Canada has a formal Overeaters Anonymous, Sex and Love organizational structure based in New Addicts Anonymous, Survivors of Incest York City, but that structure has a Anonymous, Workaholics Anonymous, minimal relationship with AA at large just to name a few. The AA model of (Swora, 2004). recovery describes addiction as a progressive, chronic, and ultimately fatal Kurtz (1979) describes AA as both a disease. The addict is left “powerless,” fellowship of alcoholics and a program experiencing a “loss of control” in the of recovery from alcoholism, and AA ability to refrain from the drug of choice. participation and its principles are The AA model requires a commitment to considered an effective treatment for abstinence, the embrace of spirituality, alcoholism; however, AA itself is not and life-long participation in AA or therapy. AA’s program for recovery as another twelve-step program, because outlined in the Twelve Steps is a set of addiction is defined as being treatable spiritual concepts and practices that have but never curable. Lemanski stated that the purpose not of curing alcoholism, but for decades there has been strong of transforming the alcoholic, and the resistance to developing alternative key term here is spiritual. The AA programs because large numbers of model of recovery explains alcoholism treatment providers themselves have as an incurable and progressive disease been recovering twelve-step addicts and of the body, mind and spirit, with the those who have opposed the one-size- fellowship and program focusing on the fits-all dogma have been virtually spiritual aspect. The cornerstone of the viewed as heretics. AA model of recovery is the paradoxical belief that to gain control of one’s life, Alcoholics Anonymous was born in the the individual must give up control to a spring of 1935 when two middle-aged, Higher Power. Although God is spoken middle-class men met in Akron, Ohio about in AA, members believe that one’s

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 64

Higher Power can be many things or gambling. (Browne, 1991; Gifford beings. AA does distinguish between 1989; Yeary, 1987). spirituality and religion and believes that addiction is a spiritual disease as well as AA provides the individual with an a physical one, and by embracing environment where experiences can be spirituality, and not a specific religious shared and trust can be established. In dogma, AA allows all individuals to the AA environment, members can embrace a Higher Power of their own exchange stories and encourage and choosing. AA is a “spiritual program of support each other (Flores, 1988). living.” Feelings of isolation can be reduced through the AA group process (Talbot, Marion and Coleman (1991) emphasize 1990). A particular strength of AA is the belief that abstinence from substance the ability of AA to help members in use is not enough is fundamental in the times of crisis. This idea of assisting 12-step philosophy, and individuals must others originated with AA’s founding be willing to make fundamental changes members Bill W. and Bob S. Out of in their lifestyle with respect to attitudes their friendship and mutual support came and behaviors. The model is designed to the philosophy of AA that one member allow individuals to address every aspect can be of aid to another during periods of their lives to include the physical, of stress (Kurtz, 1988). emotional, social and spiritual aspects, and to make positive changes in each of AA has been instrumental in bringing these areas. Once these changes are about the acceptance of the disease implemented by an individual, the model of alcoholism (Kurtz, 1988). The individual will then reach out to others model supports the idea that some in an effort to offer assistance to others people may be “allergic” to alcohol and who are recovering from a substance unable to use it in any form (Alcoholics using lifestyle. The Twelve Traditions Anonymous World Services, 1976a), are also an important component of AA; and presents alcoholism as a progressive they govern the operation of AA. illness that can be arrested but not cured (Alcoholics Anonymous World Services, AA currently consists of an estimated 1984). Although the explanation of 1,800,000 members in 134 countries and alcoholism as a disease is supported by more than 87,000 local groups the American Medical Association (Alcoholics Anonymous World Services, (AMA), its validity continues to be 1990). It has become a major force in debated in the literature (Erickson, 1992; shaping our view of addiction (Le, Miller, 1991; Peele, 1990, 1992). For Ingvarson, & Page, 1995). The many individuals, AA’s views have treatment philosophy of AA has changed reduced feelings of guilt and shame. how many people view themselves, their The views of AA have clarified the substance use and abuse, and the roles cause of the desire to drink, and has played by the people around them. The helped to remove much of the stigma influence of AA is not only seen in associated with treatment. Although AA alcoholism treatment, but in the range of believes in a medical cause for support groups for varying concerns of alcoholism, their treatment program is a eating disorders, drug addiction, and non-medical one that includes both

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 65ExistentialExistential Approach Approach social and emotional elements (Le, focused more intensely on the factors Ingvarson, & Page, 1995). that contribute to affiliation and participation in self-help and support A majority of professional substance groups, while recognizing that groups abuse programs in the United States use cannot remain in existence without new the 12 steps. These programs use the 12 members, and that members cannot steps either as a basis of their treatment benefit without attending. Additional program or by introducing them to problems involved in the scientific clients as a means of recovery (Bradley, research of AA, for example, include 1988). Professionals who espouse the member anonymity, lack of control use of AA philosophy usually perceive groups, and the confounding effects of the philosophy as being of benefit to other treatment programs. These clients (Hulbert, 1992; Irwin & Stoner, difficulties have led researchers to 1991; Miller & Mahler, 1991). The conclude that the effectiveness of AA benefits of AA to newcomers are has yet to be proven (Bebbington, 1976; emphasized and the newcomers are told Bufe, 1991; Glaser & Ogborne, 1982; that sobriety can be achieved if they will Vaillant, 1995). “just work the program” and are assured that “there is no reason in the world why As research has failed to assess the it should not work for you” (Alcoholics effectiveness of AA, counseling theory Anonymous World Services, 1984, p. may be a more appropriate standard of 19). measurement. Le, Ingvarson and Page (1995) suggest that through a Research, Alcoholics Anonymous and comparison of AA and counseling Counseling Treatment philosophy it is clear that the principles of the AA program contrast with our Kurtz, (1997) explains that the research interpretation of counseling theory. on self-help and support groups has AA’s steps revolve around themes of evolved over the past 20 years from powerlessness, dependency, and anecdotal descriptions to ethnographic humility. AA members are encouraged analyses and outcome studies. In the to relinquish self-direction and self- 1980s most self-help research focused responsibility and to turn their lives over on how professionals related to self-help the care of a power outside of associations, describing and classifying themselves. The steps emphasize helping processes in the groups, and then removing character defects and personal evaluating the effect of such groups on shortcomings, rather than developing members (Kurtz, 1992). Current strengths and abilities. Unlike the AA research has continued to focus on the program, most professionals in the helping processes and outcomes, but has counseling field value helping clients increasingly recognized that self-help is develop their responsibility for self and not treatment, and that clinical trials and use their strengths. Individuals are outcome evaluations may be a misuse of usually encouraged to choose their own research resources (Borkman & direction and personal differences are Schubert, 1995; Kennedy & Humphries supported. These philosophical 1995; Kurtz;,1992; Rappaport, 1993). differences may be the reason why AA According to Kurtz (1997), research has has been questioned, doubted, and

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 66 encouraged to change by many working roles have grown confused. If a healthy with the counseling field. Ellis and relationship between the two is to be Schoenfield (1990) questioned the use of achieved, then a clarification of religion by AA; questions related to AAs boundaries is needed. These boundaries self-absorption and irrationality were must be solid enough that both clients raised by Bufe (1991) , and Trimpey and counselors are aware of the (1989) was particularly concerned about important differences between AA those who specifically objected to AA philosophy and non-AA treatment philosophies. The temptation to programs, but flexible enough that encourage AA to change its program to clients can be referred to AA, if fit counseling values is great. However, desirable. Le, Ingvarson and Page urging an organization to change its emphasize that for appropriate referrals, values because they are not similar to it is important that counselors are not one’s own beliefs is dogmatic and only familiar with the differences undesirable. AA is a vital community between AA and general counseling resource that has made a significant philosophy, but also with the variations contribution to the growth of self-help that can exist between AA groups. In groups. It has grown to offer several the end, counselors can have the types of groups to help meet differing opportunity to decide for themselves if needs. The AA group atmosphere the AA program is consistent with their provides support, feedback, counseling values and potentially helpful socialization, and encouragement, and in for their clients. This decision is similar times of crisis AA help is available 24 to the numerous choices that counselors hours a day through their sponsorship must make concerning the use of program. different treatment methods, models, techniques, and schools of thought such Even though AA’s philosophies may as the existential approach to counseling, differ from those of counseling, AA can for instance. Becoming well acquainted still continue to grow and be helpful to with the AA program will help to make many. Nevertheless, AA is not the right this choice easier, and will allow program for everyone. According to Le, counselors to be clearer on the extent to Ingvarson and Page (1995), it is not with which they wish to integrate AA into AA that changes need to occur, but with their work. the relationship of the counseling profession has formed with AA. An Existential Approach to Substance Numerous treatment centers use the 12 Abuse Therapy step program without considering whether the principles of AA are Counselors who approach psychotherapy consistent with their counseling values from an existential perspective regard it and acceptable for their clients. A full as a series of functions resulting in 80% of AA members are directed to AA helping clients clarify the ways in which through professional treatment and they construct meaning (Corey, 1991). counseling programs (Alcoholics It can best be described as a Anonymous World Services, 1990). It is philosophical approach that affects the clear that counseling theory and AA therapeutic practice of a counselor principles have become enmeshed and (Corey, 2001). This approach is not

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 67ExistentialExistential Approach Approach specific and does not provide a new set living. Clients need help in deciding on of rules for therapy. Existential therapy the best road to take, so they can seeks to answer deep, philosophical eventually find their own way. This questions about the nature of human therapy involves a process of searching beings, and the nature of anxiety, for meaning and value in life, and the despair, grief, loneliness and isolation basic task of the therapist is to encourage (Corsini & Wedding, 2000). According clients to seek out options for creating a to May and Yalom (1995), “ the main meaningful existence. We begin with a goal of the founders of existential recognition that we do not have to be therapy was to integrate the key concepts passive victims of our circumstances, but and themes of existential therapy into all that we instead become the architects of therapeutic schools rather than have our lives (van Deurzen-Smith, 1988, existential therapy being a separate 1997). school. The existential philosophy provides a solid foundation for Because psychological problems such as approaches to therapy that concentrate alcohol abuse disorders are viewed as a on the alienated and fragmented result of inhibited ability to make individual who finds no meaning in the authentic, meaningful, and self-directed family or in social institutions. choices about how to live, the Existential therapy addresses themes in conceptualization process and modern-day living such as isolation, intervention strategies for alcohol alienation and meaninglessness while abusers are aimed at increasing client addressing itself to people who are self-awareness and self-understanding experiencing difficulty in finding (National Institute on Drug Abuse significance in their lives and failing to (NIDA), 2005). The existential recognize their purpose in life and in therapist is more interested in helping maintaining their identity.” the client find philosophical meaning in the face of anxiety by choosing to think One basic premise of existential therapy and act authentically and responsibly. is that we are not victims of Humans are in a constant state of circumstance, because to a large degree, transition, emerging, evolving, and we are what we choose to be, and a becoming. To be a person implies that specific aim of therapy is to inspire in we are trying to make sense of our clients confidence to reflect on life, to existence, and as persons we continually recognize their range of alternatives, and question ourselves, question others, and then to decide among those alternatives. the world. Although our questions vary Once clients begin to recognize the ways according to our developmental stage in in which they have submitted themselves life, the fundamental themes do not vary. into accepting circumstances and Corey (2001) explains that a distinct surrendering their control, they can then human characteristic is the struggle for a begin on a new path of awareness and sense of significance in life. He argues begin shaping their own lives (Corey, that the fundamental conflicts that bring 2001). Existential counseling was never people into counseling and therapy are conceived as a “cure” for people as in centered in these existential questions: the medical model tradition, but views “Why am I here?” “What do I want clients as being sick of life and clumsy at from life?” “What gives my life

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 68 purpose?” “Where is the source of The existential therapist also understands meaning for me in life?” According to that humans are shaped by biology, Corey, therapy can provide the culture, and luck. (National Institute on conceptual framework for helping clients Drug Abuse 2005). Existential therapy challenge the meaning in their lives with assumes the belief that the problems of questions a therapist can ask such as, people come from not exercising choice “Do you like the direction of your life?” and judgment enough to forge meaning “Are you pleased with what you are now in their lives, and that each individual is and what you are becoming?” “What do responsible for making meaning out of you want for yourself and what are you life. Existential therapy recognizes, doing to get some clarity?” however, that outside forces may contribute to the individual’s limited Yalom (1981) identifies four ultimate ability to exercise choice and live a concerns we all share and they are death, meaningful life. isolation, freedom and emptiness, and these concerns have considerable relevance for therapy. The individual’s Existential Brief Therapy confrontation with each of these concerns constitutes the context of the There has been a tendency among inner conflict of the individual from the existential therapists to be somewhat existential perspective. The existential wary of brief therapy approaches in therapist is more interested in helping which a specific number of sessions, the client find philosophical meaning in usually between 6 and 20, are agreed at the face of anxiety by choosing to think the beginning of therapy. Existential and act authentically and responsible. therapists tend to believe that there are no quick and easy answers to life’s Existential therapists are primarily challenges (van Deurzen-Smith, 1988). concerned with understanding the However, existential therapists tend to subjective world of clients, focusing on have a preference for flexibility over the clients’ current life situations (May rigid boundaries. & Yalom, 1995). According to the existential therapist, the central problems Brief therapy demands the rapid people face are embedded in anxiety formation of a therapeutic alliance over loneliness, isolation, despair, and compared with the long-term treatment ultimately, death. Creativity, love, modalities, and this therapy penetrates at authenticity, and free will are recognized a deeper level to issues related to as potential avenues toward substance-related disorders, often transformation, thus, enabling people to serving as a catalyst for seeking live meaningful lives in the face of alternatives to substances to fill the void uncertainty and suffering. Everyone of the client’s experience. The empathy suffers losses in life, parents die, friends and acceptance by the counselor, as well die and relationships end, and these as the insight gained by the client losses cause anxiety because they are contribute to the recovery of the client reminders of our limitations and by providing opportunities to make new inevitable death. existential choices, beginning with an informed decision to use or abstain from

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 69ExistentialExistential Approach Approach substances (National Institute on Drug each client (National Institute on Drug Abuse, 2005). Abuse, 2005).

Existential therapy approaches are Existential therapists assist individuals in particularly appropriate for short-term discovering the reason for their alcoholism treatment because they tend “stuckness” and they are especially to enhance counselor-client rapport, concerned with clients avoiding increases self-awareness of the client, responsibility and invite clients to accept stresses tapping into the inner resources personal responsibility. When clients of the client, and it maintains that the complain about the predicaments they client is responsible for recovery. Thus, are encountering such as addiction and clients may be more likely to see beyond blaming others, the therapist is likely to the limitations of short-term treatment ask them how they contributed to the and envision recovery as a lifelong situation (Vontress, Johnson, & Epp, process of working to reach their full 1999). Therapists with an existential potential. The role of the therapist is to orientation usually deal with people who help the client focus on personal have what could be called a “restricted responsibility for making decisions, and existence.” These clients have a limited the therapist may integrate some awareness of who they are, and are often humanistic approaches and techniques. vague about the nature of their problems. The therapist, in turn, is perceived as a They may see few, if any, options in “fellow traveler” through life, and he dealing with life situations, and they uses empathy and support to elicit tend to express feelings of being trapped insight and choices. In the context of or helpless. A central task of the treating substance abuse disorders, the therapist is to confront these clients with existential therapist often serves as a the ways they are living a “restricted coach helping the client confront the existence”, or how they are “stuck”, and anxiety that tempts him to abuse alcohol to help them become aware of their own or other substances. Because this part in creating this condition. Once approach attempts to address the clients are aware of factors in their past underlying factors of substance abuse and of stifling modes of their present disorders, it may not always directly existence, they can begin to accept confront the abuse itself. Typically, responsibility for changing their future existential therapists show wide latitude (Corey , 2001). in the methods they employ, varying not only from client to client but also with In a discussion of therapeutic techniques, the same client at different phases of the van Deurzen-Smith (1990) points out therapeutic process. On one hand, they that the existential approach is well may make use of techniques that grow known for its de-emphasis of techniques. from diverse theoretical orientations, yet She stresses the importance of therapists no set of techniques is considered reaching sufficient depth and openness essential. And yet, some existential in their own lives to allow them to therapists abhor techniques seeing them venture into “client’s murky waters” and as rigid, routine, and manipulative and, not get lost. Existential therapy is a instead, focus on the unique struggle of collaborative adventure in which both the client and the therapist will be

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 70 transformed if they allow themselves to she is encountering. She is not sleeping be touched by life. Baldwin (1987) well and she traces the onset of her states that the use of the therapist’s self symptoms to her home being vandalized is the core of therapy. It is in the I/Thou about three months ago while the family encounter, when the deepest self of the was away at work and at school. Sarah therapist meets the deepest part of the states that she has always been a social client, that the counseling process is at drinker, but she has been drinking its best. Perhaps the most important excessively in the last few months concept for describing the patient- especially since the incident occurred in therapist relationship is the term her home and admits she now relies presence (May & Yalom, 1995). The more on alcohol to get her through some therapist must to be fully present as he or “tough” days. She reports that her she strives for an authentic encounter husband and her daughters are most with the client. Therapy is a creative, affected by the symptoms because they evolving process of discovery that can worry about her. Sarah reports that the be conceptualized in three phases. alcohol seems to quell her anxiety and worry. She reports that she is used to The Case of Sarah taking charge of situations, but now feels a sense of having a loss of control of her Sarah is a 46-year old African American life. Her work has been affected. Sarah who has been married to her first and is very successful as a nurse practitioner only husband for 21 years and she in primary care. Recently because of the presents herself voluntarily for therapy nursing shortage at the hospital, she is because she recognizes that her putting in more hours at her work and pressurized life is no longer manageable her duties at home are being neglected for her. She appears nervous and shaky more than she likes. She gets along well and states that she has been experiencing with her boss, also a woman. Socially, anxiety and worry. She relates that she she and her husband have a few close has been drinking alcohol in excessive friends. She reports that her marriage amounts during the past several months. and family life are good, but much of the Sarah and her husband have two teenage household responsibilities fall on her and female children, ages 15 and 17. She she feels overwhelmed most of the time. has a master’s degree in nursing and she She became extremely upset with her works as a nurse practitioner at a local husband when he implied that the break hospital. Her husband is a healthcare in of the home was her fault for failing administrator and he works at another to set the alarm system when she left hospital in town. Sarah has no home to go to work that particular significant medical history and she is on morning. She feels guilty for leaving it no medication. Sarah admits that she is off; her home may not have been drinking at least every other day and her vandalized had she been more alert. Her supervisor at work expressed some husband works long hours and he does concern about her fitness for duty on at not contribute as much to running the least two occasions; her supervisor has daily affairs of the home as she believes noticed alcohol on Sarah’s breath. Her he should. Sarah feels he is insensitive supervisor strongly encouraged Sarah to to the fact that she is now working seek professional help for any problems longer hours too, and her responsibilities

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 71ExistentialExistential Approach Approach at home have not changed. Additionally, question the meaning of life and to she is feeling apprehensive about what challenge some of her comfortable but effect their work schedules are having on sometimes erratic patterns. Sarah is their daughters. She feels guilty about facing a number of developmental crises, neglecting them so much and the quality such as wondering what life is about time she has spent with him in the past now that her children are getting older has been significantly diminished. and are at that critical stage of preparing for their future, and as Sarah begins to Sarah states that she needs to stop expand her vision of the choices open to drinking alcohol to quell her anxiety and her, her anxiety is increasing. She is worry because she is drinking more and grappling with what she wants for more. Drinking is impeding her ability to herself, apart from her long-standing be a good wife, mother and employee. definition of herself as wife, mother and She is unsure why she is so anxious, nurse practitioner; she is feeling guilty why she worries so much, as well as about not being present for her family. why she is drinking so much, but feels it A major theme here can be posed by the is related to the pressures in her life and question “How well is Sarah living her her home being vandalized, as well as life?” her husband’s unsympathetic stance towards the pressure she is experiencing. During the initial phase, the therapist Sarah feels people expect so much from assists their clients in identifying and her; she feels she needs to be perfect. clarifying their assumptions about the world (Corey, 2001). In this case, Sarah Existential Therapy Applied to the Case is invited to define and question the of Sarah ways in which she perceives and makes sense of her existence as wife, mother Existential counselors construct the and nurse in her professional world. The counseling process around two major counselor asks Sarah to examine her themes, anxiety and authenticity. values, beliefs, and assumptions to Existential anxiety basically reflects determine their validity. Sarah has a deep feelings of unease that limited awareness of who she is and she accompanies awareness that one’s is vague about the nature of her problem. existence is frail, and that one is She sees few options in dealing with life ultimately responsible for the purpose of situations; she feels trapped, helpless and direction of one’s own existence. uses alcohol excessively to quell anxiety Authenticity refers to the kind of and worry. Sarah is drinking and existence people have when they accept blaming others, her husband, her responsibility for choosing the ideas and teenagers, her supervisor at work, for her thoughts that direct their actions and predicaments and feelings of these concepts are interrelated. The goal inadequacy. The counselor’s role is to of existential therapy is to help clients ask her how she contributes to her like Sarah become aware of what she is situation and helps her become aware of doing and to prod her out of the stance her own part in creating this condition. of victim (Corey, 2001). Sarah appears Once she becomes aware of factors in to be a good candidate for existential her past and present existence, she can therapy. She is courageous enough to begin to accept responsibility for

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 72 changing her future. The counselor will process of opening up doors little by assist Sarah in discovering the reasons little giving her room for more choices. for her “stuckness” and invite her to Sarah and the counselor will have open accept personal responsibility. Clients discussion and talk about how they are are asked to define and question the experiencing each other, and this process ways in which they perceive and make happens because of the relationship sense of their existence. This is a between the counselor and Sarah. Sarah difficult task for many clients because will learn that she is constantly creating they may present their problems as herself by the choices she is making, as resulting almost entirely from external well as by the choices she is not making. causes and focus on what other people The goal for the counselor is to show “make them feel” or on how others are Sarah the connection between the largely responsible for their actions or choices she is making or not making and inaction (Corey, 2001). Sarah’s the anxiety and worry she is substance abuse is viewed by the experiencing. counselor as a result of her inhibited According to Corey (2001) the final ability to make authentic, meaningful phase of existential counseling focuses and self-directed choices about how to on helping clients take what they are live; therefore, interventions with learning about themselves and put it into substance abuse are aimed at increasing action. Awareness of responsibility self-awareness and self-understanding. alone does not make change take place, Because this approach attempts to nor does one’s awareness of thoughts, address the underlying factors of feelings and behaviors. This is only the substance abuse disorders and not first step in the process of change. directly confront substance abuse itself, When Sarah is aware of her actions, existential therapy is best considered as takes responsibility for them and an invitation to clients to recognize the genuinely desires to change, the ways in which they are not living fully counselor will see the client’s readiness authentic lives and to make choices, to accept responsibility and to change. such as in the case of Sarah, that will Sarah has then begun the journey of lead to her becoming what she is capable moving from awareness to action. of being. The counselor’s role is to Counseling can lead to personality teach Sara how to reflect on her own change only as it guides the client to existence and to examine her role in embrace a new mode of behavior. A creating her problems. real change that happens without action on the part of the client is a practically In the middle phase of existential and theoretically impossible (Yalom, counseling, Sarah is encouraged to more 1980). fully examine the source and authority of her present value system and this self- Conclusion exploration will typically lead to new insights and some restructuring of her The value and vitality of a values and attitudes. Sarah’s experience psychotherapy approach depends on its in therapy stresses the basic premise that ability to assist clients in dealing with there are no absolute answers outside of the sources of pain and dissatisfaction in her. Sarah learns that therapy is a their lives. The existential orientation is

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 73ExistentialExistential Approach Approach particularly suited to individuals who are REFERENCES experiencing a lack of sense of identity that occurs in the cases of substance Alcoholics Anonymous World Services. abuse and alcoholic addiction. The aim (1976). Alcoholics Anonymous (3rd ed.). of existential therapy is that its key New York: Author. concepts and themes will become integrated into all therapeutic schools Alcoholics Anonymous World Services rather than existential therapy being a (1984). This is AA. An introduction to separate school. Existential therapists the AA recovery program. New York: suggest that this form of therapy is best Author. suited for clients who are committed to American Psychiatric Association. dealing with their problems about living (1994). Diagnostic and statistical and has particular relevance for people manual of mental disorders. (4th who feel alienated from the current ed.). Washington, DC: Author. expectation of society or for those who are searching for meaning in their lives. Baldwin, D. C., Jr. (1987). Some The existential view provides the philosophical and psychological contributions to the use of self in framework for understanding universal therapy. In M. Baldwin, V. Satir (eds.), human concerns. These themes that The use of self in therapy (pp. 27-44). come up in counseling sessions include New York: Haworth Press. wrestling with the problem of personal freedom, dealing with the self-alienation and estrangement from others, facing the Bebbington, P. E. (1976). The efficacy fear of death and nonbeing, finding the of Alcoholics Anonymous: The courage to live from within one’s center, elusiveness of hard data. British Journal searching for a meaningful life, of Psychiatry, 128, 572-580. discovering a personal set of values, being able to deal constructively with Beck, A. T., Wright, F. D., Newman, C. anxiety and guilt, and making choices F., & Liese, F. S. (1993). Cognitive that lead to a fullness of personal therapy of substance abuse. New York: expression. In short, this perspective Guilford. provides a sound philosophical base on which the therapist can build a personal and unique therapeutic style because it Borkman, T., & Schubert, M. (1995). addresses itself to the core struggles of Participatory action research as a the contemporary person‹ strategy for studying self-help groups internationally. In F. Lavoie, T. AUTHOR NOTE Borkman, & B. Gidron (Eds.). Self-help and mutual-aid groups: International Correspondence regarding this and multicultural perspectives (pp. 45- 68). New York: Haworth. manuscript should be directed to: Maria A. Rogers, 3624 Woodley Road, Auburn Alabama 36116. Email: [email protected]

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 74

Bradley, A. M. (1988). Keep coming Flores, P. L. (1988). Alcoholics back. Alcohol Health & Research World, Anonymous: A phenomenological and 12(3). 194-199. existential perspective. Alcoholism Treatment Quarterly, 5, 73-94.

Brown, S. (1985). Treating the alcoholic: A developmental model of Gifford, P. D. (1989). AA and NA for recovery. New York: Wiley. adolescents. Journal of Chemical Dependency Treatment, 2(1), 265-284.

Browne, B. R. (1991). The selective adaption of the Alcoholics Anonymous Glaser, E. B., & Ogborne, A. C. (1982). program by Gamblers Anonymous. Does AA really work? British Journal of Journal of Gambling Studies, 7, 187- Addiction, 77, 123-129. 206.

Hulbert, R. J. (1992). The Iowa Bufe, C. Q. (1991). Alcoholics therapeutic community model of Anonymous: Cult or cure? San chemical dependency treatment. Francisco, CA: See Sharp. Journal of Substance Abuse Treatment, 9(4), 389-393.

Corey G. (1991). Approach to counseling and psychotherapy (3rd ed.). Irwin, P. P., & Stoner, S. B. (1991). Belmont, CA: Wadsworth, Inc. Women’s chemical dependency treatment program: A pilot study. Alcoholism Treatment Quarterly, 8(1), Corey, G. (2001). Theory and practice of 123-130. counseling and psychotherapy (6th ed.). Belmont, CA: Wadsworth, Inc. Kennedy, M., & Humphries, K. (1995). Understanding worldview Corsini, R. J., Wedding, D. (2000). transformation in members of mutual Current psychotherapies (6th ed.). help groups. In F. Lavoie, T. Borkman, Itasca, IL: F. E. Peacock Publishers, Inc. & B. Gidron, Self-help and mutual aid groups: International and multicultural perspectives (pp. 181-198). New York: Ellis, A., & Schoenfeld, E. (1990). Haworth. Divine intervention and the treatment of chemical dependency. Journal of Substance Abuse, 2, 459-468. Khantzian, E. J. (1985). Psychotherapeutic intervention with substance abusers: The clinical context. Erickson, C. K. (1992). A Journal of Substance Abuse Treatment, pharmacologist’s opinion: Alcoholism: 2, 83-88. The disease debate needs to stop. Alcohol and Alcoholism, 27(4), 325-328.

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 75ExistentialExistential Approach Approach

Kurtz, E. (1992). Commentary. In J. W. Peele, S. (1990). Why and by whom the Langenbucher, B. S. McCrady, W. American alcoholism treatment industry Frankenstein, & P. E. Nathan (Eds.). is under siege. Journal of Psychoactive Annual review of addictions research Drugs, 22(1), 1-13. and treatment: Volume 2, (pp. 397-400). New York: Pergamon. Peele, S. (1992). Why everybody always pickin’ on me? A response to comments. Kurtz, L. F. (1997). Self-help and Addictive Behaviors, 17(1), 83-93. support groups: A handbook for practitioners. Thousand Oaks, CA: Sage. Polcin, D. L. (1997b). The etiology and diagnosis of alcohol dependence: Differences in the professional literature. Le, C., Ingarson, Erik P., Page, R. C. Psychotherapy, 34, 297-306. (1995). Alcoholics Anonymous and the counseling profession: philosophies in conflict. Journal of Counseling and Polcin, D. L. (2000). Professional Development, 73, 603-609. counseling versus specialized programs for alcohol and drug abuse treatment. Journal of Addictions & Offender Lemanski, J. J. (2000). Addiction Counseling, 21, 2-12. alternatives for recovery. Humanist, 60, 14-18. Rappaport, J. (1993). Narrative studies, personal stories, and identity Marion, T. R., & Coleman, K. (1991). transformation in the mutual help Recovery issues and treatment resources. context. Journal of Applied Behavioral In D. C. Daily & M. S. Raskin (Eds.). Science, 29, 239-256. Treating the chemically dependent and their families (pp. 100-127). Newbury Park, CA: Sage. Regier, D. A., Farmer, M. E., Rae, D. S., Locke, F. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of May R., Yalom, I. (1995). Existential mental disorders with alcohol and other psychotherapy. In R. J. Corsini, D. drug abuse: Results from the Wedding (Eds.). Current Epidermiologic Catchment Area (ECA) psychotherapies (5th ed.). (pp. 262-292). study. Journal of the American Medical Itasca, IL: F. E. Peacock. Association, 264, 2511-2518.

Miller, N. S., & Mahler, J. C. (1991). Shaffer, H. (1986). Observations on Alcoholics Anonymous and the “AA” substance abuse theory. Journal of model for treatment. Alcoholism Counseling and Development, 65, 26-30. Treatment Quarterly, 8(1), 39-51. NIDA (2005). Humanistic and Swora, M. G. (2004). The rhetoric of existential therapies. Retrieved July 31, transformation in the healing of 2007, from alcoholism: The twelve steps of http://www.addictioninfo.org/article/22/ Alcoholics Anonymous. Mental Health, 1/page1.html. Religion & Culture, 7, 187-209.

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008 ExistentialExistential Approach Approach 76

Timpey, J. (1989). The Small Book. Velleman, R. (1989). Counseling people New York, NY: Bantam. with alcohol and drug problems. In W. Dryden, D. Charles-Edwards & R. Woolfe (Eds.). Handbook of Counselling Vaillant, G. E. (1995). The natural in Britain. London: history of alcoholism. Cambridge, MA: Tavistock/Routledge. Harvard University Press. Vontress, C. E., Johnson, J. A., Epp, L. R. (1999). Cross-cultural counseling: A Van Deurzen-Smith, E. (1988). casebook. Alexandria, VA: American Existential counseling in practice. Counseling Association. London: Routledge. White, W. L. (1998). Slaying the dragon: The history of addiction Van Deurzen-Smith, E. (1990b). What is treatment and recovery in America. existential analysis? Journal of the Bloomington, IL: Chestnut Health Society for Existential Analysis, 1, 6-14. Systems.

Yalom, I. (1981). Existential Van Deurzen-Smith, E. (1997). psychotherapy. New York: Basic Books. Everyday mysteries: Existential dimensions of psychotherapy. London: Yeary, J. (1987). The use of Overeaters Routledge. Anonymous in the treatment of eating disorders. Journal of Psychoactive Drugs, 19(3), 303-309.

The Alabama Counseling Association Journal, Volume 34, Number 1, Spring 2008