What Role Philosophy in Psychotherapy?

As this issue reflects, the psychiatric mental health nurse assists groups and individuals throughout the entire life cycle. Those who are approaching the end of their existence in this world have at least as much need of our assistance as those who are just beginning their life journey.

Existentialism provides the most useful theoretical basis for counseling the geriatric client because the existential approach emphasizes the present instead of the past, quality rather than quantity, subjective rather than objective awareness, and “being” rather than “nothingness.” While existential psychotherapy is appropriate with anyone confronting death, an important decision, isolation, or milestone, it is a particularly useful frame of reference for working with the older adult who has mental health problems.

In the United States the existential psychotherapy movement began in 1958 with the introduction of Rollo May’s book, “Existence: A New Dimension in Psychiatry and Psychology.” Yet more than 30 years later, existential writers have exerted little influence upon American psychotherapeutic practice. Perhaps they have had no impact because we harbor the suspicion that existential analysis is an encroachment of philosophy into psychiatry, and does not have much to do with science. However, the goal of existential psychotherapists is to enter the patient’s experiential world without imposing scientific presuppositions that distort understanding (Yalom, 1980). Rather than search for hidden meanings, the existential therapist listens and accepts at face value what the client has to say.

Most existential psychotherapists agree that “anxiety” is the main problem initially confronted in therapy. The therapist assumes that the client experiences anxiety that stems from some existential conflict, often unconscious, related to guilt, choice, commitment, self-awareness, freedom, isolation, loss, meaninglessness, and death (Yesavage & Karasu, 1982). Certainly, the emotional experiences of older people reflect these themes. Older persons expend enormous amounts of physical and psychic energy grieving and resolving grief, adapting to changes, and recovering from the stresses inherent in the aging process. Somatic complaints often mask manifestations of unresolved grief, guilt, loneliness, and anger. Depressive reactions, often associated with physical disease, are the most common emotional illness of older people (Chaisson-Stewart, 1985). Many elderly face multiple personal losses, chronic illness, social isolation, financial problems, and the lack of intimate, confiding relationships.

Imminent death, or the thought of time running out, propels individuals into a personal confrontation with their existential situation in the world. Awareness of pending death may shift older persons away from trivial preoccupations and provide life with depth, poignancy, and an entirely different perspective. When effectively confronted, death can alter one’s life perspective and promote a truly authentic immersion in life. If not confronted, the fear of death constitutes a primary source of anxiety, which often is inversely proportional to life satisfaction.

Older adults have special needs that can best be addressed within an existential frame of reference. Existential models of psychotherapy typically espouse the actualization of potential in order to obtain a sense of completeness and personal dignity. The aim of therapy is to assist older adults to understand their unconscious conflict, to diminish secondary anxiety by correcting maladaptive modes of dealing with themselves, and others, and to develop adaptive ways of coping with primary anxiety. These mechanisms occur as they embark on a course of self investigation by exploring four ultimate concerns—namely, death, freedom, isolation, and meaninglessness. Undoubtedly, many elderly who seek out mental health professionals do so because they are facing such an existential crisis.